Special nutritious solutions to enhance complementary feeding

This special issue of Maternal & Child Nutrition brings together cutting edge research that addresses specific aspects of the composition, distribution and impact of special nutritious solutions to improve nutrient intake of young children, especially during the complementary feeding period. Most articles focus on nutritious commodities that were provided from 6- to 23- or 6- to 59-month-old children: lipid-based nutrient supplements (LNS, mainly small quantity, i.e. 20 g/day) (Abbeddou et al. 2015; Arimond et al. 2015; Flax et al. 2015; Ickes et al. 2015; Lesorogol et al. 2015; Mangani et al. 2015; Segrè et al. 2015; Thakwalakwa et al. 2015), micronutrient powder (MNP; Barth-Jaeggi et al. 2015; Jefferds & Flores-Ayala 2015; Jefferds et al. 2015; Osei et al. 2015) fortified complementary food (Bauserman et al. 2015; Chavasit et al. 2015; Mangani et al. 2015; Thakwalakwa et al. 2015 – the latter two studies compared it to LNS) and ready-to-use therapeutic food (RUTF) (Irena et al. 2015). The remaining papers assessed impact of fortified wheat flour among school-age children (Rahman et al. 2015), discussed issues around the inclusion of folic acid in MNP for home fortification where malaria is endemic (Kupka 2015) and interpreted data on indicators of iron status in the presence of infection (Nel et al. 2015). Complementary feeding refers to foods that are consumed in addition to breastfeeding, which should be practiced between 6 and 23 months of age, after exclusive breastfeeding for the first 6 months of life, and could still be continued after 24 months. During this period of life, nutrient needs are very high, due to rapid growth and development, and they may be further increased in case of frequent illness, such as diarrhoea and others. Exclusive breastfeeding is recommended for the first 6 months of life. Thereafter, breast milk in combination with nutrient stores that were present at birth (e.g. iron) cannot adequately meet the nutrient requirements of the child anymore. Meeting the additional nutrient needs from the complementary feeding diet is challenging, because the child's food intake is small compared with his or her nutrient needs. For example, the 6- to 11-month-old infant requires nine times as much iron from 100 kcal of food, compared with an adult male, because the adult consumes many more kcals. This challenge has likely been a characteristic of the human infant's diet since the agricultural revolution approximately 10 000 years ago when diets became more cereal-based (Dewey 2013). When the complementary feeding diet largely consists of watery plant source-based gruels and porridges, it will be deficient in several nutrients and the child's needs will not be met. The guiding principles for complementary feeding of the breastfed child (PAHO and WHO 2001) as well as results of linear programming analyses (Briend et al. 2001; Baldi et al. 2013; Skau et al. 2013) confirm the following: (i) the complementary feeding diet has to include several servings of different types of animal source and/or fortified foods per week in addition to plant-source foods; and (ii) that obtaining such a diet is beyond the financial means of many households in low and middle income countries. Furthermore, there are practical constraints to meeting dietary diversity requirements, including distance to and frequency of market days, inability to keep fresh foods cool (food safety requirement) and availability of time to prepare and feed frequent, balanced meals to young children. Therefore, in addition to improving infant and young child feeding practices, including breastfeeding, choice of foods, frequency of meals, hygienic preparation and feeding practices, to the fullest extent possible, the nutrient content of complementary foods often needs further improvement, especially for nutrients such as vitamin A, iron, zinc, iodine, calcium and essential fatty acids. There are two main ways to provide these additional nutrients to this target group of young children (6–23 months mainly), fortification and supplementation (De Pee & Bloem 2009). Fortification can be carried out in different ways, including home fortification, where a small amount of powder or spread is added to a home-prepared meal; fortification of foods intended for this target group, such as fortified blended food, or infant porridge; or fortification of foods that are consumed by the general population, such as flour, rice, vegetable oil and sugar. However, for the latter, fortification levels are not designed to meet the needs of young children, so that while they can contribute to their nutrient intake, they are insufficient to fully prevent deficiencies. Supplementation for this age group is often limited to single nutrients (vitamins A or D, iron) and can only be provided as drops or syrup. Syrup is bulky to transport and high-dose