Changes in growth,anaemia, and iron deficiency among children aged 6–23 months in two districts in Nepal that were part of the post‐pilot scale‐up of an integrated infant and young child feeding and micronutrient powder intervention

There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross‐sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6–23 months in two districts in Nepal that were part of a post‐pilot scale‐up of a IYCF–MNP programme. Multivariable log‐binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length‐for‐age z‐score <?2), wasting (weight‐for‐length z‐score <?2), underweight (weight‐for‐age z‐score <?2), anaemia (altitude‐adjusted haemoglobin <110 μg/L), moderate or severe anaemia (altitude‐adjusted haemoglobin <100 g/L), iron deficiency (inflammation‐adjusted ferritin <12 μg/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers' interactions with female community health volunteers (FCHVs; >1× per month or monthly vs. <1× per month) and MNP coverage (1 or ≥2 distributions vs. none among children 12–23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable‐adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal–FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF–MNP programmes to improve children's nutritional status.     

Micronutrient powder supplements combined with nutrition education marginally improve growth amongst children aged 6–23 months in rural Burkina Faso: A cluster randomized controlled trial

Micronutrients powder (MNP) can prevent anaemia amongst children 6–23 months old. However, evidence of an effect on growth is limited and concerns about the safety of iron‐containing MNP interventions limits their applicability. In a cluster randomized controlled intervention, we evaluated the effectiveness of a nutritional package including counselling and provision of MNP to improve the nutritional status of children aged 6–23 months and the effect of sustained use of MNP on morbidity in a malaria‐endemic area. Child feeding practises and nutritional status were assessed through cross‐sectional surveys. Biweekly morbidity surveillance and anthropometry measurements were carried out in a nested cohort study. No significant differences in the prevalence of wasting (?0.7% [?6.8, 5.3] points; p = .805), stunting (+4.6% [?2.9, 12.0] points; p = .201), or mean length‐for‐age z‐score and weight‐for‐length z‐score scores were found between study groups. The proportion of children with a minimum dietary diversity score and those with a minimum acceptable diet significantly increased in the intervention group compared with the control by 6.5% points (p = .043) and 5.8% points (p = .037), respectively. There were no significant differences in the risk of diarrhoea (RR: 1.68, 95% CI [0.94, 3.08]), fever (RR: 1.20 [0.82, 1.77]), and malaria (RR: 0.68 [0.37, 1.26]) between study groups. In the nested study, the rate of linear growth was higher in the intervention than in the control group by 0.013 SD/month (p = .027). In a programmatic intervention, MNP and nutrition education marginally improved child feeding practises and growth, without increasing morbidity from malaria or fever.     

The impact of home fortification with multiple micronutrient powder on vitamin A status in young children: A multicenter pragmatic controlled trial in Brazil

Home fortification with multiple micronutrient powder (MNP) is effective in the prevention of anemia in young children. However, the impact on their vitamin A status remains controversial. This study aimed to evaluate the effect of MNP on vitamin A status in young Brazilian children. A multicenter pragmatic, controlled trial was carried out in primary health centers in four Brazilian cities. In the beginning of the study, the control group (CG) consisted of children 11–14 months old (n = 395) attending in routine pediatric health care. In parallel, the intervention group (IG) was composed of children 6–8 months old (n = 399), in the same health centers, who followed the intervention with MNP for 2–3 months. The analysis of the effect of MNP on vitamin A status was performed by comparing the IG with the CG after a 4‐ to 6‐month follow‐up when IG children had reached the age of the controls. The prevalence of vitamin A deficiency (VAD; serum retinol <0.70 μmol/L) in the CG was 16.2%, while in the IG was 7.5%—a 55% reduction in the VAD [prevalence ratio (95% confidence interval) = 0.45 (0.28; 0.72)]. This reduction was also significant when stratifying the study centers by coverage of the Brazilian Vitamin A Supplementation Program. The adjusted mean of vitamin A serum concentrations improved in the IG compared with CG children, with a shift to the right in the vitamin A distribution. Home fortification with MNP was effective in reducing VAD among young Brazilian children.     

