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Community-based supplementary feeding for promoting the growth of young children in developing countries

  1. Yanina Sguassero1,*,
  2. Mercedes de Onis2,
  3. Guillermo Carroli1

Editorial Group: Cochrane Developmental, Psychosocial and Learning Problems Group

Published Online: 19 OCT 2005

Assessed as up-to-date: 14 JUN 2005

DOI: 10.1002/14651858.CD005039.pub2


How to Cite

Sguassero Y, de Onis M, Carroli G. Community-based supplementary feeding for promoting the growth of young children in developing countries. Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD005039. DOI: 10.1002/14651858.CD005039.pub2.

Author Information

  1. 1

    Centro Rosarino de Estudios Perinatales, Rosario, Argentina

  2. 2

    World Health Organisation, Department of Nutrition for Health and Development, 1211 Geneva 27, Switzerland

*Yanina Sguassero, Centro Rosarino de Estudios Perinatales, Pueyrredón 985, Rosario, S2000QIC, Argentina. ysguassero@crep.com.ar. crep@crep.com.ar.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 19 OCT 2005

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This is not the most recent version of the article. View current version (13 JUN 2012)

 
Characteristics of included studies [ordered by study ID]
Guatemala 1995

MethodsCluster randomised controlled study.Allocation concealment not stated. Authors said "assignment of treatments across villages was random" but the method was not described.


ParticipantsPregnant and lactating women and children younger than 7 years of age living in four rural Guatemalan villages. This intervention was provided "universally", i.e. inclusion criteria were not based on nutritional status at baseline.


InterventionsExp (n = 2 villages, one small and one large): high energy- protein drink called Atole (90.5 kcal and 6.3 g of protein/100 ml).Control (n = 2 villages, one small and one large): low energy-non protein drink called Fresco (33 kcal/100 ml). Both drinks were enriched with vitamins and minerals in equal concentrations. However, Atole differed in name, appearance, and taste.These drinks were distributed at a feeding centre twice a day, and were available on demand to all members of the community, including week-ends.


OutcomesLength (cm), Weight (g).


NotesOriginally, three pairs of villages were selected. Due to budgetary constraints, the number was reduced to two pairs, with dire consequences for statistical power.The number of children included in each study group was not provided.Outcome assessors were not blinded of treatment groups.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Indonesia 1991

MethodsCluster randomised controlled study. The study children were divided into two age groups according to the types of psychological tests to be administered to them. DCC assignment to the two types of interventions was randomised and stepwise by pairs. Allocation concealment not stated. No further information.


ParticipantsPre-school children attending to DCCs at six plantations in West Java, Indonesia. The younger age group (6 to 20 mo) was considered for anthropometrical assessment.


InterventionsExp (n = 9 DCCs, 75 children). The daily supplement consisted of twice-a-day snacks given 6d/week for 90 days. They included rice, rice flour, wheat flour, bread, cassava, potatoes, sweet potatoes, coconut milk, refined sugar, brown sugar and edible oil. Based on 20 different recipes used, the energy of the snacks varied from 187 kcal to 216 kcal and protein content ranged from 1.8 g to 4.4 g. On average, the daily supplement provided 400 kcal and 5 g protein.Control (n = 11 DCCs, 38 children): no food supplementation


OutcomesWeight and height z- scores.


NotesThe study was designed to compare pre-to post treatment changes for children with and without supplementation, focusing on motor maturation. DCCs were selected for the study based on their having more than 15 children aged from 6 to 59 mo inclusive.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Indonesia 2000

MethodsAuthors stated that the design of the study included the randomisation of treatment by community-run DCCs to one of three intervention schemes. Allocation concealment not stated. No further information.


ParticipantsA 12-month-old and an 18-month-old cohort of moderately stunted and wasted children (L-F-A below -1 SD and W-F-L between -1 and -2 SD of the median of the NCHS/WHO references values, respectively) recruited from 24 community-run DCCs in tea plantations of West Java, Indonesia.Excluded: Children with signs of chronic disease, L-F-A < or = - 1 SD, and W-F-L between -1 and -2 SD of the median value of the NCHS/WHO reference.


InterventionsExp (n = 38): 11 teaspoons of condensed milk (250 kcal and 6 g of protein per ration) and a dissolved tablet of micronutrients.Placebo (n = 37): 11 teaspoons of skimmed milk (20 kcal and 1.35 g of protein per ration) and a dissolved tablet of micronutrients.The supplements were given twice daily at the DCC, 6 days a week for 12 mo.


