What Works? Evidence Based Maternal, Child and Adolescent Nutrition Interventions

The objective of this review was to assess the impact of lifestyle interventions (including dietary interventions, physical activity, behavioral therapy, or any combination of these interventions) to prevent and manage childhood and adolescent obesity. We conducted a comprehensive literature search across various databases and grey literature without any restrictions on publication, language, or publication status until February 2020. We included randomized controlled trials and quasi-experimental studies from both high income countries (HIC) and low-middle-income countries (LMICs). Participants were children and adolescents from 0 to 19 years of age. Studies conducted among hospitalized children and children with any pre-existing health conditions were excluded from this review. A total of 654 studies (1160 papers) that met the inclusion criteria were included in this review. A total of 359 studies targeted obesity prevention, 280 studies targeted obesity management, while 15 studies targeted both prevention and management. The majority of the studies (81%) were conducted in HICs, 10% of studies were conducted in upper middle income countries, while only 2% of the studies were conducted in LMICs. The most common setting for these interventions were communities and school settings. Evidence for the prevention of obesity among children and adolescents suggests that a combination of diet and exercise might reduce the BMI z-score (MD: −0.12; 95% CI: −0.18 to −0.06; 32 studies; 33,039 participants; I² 93%; low quality evidence), body mass index (BMI) by 0.41 kg/m² (MD: −0.41 kg/m²; 95% CI: −0.60 to −0.21; 35 studies; 47,499 participants; I² 98%; low quality evidence), and body weight (MD: −1.59; 95% CI: −2.95 to −0.23; 17 studies; 35,023 participants; I² 100%; low quality evidence). Behavioral therapy alone (MD: −0.07; 95% CI: −0.14 to −0.00; 19 studies; 8569 participants; I² 76%; low quality evidence) and a combination of exercise and behavioral therapy (MD: −0.08; 95% CI: −0.16 to −0.00; 9 studies; 7334 participants; I² 74%; low quality evidence) and diet in combination with exercise and behavioral therapy (MD: −0.13; 95% CI: −0.25 to −0.01; 5 studies; 1806 participants; I² 62%; low quality evidence) might reduce BMI z-score when compared to the control group. Evidence for obesity management suggests that exercise only interventions probably reduce BMI z-score (MD: −0.13; 95% CI: −0.20 to −0.06; 12 studies; 1084 participants; I² 0%; moderate quality evidence), and might reduce BMI (MD: −0.88; 95% CI: −1.265 to −0.50; 34 studies; 3846 participants; I² 72%) and body weight (MD: −3.01; 95% CI: −5.56 to −0.47; 16 studies; 1701 participants; I² 78%; low quality evidence) when compared to the control group. and the exercise along with behavioral therapy interventions (MD: −0.08; 95% CI: −0.16 to −0.00; 8 studies; 466 participants; I² 49%; moderate quality evidence), diet along with behavioral therapy interventions (MD: −0.16; 95% CI: −0.26 to −0.07; 4 studies; 329 participants; I² 0%; moderate quality evidence), and combination of diet, exercise and behavioral therapy (MD: −0.09; 95% CI: −0.14 to −0.05; 13 studies; 2995 participants; I² 12%; moderate quality evidence) also probably decreases BMI z-score when compared to the control group. The existing evidence is most favorable for a combination of interventions, such as diet along with exercise and exercise along with behavioral therapy for obesity prevention and exercise alone, diet along with exercise, diet along with behavioral therapy, and a combination of diet, exercise, and behavioral therapy for obesity management. Despite the growing obesity epidemic in LMICs, there is a significant dearth of obesity prevention and management studies from these regions. Full article

Background: Suboptimal nutritional status of a newborn is a risk factor for short- and long-term morbidity and mortality. The objectives of this review were to assess the efficacy and effectiveness of neonatal synthetic vitamin A supplementation, dextrose gel and probiotic supplementation for prevention of morbidity and mortality during infancy in low and middle-income countries. Methods: We included randomized trials. Primary outcome was all-cause mortality. We conducted electronic searches on multiple databases. Data were meta-analyzed to obtain relative risk (RR) and 95% confidence interval (CI). Studies for vitamin A and Probiotics were analyzed separately. No studies were found for dextrose gel supplementation during neonatal period. The overall rating of evidence was determined by Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Results: Sixteen studies assessed the effect of vitamin A supplementation during the neonatal period. Based on pooled data from community-based studies only, there was no significant effect of vitamin A on all-cause mortality at age 1 month (RR 0.99, 95% CI 0.90, 1.08), 6 months (RR 0.98; 95% CI 0.89–1.08) and 12 months (RR 1.04, 95% CI 0.94, 1.14) but increased risk of bulging fontanelle (RR 1.53, 95% CI 1.12, 2.09). The overall quality of evidence was high for the above outcomes. Thirty-three studies assessed the effect of probiotic supplementation during the neonatal period and were mostly conducted in the hospital setting. Probiotics reduced the risk of all-cause mortality (RR 0.80, 95% CI 0.66, 0.96), necrotizing enterocolitis (RR 0.46, 95% CI 0.35, 0.59) and neonatal sepsis (RR 0.78, 95% CI 0.70, 0.86). The grade ratings for the above three outcomes were high. Conclusions: Vitamin A supplementation during the neonatal period does not reduce all-cause neonatal or infant mortality in low and middle-income countries in the community setting. Probiotic supplementation during the neonatal period seems to reduce all-cause mortality, NEC, and sepsis in babies born low birth weight and/or preterm in the hospital setting. Full article