Inadequacy of nutrients and contaminants found in porridge‐type complementary foods in Rwanda

Child malnutrition remains persistently high in Rwanda. Complementary foods play a key role in young child nutrition. This study explores the quality and safety of complementary food products available in the Rwandan market. Ten of the most consumed porridge‐type complementary food products in Rwanda have been analysed. Mean values of macronutrient and micronutrient contents were compared against three international standards and evaluated against label claims. Mean mycotoxin, microbiological, and pesticide contamination were compared with maximum tolerable limits. Mean energy density (385 kcal/100 g) and total fat content (7.9 g/100 g) were lower than all three international benchmarks. The mean fibre content of 8.5 g/100 g was above the maximum recommended amount of Codex Alimentarius and more than double the amount claimed on labels. Mean levels of vitamin A (retinyl palmitate, 0.54 mg/100 g) and vitamin E (α‐tocopherol, 3.7 mg/100 g) fell significantly short of all three standards, whereas calcium and zinc requirements were only partially met. Average iron content was 12.1 mg/100 g. The analysis revealed a mean aflatoxin contamination of 61 μg/kg, and high mold and yeast infestation. Escherichia coli and pesticide residues were found, whereas no heavy metals could be quantitated. Overall, complementary food products in Rwanda show inadequate nutrient contents and high aflatoxin and microbial contamination levels. Improved regulation and monitoring of both local and imported products are needed to improve the quality and safety of complementary foods in Rwanda.     

Amylase increases energy and nutrient density of Super Cereal Plus porridge as prepared and accepted by Rwandan caregivers

Adding amylase to Super Cereal Plus (SC+A) improves energy and nutrient intake as porridge energy density reaches 1.0 kcal/g, meeting the recommended ≥0.8 kcal/g for prepared foods for young children. Caregiver response to SC+A in terms of adjusting porridge preparation using printed pictogram instructions was not yet investigated. The study assessed (a) porridge preparation by caregivers; (b) porridge energy density; (c) sensory porridge acceptability; and (d) understanding of preparation instructions. An 8‐day follow‐up intervention study was conducted amongst caregivers of children aged 6–23 months (n = 238) in Rwanda. Caregivers prepared porridge using SC+A whilst referring to printed pictogram instructions at the study site on Days 1 and 8 and received flour for preparation at home on Days 2–7. At the site, data were collected on porridge preparation procedures, energy density, consistency, acceptability, and interviews (n = 12), and focus group discussions (n = 6) were conducted. Mean porridge dry matter (DM) increased from 21.3 ± 4.4% (Day 1) to 25.1 ± 4.8% (Day 8; p < 0.0005). Flour and water were mixed before cooking by 95% of the participants, as per printed instructions. Sensory porridge acceptability was high, and the printed instructions enabled caregivers to prepare an accepted and energy dense porridge. The preferred water/flour volume ratio was 2.5 instead of 3. In conclusion, Rwandan caregivers prepared well‐accepted SC+A porridges with a preferred consistency and mean DM content of 25.1% (1.0 kcal/g), after 1 week practicing at home. This supports introducing SC+A with the tested instructions at scale.     