OutcomesHeight (cm), Weight (g), HC (cm), MUAC (cm).


NotesThe trial profile was based on three study groups: E = condensed milk plus micronutrients, and M = skimmed milk plus micronutrients, S=skimmed milk plus placebo tablet.Outcome assessors were not blinded of treatment groups.


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear





Jamaica 1991

MethodsAuthors said "random assignment to treatment group" but the method was not described. Allocation concealment not stated. No further information.


Participants65 Jamaican stunted children (recumbent lengths < - 2 SD of the NCHS reference) aged 9-24 mo.Excluded: children with W-F-H > the NCHS median considered more likely to be genetically short.


InterventionsExp (n = 32): 1 kg of a milk-based formula per week containing 525 kcal and 14 g protein/100 g. The supplement was delivered weekly to the home for 12 mo. In addition, 0.9 kg cornmeal and skimmed milk powder were given to the family.Control (n=33): no food supplementation


OutcomesLength (cm), Weight (g), HC (cm), MUAC (cm), TSF (mm), SSF (mm), W-F-L z- score.


NotesStunted children were recruited by house-to-house survey. The trial profile was based on four groups: 1- Supplementation group (n = 32), 2-Stimulation group (n = 30), 3- Supplementation and stimulation (n = 32), 4- Control group (n = 33). In this regard, there were two important basic disparities among the children in the control and in the supplemented groups, such as birth-weight (21% weighted 1.8-2.3 kg and 100% weighted more than 2.3 kg at enrolment, respectively) and guardian's employment (75% vs 94% were unemployed, respectively).


Risk of bias

ItemAuthors' judgementDescription

Allocation concealment?UnclearB - Unclear

 cm = centimeter, d = day, DCCs = day care centres, Exp = experimental, g = gram, HC = head circumference, kg = kilogram, L-F-A = length-for -age, mo = months, MUAC = mid-upper-arm circumference, n = number, NCHS = National Center Health Statistics, SD = standard deviation, SSF = subscapular skinfold thickness, TSF = triceps skinfold thickness, vs = versus, W-F-L = weight-for-length, wk = weeks, WHO = World Health Organization.


 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Bangladesh 1992The intervention is an energy-dense supplementary food together with nutritional education vs nutritional education alone.
Method: random generation after obtaining caregiver consent was done by using a computer-generated random number table.
Participants: children aged 6-12 mo with a MUAC between 110 and 129 mm.
Intervention: 450 g of pre-mixed roasted and packed rice, wheat and lentil powder along with 90 g of cooking oil. The mothers were taught by local community nutrition workers how to prepare an energy-dense porridge from these ingredients, adding salt or sugar as appropriate (energy content of 163 kcal/100 g). They were instructed to give it three times daily. Families with older siblings under 5 years of age received an additional packet to compensate for the effect of food sharing.
Outcomes: mean monthly weight gain.

Bolivia 199624% of withdrawals in the control group (15 refusal of parents to continue participation and 5 absences).
Method: random generation after inclusion of each child was done by drawing lots.
Participants: 127 children aged 4-7 mo.
Intervention: food supplementation vs non supplementation. The supplement was a cereal based pre-cooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation. Introduction was progressive, 25 g dry supplement in 75 ml water per meal, i.e. 103 kcal in 100 g from 4 to 5 mo and 50 g supplement and 135 ml water per meal, i.e. 205 kcal in 185 g from 5 to 7 mo. The packets were delivered at home twice daily for three months by a fieldworker who monitored its consumption.
Outcomes: 4-7 length increments.

Colombia 198123% of children excluded after randomisation (4 stillbirth, 4 multiple births, 3 changes of address, 8 missing data after birth, and 22 without a clearly reason for exclusion (mortality or changes of address). Food supplements were provided from the onset of the third trimester of pregnancy until the children reached the age of 3 years old. Though, supplementation of mothers during pregnancy complicates the interpretation of results because effects cannot be analysed separately.
Method: "families were randomly assigned to control and supplemented groups". No further information provided.
Participants: 131 Colombian children aged 0-36 mo.
Intervention: food supplementation vs non supplementation. The supplement was delivered weekly at home. Infants aged 3-12 mo received a high-protein, whole-powered-milk-and vegetable mixture. After 12 mo of age, they received enriched bread, powered skim milk, and vegetable oil as did all other family members. In addition, children were also provided with 7.5 mg or 15 mg ferrous sulphate daily in the form of oral drops and a standard dose of 60,000 ug of vitamin A every 6 mo.
Outcomes: prevalence of malnutrition, physical growth and child morbidity during the first 3 y of life.

