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Community-based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries

  1. Yanina Sguassero1,*,
  2. Mercedes de Onis2,
  3. Ana María Bonotti3,4,
  4. Guillermo Carroli1

Editorial Group: Cochrane Developmental, Psychosocial and Learning Problems Group

Published Online: 13 JUN 2012

Assessed as up-to-date: 31 JUL 2011

DOI: 10.1002/14651858.CD005039.pub3


How to Cite

Sguassero Y, de Onis M, Bonotti AM, Carroli G. Community-based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries. Cochrane Database of Systematic Reviews 2012, Issue 6. Art. No.: CD005039. DOI: 10.1002/14651858.CD005039.pub3.

Author Information

  1. 1

    Centro Rosarino de Estudios Perinatales, Rosario, Argentina

  2. 2

    World Health Organization, Department of Nutrition for Health and Development, Geneva, Switzerland

  3. 3

    Ministry of Health, Province of Buenos Aires, Buenos Aires, Argentina

  4. 4

    Instituto de Efectividad Clínica y Sanitaria, Buenos Aires, Argentina

*Yanina Sguassero, Centro Rosarino de Estudios Perinatales, Moreno 878, Rosario, S2000DKR, Argentina. ysguassero@crep.org.ar. crep@crep.org.ar.

Publication History

  1. Publication Status: New search for studies and content updated (no change to conclusions)
  2. Published Online: 13 JUN 2012

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Characteristics of included studies [ordered by study ID]
Brazil 2006

MethodsDouble-blind RCT with a longitudinal follow-up of children.


ParticipantsChildren aged 1 to 6 years attending 4 municipal crèches of João Pessoa, Paraíba, Brazil.


InterventionsExp (n = 45): 10 g of multi-mixture per day during 2 mo. For each 100 g of preparation the intervention contains: 47.5% of wheat flour, 47.5% of cornmeal, 4% of melon seed powder, sesame, gourd and peanut, 0.5% of cassava leaf powder and 0.5% of eggshells, and presents the following centesimal composition: 2.7 g of ashes, 5.2 g of lipids, 11.7 g of proteins, 74.2 g of carbohydrate and 6.2 g of fibres. The mineral composition was: 8 mg of iron, 357 mg of calcium, 235 mg de magnesium, 677 mg of potassium, 570 mg de phosphorus and 7 mg of sodium. Total amount of calories/100 g of multi-mixture estimated: 390 kcal.

Control (n = 42): 5 g of cassava flour similar to mixture in colour and thickness of grains. For each 100 g of preparation the mixture contains the following centesimal composition: 336.8 calories, 81.1 g of carbohydrate, 2.2 g of proteins, 0.05 g of lipids, 21 mg of calcium, 105 mg of phosphorus and 0.8 mg of iron.


OutcomesMean W-F-A, H-F-A and W-F-H z-scores; and prevalence of underweight, stunting, wasting, and overweight.


NotesThe trial profile was based on three study groups: intervention 1 (GI1 = 48), intervention 2 (GI2 = 45) and control (CG = 42), receiving 5 g and 10 g of multi-mixture and placebo, respectively.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskFour out of 15 crèches were selected by drawing lots to participate in the study. No further information was provided.

Allocation concealment (selection bias)Low riskThe food supplement was concealed (intervention versus placebo).

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo losses to follow-up in any of the study groups.

Selective reporting (reporting bias)Low riskThe study published results with lack of clinical importance or lack of statistical significance.

Blinding of participants and personnel (performance bias)
All outcomes
Low riskThe multi-mixture of the intervention group was similar to mixture of the placebo group in colour and thickness of grains. There was not any modification on the feeding scheme at crèches. The plates of children were marked with the child's name plus a code. Only one trained member of the research team was in charge of providing the multi-mixture (bran-based cereal mixture or placebo) to the study groups daily.

Blinding of outcome assessment (detection bias)
All outcomes
Low riskThe authors said that the study was double blind but no details on blinding of outcome assessors were provided.

Reliability of primary outcome measurementsLow riskInformation about anthropometric procedures and instruments used was provided.

Brazil 2008

MethodsCommunity randomised controlled study. The slum of Lona in Maceió city was divided in two sectors (A and B) taking a central street as reference. All children were evaluated and 50 children with the lowest W-F-A z-score were selected in each sector. Authors said "children were randomly assigned to the intervention or the control group by drawing lots" but the method was not clearly described.


ParticipantsChildren aged 6 to 60 months from a slum area in the city of Maceió, State of Alago, Brazil, classified according to their W-F-A at baseline.


InterventionsExp (n = 48 children): two tablespoons of multi-mixture during the child meals for 10 mo. The multi-mixture contained 80% wheat flour, 10% of cassava leaf powder, and 10% of eggs shells. These ingredients were cooked over a low heat for 5 to 10 minutes and then the heat was stifled for their homogenisation. The food supplement was delivered at home on a fortnightly basis.

Control (n = 60): no supplementation.


OutcomesMean H-F-A, W-F-A and W-F-H z- score.


Notes


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskThe random sequence generation was not described.

Allocation concealment (selection bias)Unclear riskThe method of allocation concealment was not reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskTwo children of the intervention group excluded from the analysis.

Selective reporting (reporting bias)Low riskThe study published results with lack of clinical importance or lack of statistical significance.

Blinding of participants and personnel (performance bias)
All outcomes
High riskEach child received a special package containing a quantity of multi-mixture for 15 days. A member of the research team visited the family every fortnight in order to monitoring the multi-mixture utilisation and consumption.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskThe anthropometric measurements were taken by trained students graduated in nutrition but no details about blinding of outcome assessment were provided.

Reliability of primary outcome measurementsLow riskInformation about anthropometric procedures and instruments used was provided.

China 2005

MethodsRandomised controlled trial. The authors said “subjects were randomly allocated to either the control group or the yogurt group”.


ParticipantsChildren aged 3-5 years from 7 kindergartens in Beijing suburbs, China.


InterventionsExp (n = 179): a daily serving of yogurt (125 g/cup) with 3.8 g of protein, 150 mg of calcium, 0.19 mg of vitamin B2 from Monday to Friday during 9 mo.

Control (n = 169): no supplementation.