Determinants of adherence to micronutrient powder use among young children in Ethiopia

In Ethiopia, home fortification of complementary foods with micronutrient powders (MNPs) was introduced in 2015 as a new approach to improve micronutrient intakes. The objective of this study was to assess factors associated with intake adherence and drivers for correct MNP use over time to inform scale‐up of MNP interventions. Mixed methods including questionnaires, interviews and focus group discussions were used. Participants, 1,185 children (6–11 months), received bimonthly 30 MNP sachets for 8 months, with instruction to consume 15 sachets/month, that is, a sachet every other day and maximum of one sachet per day. Adherence to distribution (if child receives ≥14 sachets/month) and adherence to instruction (if child receives exactly 15[±1] sachets/month) were assessed monthly by counting used sachets. Factors associated with adherence were examined using generalized estimating equations. Adherence fluctuated over time, an average of 58% adherence to distribution and 28% for adherence to instruction. Average MNP consumption was 79% out of the total sachets provided. Factors positively associated with adherence included ease of use (instruction), child liking MNP and support from community (distribution and instruction) and mother''s age >25 years (distribution). Distance to health post, knowledge of correct use (OR = 0.74, 95% CI = 0.66–0.81), perceived negative effects (OR = 0.73, 95% CI = 0.54–0.99) and living in Southern Nations, Nationalities and People Region (OR = 0.59, 95% CI = 0.52–0.67) were inversely associated with adherence to distribution. Free MNP provision, trust in the government and field staff played a role in successful implementation. MNP is promising to be scaled‐up, by taking into account factors that positively and negatively determine adherence.     

Use of monitoring data to improve implementation of a home fortification program in Bihar,India

This paper describes the use of program‐monitoring data to track program performance and inform activities. Monitoring data were collected as part of an effectiveness trial of multiple micronutrient powders (MNPs) for children 6–18 months in Bihar, India. Communities (n = 70; reaching over 10,000 children) were randomized to receive either counselling on infant and young child feeding or both counselling and MNPs. Government frontline health workers (FLWs) implemented and monitored program activities with support from CARE India and university partners. Monitoring data were collected over the duration of the entire program to assess program impact pathways using various checklists, which captured information about (a) attendance and training of FLWs at health subcentre meetings, (b) distribution of MNPs, (c) receipt and use of MNPs at the household level, and (d) midline mixed methods survey. At the beginning of the program, 72% of households reported receiving and 53% reported currently consuming MNPs. These numbers fell to 40% and 43% at midline, respectively. The main barrier to use by household was a lack of MNPs, due in part to infrequent FLW distribution. However, FLWs rarely reported MNP shortages at Anganwadi centres. Side effects also emerged as a barrier and were addressed through revised recommendations for MNP use. Qualitative data indicated high community acceptance of MNPs and a good understanding of the program by FLWs. The use of real‐time program data allowed for recognition of key program issues and decision‐making to enhance program implementation.     

Acceptability of locally‐produced Ready‐to‐Use Supplementary Food (RUSF) for children under two years in Cambodia: A cluster randomised trial

In Cambodia, existing food products for treating or preventing undernutrition have met with limited success. Therefore, in 2014, alternative ready‐to‐use foods were developed. This trial aimed to assess the acceptability of the novel ready‐to‐use supplementary food (RUSF) as a snack or mixed with borbor (white rice porridge), compared with corn–soy blend plus plus (CSB++) and borbor fortified with micronutrient powder (MNP). The nonblinded, randomised 4 × 4 crossover trial recruited 95 children aged 9–23 months from communities in peri‐urban Phnom Penh. Small quantities (100 g for porridges, 42 g for snack) of each food were offered for three consecutive days at testing sites (homes of health volunteers). Main outcomes were children's consumption, caregivers' assessment of children's preferences, and caregivers' ranking of the foods. Median percentage consumed of the test food servings ranged from 21 to 50% (p = 0.003). The odds of children consuming over 50% were greatest for borbor fortified with MNP versus RUSF snack (unadjusted OR = 6.79, CI = 2.80–16.47, p < 0.001). However, the median energy children received when consuming the RUSF with borbor (57 kcals) or as a snack (48 kcals) was greater than with CSB++ (15 kcals) or borbor fortified with MNP (18 kcals; p < 0.001). Therefore, although children ate less RUSF, it provided approximately three times more kilocalories. Caregivers reported that their children had the highest preference for borbor fortified with MNP. Caregivers themselves ranked the novel RUSF snack highest. Thus, the innovative RUSF was considered sufficiently acceptable to proceed to an effectiveness trial.     