Undernutrition is associated with 45% of total infant deaths, totalling 2.7 million globally per year. The vast majority of the burden is felt in low- and middle-income countries (LMICs). This review aims to assess the effectiveness of infant and young child feeding (IYCF) interventions. We searched multiple databases including Cochrane Controlled Trials Register (CENTRAL), MEDLINE, EMBASE. Title/abstract screening and full-text screening and data extraction filtered 77 studies for inclusion. Breastfeeding education interventions (n = 38) showed 20% increase in rates of early initiation of breastfeeding, 102% increase in exclusive breastfeeding (EBF) at 3 months and 53% increase in EBF at 6 months and 24% decreases in diarrheal diseases. Complementary feeding education intervention (n=12) showed a 0.41 standard deviation (SD) increase in WAZ, and 0.25 SD in HAZ in food secure setting. Complementary food provision with or without education (n=17) showed a 0.14 SD increase in HAZ and 36% decrease in stunting. Supplementary food interventions (n=12) showed a significant 0.15 SD increase in WHZ. Subgroup analyses showed healthcare professional led interventions were largely more effective, especially on breastfeeding outcomes. We believe this is a comprehensive review of the existing literature on IYCF studies in LMICs. Though breastfeeding education is well supported in its effectiveness on breastfeeding practices, limited evidence exists for growth outcomes. Supplementation interventions seem to have better effects at improving growth. However, more research is required to reach more substantial conclusions. Full article

Pregnancy in adolescence and malnutrition are common challenges in low- and middle-income countries (LMICs), and are associated with many complications and comorbidities. The preconception period is an ideal period for intervention as a preventative tactic for teenage pregnancy, and to increase micronutrient supplementation prior to conception. Over twenty databases and websites were searched and 45 randomized controlled trials (RCTs) or quasi-experimental interventions with intent to delay the age at first pregnancy (n = 26), to optimize inter-pregnancy intervals (n = 4), and supplementation of folic acid (n = 5) or a combination of iron and folic acid (n = 10) during the periconception period were included. The review found that educational interventions to delay the age at first pregnancy and optimizing inter-pregnancy intervals significantly improved the uptake of contraception use (RR = 1.71, 95% CI = 1.42–2.05; two studies, n = 911; I² = 0%) and (RR = 2.25, 95% CI = 1.29–3.93; one study, n = 338), respectively. For periconceptional folic acid supplementation, the incidence of neural tube defects were reduced (RR = 0.53; 95% CI = 0.41–0.77; two studies, n = 248,056; I² = 0%), and iron-folic acid supplementation improved the rates of anemia (RR = 0.66, 95% CI = 0.53–0.81; six studies; n = 3430, I² = 88%), particularly when supplemented weekly and in a school setting. Notwithstanding the findings, more robust RCTs are required from LMICs to further support the evidence. Full article

Optimal nutrition plays a crucial role in pregnancy. Maternal malnutrition is a risk factor for maternal, fetal, and neonatal complications and is more prevalent in low and middle-income countries (LMICs). This review aims to study the effectiveness of antenatal macronutrient nutritional interventions on maternal, neonatal, and child outcomes. We searched the CENTRAL, PubMed, Embase, and other databases for randomized controlled trials and quasi-experimental designs on healthy pregnant women in LMICs. We also searched grey literature and reports from Google Scholar, Web of Science, and websites of different organizations. Title/abstract screening, full-text screening, and data extraction filtered 15 studies for inclusion. Balanced energy protein (BEP) supplementation (n = 8) studies showed a reduced incidence of perinatal mortality, stillbirths, low birth weight (LBW) infants, small for gestational age (SGA) babies and increased birth weight. Food distribution programs (FDPs) (n =5) witnessed reduced rates of SGA, stunting, wasting, and increased birth weight and birth length. Studies on intervention for obesity prevention (n = 2) showed reductions in birth weight. Other findings were statistically insignificant. Subgroup analyses were conducted to study the effectiveness of supplementation between regions, location, the timing of supplementation and nutritional status; however, there were a limited number of studies in each subgroup. Data from our review supports the antenatal supplementation of BEP and FDP for the prevention of adverse maternal, neonatal, and child outcomes that can be utilized for future policymaking. However, more research is required before recommending obesity prevention programs. Full article