OutcomesIncrease in weight (kg), height (cm), and MUAC (cm), and change of H-F-A, W-F-A z-score at baseline and after 3, 6, and 9 months of study.


NotesOther outcomes reported were morbidity and bone mineral density of forearm.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandom sequence generation was not described.

Allocation concealment (selection bias)Unclear riskThe method of allocation concealment was not reported.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskThe information was not reported by trialist. However, according to the footnotes of two tables (Table 4 and 6) of the study published report, 16% and 11% of the children were lost to follow-up in the control and intervention groups, respectively.

Selective reporting (reporting bias)Unclear riskThe study published harmful effects and results with lack of clinical or statistical relevance.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskBlinding of participants and personnel was not described.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskBlinding of outcome assessors was not described.

Reliability of primary outcome measurementsUnclear riskOnly information on instruments for anthropometrical measurements and the growth reference used were provided.

Guatemala 1995

MethodsCluster randomised controlled study. The authors said "allocation of treatment across villages was random paired to be as similar as possible (one pair was large, i.e. about 900 inhabitants and one pair was small, i.e. about 500 people in each)".


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, no 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 at week-ends.


OutcomesLength (cm), weight (g) before and after the beginning of the study.


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.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandom sequence generation was not described.

Allocation concealment (selection bias)Low riskThe authors said that "allocation of treatment was assigned across villages paired to be as similar as possible" (a table with the selection criteria of villages was provided) and that "the villages were far enough apart from each other, to make contact among villages unlikely”.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information provided.

Selective reporting (reporting bias)Unclear riskThe before-after comparison was possible only for selected variables collected with adequate sample sizes in 1968, before the intervention began, or for variables collected in the first months of the study which could not be affected by supplementation.

Blinding of participants and personnel (performance bias)
All outcomes
High riskThe intervention had to be prepared at the time of ingestion and therefore required a central kitchen and feeding hall, precluding blinding of people and staff.

Blinding of outcome assessment (detection bias)
All outcomes
High riskThe study team rotated through all the villages for equal durations of time and visited the families twice a month. The enthusiasm for participation or follow-up may be influenced by group allocation.

Reliability of primary outcome measurementsUnclear riskNo information provided.

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. Authors said "DCC assignment to the two types of intervention was randomized and stepwise by pairs".


ParticipantsChildren 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 6 d/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

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandom sequence generation was not described.

Allocation concealment (selection bias)Unclear riskThe method of allocation concealment was not reported.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information provided.

Selective reporting (reporting bias)Low riskThe study published results with lack of clinical importance or lack of statistical significance.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskBlinding of participants and personnel not described.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskBlinding of outcome assessors not described.

Reliability of primary outcome measurementsUnclear riskOnly information on instruments for anthropometrical measurements and the growth reference used were provided.

Indonesia 2000

MethodsThe study design included the randomisation of treatment by community-run DCCs to different intervention schemes. The authors said "two cohorts of children were randomly assigned to three treatments".


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.


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 months.


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.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandom sequence generation was not described.

Allocation concealment (selection bias)Unclear riskThe method of allocation concealment was not reported.

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNo information provided.

Selective reporting (reporting bias)Low riskThe study published results with lack of clinical importance or lack of statistical significance.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskBlinding of participants and personnel not described.

Blinding of outcome assessment (detection bias)
All outcomes
High riskOutcome assessors were not blinded.

Reliability of primary outcome measurementsUnclear riskOnly information on instruments for anthropometrical measurements and the growth reference used were provided.

Jamaica 1991

MethodsThe authors said that "children were randomly assigned to four study groups".


ParticipantsStunted children (recumbent lengths < - 2 SD of the NCHS reference) aged 9-24 months. 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 months. 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 the supplemented groups, such as birthweight (21% weighted 1.8-2.3 kg and 100% weighted more than 2.3 kg at enrolment, respectively) and guardian's employment (75% versus 94% were unemployed, respectively).


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandom sequence generation was not described.

Allocation concealment (selection bias)Unclear riskThe method of allocation concealment was not reported.

Incomplete outcome data (attrition bias)
All outcomes
Low riskNo losses to follow-up.

Selective reporting (reporting bias)Low riskThe study published results with lack of clinical importance or lack of statistical significance.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskBlinding of participants and personnel not described.

Blinding of outcome assessment (detection bias)
All outcomes
Unclear riskBlinding of child growth outcome assessors not described.

Reliability of primary outcome measurementsLow riskInformation about anthropometrical procedures and instruments used was provided.

Multicountry study 1996

MethodsFour country RCT.


ParticipantsChildren aged 4 to 7 months.


InterventionsExp (n = 214 children): a cereal based precooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation. Per 100 g of dry porridge the supplemental food provided: 410 kcal, 9 g of protein, 10 g of lipids, and 67 g of carbohydrates. It also contained micronutrients, vitamins and minerals. The packets were delivered at home twice daily for 3 months by a fieldworker who monitored its consumption. Introduction was progressive, 25 g dry supplement in 75 ml water per meal, i.e.103 kcal in 100 g from 4 to 5 months and 50 g supplement and 135 ml water per meal, i.e. 205 kcal in 185 g from 5 to 7 months. No food was given for other family members.

Controls (n = 233): no supplementation.


OutcomesWeight and length at the end of the intervention, and 4 to 7 months weight and length increments.


NotesThe authors reported the results of the four included countries separately.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskRandomisation was done after inclusion of each child by drawing lots. No further information was provided.

Allocation concealment (selection bias)Unclear riskThe method of allocation concealment was not reported.

Incomplete outcome data (attrition bias)
All outcomes
High riskPercentages of excluded children were higher than 20% in many of the study groups during three months of intervention. Reasons for exclusions were: death, illness, refusals and absences.

-Bolivia: 24% (control) and 16% (intervention).

-Congo: 11% (control) and 32% (intervention).

-New Caledonia: 11% (control) and 31% (intervention).

-Senegal: 16% (control) and 20% (intervention).

Selective reporting (reporting bias)Low riskThe study published results with lack of clinical importance or lack of statistical significance.

Blinding of participants and personnel (performance bias)
All outcomes
Unclear riskBlinding of participants and personnel not described.