Measuring exclusive breastfeeding social support: Scale development and validation in Uganda

The World Health Organization recommends exclusive breastfeeding (EBF) for 6 months and continued breastfeeding for at least 2 years. Social support has been widely recognized to influence breastfeeding practices. However, existing scales do not measure exclusive breastfeeding social support (EBFSS), rather they assess social support for any breastfeeding. Further, they are tailored towards high‐income settings. Therefore, our objectives were to develop and validate a tool to measure EBFSS in low‐income settings. To develop the scale, local and international breastfeeding experts were consulted on modifications to the Hughes' Breastfeeding Social Support Scale. It was then implemented in an observational cohort in Gulu, Uganda, at 1 (n = 238) and 3 (n = 237) months post‐partum (NCT02925429). We performed polychoric and polyserial correlations to remove redundant items and exploratory factor analysis at 1 month post‐partum to determine the latent factor structure of EBFSS. We further applied confirmatory factor analysis to assess dimensionality of the scale at 3 months post‐partum. We then conducted tests of predictive, convergent, and discriminant validity against EBF, self‐efficacy, general social support, and depression. The modification of the Hughes' scale resulted in 18 items, which were reduced to 16 after examining variances and factor loadings. Three dimensions of support emerged: Instrumental, Emotional, and Informational, with alpha coefficients of 0.79, 0.85, and 0.83, respectively. Predictive, convergent, and discriminant validity of the resultant EBFSS scale was supported. The EBFSS scale is valid and reliable for measuring EBFSS in northern Uganda and may be of use in other low‐income settings to assess determinants of EBF.     

Strengthening nutrition services within integrated community case management (iCCM) of childhood illnesses in the Democratic Republic of Congo: Evidence to guide implementation

In the Democratic Republic of Congo, 43% of children under 5 years of age suffer from stunting, and the majority (60%) of children, 6–59 months of age, are anaemic. Malaria, acute respiratory infections, and diarrheal diseases are common among children less than 5 years of age, with 31% of children 6–59 months affected by malaria. This qualitative implementation science study aimed to identify gaps and opportunities available to strengthen service delivery of nutrition within integrated community case management (iCCM) at the health facility and community level in Tshopo Province, Democratic Republic of Congo, through the following objectives: (a) examine cultural beliefs and perceptions of infant and young child feeding (IYCF) and child illness, (b) explore the perspectives and knowledge of facility‐based and community‐based health providers on nutrition and iCCM, and (c) gain an understanding of the influence of key family and community members on IYCF and care‐seeking practices. This study involved in‐depth interviews with mothers of children under 5 years of age (n = 48), grandmothers (n = 20), fathers (n = 21), facility‐based providers (n = 18), and traditional healers (n = 20) and eight focus group discussions with community health workers. Study findings reveal most mothers reported diminished quantity and quality of breastmilk linked to child/maternal illness, inadequate maternal diet, and feedings spaced too far apart. Mothers' return to work in the field led to early introduction of foods prior to 6 months of age, impeding exclusive breastfeeding. Moreover, children's diets are largely limited in frequency and diversity with small quantities of foods fed. Most families seek modern and traditional medicine to remedy child illness, dependent on type of disease, its severity, and cost. Traditional healers are the preferred source of information for families on certain child illnesses and breastmilk insufficiency. Community health workers often refer and accompany families to the health centre, yet are underutilized for nutrition counselling, which is infrequently given. Programme recommendations are to strengthen health provider capacity to counsel on IYCF and iCCM while equipping health workers with updated social and behavior change communication (SBCC) materials and continued supportive supervision. In addition, targeting key influencers to encourage optimal IYCF practices is needed through community and mother support groups. Finally, exploring innovative ways to work with traditional healers, to facilitate referrals for sick/malnourished children and provide simple nutrition advice for certain practices (i.e., breastfeeding), would aid in strengthening nutrition within iCCM.     

