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. 2019 May 2;5(5):CD012611.
doi: 10.1002/14651858.CD012611.pub3.

Preventive lipid-based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes

Jai K Das  1 , Rehana A Salam, Yousaf Bashir Hadi, Sana Sadiq Sheikh, Afsah Z Bhutta, Zita Weise Prinzo, Zulfiqar A Bhutta
Affiliations

Preventive lipid-based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes

Jai K Das et al. Cochrane Database Syst Rev. .

Abstract

Background: One nutritional intervention advocated to prevent malnutrition among children is lipid-based nutrient supplements (LNS). LNS provide a range of vitamins and minerals, but unlike most other micronutrient supplements, LNS also provide energy, protein and essential fatty acids. Alternative recipes and formulations to LNS include fortified blended foods (FBF), which are foods fortified with vitamins and minerals, and micronutrient powders (MNP), which are a combination of vitamins and minerals, OBJECTIVES: To assess the effects and safety of preventive LNS given with complementary foods on health, nutrition and developmental outcomes of non-hospitalised infants and children six to 23 months of age, and whether or not they are more effective than other foods (including FBF or MNP).This review did not assess the effects of LNS as supplementary foods or therapeutic foods in the management of moderate and severe acute malnutrition.

Search methods: In October 2018, we searched CENTRAL, MEDLINE, Embase, 21 other databases and two trials registers for relevant studies. We also checked the reference lists of included studies and relevant reviews and contacted the authors of studies and other experts in the area for any ongoing and unpublished studies.

Selection criteria: Randomised controlled trials (RCTs) and quasi-RCTs that evaluated the impact of LNS plus complementary foods given at point-of-use (for any dose, frequency, duration) to non-hospitalised infants and young children aged six to 23 months in stable or emergency settings and compared to no intervention, other supplementary foods (i.e. FBF), nutrition counselling or multiple micronutrient supplements or powders for point-of-use fortification of complementary foods.

Data collection and analysis: Two review authors independently screened studies for relevance and, for those studies included in the review, extracted data, assessed risk of bias and rated the quality of the evidence using the GRADE approach. We carried out statistical analysis using Review Manager software. We used a random-effects meta-analysis for combining data as the interventions differed significantly. We set out the main findings of the review in 'Summary of findings' tables,.

Main results: Our search identified a total of 8124 records, from which we included 17 studies (54 papers) with 23,200 children in the review. The included studies reported on one or more of the pre-specified primary outcomes, and five studies included multiple comparison groups.Overall, the majority of trials were at low risk of bias for random sequence generation, allocation concealment, blinding of outcome assessment, incomplete outcome data, selective reporting and other sources of bias, but at high risk of bias for blinding of participants and personnel due to the nature of the intervention. Using the GRADE approach, we judged the quality of the evidence for most outcomes as low or moderate.LNS+complementary feeding compared with no intervention Thirteen studies compared LNS plus complementary feeding with no intervention. LNS plus complementary feeding reduced the prevalence of moderate stunting by 7% (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.88 to 0.98; nine studies, 13,372 participants; moderate-quality evidence), severe stunting by 15% (RR 0.85, 95% CI 0.74 to 0.98; five studies, 6151 participants; moderate-quality evidence), moderate wasting by 18% (RR 0.82, 95% CI 0.74 to 0.91; eight studies; 13,172 participants; moderate-quality evidence), moderate underweight by 15% (RR 0.85, 95% CI 0.80 to 0.91; eight studies, 13,073 participants; moderate-quality evidence), and anaemia by 21% (RR 0.79, 95% CI 0.69 to 0.90; five studies, 2332 participants; low-quality evidence). There was no impact of LNS plus complementary feeding on severe wasting (RR 1.27, 95% CI 0.66 to 2.46; three studies, 2329 participants) and severe underweight (RR 0.78, 95%CI 0.54 to 1.13; two studies, 1729 participants). Adverse effects did not differ between the groups (RR 0.86, 95% CI 0.74 to 1.01; three studies, 3382 participants).LNS+complementary feeding compared with FBF Five studies compared LNS plus complementary feeding with other FBF, including corn soy blend and UNIMIX. We pooled four of the five studies in meta-analyses and found that, when compared to other FBF, LNS plus complementary feeding significantly reduced the prevalence of moderate stunting (RR 0.89, 95% CI 0.82 to 0.97; three studies, 2828 participants; moderate-quality evidence), moderate wasting (RR 0.79, 95% CI 0.65 to 0.97; two studies, 2290 participants; moderate-quality evidence), and moderate underweight (RR 0.81, 95% CI 0.73 to 0.91; two studies, 2280 participants; moderate-quality evidence). We found no difference between LNS plus complementary feeding and FBF for severe stunting (RR 0.41, 95% CI 0.12 to 1.42; two studies, 729 participants; low-quality evidence), severe wasting (RR 0.64, 95% CI 0.19 to 2.81; two studies, 735 participants; moderate-quality evidence), and severe underweight (RR 1.23, 95% CI 0.67 to 2.25; one study, 173 participants; low-quality evidence).LNS+complementary feeding compared with MNP Four studies compared LNS plus complementary feeding with MNP. We pooled data from three of the four studies in meta-analyses and found that compared to MNP, LNS plus complementary feeding significantly reduced the prevalence of moderate underweight (RR 0.88, 95% CI 0.78 to 0.99; two studies, 2004 participants; moderate-quality evidence) and anaemia (RR 0.38, 95% CI 0.21 to 0.68; two studies, 557 participants; low-quality evidence). There was no difference between LNS plus complementary feeding and MNP for moderate stunting (RR 0.92, 95% CI 0.82 to 1.02; three studies, 2365 participants) and moderate wasting (RR 0.97, 95% CI 0.77 to 1.23; two studies, 2004 participants).

