Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age

 

Abstract

Background

Vitamin and mineral deficiencies, particularly those of iron, vitamin A and zinc, affect more than two billion people worldwide. Young children are highly vulnerable because of rapid growth and inadequate dietary practices. Micronutrient powders (MNP) are single-dose packets containing multiple vitamins and minerals in powder form that can be sprinkled onto any semi-solid food.The use of MNP for home or point-of-use fortification of complementary foods has been proposed as an intervention for improving micronutrient intake in children under two years of age.

Objectives

To assess the effects and safety of home (point-of-use) fortification of foods with multiple micronutrient powders on nutritional, health and developmental outcomes in children under two years of age.

Search methods

We searched the following databases in February 2011: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (1948 to week 2 February 2011), EMBASE (1980 to Week 6 2011), CINAHL (1937 to current), CPCI-S (1990 to 19 February 2011), Science Citation Index (1970 to 19 February 2011), African Index Medicus (searched 23 February 2011), POPLINE (searched 21 February 2011), ClinicalTrials.gov (searched 23 February 2011), mRCT (searched 23 February 2011), and World Health Organization International Clinical Trials Registry Platform (ICTRP) (searched 23 February 2011). We also contacted relevant organisations (25 January 2011) for the identification of ongoing and unpublished studies.

Selection criteria

We included randomised and quasi-randomised trials with either individual or cluster randomisation. Participants were children under the age of two years at the time of intervention, with no specific health problems. The intervention was consumption of food fortified at the point of use with multiple micronutrient powders formulated with at least iron, zinc and vitamin A compared with placebo, no intervention or the use of iron containing supplements, which is the standard practice.

Data collection and analysis

Two review authors independently assessed the eligibility of studies against the inclusion criteria, extracted data from included studies and assessed the risk of bias of the included studies.

Main results

We included eight trials (3748 participants) conducted in low income countries in Asia, Africa and the Caribbean, where anaemia is a public health problem. The interventions lasted between two and 12 months and the powder formulations contained between five and 15 nutrients. Six trials compared the use of MNP versus no intervention or a placebo and the other two compared the use of MNP versus daily iron drops. Most of the included trials were assessed as at low risk of bias.

Home fortification with MNP reduced anaemia by 31% (six trials, RR 0.69; 95% CI 0.60 to 0.78) and iron deficiency by 51% (four trials, RR 0.49; 95% CI 0.35 to 0.67) in infants and young children when compared with no intervention or placebo, but we did not find an effect on growth.

In comparison with daily iron supplementation, the use of MNP produced similar results on anaemia (one trial, RR 0.89; 95% CI 0.58 to 1.39) and haemoglobin concentrations (two trials, MD -2.36 g/L; 95% CI -10.30 to 5.58); however, given the limited amount of data these results should be interpreted cautiously.

No deaths were reported in the trials and information on side effects and morbidity, including malaria, was scarce.

It seems that the use of MNP is efficacious among infants and young children six to 23 months of age living in settings with different prevalences of anaemia and malaria endemicity, regardless of whether the intervention lasts two, six or 12 months or whether recipients are male or female.

Authors' conclusions

Home fortification of foods with multiple micronutrient powders is an effective intervention to reduce anaemia and iron deficiency in children six months to 23 months of age. The provision of MNP is better than no intervention or placebo and possibly comparable to commonly used daily iron supplementation. The benefits of this intervention as a child survival strategy or on developmental outcomes are unclear. Data on effects on malaria outcomes are lacking and further investigation of morbidity outcomes is needed. The micronutrient powders containing multiple nutrients are well accepted but adherence is variable and in some cases comparable to that achieved in infants and young children receiving standard iron supplements as drops or syrups.