Maternal nutrition practices in Uttar Pradesh,India: Role of key influential demand and supply factors

Despite strong policy and program commitment, essential maternal nutrition services are not reaching enough women in many countries. This paper examined multifactorial determinants (personal, family, community, and health services) associated with maternal nutrition practices in Uttar Pradesh, India. Data were from a household survey of pregnant (n = 667) and recently delivered women (n = 1,835). Multivariable regression analyses were conducted to examine the determinants of four outcomes: consumption of diverse diets, consumption of iron folic acid (IFA) and calcium tablets, and weight monitoring during pregnancy. Population attributable risk analysis was used to estimate how much the outcomes can be improved under optimal program implementation. During pregnancy, women consumed 28 IFA and 8 calcium tablets, 18% consumed diverse diet, and 17% were weighed ≥3 times. Nutrition knowledge was associated with consumption of diverse diet (odds ratio [OR] = 2.2 times), IFA (2.3 times), calcium (11.7 times), and weight monitoring (1.3 times). Beliefs and self‐efficacy were associated with IFA (OR = 2.0) and calcium consumption (OR = 4.6). Family support and adequate health services were also associated with better nutrition practices. Under optimal program implementation, we estimate that 51% of women would have adequate diet diversity, an average consumption of 98 IFA, and 106 calcium tablets, and women would be weighed 4.9 times during pregnancy. Strengthening existing program operations and increasing demand for services has the potential to result in large improvements in maternal nutrition practices from current baseline levels but may not be sufficient to meet World Health Organization‐recommended levels without creating an enabling environment including improvements in education and income levels to support behaviour change.     

Water,sanitation, and hygiene practices mediate the association between women's empowerment and child length‐for‐age z‐scores in Nepal

In Nepal, more than one‐third of children are stunted. Prior studies have shown that women's empowerment in agriculture is associated with child (<2 years) length‐for‐age z‐scores (LAZ) in Nepal. This study tests whether child dietary diversity (DD) and household water, sanitation, and hygiene (WASH) facilities and practices mediate the associations between women's empowerment and LAZ. With a cross‐sectional dataset of 4,080 households from 240 rural communities across 16 districts of Nepal, we used ordinary least squares regression models to first estimate the associations between women's empowerment and LAZ for children 6 to 24 months (n = 1,402; our previous published analysis included all children <24 months of age), using the Women's Empowerment in Agriculture Index's Five Domains of Empowerment subindex. We used standardized structural equation models to test whether child DD and/or household WASH mediated the association between women's empowerment and child LAZ. Overall, women's empowerment was positively associated with child LAZ (β = 0.24, P = 0.03), as found in our previous analyses. In the mediation analysis, women's empowerment was positively associated with WASH (β = 0.78, P < 0.001), and in turn child LAZ (β = 0.09, P < 0.001). Women's empowerment was not associated with DD, but DD was associated with LAZ (β = 0.06, P = 0.05). Empowered women had better WASH practices than nonempowered women, which translated into higher child LAZ. Child DD was not a mediating factor in the association between women's empowerment and child LAZ. More research is needed to explore other pathways by which women's empowerment may affect child nutrition outcomes.     

