evidence-based blog of Filippo Dibari

Systematic Review of Complementary Feeding Strategies amongst Children Less than Two Years of Age

In Under-nutrition on March 26, 2014 at 3:24 pm

by Zohra S. Lassi, Guleshehwar Zahid, Jai K. Das, Zulfiqar A. Bhutta

UKAID – 2013 (download)

Extract from Executive Summary

The prevalence of malnutrition in low- and middle-income countries (LMICs) is considerably high. Malnutrition leads to susceptibility to preventable infectious diseases and has an indirect association with the leading causes of death in children. According to an estimate, 19.4% of children less than five years of age in these countries wereunderweight (weight-for-age [WAZ] Z score <-2) and about 29.9% werestunted in the year 2011 (height-for-age [HAZ] Z score <-2). Malnutrition is preventable through effective complementary feeding practices. Several strategies have been employed to improve complementary feeding practices. These include nutritional education to mothers designed to promote healthy feeding practices; provision of complementary food offering extra energy (with or without micronutrient fortification); and increasing energy density of complementary foods through simple technology.

In this review, we have included randomised controlled trials (RCTs)and non-RCTsthat assessed the impact of complementary feedingand education on complementary feeding on linear growth, weight gain, iron status, and morbidity. Broadly, interventions were classified as education on complementary feedingand complementary feedingwith or without nutrition education. We have also mentioned the costs of the interventions given in the included studies and other complementary foods available globally.

All available papers/reports on the effect of complementary feeding(fortified or unfortified, but not micronutrients alone) and education on complementary feeding on children less than twoyears of age in Low and middle income countries (LMIC) were included. Studies that delivered intervention and assessed outcome for at least sixmonths were included. We excluded all those studies in which intervention was given for supplementary and therapeutic purposes and those that assessed the impact of micronutrients alone.

We included 11 randomised controlled trials (RCTs) and 7 non-RCTs. We conducted meta-analysis on RCTs. Amongst all RCTs, eight were on nutritionaleducation only.We found significant impact of nutritional education on linear growth (height-for-age Z scores: SMD 0.22; 95% Confidence Interval [CI]: 0.08, 0.37, n=1,486, 4 studies; stunting: risk ratio (RR) 0.72; 95% CI: 0.57, 0.93, n=1445, 2 studies)and weight (weight-for-age [WAZ]Z scores: SMD 0.20; 95%CI: 0.07, 0.33, n=1673, 4 studies). On the other hand, we found fourtrials in which children were provided with complementary feeding with orwithout nutrition education. We found that complementary feeding with or without education had a non-significant impact on HAZ scores (SMD 0.46; 95% CI: -0.24, 1.17, 4 studies, n=500), and WAZ(SMD 0.15; 95% CI: -0.09, 0.40, 2 studies, n=262).We also performed a meta-analysis based on the type of food, but we are unable to conclude which types of foods are the most effective in preventing undernutrition because the numbers of studies in each subtype were few.

We found that these interventions had a significant impact on reducing the prevalence of respiratory illness (RR 0.68; 95% CI: 0.48, 0.97, 2 studies, n=629). However, there was no difference in fever and diarrhoea episodes.

We also attempted to gather data on cost of the interventions, food products, and complementary feeding strategies used in the included studies. Most papers did not mention estimates of cost and thus, we contacted the authors with the request to provide us with cost data. We have also included cost estimates of various complementary foods that were not used in any of the interventions included in this review but can potentially have an impact in reducing undernutrition. The cost of different baby food products, including cereals, porridge, and biscuits produced by different manufacturers were identified via web search.

The scarcity of available studies and their heterogeneity as well as the variety in complementary feeding interventions make it difficult to determineone particular type of complementary feeding intervention as the most effective. Nonetheless, the results of this review indicate that effectively implemented provision of complementary feedingand education on complementary feedinghave a potential to prevent undernutrition in children. Our review also found that nutritional education and complementary feeding (either individually or combined) both have the potential to reduce morbidity from respiratory infections. However, further high-quality studies need to be conducted which report consistent outcome measures and similar interventions in order to accurately map out which interventions, if scaled up, can be effective.Moreover, these trials should consider using standardised types of food inthe intervention so that evidence can be formulated on which type of food is most effective. It is ideal to keep the duration of intervention for at least six months since anthropometric improvements are gradual. Trials should report consistent outcomes and also include morbidity outcomes. Despite clear evidence of the disastrous consequences of childhood nutritional deprivation in the short and long terms, nutritional health remains a low priority. Therefore, enhanced and rigorous actions are needed to deliver and scale up nutritional education and complementary feeding interventions.

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