Congo 199628% of withdrawals in the group receiving food supplementation (12 refusal of parents to continue participation, 7 absences and 2 deaths).
Method: random generation after inclusion of each child was done by drawing lots.
Participants: 120 children aged 4-7 mo.
Intervention: food supplementation vs non supplementation. The supplement was a cereal based pre-cooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation. Introduction was progressive, 25 g dry supplement in 75 ml water per meal, i.e.103 kcal in 100 g from 4 to 5 mo and 50 g supplement and 135 ml water per meal, i.e. 205 kcal in 185 g from 5 to 7 mo. The packets were delivered at home twice daily for three months by a fieldworker who monitored its consumption.
Outcomes: 4-7 length increments.

Gambia 1998The age of the children participating in the study was 68 ±21 mo (values are given as mean ± SD).
Method: groups were randomly allocated to receive either a high fat supplement, an isocaloric high CHO supplement or no supplement at all. No further information was provided.
Participants: 90 stunted children with a H-F-A z score < -2 aged between 3 and 9 years old. Wasted children with a H-F-A z score < -2 were excluded.
Intervention: Children were supplemented with biscuits containing different proportions of rice, flour, roasted groundnuts, sugar, vegetable oil and honey. They were similar regarding their micronutrient and vitamin constitution with exception that high fat biscuits contained notably more vitamin E. The high CHO biscuit contains 533 kcal/ 100 g of raw biscuit. The supplements were given 5 d/week for one year.
Outcomes: weight (g), height (cm), skinfolds (mm), HC (cm), MUAC (cm)

India 2001The intervention is a micronutrient-fortified food supplement supported by counselling or nutritional counselling.
Method: "children were randomly assigned to one of four study groups". No further information.
Participants: 418 infants aged 4-12 mo.
Intervention: milk-based cereal supplement and nutritional counselling (a packet of 50 g was delivered at home during the twice-weekly visits for morbidity ascertainment) vs no intervention.
Outcomes: anthropometric outcomes (weight and length), morbidity, impact on breastfeeding rates and energy intake.

Malawi 2004A 12-week supplementation trial among underweight and stunted children aged 42 to 60 months of age who were randomised to receive either RTUF or maize and soy flour.
Method: "allocation to the study group was made using computer-generated random numbers by one author not participating in data collection. Group allocation was sealed in individual opaque envelopes at study commencement. Research assistant and participant's guardian were aware of the group allocation, while the study physician remained blinded until study completion.
Participants: 61 underweight, stunted children 42 to 60 months of age from a rural community in Malawi, south eastern Africa.
Intervention: RTUF (92 g/day) vs maize and soy flour (140 g/day). They were intended to provide 500 kcal/day energy and additional macro-and micronutrients. RTUF could be eaten without additional preparation, whereas the maize and soy flour required cooking. Both food supplements were delivered fortnightly to the child's home.
Outcomes: weight and height were measured at baseline and intervention periods, and at the end of the 12-week follow-up.

Mexico 2004Children and pregnant and lactating women in participating households received fortified nutrition supplements, and the families received nutrition education, health care and cash transfers.
Method: 506 communities were randomly selected from a pool of communities that were eligible to receive the program benefits, 320 of these were randomly assigned to receive a packet of interventions, whereas the rest of the communities (n = 186) were assigned to act as controls. The nutritional impact sub study was conducted in a random selection of 205 of the 320 communities (intervention group) and in 142 communities randomly selected from the 186 (control group).Random generation not described.
Participants: children aged 4 to 23 months, underweight children aged 2 to 4 years, pregnant and lactating women in low-income rural households.
Intervention: 205 intervention communities (n = 461 children aged < or equal 12 months) received a 240-g packages containing 5 daily rations of dry whole milk, sugar, maltodextrin, and micronutrients (iron, zinc, vit A, E, C, B12, folic acid) for 24 months. They were distributed at health centres where mothers were instructed to add 4 spoons of boiled water to one ration, which produces a puree consistency. In addition, other interventions such as cash transfers and maternal health and nutrition education were included in the program. The 142 control communities (n = 334 children aged < or equal 12 months) were enrolled 12 months later and are referred to as crossover intervention communities.
Outcomes: two-year height increments and anaemia rates as measured by blood haemoglobin levels.