An mHealth voice messaging intervention to improve infant and young child feeding practices in Senegal

Mobile health (mHealth) interventions have the potential to improve infant and young child feeding (IYCF) practices; however, gaps in the literature remain regarding their design, implementation, and effectiveness. The aims of this study were to design an mHealth voice messaging intervention delivered to mothers and fathers targeting IYCF practices and examine its implementation and impact in households with children 6–23 months in three rural villages in Senegal. We conducted focus groups (n = 6) to inform the intervention development. We then conducted a pilot study (n = 47 households) to examine the impact of the intervention on IYCF practices of children 6–23 months. Voice messages were sent to the children's mothers and fathers over a period of 4 weeks (two messages per week; eight messages in total), and 24‐hr dietary recalls and food frequency questionnaires (FFQs) were conducted before and immediately after the implementation of the mHealth intervention to examine its impact on IYCF practices. Overall, three of the eight behaviours increased and one decreased. There was a significant increase in the number of children that consumed fish (60% vs. 94%; p = .008) as measured by the 24‐hr recall after the completion of the intervention. We also found significantly higher frequency of egg (p = .026), fish (p = .004), and thick porridge (p = .002) consumption in the previous 7 days measured by the FFQ. Our findings suggest that voice messaging IYCF interventions in Senegal have the potential to improve IYCF behaviours among young children in the short term. Future research should entail scaling‐up the intervention and examining its sustainability over the long‐term.     

Associations of plasma total phospholipid fatty acid patterns with feeding practices,growth, and psychomotor development in 6‐month‐old South African infants

The objective of this study was to assess plasma fatty acid (FA) patterns of 6‐month‐old South African infants and to determine their association with feeding practices, growth, and psychomotor development. Plasma total phospholipid FA composition (% of total FAs) of 6‐month‐old infants (n = 353) from a peri‐urban township was analysed, and principal component and factor analysis were performed to identify plasma FA patterns. Feeding practices, anthropometric measurements, and psychomotor development scores were determined. Four major plasma phospholipid FA patterns were identified: A plant‐based C18 FA, a high n‐6 long‐chain polyunsaturated fatty acids (LCPUFA), a C16:1 and long‐chain saturated fatty acid (SFA), and a high n‐3 and low n‐6 LCPUFA pattern. Formula feeding was associated with higher, whereas breastfeeding was associated with lower scores for the plant‐based C18 FA and C16:1 and long‐chain SFA patterns. On the other hand, breastfeeding, the consumption of cow's milk, and the consumption of semisolid foods were associated with higher scores, whereas formula feeding was associated with lower scores for the high n‐6 LCPUFA pattern. Breastfeeding and the consumption of semisolids were also associated with higher high n‐3 and low n‐6 LCPUFA pattern scores. The C16:1 and long‐chain SFA and high n‐3 and low n‐6 LCPUFA patterns were positively associated with psychomotor development scores. In 6‐month‐old South African infants, we identified distinct plasma FA patterns that presumably represent the FA quality of their diet and that are associated with psychomotor development. Our results suggest that breast milk is an important source of n‐6 LCPUFAs and formula‐fed infants may be at risk of inadequate LCPUFA intake.     

Factors influencing the implementation of the Becoming Breastfeeding Friendly initiative in Ghana

Becoming Breastfeeding Friendly (BBF) is an initiative designed to help countries assess their readiness to scale‐up breastfeeding programs and develop key recommendations to strengthen their breastfeeding environment. In 2016, Ghana was one of two countries to first pilot BBF. In applying BBF, a committee of 15 Ghanaian nutrition, health, and breastfeeding experts implemented the BBF toolbox over 8 months. Following implementation, semistructured interviews were conducted with 12 committee members (CMs) to (a) identify facilitators and barriers to implement BBF and (b) determine factors needed to strengthen the breastfeeding environment in Ghana. Using a grounded theory approach, five domains were identified. First, a dynamic committee of key stakeholders drove the implementation of BBF. Second, CMs faced some logistical and methodological challenges, including difficulty accessing data and the need for strong in‐country technical support for adhering to the BBF process. Third, CMs felt well positioned to facilitate and lead the dissemination and implementation of recommendations. Fourth, accountability would be essential to properly translate recommendations. Fifth, to move recommendations to action, advocacy would be a required first step, and BBF was proposed to facilitate this step. BBF provided an in‐depth analysis of Ghana's current breastfeeding environment to help Ghana strengthen its breastfeeding governance, policies, and programs while informing CMs' government and non‐governmental organizations' breastfeeding efforts.     