Blinding of outcome assessment (detection bias)
All outcomes
High riskOutcome assessors were not blinded.

Reliability of primary outcome measurementsHigh riskReliability of personnel in charge of taken anthropometric measurement among study sites was not assessed. This is judged as inadequate training of outcome assessors.

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Bangladesh 1992The intervention is an energy-dense supplementary food together with nutritional education versus 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 months with a MUAC between 110 and 129 mm.
Intervention: 450 g of premixed 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 five years of age received an additional packet to compensate for the effect of food sharing.
Outcomes: mean monthly weight gain.

Brazil 200739% of children aged more than 60 months of age at the start of the study.

Method: cluster-randomised controlled trial. The control and intervention groups were defined by drawing lots to choose schools that had previously been paired for nutritional status based on the mean z-score for H-F-A. No further information was provided.

Participants: 1464 children aged more than 12 months and attending 24 preschools in the suburban neighbourhoods of the city of Pelotas, Brazil.

Intervention: multi-mixture supplementation (12 school, 549 children) versus no supplementation (12 schools, 526 children). 10 g of daily multi-mixture added to the food provided by the school from Monday to Friday for 6 months. The multi-mixture was made up of 30% rice bran, 30% wheat bran, 10% wheat flour, 15% corn flour, 5% powdered cassava leaves, 5% powdered egg shells and 5% powdered pumpkin or sunflower seeds.

Outcomes: mean W-F-A, H-F-A, W-F-H z-scores after 6 months of supplementation.

24% of children excluded in the intervention group (21% lost during follow-up and 3% lost during analysis).

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 months.
Intervention: food supplementation vs no 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 months.
Outcomes: prevalence of malnutrition, physical growth and child morbidity during the first 3 year of life.

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 12 mo.
Outcomes: weight (kg), height (cm), skinfolds (mm), HC (cm), MUAC (cm).

Haiti 2008This cluster-randomised trial aimed to compare the effect on child growth of a preventive and a recuperative approach of targeting food assistance. The study compared two different models of targeting food assistance to children: the traditional (recuperative model) that provides food assistance for 9 months which to underweight children (W-F-A z-scores <–2) aged 6–59 months; and the preventive model which targets all children aged 6–23 months and provides them food assistance up to 18 months.

Method: 20 clusters of communities were selected for the evaluation from programme areas in Central Plateau, Haiti. For each pair of matched clusters the group assignment was determined by drawing lots. The first cluster drawn from the pair was assigned to the preventive group and the one remaining was assigned to the recuperative group.

Participants: all children aged 6–23 months (preventive model) and underweight (W-F-A z-score <–2) children aged 6–60 months (recuperative model). Both models also targeted pregnant and lactating women up to 6 months postpartum.

Intervention: a packet of interventions was offered to all community members, including prenatal and postnatal consultations, health education, growth monitoring, services for preventive maternal and child health and nutrition, immunisation, vitamin A supplementation, the provision of oral rehydration salts and anthelmintic drugs, and home visits for newborn infants or severely undernourished children. Monthly food ration targeted only to pregnant and lactating women (up to 6 months postpartum) and to children 0-59 months of age identified as underweight (W-F-A z-scores <–2). The monthly food ration for pregnant and lactating women consists of 5 kg of soy-fortified bulgur, 1·5 kg of vegetable oil, and 2 kg of lentils, and an indirect (family) ration of 5 kg of wheat-soy blend, 1·5 kg of oil, and 2 kg of lentils. The monthly food ration for children consists of 8 kg of micronutrient-fortified wheat soy blend and 2 kg of oil, and an indirect ration intended for general household consumption of 10 kg of wheat-soy blend and 2·5 kg of lentils. Food assistance was conditional on monthly participation in the rally posts and mothers’ clubs.

Outcomes: mean z-scores for H-F-A, W-F-A, and W-F-H, and the prevalence of childhood stunting, underweight and wasting.

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 months.
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) versus 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) versus 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 was conducted in a random selection of 205 of the 320 intervention communities 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 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.

 
Comparison 1. Energy-protein supplementation versus no supplementation in stunted children after 12 months

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

 1 Weight (kg) at the end of the intervention165Mean Difference (IV, Fixed, 95% CI)0.29 [-0.29, 0.87]

 2 Length (cm) at the end of the intervention165Mean Difference (IV, Fixed, 95% CI)1.30 [0.03, 2.57]

 3 Weight-for-length z-score at the end of the intervention165Mean Difference (IV, Fixed, 95% CI)0.0 [-0.39, 0.39]

 4 Head circumference (cm) at the end of the intervention165Mean Difference (IV, Fixed, 95% CI)0.40 [-0.21, 1.01]

 5 Mid-upper-arm circumference (cm) at the end of the intervention165Mean Difference (IV, Fixed, 95% CI)0.20 [-0.29, 0.69]

 6 Triceps skinfold thickness (mm) at the end of the intervention165Mean Difference (IV, Fixed, 95% CI)0.20 [-0.51, 0.91]

 7 Subscapular skinfold thickness (mm) at the end of the intervention165Mean Difference (IV, Fixed, 95% CI)0.20 [-0.34, 0.74]

 
Comparison 2. High energy and protein supplementation versus low-energy, low protein supplementation in stunted or wasted children after 12 months

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

 1 Weight (kg) at the end of the intervention175Mean Difference (IV, Fixed, 95% CI)0.16 [-0.27, 0.59]

 2 Height/length (cm) at the end of the intervention175Mean Difference (IV, Fixed, 95% CI)-0.10 [-1.61, 1.41]

 3 Head circumference (cm) at the end of the intervention175Mean Difference (IV, Fixed, 95% CI)0.19 [-0.41, 0.79]

 4 Arm circumference (cm) at the end of the intervention175Mean Difference (IV, Fixed, 95% CI)0.10 [-0.22, 0.42]

 
Comparison 3. Energy-protein supplementation versus no supplementation in poor children after three months

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

 1 Weight z-scores at the end of the intervention1113Mean Difference (IV, Fixed, 95% CI)0.19 [-0.18, 0.56]

 2 Height z-scores at the end of the intervention1113Mean Difference (IV, Fixed, 95% CI)0.12 [-0.31, 0.55]

 
Comparison 4. Multi-mixture versus no supplementation in poor children after 10 months