 

Plain language summary

Use of a powder mix of vitamins and minerals to fortify complementary foods immediately before consumption and improve health and nutrition in children under two years of age

Deficiencies of vitamins and minerals, particularly of iron, vitamin A and zinc, affect approximately half of the infants and young children under two years of age worldwide. Exclusive breastfeeding until six months of age and continued breastfeeding for at least two years are recommended to maintain children's adequate health and nutrition. After six months of age, infants start receiving semi-solid foods but the amount of vitamins and minerals can be insufficient to fulfil all the requirements of the growing baby. Micronutrient powders (MNP) are single-dose packets of powder containing iron, vitamin A, zinc and other vitamins and minerals that can be sprinkled onto any semi-solid food at home or at any other point of use to increase the content of essential nutrients in the infant's diet during this period. This is done without changing the usual baby diet.

This review includes eight good quality trials that involved 3748 infants and young children from low income countries in Asia, Africa and the Caribbean. We found that a variety of MNP formulations containing between five and 15 vitamins and minerals have been given for between two and 12 months to infants and young children aged six to 23 months of age.

The use of MNP containing at least iron, zinc and vitamin A for home fortification of foods was associated with a reduced risk of anaemia and iron deficiency in children under two. The studies did not find any effects on growth. Although the acceptability of this innovative intervention was high, there is no additional benefit to usually recommended iron drops or syrups, however few studies compared these different interventions. No deaths were reported in the trials and information on side effects and morbidity, including malaria, was scarce. The use of MNP was beneficial for male and female infants and young children six to 23 months of age, independent of whether they lived in settings with different anaemia and malaria backgrounds or whether the intervention was provided for two, six or 12 months. The most appropriate arrangements for use (daily or intermittently), the appropriate vitamin and mineral composition of the mix of powders and the way to deliver this intervention effectively in public health programmes to address multiple micronutrient deficiencies remain unclear.

 

摘要

強化家庭食品添加多種微量營養粉以促進2歲以下兒童的健康及營養

研究背景

維生素及礦物質不足，尤其是鐵、維生素A、鋅的不足，影響了全球20億以上人口。幼童的健康會因為成長快速以及不適當的飲食習慣而致使其極度脆弱。微量營養粉(MNP)是一種單劑量包裝粉末，內含多種維生素及礦物質，可以撒在任何半固體食物上面。添加MNP於家庭或終端食品(pointofuse)以強化補充食品，已被推薦用來改善2歲以下兒童的微量營養素的攝取。

研究目的

本回顧旨在評估家庭(終端)食品強化添加多種微量營養粉對於兩歲以下兒童的營養的、健康的與發展的結果的影響及安全性。

检索方法

我們在2011年2月搜尋以下資料庫：Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), MEDLINE (1948年到2011年2月第2週, EMBASE (1980年到2011年第6週), CINAHL (1937年迄今), CPCIS (1990年到2011年2月19日), Science Citation Index (1970年到2011年2月19日), African Index Medicus (搜尋2011年2月23日止), POPLINE (搜尋2011年2月21日止), ClinicalTrials.gov (搜尋2011年2月23日止), mRCT (搜尋2011年2月23日止)，以及 World Health Organization International Clinical Trials Registry Platform (ICTRP) (搜尋2011年2月23日止)。此外，我們亦聯繫相關機構(2011年1月25日)，以便確認正在進行以及未發表的研究。

纳入标准

我們納入單一或是群集隨機化的隨機及類隨機試驗。受試者定義，在介入時間當下，年齡為2歲以下、沒有特定健康問題的兒童。介入係指以多種微量營養粉的食品強化，至少含有鐵、鋅、維生素A的補充，對照組則是指安慰劑、無介入方案或是使用鐵劑補充等的標準作法。