The co‐occurrence of anaemia and stunting in young children

Anaemia and stunting are prevalent nutritional problems among children of low‐income countries that have profound effects on development, morbidity, and mortality. Many use a single conceptual framework to identify the basic determinants of these and other forms of malnutrition. One would expect that problems with matching underlying determinants should co‐occur in affected individuals to a greater degree than by chance. In 2 populations of children—ages 6–18 months in Bihar, India, (n = 5,664) and 6–36 months in Lambayeque, Peru (n = 688)—we measured the frequency of the co‐occurrence of anaemia and stunting. We compared this value with the value expected by chance, the product of the prevalence of anaemia and stunting, using a chi‐square test. We also built logistic regression models for each condition. The frequency of co‐occurrence in the Indian population was 21.5%, and in the Peruvian population, it was 30.4%, which are similar to frequencies expected by chance, 21.3% (p = .97) and 31.5% (p = .85). In Peru, anaemia was associated with age and consumption of treated water. Stunting was associated with age, sex, dietary diversity, hand washing, language spoken, and wealth. In India, anaemia was associated with age, sex, caste, dietary diversity, and household hunger. Stunting was associated with age, sex, caste, wealth, and maternal illiteracy. Despite some basic shared factors, anaemia and stunting are more independent than commonly assumed. Interventions that target children based on 1 condition may miss children with the other form of malnutrition.     

Contribution of commercial infant products and fortified staple foods to nutrient intake at ages 6, 12, and 18 months in a cohort of children from a low socio‐economic community in South Africa

Fortification of two staple foods, maize meal and wheat flour (bread), is mandatory, and commercial infant products are widely available in South Africa. Using a 24‐hr recall, we determined the contribution of these foods towards nutrient intakes at ages 6 (n = 715), 12 (n = 446), and 18 (n = 213) months in a cohort of children in a peri‐urban community, North West province. On the day of recall, commercial infant products were consumed by 83% of children at 6 months, 46% at 12 months, and 15% at 18 months; fortified staples were consumed by 23%, 81%, and 96%, respectively. For consumers thereof, commercial infant products contributed 33% energy and 94% iron intakes at 6 months and 27% energy and 56% iron intakes at 12 months; nutrient densities of the complementary diet was higher than for nonconsumers for most micronutrients. For consumers of fortified staples, energy contribution thereof was 11% at 6 months versus 29% at 18 months; at 18 months, fortified staples contributed >30% of iron, zinc, vitamin A, thiamine, niacin, vitamin B6, and folate; at 12 months, nutrient densities of the complementary diet were higher for zinc, folate, and vitamin B6 but lower for calcium, iron, vitamin A, niacin, and vitamin C than nonconsumers. At ages 12 and 18 months, ~75% of children had low calcium intakes. At 12 months, 51.4% of consumers versus 25.0% (P = 0.005) of nonconsumers of fortified staples had adequate intakes (>EAR) for all eight fortificant nutrients. However, despite fortification, nutrient gaps remain.     

Evaluation of a social network intervention on child feeding practices and caregiver knowledge