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

 1 Weight-for-age z-score at the end of the intervention1108Mean Difference (IV, Fixed, 95% CI)-0.21 [-0.64, 0.22]

 2 Height-for-age z-score at the end of the intervention1108Mean Difference (IV, Fixed, 95% CI)-0.36 [-0.86, 0.14]

 3 Weight-for-height z-score at the end of the intervention1108Mean Difference (IV, Fixed, 95% CI)-0.02 [-0.39, 0.35]

 
Comparison 5. Yogurt supplementation versus no supplementation in nutritionally-at-risk children after nine months

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

 1 Weight gain (kg) during the intervention1348Mean Difference (IV, Fixed, 95% CI)0.22 [0.07, 0.37]

 2 Height gain (cm) during the intervention1348Mean Difference (IV, Fixed, 95% CI)0.19 [0.04, 0.34]

 3 MUAC (cm) at the end of the intervention1348Mean Difference (IV, Fixed, 95% CI)-0.08 [-0.31, 0.15]

 4 Change in weight-for-age z-score during the intervention1348Mean Difference (IV, Fixed, 95% CI)0.12 [0.05, 0.19]

 5 Change in height-for-age z-score during the intervention1348Mean Difference (IV, Fixed, 95% CI)0.05 [0.01, 0.08]

 
Comparison 6. Multi-mixture versus placebo in nutritionally-at-risk children after two months

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

 1 Weight-for-age z-score at the end of the intervention187Mean Difference (IV, Fixed, 95% CI)-0.16 [-0.60, 0.29]

 2 Height-for-age z-score at the end of the intervention187Mean Difference (IV, Fixed, 95% CI)0.23 [-0.15, 0.61]

 3 Weight-for-height z-score at the end of the intervention187Mean Difference (IV, Fixed, 95% CI)-0.33 [-0.77, 0.12]

 
Comparison 7. Energy-protein supplementation versus no supplementation in poor Bolivian children after three months

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

 1 Weight (kg) at the end of the intervention1127Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.29, 0.23]

 2 Length (cm) at the end of the intervention1127Mean Difference (IV, Fixed, 95% CI)0.52 [-0.15, 1.19]

 3 Weight gain (kg) during the intervention1127Mean Difference (IV, Fixed, 95% CI)0.05 [-0.07, 0.17]

 4 Length gain (cm) during the intervention1127Mean Difference (IV, Fixed, 95% CI)0.25 [-0.05, 0.55]

 
Comparison 8. Energy-protein supplementation versus no supplementation in poor Caledonian children after three months

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

 1 Weight (kg) at the end of the intervention190Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.41, 0.39]

 2 Length (cm) at the end of the intervention190Mean Difference (IV, Fixed, 95% CI)0.56 [-0.38, 1.50]

 3 Weight gain (kg) during the intervention190Mean Difference (IV, Fixed, 95% CI)-0.08 [-0.25, 0.09]

 4 Length gain (cm) during the intervention190Mean Difference (IV, Fixed, 95% CI)0.05 [-0.50, 0.60]

 
Comparison 9. Energy-protein supplementation versus no supplementation in poor Congolese children after three months

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

 1 Weight (kg)1120Mean Difference (IV, Fixed, 95% CI)-0.37 [-0.73, -0.01]

 2 Length (cm)1120Mean Difference (IV, Fixed, 95% CI)-0.45 [-1.36, 0.46]

 3 Weight gain (kg)1120Mean Difference (IV, Fixed, 95% CI)-0.12 [-0.29, 0.05]

 4 Length gain (cm)1120Mean Difference (IV, Fixed, 95% CI)-0.15 [-0.54, 0.24]

 
Comparison 10. Energy-protein supplementation versus no supplementation in poor Senegalese children after three months

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

 1 Weight (kg) at the end of the intervention1110Mean Difference (IV, Fixed, 95% CI)0.03 [-0.30, 0.36]

 2 Length (cm) at the end of the intervention1110Mean Difference (IV, Fixed, 95% CI)-0.12 [-1.08, 0.84]

 3 Weight gain (kg) during the intervention1110Mean Difference (IV, Fixed, 95% CI)0.05 [-0.14, 0.24]

 4 Length gain (cm) during the intervention1110Mean Difference (IV, Fixed, 95% CI)0.48 [0.07, 0.89]

 
Comparison 11. Energy-protein supplementation versus no supplementation in children from four countries after three months

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

 1 Weight (kg) at the end of the intervention1447Mean Difference (IV, Fixed, 95% CI)-0.08 [-0.24, 0.08]

 2 Length (cm) at the end of the intervention1447Mean Difference (IV, Fixed, 95% CI)0.20 [-0.22, 0.62]

 3 Weight gain (kg) during the intervention1447Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.09, 0.07]

 4 Length gain (cm) during the intervention1447Mean Difference (IV, Fixed, 95% CI)0.18 [-0.01, 0.37]

 
Comparison 12. Supplementary feeding by age of children

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

 1 Weight (kg) at the end of the intervention3587Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.17, 0.12]

    1.1 Children younger than 24 months
3587Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.17, 0.12]

 2 Length/height (cm) at the end of the intervention3587Mean Difference (IV, Fixed, 95% CI)0.28 [-0.11, 0.67]

    2.1 Children younger than 24 months
3587Mean Difference (IV, Fixed, 95% CI)0.28 [-0.11, 0.67]

 3 Weight (kg) gain during the intervention2795Mean Difference (IV, Fixed, 95% CI)0.04 [-0.03, 0.11]

    3.1 Children younger than 24 months
1447Mean Difference (IV, Fixed, 95% CI)-0.01 [-0.09, 0.07]

    3.2 Children older than 24 months
1348Mean Difference (IV, Fixed, 95% CI)0.22 [0.07, 0.37]

 4 Length/height (cm) gain during the intervention2795Mean Difference (IV, Fixed, 95% CI)0.19 [0.07, 0.31]

    4.1 Children younger than 24 months
1447Mean Difference (IV, Fixed, 95% CI)0.18 [-0.01, 0.37]

    4.2 Children older than 24 months
1348Mean Difference (IV, Fixed, 95% CI)0.19 [0.04, 0.34]

 5 Weight-for-age z-score at the end of the intervention2195Mean Difference (IV, Fixed, 95% CI)-0.18 [-0.49, 0.12]

    5.1 Other age range (6 months to 6 years)
2195Mean Difference (IV, Fixed, 95% CI)-0.18 [-0.49, 0.12]

 6 Length/height-for-age z-score at the end of he intervention2195Mean Difference (IV, Fixed, 95% CI)0.02 [-0.29, 0.32]

    6.1 Other age range (6 months to 6 years)
2195Mean Difference (IV, Fixed, 95% CI)0.02 [-0.29, 0.32]

 7 Weight-for-length/height z-score at the end of the intervention3260Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.33, 0.13]