Almost two billion people are deficient in key vitamins and minerals, mostly women and children in low- and middle-income countries (LMICs). Deficiencies worsen during pregnancy due to increased energy and nutritional demands, causing adverse outcomes in mother and child, but could be mitigated by interventions like micronutrient supplementation. To our knowledge, this is the first systematic review that aimed to compile evidence from both efficacy and effectiveness trials, evaluating different supplementation interventions on maternal, birth, child health, and developmental outcomes. We evaluated randomized controlled trials and quasi-experimental studies published since 1995 in peer-reviewed and grey literature that assessed the effects of calcium, vitamin A, iron, vitamin D, and zinc supplementation compared to placebo/no treatment; iron-folic (IFA) supplementation compared to folic acid only; multiple micronutrient (MMN) supplementation compared to IFA; and lipid-based nutrient supplementation (LNS) compared to MMN supplementation. Seventy-two studies, which collectively involved 314 papers (451,723 women), were included. Meta-analyses showed improvement in several key birth outcomes, such as preterm birth, small-for-gestational age (SGA) and low birthweight with MMN supplementation, compared to IFA. MMN also improved child outcomes, including diarrhea incidence and retinol concentration, which are findings not previously reported. Across all comparisons, micronutrient supplementation had little to no effect on mortality (maternal, neonatal, perinatal, and infant) outcomes, which is consistent with other systematic reviews. IFA supplementation showed notable improvement in maternal anemia and the reduction in low birthweight, whereas LNS supplementation had no apparent effect on outcomes; further research that compares LNS and MMN supplementation could help understand differences with these commodities. For single micronutrient supplementation, improvements were noted in only a few outcomes, mainly pre-eclampsia/eclampsia (calcium), maternal anemia (iron), preterm births (vitamin D), and maternal serum zinc concentration (zinc). These findings highlight that micronutrient-specific supplementation should be tailored to specific groups or needs for maximum benefit. In addition, they further contribute to the ongoing discourse of choosing antenatal MMN over IFA as the standard of care in LMICs. Full article

Weak delivery systems reduce the potential of evidence-supported interventions to improve nutrition. We synthesized the evidence for the effectiveness of nutrition-specific intervention delivery platforms for improving nutrition outcomes in low and middle-income countries (LMIC). A systematic literature search for studies published from 1997 to June 2018 resulted in the inclusion of 83 randomized controlled trials (RCTs), quasi-randomized, and controlled before–after studies across a variety of delivery platforms. In this paper, we report on meta-analysed outcomes for community health worker (CHW) home visits and mother/peer group delivery platforms. Compared to care as usual, CHW home visits increased early initiation of breastfeeding (EIBF) (OR: 1.50; 95% CI: 1.12, 1.99; n = 10 RCTs) and exclusive breastfeeding (EBF) (OR: 4.42; 95% CI: 2.28, 8.56; n = 9 RCTs) and mother/peer groups were effective for improving children’s minimum dietary diversity (OR: 2.34; 95% CI: 1.17, 4.70; n = 4) and minimum meal frequency (OR: 2.31; 95% CI: 1.61, 3.31; n = 3). Pooled estimates from studies using both home visit and group platforms showed positive results for EIBF (OR: 2.13; 95% CI: 1.12, 4.05; n = 9), EBF (OR: 2.43; 95% CI: 1.70, 3.46; n = 12), and < 5 wasting (OR: 0.77; 95% CI: 0.67, 0.89; n = 4). Our findings underscore the importance of interpersonal community platforms for improving infant and young child feeding practices and children’s nutritional status in LMICs. Full article

