Home Fortification of Complementary Foods Reduces Anemia and Diarrhea among Children Aged 6-18 Months in Bihar, India: A Large-Scale Effectiveness Trial

Abstract

Background: Home fortification of complementary foods with multiple micronutrient powders (MNPs) is recommended to reduce child anemia in resource-poor settings. However, evidence of program effectiveness in India to guide policies and programs is lacking.

Objectives: We implemented a large-scale intervention of MNPs in Bihar, India. The primary outcome was MNP consumption and change in hemoglobin concentration among children aged 6-18 mo between baseline and endline (12 mo). Secondary outcomes were change in child weight and length and infant and young child feeding (IYCF) practices (initiation, diversity, and feeding frequency). Ad hoc analyses included changes in anemia; stunting; underweight; wasting; and reported diarrhea, fever, and hospitalization.

Methods: We conducted a cluster-randomized, effectiveness trial in >4000 children within the context of ongoing health and nutrition programs implemented by CARE, India. Seventy health subcenters were randomly assigned to receive either MNPs with IYCF counseling (intervention) or IYCF counseling only (control). We used an adjusted difference-in-difference approach using repeat cross-sectional surveys at baseline and endline to evaluate impact.

Results: At baseline, 75% of intervention and 69% of control children were anemic and 33% were stunted. By endline, 70% of intervention households reported their child had ever consumed MNPs, and of those, 64% had consumed MNPs in the past month. Relative to control, hemoglobin concentration increased (0.22 g/dL; 95% CI: 0.00, 0.44 g/dL) and anemia declined by 7.1 percentage points (pp) (95% CI: -13.5, -0.7 pp). There was no impact on anthropometry nor IYCF practices. However, there was a decline of 8.0 pp (95% CI: -14.9, -1.1 pp) in stunting among children aged 12-18 mo. Diarrhea prevalence in the past 2 wk was reduced by 4.0 pp (95% CI: -7.6, -0.4 pp).

Conclusions: Home fortification of complementary foods within a government-run program in Bihar had moderate compliance and caused modest improvements in hemoglobin and reductions in anemia and diarrhea prevalence.

Keywords: India; anemia; children; hemoglobin; multiple micronutrient powders.

FIGURE 1

CONSORT participant flow diagram for cluster-randomized controlled effectiveness trial of multiple micronutrient powders in Bihar. CONSORT, Consolidated Standards of Reporting Trials.

FIGURE 2

DID impact analysis comparing changes from baseline to endline in the prevalence of anemia (A), stunting (B), diarrhea in the previous 2 wk (C), and meeting minimum dietary diversity in the previous 24 h (D) in children aged 6–18 mo who received multiple micronutrient powders relative to the changes in the control group. Complex survey procedures were used to account for clustering of the data. *Different from control, P < 0.05. (A) DID in the prevalence of anemia among children aged 6–18 mo (7.1 pp, P < 0.05). (B) DID in the prevalence of stunting among children aged 12–18 mo (8.0 pp, P < 0.05). (C) DID in the prevalence of diarrhea in the previous 2 wk among children aged 6–18 mo (4.0 pp, P < 0.05). (D) DID in the prevalence of children aged 6–18 mo meeting minimum dietary diversity in the previous 24 h (no difference). DID, difference-in-difference; pp, percentage points.