supplements (e.g. vitamin A capsules) need to be provided under health care workers supervision that seriously constrains the possible frequency of provision, which is a problem for nutrients that should be consumed more regularly, because they cannot be dosed at high levels and/or are not stored by the body. For providing multiple micronutrients, fortification options are hence preferred. The papers discuss a range of different aspects of these commodities, including composition, acceptance and consumption, access and distribution modalities, monitoring of programming and evaluation of impact. These topics, and the specific contributions of the different papers, are discussed below. A total of nine papers deal with the forms and amounts of iron that can be included in different types of food, whether folic acid can be included in complementary feeding commodities in areas where malaria is endemic, whether including milk powder results in additional benefits that are worth their higher cost, and inclusion of local nutrient-dense ingredients instead of vitamin/mineral premix, that is, caterpillars in blended food (Bauserman et al. 2015), and Moringa oleifera extract in LNS (Ickes et al. 2015). With regard to iron, the study by Chavasit et al. (2015) among 8- to 24-month-old Thai children showed that meals consisting of broken rice fortified with a combination of iron EDTA and ferrous sulphate achieved greater iron absorption than ferric ammonium citrate. The amount of iron that can be added in the form of iron EDTA is limited by the ADI (acceptable daily intake) for EDTA (Wreesmann 2014), and hence restricts the dose for young children to approximately 2.5 mg iron/d, which is why they added another iron form. Barth-Jaeggi et al. (2015) assessed whether MNP with 15 micronutrients, including 2.5 mg iron from EDTA, resulted in improvements of iron status among Kenyan children enrolled at the age of 6 months as compared with the same MNP without iron, and found no evidence of impact, indicating that more iron may be required by the children that participated in this study, who also suffered from frequent infections. The need to select an iron compound with good bioavailability was also confirmed by the study by Rahman et al. (2015) who did not find an impact on haemoglobin concentration or iron status from consumption of chapattis made from flour fortified with hydrogen-reduced elemental iron, which is also what would be expected based on the interim consensus statement on wheat and maize flour fortification (WHO et al. 2009). The paper by Kupka (2015) reviews the literature on the interaction between folic acid and anti-folate anti-malaria drugs that inhibit the parasite's access to folate; this therapy could potentially fail when the host has plenty of folate circulating in the blood stream. While supra-physiological doses of folic acid are not recommended where anti-folate anti-malarials are used; too little is known about the potential for negative impact at normal recommended intakes. As a precautionary measure, while still ensuring adequate folate nutriture at the same time, commodities could include lower levels of folic acid when distributed among children who may also receive anti-folate anti-malarials. Milk is a key ingredient (approximately 20% on a weight basis) of ready-to-use therapeutic food. While it is important for recovery from SAM, and also for achieving linear growth (prevention of stunting) (Hoppe et al. 2006), it is also a costly ingredient. The study by Irena et al. (2015) assessed recovery from SAM on a standard RUTF and on a milk-free soy-maize-sorghum RUTF with the same nutrient content. While they were not found to be equivalent, that is, recovery was better on the milk containing standard formulation; this was particularly true for to the younger age group (6–23 months). This is an interesting finding with regard to the importance of milk for (re)building body tissues by younger children. The study by Mangani et al. (2015) found that medium quantity LNS (280 kcal/day) containing milk resulted in a lower decline of length-for-age z-scores (−0.02) between 9 and 12 months of age as compared with non-milk LNS (−0.12), corn soy blend (−0.18) or nothing (−0.15), but this difference was not maintained over the next 6 months. In quantitative terms, the milk content of the LNS was 25%, which for a dose of 54 g/day is equivalent to 14 g/day of dried skimmed milk. This finding suggests that linear growth improved with this amount of milk, in this population, between 9 and 12 months of age, and also that the dose was not sufficient to adequately support linear growth thereafter, or that there were other unmet nutrient needs that were more constraining. Bauserman et al. (2015) developed a local food for complementary feeding that contained caterpillars, ground corn, palm oil, sugar and salt and found that it was liked by 8- to 10-month-old