Optimal nutrition is crucial during the critical period of the first 1,000 days from conception to 2 years after birth. Prenatal and postnatal supplementation of mothers with miltimicronutrient-fortified balanced energy-protein (BEP) supplements is a potential nutritional intervention. However, evidence on the long-term effects of BEP supplementation on child growth is inconsistent. We evaluated the efficacy of daily fortified BEP supplementation during pregnancy and lactation on infant growth in rural Burkina Faso. A 2×2 factorial individually randomized controlled trial (MISAME-III) was implemented in 6 health center catchment areas in Hounde district under the Hauts-Bassins region. From October 2019 to December 2020, 1,897 women aged 15 to 40 years with gestational age <21 completed weeks were enrolled. Women were randomly assigned to the prenatal intervention arms receiving either fortified BEP supplements and iron-folic acid (IFA) tablets (i.e., intervention) of IFA alone (i.e., control), which is the standard of care during pregnancy.  The same women were concurrently randomized to receive either of the postnatal intervention, which comprised fortified BEP supplementation during the first 6 months postpartum in combination with IFA for the first 6 weeks (i.e., intervention), or the postnatal control, which comprised IFA alone for 6 weeks postpartum (i.e., control). Supplements were provided by trained village-based project workers under direct observation during daily home visits. This study provides evidence that the benefits obtained from prenatal BEP supplementation on size at birth are sustained during infancy in terms of linear growth. Maternal BEP supplementation during lactation may lead to a slightly better linear growth towards the second half of infancy. These findings suggest that BEP supplementation during pregnancy can contribute to the efforts to reduce the high burden of child growth faltering in low-and middle-income countries.

The Tanzania Food and Nutrition Center (TFNC) carried out research studies in Mbeya Region, Tanzania to inform the Improving Maternal and Adolescents Nutrition (IMAN) project. One component of the IMAN project was a trial integrating multiple micronutrient supplements and nutrition interventions into an existing maternal, neonatal, and child health program. To inform the trial, TFNC conducted a dietary assessment study among pregnant and lactating women. The objective was to assess micronutrient intake and the prevalence of inadequate intake among non-pregnant, non-lactating women of reproductive age (WRA; 15-49 years). This study will help guide nutrition programs to improve interventions to address micronutrient inadequacy in the area. Inadequate consumption of 11 key micronutrients is highly prevalent among WRA in Mbeya Region, Tanzania. Nearly all women in the study population would benefit from increased consumption of vitamin C and E, riboflavin, iron, and zinc.

Designing a cost-effective portfolio of micronutrient intervention programs is complex and generally undertaken with limited data. We developed the MINIMOD-Secondary Data (MINIMOD-SD) tool, which uses household consumption and expenditure survey data and other secondary data to estimate apparent nutrient intakes and model the effectiveness and cost-effectiveness of micronutrient intervention programs. We present the SD tool methodology and results in the context of Cameroon, with a particular focus on vitamin A (VA) for children and folate for women of reproductive age (WRA). We compared the MINIMOD-SD tool estimates with those of the full MINIMOD tool, which uses 24-h dietary recall data. Qualitatively, however, the two tools were generally consistent in predicted subnational patterns of micronutrient adequacy and identification of effective and cost-effective (cost per child/WRA moving from inadequate to adequate intake) interventions. Secondary data and the MINIMOD-SD tool can provide policymakers with information to qualitatively assess deficiency risks and identify cost-effective interventions. However, accurately quantifying individual-level deficiency or dietary inadequacy and intervention effectiveness and cost-effectiveness will likely require individual-level dietary data and biomarker measurements.