New Caledonia 199632% of withdrawals in the group receiving food supplementation (8 refusal of parents to continue participation, 11 absences and 1 illness).
Method: random generation after inclusion of each child was done by drawing lots.
Participants: 90 children aged 4-7 mo.
Intervention: food supplementation vs non supplementation. The supplement was a cereal based pre-cooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation. Introduction was progressive, 25 g dry supplement in 75 ml water per meal, i.e. 103 kcal in 100 g from 4 to 5 mo and 50 g supplement and 135 ml water per meal, i.e. 205 kcal in 185 g from 5 to 7 mo. The packets were delivered at home twice daily for three months by a fieldworker who monitored its consumption.
Outcomes: 4-7 length increments.

Senegal 199620% of withdrawals in the group receiving food supplementation (7 refusal of parents to continue participation, 3 absences,1 illness and 2 deaths).
Method: random generation after inclusion of each child was done by drawing lots.
Participants: 110 children aged 4-7 mo.
Intervention: food supplementation vs non supplementation. The supplement was a cereal based pre-cooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation. Introduction was progressive, 25 g dry supplement in 75 ml water per meal, i.e. 103 kcal in 100 g from 4 to 5 mo and 50 g supplement and 135 ml water per meal, i.e. 205 kcal in 185 g from 5 to 7 mo. The packets were delivered at home twice daily for three months by a fieldworker who monitored its consumption.
Outcomes: 4-7 length increments.

 CHO = carbohydrate, g = gram, HC = head circumference, H-F-A = height-for-age, Kcal = kilocalories, mg = milligram, ml = millilitre, mo = months, MUAC = mid upper arm circumference, RTUF = ready-to-use food, SD = standard deviation, ug = microgram; vs = versus, y = years.


 
Comparison 1. Energy-protein supplementation vs non supplementation in stunted children after 12 months

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Weight (kg)165Mean Difference (IV, Fixed, 95% CI)0.29 [-0.29, 0.87]

 2 Length (cm)165Mean Difference (IV, Fixed, 95% CI)1.30 [0.03, 2.57]

 3 Weight-for-length z-score165Mean Difference (IV, Fixed, 95% CI)Not estimable

 4 Head circumference (cm)165Mean Difference (IV, Fixed, 95% CI)0.40 [-0.21, 1.01]

 5 Mid-upper-arm circumference (cm)165Mean Difference (IV, Fixed, 95% CI)0.20 [-0.29, 0.69]

 6 Triceps skinfold thickness (mm)165Mean Difference (IV, Fixed, 95% CI)0.20 [-0.51, 0.91]

 7 Subscapular skinfold thickness (mm)165Mean Difference (IV, Fixed, 95% CI)0.20 [-0.34, 0.74]

 
Comparison 2. Energy-protein supplementation vs low-energy /low protein supplementation in poor children after 12 mo

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Weight (kg)175Mean Difference (IV, Fixed, 95% CI)0.16 [-0.27, 0.59]

 2 Height/length (cm)175Mean Difference (IV, Fixed, 95% CI)-0.10 [-1.61, 1.41]

 3 Head circumference (cm)175Mean Difference (IV, Fixed, 95% CI)0.19 [-0.41, 0.79]

 4 Arm circumference (cm)175Mean Difference (IV, Fixed, 95% CI)0.10 [-0.22, 0.42]

 
Comparison 3. Energy-protein supplementation vs non supplementation in poor children after 3 months

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Weight z-scores120Mean Difference (IV, Fixed, 95% CI)0.19 [-0.64, 1.02]

 2 Height z-scores120Mean Difference (IV, Fixed, 95% CI)0.12 [-0.87, 1.11]

 
Table 1. Length(1) of 3-year-old children before and after supplementation by villa

GUATEMALA STUDY 1995Large village-AtoleLarge village-FrescoSmall village-AtoleSmall village-Fresco

After (2)86.7084.0085.9584.35

Before (3)83.4583.3083.4084.15

Change3.250.702.550.20


Difference in change (large villages): 2.55

Difference in change (small villages): 2.35

Overall difference in change: mean = 2.45 +/- 0.10, t-test= 24.50, p< 0.005 (Two-tailed probability, df = 2).

(1) Means of sex-specific data calculated from Table 3 in Martorell et al. (1982).
(2) Born between 1969 and 1973.
(3) Measured in 1968.