infants and caretakers. The authors state that the food had adequate nutrient composition for young child feeding; however, this statement is not adequately supported by their data as they only analyzed the content of macro-nutrients, iron, zinc, copper and magnesium, and did not provide the target composition to which they compared the food. Another study assessed adequacy of nutrient intake among children with moderate acute malnutrition who consumed a local diet supplemented with a large quantity (126 g/day) of LNS (also called ready to use supplementary food or RUSF) that was locally developed, consisted of roasted groundnut paste, roasted soy flour and, instead of a premix of vitamins and minerals, M. oleifera extract (Ickes et al. 2015). For a number of nutrients, the estimated average requirement (EAR) was not met, especially among older children. This may be the first LNS recipe that does not include a comprehensive vitamin and mineral premix, which is a key characteristic of other LNS, RUSF and RUTF formulations. This difference needs to be well recognized. These different studies assessed whether specific recipes (choice of ingredients) and compositions (nutrient content) resulted in specific or improved outcomes in terms of nutrient intake and/or nutritional status. The key question is what to conclude when a specific formulation did not result in the desired change of nutritional status: (i) this commodity is not effective and should therefore not be used; (ii) the commodity may not have been consumed as desired; (iii) the gap of nutrient intake from the diet, together with any pre-existing deficiencies, was not adequately compensated by the commodity; and (iv) nutritional status is also affected by other factors that were not addressed concurrently and hence constrained the impact of the commodity. All points are likely to apply, except (i), which is an oversimplification that does not further our understanding of how best to improve complementary feeding. It is important to think quantitatively when considering complementary feeding options, that is, is a nutrient gap likely, how large is it and in what ways can it be closed. And when assessing impact, to carefully consider questions such as what else may impact the outcome of interest, that is, nutritional status, and whether other, unmeasured, outcomes may be impacted (e.g. micronutrient status, but not stunting). For example, different studies with small amounts of iron, milk or local nutrient-dense ingredients that found a small or no impact could have benefited from including a positive comparison group that received a higher dose, to answer the question whether there is no benefit of including the ingredient or that its dose was too low. Also, since any change of nutritional status comes from either a change of dietary intake or disease, all studies that aim to improve nutritional status need to monitor changes of intake, including the special complement as well as the rest of the diet, and clinical and subclinical illness and infection, including enteropathy which affects nutrient utilization.. As results of the iLiNS studies, which tested different formulations for different outcomes (Arimond et al. 2015), are becoming available, these points are important for interpreting their findings. It is also important to note that the EAR can be used to estimate the proportion of the population with deficient intake (i.e. those below the EAR) (Ickes et al. 2015) and as a target level that the intake of all individuals in the population should be above (Allen et al. 2006). However, the EAR is not to be used as the target for the population's average intake, because the proportion below that level would be assumed to have a deficient intake. The RNI should be the target, because at this level, the needs of 97.5% of normal, healthy individuals in the population would be met. In order for a special complementary feeding commodity to have the desired impact in terms of improving nutrient intake, and therefore impacting on nutritional status, it needs to be acquired and consumed as intended. These so-called demand-side aspects were reported in four of the papers. Under controlled circumstances, one can ensure that a commodity is acquired by distributing it directly to study participants, but actual consumption by the intended recipients and preventing that it replaces other components of the diet is beyond the direct control of both investigators and programme implementers. This was clearly illustrated in the study by Abbeddou et al. (2015) who found that despite high self-reported consumption and disappearance rate of LNS-SQ and zinc supplements, consumption of both commodities during 12 h in-home observation sessions was much lower (approx. 