Meeting children’s vitamin A (VA) needs remains a policy priority. Doing so efficiently is a fiscal imperative and protecting at-risk children during policy transitions is a moral imperative. Using the Micronutrient Intervention Modeling tool and data for Cameroon, we predict the impacts and costs of alternative VA intervention programs, identify the least-cost strategy for meeting targets nationally, and compare it to a business-as-usual (BAU) strategy over 10 years. BAU programs effectively cover ~12.8 million (m) child-years (CY) and cost ~$30.1m; ~US$2.34per CY effectively covered. Improving the VA-fortified oil program, implementing a VA-fortified bouillon cubeprogram, and periodic VA supplements (VAS) in the North macro region for 3 years effectively cover ~13.1m CYat a cost of ~US$9.5m, or~US$0.71 per CY effectively covered. The tool then identifies a sequence of subnational policy choices leading from the BAU toward the more efficient strategy, while addressing VA-attributable mortality concerns. By year 4, fortification programs are predicted to eliminate inadequate VA intake in the South and Cities macro regions, but not the North, where VAS should continue until additional delivery platforms are implemented. This modeling approach offers a concrete example of the strategic use of data to follow the Global Alliance for VA framework and do so efficiently.

Balanced energy protein (BEP) supplementation is an efficacious intervention in pregnancy for improving birthweight and is recommended by World Health Organization (WHO) in countries with high maternal undernutrition. Few countries have implemented BEP programmes due in part to high cost, lack of data on acceptability and feasibility, and complexity of delivery. We sought to address implementation gaps in BEP interventions through a formative study designed to understand implementation outcomes. WE conducted 52 in-depth interviews and 8 focus-group discussions with married women of reproductive age, family members, health care providers and pharmacists in three unions of the Gaibandha district in rural Bangladesh. Interviews were translated and transcribed in English and analysed using an analytic framework for implementation science in nutrition. BEP was viewed as an acceptable and appropriate intervention to combat undernutrition in this setting. There was a lack of clarity on who should or could be responsible for providing/distributing BEP in a way convenient to mothers. Many participants preferred door-to-door delivery and thought this approach could address social and gender inequities, but providers mentioned already being overworked and worried about adding new tasks. Participants were concerned about the affordability of BEP and opportunity costs associated with travel to proposed distribution sites such as ANC or pharmacies. Women in these communities do not always have the agency to travel without supervision or make purchasing decisions. BEP supplementation is a complex intervention; future trials seek to assess ways to overcome these implementation challenges and inform a long-term systems-owned BEP intervention.

Prenatal multiple micronutrient supplementation (MMS) and lipid-based nutrient supplementation (LNS) can improve birth outcomes relative to iron-folic acid supplementation (IFA); however, effects on child postnatal growth remain unclear. The aim was to compare the effect of prenatal MMS, medium-quantity LNS (MQ-LNS), and IFA on child growth up to 2 y of age. We conducted a cluster randomized controlled trial of prenatal nutritional supplementation in Madarounfa, Niger. Villages were randomly assigned for pregnant women to receive IFA (17 villages, 1105 women), MMS (18 villages, 1083 women) or MQ-LNS (18 villages, 1144 women). Pregnant women received nutritional supplements weekly until delivery, and children were followed up monthly from 6-8 weeks to 24 months of age. We assessed the effect of prenatal MMS and MQ-LNS compared with IFA and the effect of prenatal MMS compared with MQ-LNS on child length for-age z scores (LAZ), weight-for-age z scores (WAZ), and weight-for-length z scores (WLZ) at 24 months of age using generalized linear models. In secondary analyses, we used mixed-effects models to assess the trajectories of anthropometric z scores longitudinally from 6-8 weeks to 24 mo. Compared with IFA, MMS and MQ-LNS had no effect on child LAZ, WAZ, or WLZ at 24 months of age (P>0.05). Children in the MQ-LNS arm had significantly higher mid-upper arm circumference at 24 months than children in the MMS arm: mean difference 0.50cm (95% CI 0.10, 0.91cm). WAZ and WLZ trajectories were more negative in the MQ-LNS arm compared with IFA and MMS, with lower z scores from 14 to 20 months of age. However, WAZ and WLZ trajectories converged after 20 months of age, and there were no differences by 24 months of age. Prenatal MMS and MQ-LNS had limited effect on anthropometric measures of child growth up to 24 months of age as compared with IFA in rural Niger.