    7.1 Children younger than 24 months
165Mean Difference (IV, Fixed, 95% CI)0.0 [-0.39, 0.39]

    7.2 Other age range (6 months to 6 years)
2195Mean Difference (IV, Fixed, 95% CI)-0.15 [-0.43, 0.14]

 8 Change in weight-for-age z-score during the intervention1348Mean Difference (IV, Fixed, 95% CI)0.12 [0.05, 0.19]

    8.1 Children older 24 months
1348Mean Difference (IV, Fixed, 95% CI)0.12 [0.05, 0.19]

 9 Change in height-for-age z-score1348Mean Difference (IV, Fixed, 95% CI)0.05 [0.01, 0.08]

    9.1 Children older than 24 months
1348Mean Difference (IV, Fixed, 95% CI)0.05 [0.01, 0.08]

 
Comparison 13. Supplementary feeding by nutritional status of children

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

 1 Weight (kg) at the end of the intervention3587Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.17, 0.12]

    1.1 Stunted/wasted children
2140Mean Difference (IV, Fixed, 95% CI)0.21 [-0.14, 0.55]

    1.2 Non stunted/wasted children
1447Mean Difference (IV, Fixed, 95% CI)-0.08 [-0.24, 0.08]

 2 Length/height (cm) at the end of the intervention3587Mean Difference (IV, Fixed, 95% CI)0.28 [-0.11, 0.67]

    2.1 Stunted/wasted children
2140Mean Difference (IV, Fixed, 95% CI)0.72 [-0.25, 1.69]

    2.2 Non stunted/wasted children
1447Mean Difference (IV, Fixed, 95% CI)0.20 [-0.22, 0.62]

 3 Weight-for-length/height z-score at the end of the intervention3260Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.33, 0.13]

    3.1 Stunted/wasted children
165Mean Difference (IV, Fixed, 95% CI)0.0 [-0.39, 0.39]

    3.2 Non stunted/wasted children
2195Mean Difference (IV, Fixed, 95% CI)-0.15 [-0.43, 0.14]

 
Comparison 14. Supplementary feeding by duration of the intervention

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

 1 Weight (kg) at the end of the intervention3587Mean Difference (IV, Fixed, 95% CI)-0.03 [-0.17, 0.12]

    1.1 Supplementary feeding less than 12 months
2512Mean Difference (IV, Fixed, 95% CI)-0.05 [-0.21, 0.10]

    1.2 Supplementary feeding equal or longer than12 months
175Mean Difference (IV, Fixed, 95% CI)0.16 [-0.27, 0.59]

 2 Length/height (cm) at the end of the intervention3587Mean Difference (IV, Fixed, 95% CI)0.28 [-0.11, 0.67]

    2.1 Supplementary feeding less than 12 months
2512Mean Difference (IV, Fixed, 95% CI)0.31 [-0.09, 0.71]

    2.2 Supplementary feeding equal or longer than 12 months
175Mean Difference (IV, Fixed, 95% CI)-0.10 [-1.61, 1.41]

 3 Weight gain (kg) during the intervention2795Mean Difference (IV, Fixed, 95% CI)0.04 [-0.03, 0.11]

    3.1 Supplementary feeding less than 12 months
2795Mean Difference (IV, Fixed, 95% CI)0.04 [-0.03, 0.11]

 4 Length/height gain (cm) during the intervention2795Mean Difference (IV, Fixed, 95% CI)0.19 [0.07, 0.31]

    4.1 Supplementary feeding less than 12 months
2795Mean Difference (IV, Fixed, 95% CI)0.19 [0.07, 0.31]

 5 Weight-for-age z-score at the end of the intervention2195Mean Difference (IV, Fixed, 95% CI)-0.18 [-0.49, 0.12]

    5.1 Supplementary feeding less than 12 months
2195Mean Difference (IV, Fixed, 95% CI)-0.18 [-0.49, 0.12]

 6 Length/height-for-age z-score at the end of the intervention2195Mean Difference (IV, Fixed, 95% CI)0.02 [-0.29, 0.32]

    6.1 Supplementary feeding less than 12 months
2195Mean Difference (IV, Fixed, 95% CI)0.02 [-0.29, 0.32]

 7 Weight-for-length/height z-score at the end of the intervention3260Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.33, 0.13]

    7.1 Supplementary feeding less than 12 months
3260Mean Difference (IV, Fixed, 95% CI)-0.10 [-0.33, 0.13]

 8 Change of weight-for-age z-score during the intervention1348Mean Difference (IV, Fixed, 95% CI)0.12 [0.05, 0.19]

    8.1 Supplementary feeding less than 12 months
1348Mean Difference (IV, Fixed, 95% CI)0.12 [0.05, 0.19]

 9 Change in height-for-age z-score during the intervention1348Mean Difference (IV, Fixed, 95% CI)0.05 [0.01, 0.08]

    9.1 Supplementary feeding less than 12 months
1348Mean Difference (IV, Fixed, 95% CI)0.05 [0.01, 0.08]

 
Summary of findings for the main comparison. Supplementary feeding compared to no food supplementation or low-protein/kcalories supplementation for children aged less than 24 months in low and middle income countries (LMIC)

Patient or population: Children aged less than 24 months
Settings: Bolivia, New Caledonia, Congo, Jamaica, Indonesia, Senegal
Intervention: Supplementary feeding
Comparison: No food supplementation or low-protein/kcalories supplementation

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementation or low-protein/kcalories supplementationSupplementary feeding

