Linear growth increased in young children in an urban slum of Haiti: a randomized controlled trial of a lipid-based nutrient supplement

Abstract

Background: Haiti has experienced rapid urbanization that has exacerbated poverty and undernutrition in large slum areas. Stunting affects 1 in 5 young children.

Objective: We aimed to test the efficacy of a daily lipid-based nutrient supplement (LNS) for increased linear growth in young children.

Design: Healthy, singleton infants aged 6-11 mo (n = 589) were recruited from an urban slum of Cap Haitien and randomly assigned to receive: 1) a control; 2) a 3-mo LNS; or 3) a 6-mo LNS. The LNS provided 108 kcal and other nutrients including vitamin A, vitamin B-12, iron, and zinc at ≥80% of the recommended amounts. Infants were followed monthly on growth, morbidity, and developmental outcomes over a 6-mo intervention period and at one additional time point 6 mo postintervention to assess sustained effects. The Bonferroni multiple comparisons test was applied, and generalized least-squares (GLS) regressions with mixed effects was used to examine impacts longitudinally.

Results: Baseline characteristics did not differ by trial arm except for a higher mean age in the 6-mo LNS group. GLS modeling showed LNS supplementation for 6 mo significantly increased the length-for-age z score (±SE) by 0.13 ± 0.05 and the weight-for-age z score by 0.12 ± 0.02 compared with in the control group after adjustment for child age (P < 0.001). The effects were sustained 6 mo postintervention. Morbidity and developmental outcomes did not differ by trial arm.

Conclusion: A low-energy, fortified product improved the linear growth of young children in this urban setting. The trial was registered at clinicaltrials.gov as NCT01552512.

FIGURE 1.

Flow diagram of participant progression through the RCT. During the intervention period from baseline to visit 6, children were followed monthly. At each visit, mothers were surveyed on child diet, morbidities, and developmental outcomes, and child weights and lengths were measured. Mothers in the 3-mo LNS group received a monthly supply of the LNS at each of visits 1–3, and mothers in the 6-mo LNS group received a monthly supply of the LNS during each of visits 1–6. At visit 6, the intervention period ceased, and all mother-child pairs were asked to return 6 mo later for end-line visit 7, when the end-line survey was administered, and final child weight and length measures were taken. LNS, lipid-based nutrient supplement; RCT, randomized controlled trial.

FIGURE 2.

Lowess curves derived from nonparametric, locally weighted regression illustrate trajectories of growth for the control group (black line), 3-mo LNS group (dashed line), and 6-mo LNS group (gray line) for length-for-age z score (A) and weight-for-age z score (B) for children followed monthly (visits 1–6) and again at end line (visit 7) 6 mo postintervention. The lowess graph applies least-squares smoothing at each visit and, thus, differs from the mean length-for-age and weight-for-age z scores shown in Table 3. In this descriptive data that were not adjusted for age, the 6-mo LNS group showed a length-for-age z score that was maintained at higher levels than in the control and 3-mo LNS groups until the end of the intervention period and converged with the other groups at visit 7 at 12 mo (A). The weight-for-age z score was also shown to be maintained in LNS groups during the supplementation period, whereas in the control group, there was a steadily descending slope until end line, visit 7, at 12 mo (B). LNS, lipid-based nutrient supplement.

FIGURE 3.

Child morbidity prevalence at visit 6 for control (dark gray), 3-mo LNS (light gray), and 6-mo LNS (gray) groups. Morbidities were derived from a maternal 2-wk recall for fever, cough, respiratory infection (cough plus rapid, difficult breathing), acute diarrhea (≥3 liquid or semiliquid stools/d), and prolonged diarrhea (acute diarrhea for 7–14 d) or persistent diarrhea (acute diarrhea for >14 d). There were no significant differences in morbidity prevalences in groups, P < 0.05 (chi-square test). LNS, lipid-based nutrient supplement.

FIGURE 4.

Percentages of children meeting the motor development milestone for control (dark gray), 3-mo LNS (light gray), and 6-mo LNS (gray) groups at visit 6 on the basis of maternal reporting and enumerator observation. The following WHO developmental milestone definitions were applied: crawls (≥3 consecutive movements in a row and stomach does not touch ground); stands with assistance (upright position on both feet holding onto an object and, legs do not touch object for ≥10 s); walks with assistance (upright with back straight, move sideways or forward holding an object, and one leg moves and the other leg supports weight for ≥5 steps); stands independently (upright with back straight on feet and not toes; legs support 100% of weight; no contact with people or objects for 10 s); walks independently (child takes 5 steps independently without the use of people or objects and one leg forward while the other leg supports weight). Bars with different lowercase letters signify statistically different prevalences, P < 0.05 (chi-square test). After adjustment for child age and maternal education level attained in regression modeling, the significance of developmental outcomes was no longer present. LNS, lipid-based nutrient supplement.