Food insecurity and poor infant and young child feeding (IYCF) practices contribute to undernutrition. The Kanyakla Nutrition Program was developed in rural Kenya to provide knowledge alongside social support for recommended IYCF practices. Utilizing a social network approach, the Kanyakla Nutrition Program trained community health workers (CHWs) to engage mothers, fathers, and grandparents in nutrition education and discussions about strategies to provide instrumental, emotional, and information support within their community. The 12‐week programme included six sessions and was implemented on Mfangano Island, Kenya, in 2014–2015. We analysed intervention effects on (a) nutrition knowledge among community members or CHWs and (2) IYCF practices among children 1–3 years. Nutrition knowledge was assessed using a postintervention comparison among intervention (community, n = 43; CHW, n = 22) and comparison groups (community, n = 149; CHW, n = 64). We used a quasi‐experimental design and difference‐in‐difference to assess IYCF indicators using dietary recall data from an ongoing cohort study among intervention participants (n = 48) with individuals living on Mfangano Island where the intervention was not implemented (n = 178) before the intervention, within 1 month postintervention, and 6 months postintervention. Findings showed no effect of the intervention on IYCF indicators (e.g., dietary diversity and meal frequency), and less than 15% of children met minimum acceptable diet criteria at any time point. However, knowledge and confidence among community members and CHWs were significantly higher 2 years postintervention. Thus, a social network approach had an enduring effect on nutrition knowledge, but no effects on improved IYCF practices.     

Acceptability of multiple micronutrient powders and iron syrup in Bihar,India

Nearly two thirds of young children are anaemic in Bihar, India. Paediatric iron and folic acid syrup (IFAS) and multiple micronutrient powders (MNPs) are two evidence‐based interventions to prevent anaemia. Using a randomized crossover design, we examined the acceptability of IFAS versus MNPs for children 6–23 months. In a catchment area of 2 health centres in Bihar, health front‐line workers (FLWs) delivered either (a) IFAS twice weekly or (b) MNPs for 1 month followed by the other supplementation strategy for 1 month to the same families (NCT02610881). Household surveys were conducted at baseline (N = 100), 1 month after receiving the first intervention (1 month; N = 95), and 1 month after the second intervention (2 months; N = 93). Focus group discussions (10 FLWs) and in‐depth interviews (20 mothers) were held at 1 and 2 months. We used chi‐square and Fisher exact tests to test mothers' product preferences. Qualitative data were analysed using MaxQDA and Excel employing a thematic analysis approach. There was high adherence and acceptability for both products (>80%). There was no significant difference in preference (p < .05) on perceived benefits (39% MNPs, 40% IFAS), side effects (30% MNPs, 30% IFAS), ease of use (42% IFAS, 31% MNPs), child preference (45% IFAS, 37% MNPs), and maternal preference (44% IFAS, 34% MNPs). Mothers and FLWs indicated that the direct administration of IFAS ensured that children consumed the full dose, and MNPs intake depended on the quantity of food consumed, especially among younger children, which emphasizes the need to integrate supplementation with the promotion of optimal child feeding practices.     

The impact of the UK Baby Friendly Initiative on maternal and infant health outcomes: A mixed‐methods systematic review

Global evidence demonstrates that adherence to the Baby Friendly Initiative (BFI) has a positive impact on multiple child health outcomes, including breastfeeding initiation and duration up to 1 year post‐partum. However, it is currently unclear whether these findings extend to specific countries with resource‐rich environments. This mixed‐methods systematic review aims to (a) examine the impact of BFI implementation (hospital and community) on maternal and infant health outcomes in the United Kingdom (UK) and (b) explore the experiences and views of women receiving BFI‐compliant care in the UK. Two authors independently extracted data including study design, participants, and results. There is no UK data available relating to wider maternal or infant health outcomes. Two quantitative studies indicate that Baby Friendly Hospital Initiative implementation has a positive impact on breastfeeding outcomes up to 1 week post‐partum but this is not sustained. There was also some evidence for the positive impact of individual steps of Baby Friendly Community Initiative (n = 3) on breastfeeding up to 8 weeks post‐partum. Future work is needed to confirm whether BFI (hospital and community) is effective in supporting longer term breastfeeding and wider maternal and infant health outcomes in the UK. A meta‐synthesis of five qualitative studies found that support from health professionals is highly influential to women's experiences of BFI‐compliant care, but current delivery of BFI may promote unrealistic expectations of breastfeeding, not meet women's individual needs, and foster negative emotional experiences. These findings reinforce conclusions that the current approach to BFI needs to be situationally modified in resource‐rich settings.