Weight (kg) at the end of the intervention
Weight scale
Follow-up: 3-12 months
The mean weight (kg) at the end of the intervention in the intervention groups was
0.03 lower
(0.21 lower to 0.15 higher)1
460
(3 studies2)
⊕⊕⊝⊝
low,3,4,5

Lenght/height (cm) at the end of the intervention
Measurement board
Follow-up: 3-12 months
The mean lenght/height (cm) at the end of the intervention in the intervention groups was
0.16 higher
(0.31 lower to 0.63 higher)6
460
(3 studies2)
⊕⊕⊝⊝
low3,4,5

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1The IC (-0.21 to 0.15) crosses the line of no effect.
2 A four country RCT reported results separately for Bolivia, Caledonia, Congo and Senegal.
3The allocation concealment was not described in any of these studies.
4Bias related to blinding of growth outcome assessment was unclear in two studies and high in the four country RCT.
5 Incomplete outcome data was not clearly reported in one study but it was high (i.e., equal to or more than 20% in any of the study groups) in all countries participating in the multicentre RCT.
6The IC (-0.31 to 0.63) crosses the line of no effect.
 
Summary of findings 2. Supplementary feeding compared to no food supplementation or placebo for children aged less than five years in LMIC

Patient or population: Children aged less than five years in LMIC
Settings: Bolivia, Brazil, Caledonia, China, Congo, Indonesia, Jamaica, Senegal
Intervention: Supplementary feeding
Comparison: No food supplementation

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementationSupplementary feeding

Weight gain (kg) during the intervention
Weight scale
Follow-up: 3-9 months
The mean weight gain (kg) during the intervention in the intervention groups was
0.03 higher
(0.05 lower to 0.11 higher)1
668
(2 studies2)
⊕⊝⊝⊝
very low3,4,5,6

Length/height gain (cm) at the end of the intervention
Measurement board
Follow-up: 3-9 months
The mean length/height gain (cm) at the end of the intervention in the intervention groups was
0.19 higher
(0.07 to 0.31 higher)
795
(2 studies2)
⊕⊝⊝⊝
very low3,4, 5,6

Weight-for-age z-score at the end of the intervention
Weight scale and child growth reference
Follow-up: 2-12 months
The mean weight-for-age z-score at the end of the intervention in the intervention groups was
0.03 lower
(0.27 lower to 0.21 higher)7
308
(3 studies)
⊕⊕⊕⊝
moderate

3,8,9

Lenght/height-for-age z-score at the end of the intervention
Measurement board and child growth reference
Follow-up: 2-12 months
The mean lenght/height-for-age z-score at the end of the intervention in the intervention groups was
0.05 higher
(0.2 lower to 0.3 higher)10
308
(3 studies)
⊕⊕⊝⊝
low3,8,9

Weight-for-length/height z-score at the end of the intervention
Weight scale, measurement boards and child growth reference
Follow-up: 2-12 months
The mean weight-for-length/height z-score at the end of the intervention in the intervention groups was
0.10 lower
(0.33 lower to 0.13 higher)11
260
(3 studies)
⊕⊕⊕⊝
moderate3,8

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 The CI (-0.05 to 0.11) crosses the line of no effect.
2 A four country RCT reported results separately for Bolivia, Caledonia, Congo and Senegal.
3 The allocation concealment was not described in any of these studies.
4 Blinding of outcome assessors was not clear in the Chinese study. Outcome assessors were not blinded to treatment allocation in the four country RCT.
5 Incomplete outcome data was not clearly reported in one study but it was high (i.e., equal to or more than 20% in any of the study groups) in the four country RCT.
6 The random generation sequence was not reported in the Chinese study.
7 The CI (-0.27 to 0.21) crosses the line of no effect.
8 Bias related to blinding of growth outcome assessment was unclear in two studies.
9 Incomplete outcome data was not clearly reported in the Indonesian study.
10The CI (-0.20 to 0.30) crosses the line of no effect.
11The CI (-0.33 to 0.13) crosses the line of no effect.
 
Summary of findings 3. Supplementary feeding compared to no food supplementation for children older than 24 months in LMIC

Patient or population: Children older than 24 months
Settings: China
Intervention: Supplementary feeding
Comparison: No food supplementation

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementationSupplementary feeding

Change in weight-for-age z-score during the intervention
Weight scale and and child growth reference
Follow-up: 10 months
The mean change in weight-for-age z-score during the intervention in the intervention groups was
0.12 higher
(0.05 to 0.19 higher)
348
(1 study)
⊕⊕⊝⊝
low1,2,3

Change in length/height z-score during the intevention
Measurement board and child growth reference
Follow-up: 10 months
The mean change in length/height z-score during the intevention in the intervention groups was
0.05 higher
(0.01 to 0.08 higher)
348
(1 study)
⊕⊕⊝⊝
low1,2,3

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 The random generation sequence and the allocation concealment were not described.
2 Bias related to blinding of growth outcome assessment was unclear.
3 Incomplete outcome data was not clearly reported.
 
Summary of findings 4. Supplementary feeding compared to no food supplementation or low-protein/kcalories supplementation for children aged less than five years with or without stunting or wasting in LMIC

Patient or population: Children aged less than five years with or without stunting or wasting
Settings: Bolivia, Caledonia, Congo, Jamaica1, Indonesia2, Senegal
Intervention: Supplementary feeding
Comparison: No food supplementation or low-protein/kcalories supplementation

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementation or low-protein/kcalories supplementationSupplementary feeding

Weight (kg) at the end of the intervention
Weight scale
Follow-up: 3-12 months
The mean weight (kg) at the end of the intervention in the intervention groups was
0.03 lower
(0.21 lower to 0.15 higher)3
460
(3 studies4)
⊕⊕⊝⊝
low5,6,7,8

Length/height (cm) at the end of the intervention
Measurement board
Follow-up: 3-12 months
The mean length/height (cm) at the end of the intervention in the intervention groups was
0.16 higher
(0.31 lower to 0.63 higher)9
460
(3 studies4)
⊕⊕⊝⊝
low5,6,7,8

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Children with height-for-age below -2 SD of the median of the NSCH/WHO reference values.
2 Children with length-for-age below -1SD and weight-for-length between -1 and -2 SD of the median of the NSCH/WHO reference values.
3 The CI (-0.21 to 0.15) crosses the line of no effect.
4 A four country RCT reported results separately for Bolivia, Caledonia, Congo and Senegal.
5 Information about the random sequence generation was not reported in two studies.
6 The allocation concealment was not described in any of these studies.
7 Bias related to blinding of growth outcome assessment was unclear in two studies and high in the four country RCT.
8 Incomplete outcome data was not clearly reported in one study but it was high (i.e., equal to or more than 20% in any of the study groups) in the four country RCT.
9 The CI (-0.31 to 0.63) crosses the line of no effect.
 