Micronutrient deficiencies continue to be widespread among children under-five in low- and middle-income countries (LMICs), despite the fact that several effective strategies now exist to prevent them. This kind of malnutrition can have several immediate and long-term consequences, including stunted growth, a higher risk of acquiring infections, and poor development outcomes, all of which may lead to a child not achieving his or her full potential. This review systematically synthesizes the available evidence on the strategies used to prevent micronutrient malnutrition among children under-five in LMICs, including single and multiple micronutrient (MMN) supplementation, lipid-based nutrient supplementation (LNS), targeted and large-scale fortification, and point-of-use-fortification with micronutrient powders (MNPs). We searched relevant databases and grey literature, retrieving 35,924 papers. After application of eligibility criteria, we included 197 unique studies. Of note, we examined the efficacy and effectiveness of interventions. We found that certain outcomes, such as anemia, responded to several intervention types. The risk of anemia was reduced with iron alone, iron-folic acid, MMN supplementation, MNPs, targeted fortification, and large-scale fortification. Stunting and underweight, however, were improved only among children who were provided with LNS, though MMN supplementation also slightly increased length-for-age z-scores. Vitamin A supplementation likely reduced all-cause mortality, while zinc supplementation decreased the incidence of diarrhea. Importantly, many effects of LNS and MNPs held when pooling data from effectiveness studies. Taken together, this evidence further supports the importance of these strategies for reducing the burden of micronutrient malnutrition in children. Population and context should be considered when selecting one or more appropriate interventions for programming. Full article

Childhood malnutrition is a major public health concern, as it is associated with significant short- and long-term morbidity and mortality. The objective of this review was to comprehensively review the evidence for the management of severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) according to the current World Health Organization (WHO) protocol using facility- and community-based approaches, as well as the effectiveness of ready-to-use therapeutic food (RUTF), ready-to-use supplementary food (RUSF), prophylactic antibiotic use, and vitamin A supplementation. We searched relevant electronic databases until 11 February 2019, and performed a meta-analysis. This review summarizes findings from a total of 42 studies (48 papers), including 35,017 children. Limited data show some benefit of integrated community-based screening, identification, and management of SAM and MAM on improving recovery rate. Facility-based screening and management of uncomplicated SAM has no effect on recovery and mortality, while the effect of therapeutic milk F100 for SAM is comparable to RUTF for weight gain and mortality. Local food and whey RUSF are comparable to standard RUSF for recovery rate and weight gain in MAM, while standard RUSF has additional benefits to CSB. Prophylactic antibiotic administration in uncomplicated SAM improves recovery rate and probably improves weight gain and reduces mortality. Limited data suggest that high-dose vitamin A supplementation is comparable with low-dose vitamin A supplementation for weight gain and mortality among children with SAM. Full article

The objective of this review was to assess the impact of preventive nutrition interventions on health and nutritional status of adolescents aged 10–19 years in low- and middle-income countries (LMICs). We searched the databases until 5 February 2019 without any restrictions on publication, date, language, or publication status. A total of 10 studies (15 papers) including 10,802 participants assessing the impact of micronutrient supplementation/fortification were included in this review. We did not find any study assessing the impact of nutrition education and counseling or macronutrient supplementation among adolescents. Among primary outcomes, we are uncertain of the effect of iron supplementation with or without folic acid on anemia (daily supplementation; relative risk (RR): 1.04, 95% confidence interval (CI) 0.42, 2.57; one study; 1160 participants; low-quality evidence; weekly supplementation; RR: 1.07, 95% CI: 0.46, 2.52; one study; 1247 participants; low-quality evidence). We are also uncertain of the effect of various micronutrient supplementation/fortification on body mass index (BMI) (calcium/vitamin D supplementation; (MD: −0.01 kg/m²; 95% CI: −1.20, 1.17; two studies; 730 participants; I² 94%; very-low-quality evidence, iron supplementation with or without folic acid; MD: 0.47 kg/m²; 95% CI: −0.17, 1.11; two studies; 652 participants; I² 37%; very-low-quality evidence, zinc supplementation; MD: 0.35 kg/m²; 95% CI: −0.15, 0.85; one study; 382 participants; very-low-quality evidence) and multiple micronutrient (MMN) fortification; MD: 0.23 kg/m², 95% CI: −0.11, 0.57; two studies; 943 participants; I² 22%; very-low-quality evidence). None of the included studies reported any other primary outcomes including morbidity or adverse effects. Among secondary outcomes, iron supplementation with or without folic acid may improve hemoglobin concentrations, and calcium/vitamin D supplementation may improve serum 25(OH)D levels, while calcium only supplementation and calcium and vitamin D supplementation may marginally improve total body bone mineral density (BMD). We are uncertain of the effect of MMN fortification on hemoglobin concentrations, calcium supplementation on total body bone mineral content (BMC), calcium + vitamin D supplementation on total body BMC, and zinc supplementation on zinc levels. There is limited evidence of micronutrient supplementation/fortification among adolescents, especially adolescent boys, on health and nutritional status in LMICs. These findings should be interpreted with caution due to the low quality and limited number of studies. Full article