数据收集与分析

兩位回顧作者依據納入條件對納入研究進行獨立評估、擷取資料，同時評估偏差的風險。

主要结果

我們納入8個試驗(3748名受試者)，這些試驗是在亞洲、非洲以及加勒比海(貧血是這些國家的公共健康問題)等低所得國家所進行的研究。介入持續2到12個月，至少包含5到15種營養素的營養粉。有6個試驗是比較MNP與無介入方案或安慰劑，另外2個試驗則是比較MNP與每天補充鐵滴劑。這些納入試驗大多處在低偏差的風險。在嬰兒以及幼童的表現，MNP強化家庭食品相較無介入方案或安慰劑組，降低31%的貧血發生(6個試驗，RR為0.69，95%信賴區間為0.60–0.78)，以及51%的鐵質不足(4個試驗，RR為0.49，95%信賴區間為0.35–0.67)，然而我們並沒有發現對成長的影響。與每天補充鐵劑比較，使用MNP在貧血(1個試驗，RR為0.89，95%信賴區間為0.58–1.39)及血紅素的濃度(2個試驗，平均差為−2.36 g/L，95%信賴區間為 −10.30～5.58)上有類似的結果，然而，在僅有這些有限的資料的情況下，應該小心解釋這些研究結果。這些試驗沒有報告死亡個案、副作用和罹病率，包括瘧疾，也很少見。證據似乎顯示，不論介入持續2個月、6個月或是12個月，或是性別的差異，這群居住於不同貧血以及瘧疾盛行區的6到23個月的嬰兒及幼童身上施以MNP是具有效益的。

作者结论

多種微量營養粉添加家庭食品強化在降低6到23個月兒童的貧血以及鐵質不足是具有效益的。給予MNP優於無介入方案或安慰劑組，且可比一般每日補充鐵劑。這個介入在評估兒童存活或是發展的結果上的好處是不明的。有關瘧疾影響的資料闕如，未來仍需要進行相關罹病率的研究。以粉末型式來補充多種微量營養素的方法是易於採行的，然而遵從性存在變異，在某些情況下好比給嬰兒和幼童滴劑或糖漿以補充標準的鐵劑。

 

概要

強化家庭食品添加多種微量營養粉以促進2歲以下兒童的健康及營養

在攝食前立即添加維他命和礦物質的混合粉劑來強化補充食品以改善2歲以下兒童的健康及營養：維生素及礦物質不足，尤其是鐵、維生素A、鋅的不足，影響全球大約一半2歲以下的嬰幼兒。純母乳餵養直到6個月大，建議持續以母乳餵養至少2年，以維護兒童足夠的健康和營養。6個月以後的嬰兒開始添加半固體食品，然而維生素及礦物質的量無法滿足成長中嬰兒的需求。微量營養粉(MNP)是一種單劑量包裝粉末，含有鐵、維生素A、鋅及其他多種維生素及礦物質，它可以撒在家庭或其他終端的(point of use)半固體食物上面，以增加這個時期的嬰兒基本的營養攝取。這樣並未改變平時嬰兒的飲食。本回顧納入8個品質佳的試驗，包含3748名嬰幼童，這些兒童都位處亞洲、非洲以及加勒比海等低所得國家。研究發現微量營養粉配方具有歧異，大約5到15種維生素及礦物質，給予2到12個月的嬰兒及6到23個月的幼童。MNP至少包含鐵、鋅及維生素A。2歲以下兒童的貧血及鐵質不足的風險降低與攝食添加的MNP食品有關。這些研究並未發現任何對成長的影響。雖然這種創新介入的接受度高，但與通常建議的鐵滴劑或糖漿劑比較，MNP沒有額外的好處，然而很少有研究比較這些不同的介入。這些試驗沒有死亡案例報告、副作用和罹病率，包括瘧疾，也很少見。不管是居住地點有不同的貧血和瘧疾的背景，或是介入時間為2個月、6個月或是12個月，使用MNP對男嬰和女嬰及6到23個月的幼童是有益的。在公共健康計畫裡探討多種微量營養素不足的議題，如最適當的給予方式（每日或間歇）、最佳的維生素與礦物質的混合配方、以及有效的配送方法，目前仍不清楚。

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