Authors' conclusions: The findings of this review suggest that LNS plus complementary feeding compared to no intervention is effective at improving growth outcomes and anaemia without adverse effects among children aged six to 23 months in low- and middle-income countries (LMIC) in Asia and Africa, and more effective if provided over a longer duration of time (over 12 months). Limited evidence also suggests that LNS plus complementary feeding is more effective than FBF and MNP at improving growth outcomes.

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Conflict of interest statement

We certify that we have no affiliations with, or involvement in, any organisation or entity with a direct financial interest in the subject matter of the review (e.g. employment, consultancy, stock ownership, honoraria, expert testimony).

Jai K Das ‐ none known. Rehana A Salam ‐ none known. Yousaf Bashir Hadi ‐ none known. Sana Sadiq Sheikh ‐ none known. Afsah Zulfiqar Bhutta ‐ none known. Zita Weise Prinzo is a full‐time member of staff of the WHO. Zulfiqar A Bhutta's institution was awarded a grant from the WHO to undertake this review.

The review authors alone are responsible for the views expressed in this publication; the views do not necessarily represent the official position, decisions, policy or views of the WHO.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
4
4
Forest plot of comparison: 1 LNS versus no intervention, outcome: 1.1 Moderate stunting.
5
5
Forest plot of comparison: 1 LNS versus no intervention, outcome: 1.5 Moderate wasting.
See this image and copyright information in PMC

Update of

References

References to studies included in this review

Adu‐Afarwuah 2007 {published data only}
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Christian 2015 {published data only}
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Dewey 2017 {published data only}
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Hess 2015 {published data only}
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Huybregts 2012 {published data only}
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Iannotti 2014 {published data only}
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Kumwenda 2014 {published data only}
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Luby 2018 {published data only}
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Mangani 2015 {published data only}
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Matias 2017 {published data only}
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Null 2018 {published data only}
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Olney 2018 {published data only}
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Phuka 2008 {published data only}
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Siega‐Riz 2014 {published data only}
    1. Flax VL, Siega‐Riz AM, Reinhart GA, Bentley ME. Provision of lipid‐based nutrient supplements to Honduran children increases their dietary macro‐ and micronutrient intake without displacing other foods. Maternal & Child Nutrition 2015;11(Suppl 4):203‐13. [DOI: 10.1111/mcn.12182; PUBMED: 25819697] - DOI - PMC - PubMed
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References to studies excluded from this review

Ackatia‐Armah 2015 {published data only}
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Adams 2017 {published data only}
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Ahmed 2014 {published data only}
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Cercamondi 2013 {published data only}
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References to ongoing studies

Borg 2017 {published data only}
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References to other published versions of this review

Das 2017
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Das 2019
    1. Das JK, Salam RA, Weise Prinzo Z, Sadiq Sheikh S, Bhutta ZA. Provision of preventive lipid‐based nutrient supplements given with complementary foods to infants and young children 6 to 23 months of age for health, nutrition, and developmental outcomes. Cochrane Database of Systematic Reviews 2019, Issue 3. [DOI: 10.1002/14651858.CD012611.pub2] - DOI - PMC - PubMed

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