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Poor growth and micronutrient deficiency mainly attack older infants and young children. Some countries have adopted clinically effective measures to combat malnutrition, but the compliance and improvement in efficacy of intervention vehicles in national programs require evaluation. Baseline and follow-up cross-sectional surveys were conducted before and after a nutrition intervention program in 3 national poverty counties in China. Soybean-based complementary food supplements called Yingyangbao (YYB) in Chinese and training materials on child feeding were distributed to households with children aged 6-23 months for 18 months. Representative children were selected by probability proportional to size sampling methods to assess compliance of YYB and the intervention efficacy. A questionnaire was designed to collect data on basic characteristics of children, breastfeeding, 24-hour dietary intake, and consumption and appetite of YYB. Anthropometrics and hemoglobin were measured in the field, and anemia prevalence was evaluated. Venous blood was drawn from children aged 12-35 months to evaluate micronutrient status. Logistic regression was used to identify the risk factors for children's anemia. Of the children involved in the follow-up survey (n = 693), the P50 (P25, P75) intake of YYB was 6.7 (3.5, 7.0) sachets weekly, and 54.7% of the children liked the taste of YYB. Compared with the baseline situation (n = 823), the proportion of children fed a diverse diet and foods rich in iron or vitamin A increased (P < 0.01) in the follow-up study. The prevalence of stunting and underweight decreased (P < 0.05), the prevalence of anemia decreased from 28.0% to 19.9% (P < 0.01), and the prevalence of vitamin B12 deficiency decreased from 26.8% to 15.4% (P < 0.01). For children aged 12-23 months, those who liked YYB and consumed 6 or more sachets of YYB weekly were at lower risk for anemia (OR = 0.34, 95% CI 0.13-0.90, P < 0.05), but the risk of stunting was associated with a non-diverse diet (OR = 1.48, 95% CI 1.06-2.07, P < 0.05). The quality of diet and nutritional status of children aged 6-23 months are significantly improved by the intervention of YYB and nutrition education, and good compliance to YYB contributes to a low risk for anemia. Chinese Clinical Trial Registry ChiCTR-OOC-16008846.

Community management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM's effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children <2 years of age is conducted during well-baby consultations (consultation du nourrisson sain [CNS]) at health centers. We hypothesized that the integration of a preventive package including age-appropriate behavior change communication (BCC) on nutrition, health, and hygiene practices and a monthly supply of small-quantity lipid-based nutrient supplements (SQ-LNSs) to the monthly screening would increase AM screening and treatment coverage and decrease the incidence and prevalence of AM. We used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0-17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was α = 0.016 after adjustment for multiple testing. Children's average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10-26, P < 0.001; longitudinal study: +23 pp, 95% CI 17-29, P < 0.001). There were no impacts on either AM treatment coverage (cross-sectional study: +8.0 pp, 95% CI 0.09-16, P = 0.047; longitudinal study: +7.7 pp, 95% CI -1.2 to 17, P = 0.090), AM incidence (longitudinal study: incidence rate ratio = 0.98, 95% CI 0.75-1.3, P = 0.88), or AM prevalence (cross-sectional study: -0.46 pp, 95% CI -4.4 to 3.5, P = 0.82). A study limitation is the referral of AM cases (for ethical reasons) by study enumerators as part of the monthly measurement in the longitudinal study that may have attenuated the detectable impact on AM treatment coverage. Adding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery. ClinicalTrials.gov NCT02245152.