Summary of findings 5. Supplementary feeding compared to no food supplementation or placebo for children aged less than five years with or without stunting or wasting in LMIC

Patient or population: Children aged less than five years with or without stunting/wasting in LMIC
Settings: Brazil, Jamaica1
Intervention: Supplementary feeding
Comparison: No food supplementation or placebo

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementation or placeboSupplementary feeding

Weight-for-length/height z-score at the end of the intervention
Weight scale and measurement board
Follow-up: 2-12 months
The mean weight-for-length/height z-score at the end of the intervention in the intervention groups was
0.10 lower
(0.33 lower to 0.13 higher)2
260
(3 studies)
⊕⊕⊕⊝
moderate3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Children with height-for-age below -2 SD of the median of the NSCH/WHO reference values.
2 The CI (-0.33 to 0.13) crosses the line of no effect.
3 The allocation concealment was not described in any of these studies.
4Bias related to blinding of growth outcome assessment was unclear in two studies.
 
Summary of findings 6. Supplementary feeding compared to no food supplementation or low-protein/kcalories supplementation for ≤ 12 months in children aged less than five years in LMIC

Patient or population: Children aged less than five years in LMIC
Settings: Bolivia, Caledonie, China, Congo, Jamaica, Indonesia, Senegal
Intervention: Supplementary feeding1
Comparison: No food supplementation or low-protein/kcalories supplementation

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementation or low-protein/kcalories supplementationSupplementary feeding

Weight (kg) at the end of the intervention
Weight scale
Follow-up: 3-12 months
The mean weight (kg) at the end of the intervention in the intervention groups was
0.16 higher
(0.17 lower to 0.59 higher)2
587
(3 studies3)
⊕⊕⊝⊝
low4,5,6,7

Length/height (cm) at the end of the intervention
Measurement board
Follow-up: 3-12 months
The mean length/height (cm) at the end of the intervention in the intervention groups was
0.28 higher
(0.11 lower to 0.67 higher)8
587
(3 studies3)
⊕⊕⊝⊝
low4,5,6,7

Weight gain (kg) during the intervention
Weight scale
Follow-up: 3-9 months
The mean weight gain (kg) during the intervention in the intervention groups was
0.04 higher
(0.03 lower to 0.11 higher)9
795
(2 studies3)
⊕⊝⊝⊝
very

low4,5, 6,10

Length/height gain (cm) at the end of the intervention
Measurement board
Follow-up: 3-9 months
The mean length/height gain (cm) at the end of the intervention in the intervention groups was
0.19 higher
(0.07 to 0.31 higher)
795
(2 studies3)
⊕⊝⊝⊝
very low4,5,6

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 The duration of the intervention was ≤ 12 months.
2 The CI (-0.17 to 0.59) crosses the line of no effect.
3 A four-country RCT reported results separately for Bolivia, Caledonia, Congo and Senegal.
4 Information about the random sequence generation was not reported in three studies.
5 The allocation concealment was not described in any of these studies.
6 Bias related to blinding of growth outcome assessment was unclear in three studies and high in the four country RCT.
7 Incomplete outcome data was not clearly reported in one study but it was high (i.e., equal to or more than 20% in any of the study groups) in the four country RCT.
8 The CI (-0.11 to 0.67) crosses the line of no effect.
9 The CI (-0.03 to 0.11) crosses the line of no effect.
 
Summary of findings 7. Supplementary feeding compared to no food supplementation or placebo for ≤ 12 months in children aged less than five years in LMIC

Patient or population: Children aged less than five years in LMIC
Settings: Brazil, Indonesia, Jamaica
Intervention: Supplementary feeding1
Comparison: No food supplementation

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementationSupplementary feeding for less than 12 months

Weight-for-age z-score at the end of the intervention
Weight scale and child growth reference
Follow-up: 2-12 months
The mean weight-for-age z-score at the end of the intervention in the intervention groups was
0.03 lower
(0.27 lower to 0.21 higher)2
308
(3 studies)
⊕⊕⊕⊝
moderate3,4,5

Length/height-for-age z-score at the end of the intervention
Measurement board and child growth reference
Follow-up: 2-12 months
The mean length/height-for-age z-score at the end of the intervention in the intervention groups was
0.05 higher
(0.2 lower to 0.3 higher)6
308
(3 studies)
⊕⊕⊝⊝
low3,4,5

Weight-for-length/height z-score at the end of the intervention
Weight scale, measurement boards and child growth reference
Follow-up: 2-12 months
The mean weight-for-length/height z-score in the intervention groups was
0.10 lower
(0.33 lower to 0.13 higher)7
260
(3 studies)
⊕⊕⊕⊝
moderate3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 The duration of the intervention was less than 12 months.
2 The CI (-0.27 to 0.21) crosses the line of no effect.
3 The allocation concealment was not described in any of these studies.
4 Bias related to blinding of growth outcome assessment was unclear in most of two studies.
5 Incomplete outcome data was not clearly reported in the Indonesian study.
6 The CI (-0.20 to 0.30) crosses the line of no effect.
7The CI (-0.33 to 0.13) crosses the line of no effect.
 
