- Top of page
- Declaration of interest
This is a commentary on a Cochrane review, published in this issue of EBCH, first published as: De-Regil L, Suchdev PS, Vist GE, Walleser S, Pena-Rosas JP. Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database of Systematic Reviews 2011, Issue 9. Art. N.: CD008959. DOI: 10.1002/14651858.CD008959.pub2. Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration
Micronutrient deficiencies, particularly iron, vitamin A and zinc deficiencies, affect several million children world wide1. The final solution to this problem, as well as to other aspects of malnutrition and poor general health in low income countries, would probably be to tackle underlying determinants, such as poverty, poor education and water sanitation and hygiene, etc.2. This is however not easy to achieve. To prevent and treat micronutrient malnutrition, typical interventions include promotion of breastfeeding, nutritional education, provision of micronutrients as supplements (mostly iron, vitamin A and zinc) and fortification of food such as flour, sugar and oil.
Micronutrient powders (MNP), also called ‘sprinkles’, 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 micronutrients in the diet. ‘Sprinkles’ have been recently proposed based on the rationale that (1) multiple micronutrients deficiencies often occur together, and a strategy of delivering multiple micronutrients in one single product should facilitate supply, coverage and adherence; (2) the MNP sachets are simple to store, transport and distribute; (3) MNP are easy to produce at relatively low cost; (4) MNP do not affect the usual dietary practices; (5) MNP are easy to use even without literacy and (6) the potential for overdose is low3.
‘Sprinkles’ are largely implemented world wide but what evidence is there beyond their use? The review by De-Regil et al.3 shows that MNP are effective in reducing iron deficiency by 51% and anaemia by 31% (high and moderate quality evidence, respectively) whereas very little is known about the effect of MNP on other nutritional outcomes. Only one trial evaluated the effect of MNP on vitamin A (P. S. Suchdev et al., personal communication) and zinc status4, respectively.
This Cochrane review3 has been used by World health Organization (WHO) to produce a guideline for the member states, that is freely accessible through the electronic library of Evidence for Nutrition Actions (eLENA)5. On the basis of existing evidence, WHO recommends the use of MNP to improve iron status and to reduce anaemia (strong recommendation), but not as a strategy to improve vitamin A or zinc status5. Recently, two more trials6, 7 have been published on MNP, but yet with heterogeneous results on vitamin A and zinc status.
In addition, there are other open questions on MNP. First, there are safety concerns in providing iron in areas of high malaria transmission because iron may exacerbate malaria infection. Another Cochrane review found that providing iron supplementation to children does not increase the risk of clinical malaria in the presence of regular surveillance of malaria and appropriate treatment8. Unfortunately, trials on MNP were not informative because it was unclear in the reports whether malaria prevention and control programmes were in place3. Future trials on MNP should report on the malaria outcomes more specifically. At present it is recommended that in malaria-endemic areas, MNP should be implemented in conjunction with measures to prevent, diagnose and treat malaria5.
Second, there is a potential for negative interaction among different micronutrients—such as iron and zinc—possibly limiting their absorption and utilization. More generally, the best combination of compounds, optimal dose and optimal frequency of delivery is still unclear. There is a great variability in the formulation of MNP, producers, packaging, target age groups and distribution settings. Clearly, solutions should be tailored to the needs of individual contexts3 (P. S. Suchdev et al., personal communication).
Third and more importantly, adherence to MNP has been reported as extremely variable (from 32% to around 90%)3. Although few studies are underway9, there is still a need for operational research exploring effective distribution mechanisms. WHO recommends that programmes should include a behaviour change communication strategy that integrates MNP with other evidence-based interventions of the essential nutrition package (such as recommended practices on breastfeeding, complementary foods, hygiene, attention to fever in malaria settings and management of diarrhoea)5.