Community-based management of acute malnutrition (CMAM) has been widely adopted to treat childhood acute malnutrition (AM), but its effectiveness in program settings is often limited by implementation constraints, low screening coverage, and poor treatment uptake and adherence. This study addresses the problem of low screening coverage by testing the impact of distributing small-quantity lipid-based nutrient supplements (SQ-LNSs) at monthly screenings held by community health volunteers (CHVs). Screening sessions included behavior change communication (BCC) on nutrition, health, and hygiene practices (both study arms) and SQ-LNSs (one study arm). Impact was assessed on AM screening and treatment coverage and on AM incidence and prevalence. A two-arm cluster-randomized controlled trial in 48 health center catchment areas in the Bla and San health districts in Mali was conducted from February 2015 to April 2017. In both arms, CHVs led monthly AM screenings in children 6-23 months of age and provided BCC to caregivers. The intervention arm also received a monthly supply of SQ-LNSs to stimulate caregivers' participation and supplement children's diet. We used two study designs: i) a repeated cross-sectional study (n = approximately 2,300) with baseline and endline surveys to examine impacts on AM screening and treatment coverage and prevalence (primary study outcomes) and ii) a longitudinal study of children enrolled at 6 months of age (n = 1,132) and followed monthly for 18 months to assess impact on AM screening and treatment coverage and incidence (primary study outcomes). All analyses were done by intent to treat. The intervention significantly increased AM screening coverage (cross-sectional study: +40 percentage points [pp], 95% confidence interval [CI]: 32, 49, p < 0.001; longitudinal study: +28 pp, 95% CI: 23, 33, p < 0.001). No impact on treatment coverage or AM prevalence was found. Children in the intervention arm, however, were 29% (95% CI: 8, 46; p = 0.017) less likely to develop a first AM episode (incidence) and, compared to children in comparison arm, their overall risk of AM (longitudinal prevalence) was 30% (95% CI: 12, 44; p = 0.002) lower. The intervention lowered CMAM enrollment by 10 pp (95% CI: 1.9, 18; p = 0.016), an unintended negative impact likely due to CHVs handing out preventive SQ-LNSs to caregivers of AM children instead of referring them to the CMAM program. Study limitations were i) the referral of AM cases by our research team (for ethical reasons) during monthly measurements in the longitudinal study might have interfered with usual CMAM activities and ii) the outcomes presented by child age also reflect seasonal variations because of the closed cohort design. Incorporating SQ-LNSs into monthly community-level AM screenings and BCC sessions was highly effective at improving screening coverage and reducing AM incidence, but it did not improve AM prevalence or treatment coverage. Future evaluation and implementation research on CMAM should carefully assess and tackle the remaining barriers that prevent AM cases from being correctly diagnosed, referred, and adequately treated. ClinicalTrials.gov NCT02323815.

Objective The present study examined the impacts of training on nutrition, hygiene and food safety designed by the Nutrition Working Group, Child Survival Collaborations and Resources Group (CORE). Design Adapted from the 21d Positive Deviance/Hearth model, mothers were trained on the subjects of appropriate complementary feeding, water, sanitation and hygiene (WASH) practices, and aflatoxin contamination in food. To assess the impacts on child undernutrition, a randomised controlled trial was implemented on a sample of 179 mothers and their children (<2 years old) in two districts of Malawi, namely Mzimba and Balaka. Settings A 21d intensive learning-by-doing process using the positive deviance approach. Subjects Malawian children and mothers. Results Difference-in-difference panel regression analysis revealed that the impacts of the comprehensive training were positive and statistically significant on the Z-scores for wasting and underweight, where the effects increased constantly over time within the 21d time frame. As for stunting, the coefficients were not statistically significant during the 21d programme, although the level of significance started increasing in 2 weeks, indicating that stunting should also be alleviated in a slightly longer time horizon. Conclusions The study clearly suggests that comprehensive training immediately guides mothers into improved dietary and hygiene practices, and that improved practices take immediate and progressive effects in ameliorating children’s undernutrition.