Summary of findings 8. Supplementary feeding compared to no food supplementation for ≤ 12 months in children aged less than five years in LMIC

Patient or population: Children aged less than five years in LMIC
Settings: China
Intervention: Supplementary feeding1
Comparison: No food supplementation

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of Participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

No food supplementationSupplementary feeding

Change in weight-for-age z-core during the intervention
Weight scale and and child growth reference
Follow-up: 10 months
The mean change in weight-for-age z-core during the intervention in the intervention groups was
0.12 higher
(0.05 to 0.19 higher)
348
(1 study)
⊕⊕⊝⊝
low2,3,4

Change in length/height z-score during the intervention
Measurement board and child growth reference
Follow-up: 10 months
The mean change in length/height z-score during the intervention in the intervention groups was
0.05 higher
(0.01 to 0.08 higher)
348
(1 study)
⊕⊕⊝⊝
low2,3,4

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 The duration of the intervention was ≤ 12 months.
2 The random generation sequence and the allocation concealment were not described.
3 Bias related to blinding of growth outcome assessment was unclear.
4 Incomplete outcome data was not clearly reported.
 
Table 1. Baseline characteristics of included studies (n = 8)

Country/regionYear

of

 publication
Target age

of children
Type of

delivery
Type of foodTarget ration

Exp                                 Control
Duration of the interventionOutcome

measures








Indonesia/West Java19916-20 monthsFeeding centreTwo snack foods (including, rice, rice flour, wheat flour, bread, cassava, potatoes, sweet potatoes, coconut milk, refined sugar, brown sugar, and oil)400 kcal and 5 g proteins per day (daily average estimate)No snack3 monthsWeight and height z-scores at the end of intervention.

 









Jamaica/Kingston19919-24 months (stunting)Take home supplementary food1 kg milk-based formula. In addition,

1 kg each of skimmed milk powder and cornmeal were provided were provided to other household members.
525 kcal and 14 g proteins/100 g of milk No milk supplementation12 monthsLength (cm), weight (kg), HC (cm), MUAC (cm), TSF (mm), SSF (mm), W-F-L z- score at the end of intervention.









Guatemala/El Progreso1995Birth-7 yearsFeeding centreLiquid supplement

consumed daily on a voluntary basis.
Atole: 90.5 kcal and 63.5 g proteins/100 ml

 
Fresco: 33 kcal/100 ml    N/ALength (cm), weight (kg) before and after the beginning of the study.









Bolivia/Pasankeri, La Paz [1]

 

 
19964-7 monthsTake home supplementary foodCereal based precooked porridge enriched with vitamins & minerals to be mixed with boiled water for hygienic preparation. Per 100 g of dry porridge the supplemental food provided: 410 kcal, 9 g of proteins, 10 g of lipids, and 67 g of carbohydrates

[2]
No food

supplementation
3 monthsWeight (kg), length (cm) at the end of intervention and weight (kg) and length (cm) gain during the intervention.









Congo/Mikalou, Brazzaville [1]

 
19964-7 monthsTake home supplementary foodCereal based pre-cooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation.Per 100 g of dry porridge the supplemental food provided: 410 kcal, 9 g of proteins, 10 g of lipids, and 67 g of carbohydrates [2]No food

supplementation
3 monthsWeight (kg), length (cm) at the end of intervention and weight (kg) and length (cm) gain during the intervention.









New Caledonia/Island of Mare [1]

 
19964-7 monthsTake home supplementary foodCereal based pre-cooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation.Per 100 g of dry porridge the supplemental food provided: 410 kcal, 9 g of proteins, 10 g of lipids, and 67 g of carbohydrates [2]No food

supplementation
3 monthsWeight (kg), length (cm) at the end of intervention and weight (kg) and length (cm) gain during the intervention.









Senegal [1]19964-7 monthsTake home supplementary foodCereal based pre-cooked porridge enriched with vitamins and minerals to be mixed with boiled water for hygienic preparation.Per 100 g of dry porridge the supplemental food provided: 410 kcal, 9 g of proteins, 10 g of lipids, and 67 g of carbohydrates [2]No food

supplementation
3 monthsWeight (kg), length (cm) at the end of intervention and weight (kg) and length (cm) gain during the intervention.









Indonesia/West Java200012 and 18 months (moderate stunting and wasting)Feeding centreCondensed milk500 kcal and 12 g of protein per day.

 
Skimmed milk12 monthsHeight (cm), weight (kg), HC (cm), MUAC (cm) at the end of intervention. 

China/Beijing20053-5 yearsFeeding centreYogurt (125 g per service)3.8 g protein per ration. Total amount of calories not reported.No yogurt9 months Weight gain (kg), height gain (cm), change of H-F-A, W-F-A z-score during the intervention and MUAC (cm) at the end of intervention. 

Brazil/Joao Pessoa, Paraiba20061-6 yearsFeeding centreMultimixture (wheat flour, cornmeal, melon seed powder, sesame, gourd, peanut, cassava leaf powder, eggshell )11,7 g proteins, 74,2 g of carbohydrate and 5,2 g of lipids per 100 g of preparation. No further information provided.Placebo: cassava flour

 
2 monthsW-F-A, H-F-A and W-F-H z-scores,  prevalence of underweight, stunting, wasting at the end intervention 

Brazil/Maceio, State of Alago20086-60 monthsTake home supplementary food2 soup spoons of multimixture per day (80% wheat flour, 10% cassava leaf powder, and 10% egg shells)No kcal or protein content (g) per ration reported.No multimixture10 monthsH-F-A, W-F-A and W-F-H z-score at the end of intervention. 

 Abbreviations: cm (centimetres), Exp (experimental), g (grams), H-F-A (height-for-age), kcal (kilocalories), kg (kilograms), ml (millilitres),  mm (millimetres), mo (months), MUAC (mid-upper arm circumference), N/A  (not available), W-F-A (weight-for -age), W-F-H (weight-for-height), W-F-L (weight-for-length), SSF (subscapular skin folder), TSF (tricipital skin folder).
[1] Simondon KB, Gartner A, Berger J, Cornu A, Massamba JP, San Miguel JL et al. Effect of early, short-term supplementation on weight and linear growth of 4-7-mo-old infants in developing countries: a four-country randomized trial. Effect of early, short-term supplementation on weight and linear growth of 4-7-mo-old infants in developing countries: a four-country randomized trial 1996;64 (4):537-45.
[2] Introduction was progressive, 25 g dry supplement in 75 ml water per meal, i.e.103 kcal in 100 g from 4 to 5 months and 50 g supplement and 135 ml water per meal, i.e. 205 kcal in 185 g from 5 to 7 months.
 
Table 2. Length [1] of three-year-old children before and after supplementation by village

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.