60% and 30%, respectively). Reasons for not consuming the commodity as recommended can vary widely, for example not liking the product, not understanding that it is intended for a specific individual, feeling pressured to share, with others inside or outside the household. Ickes and colleagues, for example, found that only 50 g of the 128 g of LNS provided per day was consumed by the intended recipient (Ickes et al. 2015). Another possibility is that while the nutritious commodity is consumed, it displaces other foods, and therefore the net improvement of nutrient intake is less than expected. Both Flax et al. (2015) and Thakwalakwa et al. (2015) assessed this aspect. Flax et al. (2015) found no evidence of replacement for LNS provided as 46 g/day to 6- to 18-month-old children. Thakwalakwa et al. (2015) compared intakes among control, corn-soy blend (CSB; 284 kcal/day) and LNS (220 kcal/day) groups and found that the intake of the LNS group was highest, indicating minimal displacement, which is likely related to its higher energy density (smaller volume) and the fact that it can be consumed as a ready-to-use snack, between meals, rather than as a meal (which is the case for CSB), which is more likely to replace another food or meal. These studies illustrate a couple of important points: (i) studies should carefully assess total nutrient intake, including both the specific commodity and the rest of the diet; (ii) there is a need for reliable indicators of adherence and triangulation of data from several indicators of adherence; (iii) to ensure consumption, commodities need to meet target group preferences and food preparation and consumption realities; and (iv) to stimulate consumption as intended and limit sharing, clear, well-tailored, communications should be developed and delivered, based on appropriate formative research among the target population (Kodish et al. 2011). To realize access to nutritious commodities for enhancing complementary feeding at scale under real-life circumstances, consumers need to be reached. A total of three papers dealt with this topic. The target population can be reached using health care, community-based and/or market channels. The choice of channel or combination of channels depends on the context, including type of commodity and its classification (food, pharma or dietary supplement), purchasing power of the population, needs and possibilities for behaviour change communication, existing platforms with good reach and trust among the desired target population and so on. Segre and assessed to for LNS-SQ among consumers in in order to the potential and for to whether there is a case for a local and/or whether and/or their distribution channels are also found that while consumers were to the and would be to an consumers are not used to foods for this target group, and total market would be limited et al. 2015). In LNS was as a of a complementary feeding while appropriate breastfeeding were also Lesorogol et al. (2015) found that infant and young child feeding was well ensuring good of special nutritious commodities in and for infant and young child and Osei et al. (2015) the use of the food programme as a channel for While was levels did not decline which is likely related to the low dose provided per i.e. on average of RNI per and likely also the fact that also has many other, including These papers illustrate that it is important to of nutritious commodities with other or and to use existing channels with good reach among the target population, while additional for specific that may not be well reached by those channels. A programme for improving complementary whether it a specific complementary feeding commodity or should be to the following: (i) whether the programme is as that is, and what they are to they have the and means to are commodities when and where they should intended receive the specific and (ii) as a the intended feeding are and nutrient intakes of children results should be used as to programme where and when papers, both by Jefferds and colleagues, on monitoring and a for monitoring MNP which the use of a data and a comprehensive monitoring and also points out the need for adequate to and such a & Flores-Ayala 2015). 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(2015) when assessing iron acute should also be to for of iron status The and of a programme evaluation should be practical (i.e. and choice of areas and be by an programme impact et al. 2013). This should the as well as the monitoring and evaluation of the including factors that can and/or analyses provide evidence of the of between and their and of factors that or In this one can assess not only whether impact was achieved but also how and why it was achieved or not For the should all aspects that may nutrient intake, and hence nutritional status, including the specific programme In this one will a good understanding of the possible of the special nutritious commodity for improving complementary feeding and any factors that may have or its impact in the specific target group and its