ObjectiveTo assess the effectiveness of dietary counselling and complementary food supplements on anaemia and stunting prevalence in children aged 6–23 months.DesignA controlled intervention study with measurements of height and haemoglobin levels, and cross-sectional surveys in August 2012 (baseline), 2013 (mid-term) and 2014 (end-line).SettingOne intervention county and one control county in rural Qinghai Province, China.InterventionComplementary food supplements (containing protein, fat, carbohydrate, vitamin A, B1, B2, B12, D3, folic acid, iron, zinc and calcium) and complementary feeding counselling were given in the intervention county.ParticipantsCaregivers and their children aged 6–23 months.Primary and secondary outcome measuresEffect of the interventions on the prevalence of anaemia (haemoglobin <110 g/L) and stunting (z-score of height-for-age <−2.0) (controlled for differences between the counties), and on infant feeding practices.ResultsThe surveys were conducted on 1804, 2187 and 2186 children aged 6–23 months in the intervention county in August 2012, 2013 and 2014, respectively, and 804, 680 and 790 children in the control county, respectively. Between the baseline and end-line surveys, anaemia prevalence decreased more in the intervention county than in the control county (71.1% to 47.8% vs 86.3% to 75.3%, respectively; p<0.0001). There was no difference in the decrease in stunting prevalence between the counties (9.7% to 7.1% vs 17.0% to 15.0%; p=0.7954). The proportions of children given iron-rich or iron-fortified food, introduced to (semi-) solid food at 6–8 months, and given food with minimum dietary diversity increased from 43.2% to 88.8% (p<0.0001), 81.4% to 96% (p=0.0470) and 53.0% to 59.8% (p<0.0001), respectively in the intervention county.ConclusionsWe found much higher anaemia prevalence in poor rural areas of Qinghai Province compared with the national data. Community-based complementary food supplements combined with dietary counselling can improve feeding practices and reduce anaemia prevalence. Future studies should use longer follow-up to assess the effects on stunting.Strengths and limitationsWe included a large number of participants and assessed a combined complementary food supplements and dietary counselling intervention in a poor rural area in China with high anaemia prevalence. Although the study took place in only one intervention county and one control county, we conducted an analysis that controlled for differences between the two counties. Also, although we made significant efforts to train village doctors, their education was not systematically assessed after training and thus their delivery of the interventions may have been variable.Trial registration numberChiCTRPRC12002444; Pre-results.

An integrated care pathway to manage small and nutritionally at‐risk infants under 6 months (u6m) and their mothers (MAMI Care Pathway) is consistent with 2023 WHO malnutrition guidelines and is being tested in a randomised controlled trial (RCT) in Ethiopia. To optimise trial implementation, we investigated contextual fit with key local stakeholders. We used scenario‐based interviews with 17 health workers and four district managers to explore perceived feasibility. Eighteen policymakers were also surveyed to explore policy coherence, demand, acceptability, evidence needs, opportunities and risks. The Bowen feasibility framework and an access to health care framework were adapted and applied. Health workers perceived the MAMI Care Pathway as feasible to implement with support to access services and provide care. The approach is acceptable, given consistency with national policies, local protocols and potential to improve routine care quality. Demand for more comprehensive, preventive and person‐centred outpatient care was driven by concerns about unmet, hidden and costly care burden for health services and families. Inpatient care only for severe wasting treatment is inaccessible and unacceptable. Support for routine and expanded components, especially maternal mental health, is needed for successful implementation. Wider contextual factors may affect implementation fidelity and strength. Policymakers cautiously welcomed the approach, which resonates with national commitments, policies and plans but need evidence on how it can work within varied, complex contexts without further system overstretch. A responsive, pragmatic randomised controlled trial will generate the most useful evidence for policymakers. Findings have informed trial preparation and implementation, including a realist evaluation to contextualise outcomes. A formative feasibility study investigated factors that may influence implementation of the MAMI Care Pathway during a randomised controlled trial in Ethiopia. Health workers perceived it was feasible to implement with support. Policy‐makers need evidence on how it works. Findings strengthened implementation plans and informed a process evaluation to accompany the trial. Key messages The MAMI Care Pathway integrated approach is perceived as acceptable, needed and possible to implement during a randomised control trial in outpatient clinics in Ethiopia. Contextualised inputs (training, staffing, space and supplies) will be needed to strengthen implementation of existing activities and for new components. Breastfeeding counselling skills and maternal care provision, especially maternal mental health, are varied and often limited in routine services. National policymakers need trial implementation evidence to contextualise RCT outcomes for policy development.

Evidence of the impact of community-based nutrition programs is uncommon for two main reasons: the lack of untreated controls, and implementation does not account for the evaluation design. Suchana is a large-scale program to prevent malnutrition in children in Sylhet division, Bangladesh by improving the livelihoods and nutrition knowledge of poor and very poor households. Suchana is being implemented in 157 unions, the smallest administrative unit of government, in two districts of Sylhet. Suchana will deliver a package of interventions to poor people in about 40 randomly selected new unions annually over 4 years, until all are covered. All beneficiaries will receive the normal government nutrition services. For evaluation purposes the last 40 unions will act as a control for the first 40 intervention unions. The remaining unions will receive the program but will not take part in the evaluation. A baseline survey was conducted in both intervention and control unions; it will be repeated after 3 years to estimate the impact on the prevalence of stunted children and other indicators. This stepped wedge design has several advantages for both the implementation and evaluation of services, as well as some disadvantages. The units of delivery are randomized, which controls for other influences on outcomes; the program supports government service delivery systems, so it is replicable and scalable; and the program can be improved over time as lessons are learned. The main disadvantages are the difficulty of estimating the impact of each component of the program, and the geographical distribution of unions, which increases program delivery costs. Stepped implementation allows a cluster randomized trial to be achieved within a large-scale poverty alleviation program and phased-in and scaled-up over a period of time. This paper may encourage evaluators to consider how to estimate attributable impact by using stepped implementation, which allows the counterfactual group eventually to be treated.

Background Maternal and child undernutrition have adverse consequences for pregnancy outcomes and child morbidity and mortality, and they are associated with low educational attainment, economic productivity as an adult, and human wellbeing. ‘Nutrition-sensitive’ agriculture programs could tackle the underlying causes of undernutrition. Methods/design This study is a four-arm cluster randomised controlled trial in Odisha, India. Interventions are as follows: (1) an agricultural extension platform of women’s groups viewing and discussing videos on nutrition-sensitive agriculture (NSA) practices, and follow-up visits to women at home to encourage the adoption of new practices shown in the videos; (2) women’s groups viewing and discussing videos on NSA and nutrition-specific practices, with follow-up visits; and (3) women’s groups viewing and discussing videos on NSA and nutrition-specific practices combined with a cycle of Participatory Learning and Action meetings, with follow-up visits. All arms, including the control, receive basic nutrition training from government community frontline workers. Primary outcomes, assessed at baseline and 32 months after the start of the interventions, are (1) percentage of children aged 6–23 months consuming ≥ 4 out of 7 food groups per day and (2) mean body mass index (BMI) (kg/m 2 ) of non-pregnant, non-postpartum (gave birth > 42 days ago) mothers or female primary caregivers of children aged 0–23 months. Secondary outcomes are percentage of mothers consuming ≥ 5 out of 10 food groups per day and percentage of children’s weight-for-height z -score < -2 standard deviations (SD). The unit of randomisation is a cluster, defined as one or more villages with a combined minimum population of 800 residents. There are 37 clusters per arm, and outcomes will be assessed in an average of 32 eligible households per cluster. For randomisation, clusters are stratified by distance to nearest town (< 10 km or ≥ 10 km), and low (< 30%), medium (30–70%), or high (> 70%) proportion of Scheduled Tribe or Scheduled Caste (disadvantaged) households. A process evaluation will assess the quality of implementation and mechanisms behind the intervention effects. A cost-consequence analysis will compare incremental costs and outcomes of the interventions. Discussion This trial will contribute evidence on the impacts of NSA extension through participatory, low-cost, video-based approaches on maternal and child nutrition and on whether integration with nutrition-specific goals and enhanced participatory approaches can increase these impacts. Trial registration ISRCTN , ISRCTN65922679 . Registered on 21 December 2016.

Objective To determine the effects of lipid-based nutrient supplements (LNS) on children's Hb, linear growth and development, compared with supplementation with micronutrient powder (MNP). Design The study was a two-arm parallel-group randomized controlled trial, where participants received either LNS or MNP for daily consumption during 6 months. Supplements were delivered by staff at government-run health centres. Hb, anthropometric, motor development, language development and problem-solving indicators were measured by trained research assistants when children were 12 months of age. Setting The study was conducted in five rural districts in the Province of Ambo in the Department of Huánuco, Peru. Subjects We enrolled 6-month-old children (n 422) at nineteen health centres. Results Children who received LNS had a higher mean Hb concentration and lower odds of anaemia than those who received MNP. No significant differences in height-for-age, weight-for-height or weight-for-age Z-score, or stunting and underweight prevalence, were observed. Provision of LNS was associated with a higher pre-verbal language (gestures) score, but such effect lost significance after adjustment for covariates. Children in the LNS group had higher problem-solving task scores and increased odds of achieving this cognitive task than children in the MNP group. No significant differences were observed on receptive language or gross motor development. Conclusions LNS between 6 and 12 months of age increased Hb concentration, reduced anaemia and improved cognitive development in children, but showed no effects on anthropometric indicators, motor or language development.