Globally, 45% of under-five deaths are either directly or indirectly attributable to malnutrition, and most of these deaths are in low- and middle-income countries (LMICs). Children are particularly vulnerable in the first 6 months of life. An estimated 4.7 million infants under the age of 6 months are moderately wasted, whereas 3.8 million are severely wasted. Although the children of malnourished women have an increased risk of stunting and wasting, there is little information on this issue. This is a community-based, open-label, multiarm randomized controlled trial that will include parallel group assignments with a 1:1:1 allocation ration in low-income squatter settlements in urban Karachi, Pakistan. The women in the control group (control arm) will receive standard counseling only, whereas the lactating women in the first intervention group (intervention arm 1) will receive two sachets of balanced energy protein (BEP) supplementation per day from enrollment until the infant reaches 6 months of age. The lactating women in the second intervention group (intervention arm 2) will receive the same BEP supplementation as those in intervention arm 1 while their babies will also receive a single stat dose (20 mg/kg orally) of azithromycin at 42 days. The primary outcome will be the relative length velocity from 0 to 6 months by intervention arm. The primary analysis will be intention-to-treat analysis.

In lower-middle-income settings, growth faltering in the first 6 months of life occurs despite exclusive breastfeeding. The aim was to test the efficacy of an approach to improve the dietary adequacy of mothers during lactation and thus improve the growth of their infants. Eligible mother-infant dyads (infants less or 7 d of age) were randomly assigned to either intervention or control groups. Mothers in the intervention group received snacks that were to be consumed daily, which provided 600 kcal of energy – with 25-30% of energy derived from fats (150-180kcal) and 13% of energy from protein (80kcal). Micronutrients were supplemented as daily tablets. We provided counseling on breastfeeding and infant-care practices to mothers in both groups. The primary outcome was attained infant length-for-age z scores (LAZ) at 6 months of age. Secondary outcomes included exclusive breastfeeding proportion reported by the mother, maternal BMI and midupper arm circumference (MUAC), hemoglobin concentrations in mothers and infants, and the proportion of anemic infants at 6 months of age. We enrolled 816 mother-infant dyads. The intervention did not achieve a significant effect on LAZ at 6 months (adjusted mean difference: 0.09; 95% CI: -0.03, 0.20). Exclusive breastfeeding at 5 months was higher (45.1%vs. 34.5%; RR: 1.31; 95% CI: 1.04, 1.64) in the intervention group compared with the controls. There were no significant effects on mean hemoglobin concentration. We noted significant effects on maternal nutritional status (BMI, MUAC, hemoglobin concentration, and proportion anemic). Postnatal supplementation of 600 kcal energy, 20g protein, and multiple micronutrients daily to lactating mothers did not affect infant LAZ at 6 months of age. Such supplementation may improve maternal nutritional status.

The period from conception to two years of life denotes a critical window of opportunity for promoting optimal growth and development of children. Poor nutrition and health in women of reproductive age and during pregnancy can negatively impact birth outcomes and subsequent infant survival, health and growth. Studies to improve birth outcomes and to achieve optimal growth and development in young children have usually tested the effect of standalone interventions in pregnancy and/or the postnatal period. It is not clearly known whether evidence-based interventions in the different domains such as health, nutrition, water sanitation and hygiene (WASH) and psychosocial care, when delivered together have a synergistic effect. Further, the effect of delivery of an intervention package in the pre and peri-conception period is not fully understood. This study was conceived with an aim to understand the impact of an integrated intervention package, delivered across the pre and peri-conception period, through pregnancy until 24 months of child age on birth outcomes, growth and development in children. An individually randomised controlled trial with factorial design conducted in urban and peri-urban low to mid-socioeconomic neighborhood in South Delhi, India. This study will demonstrate the improvement that can be achieved when key factors known to limit child growth and development are addresses together, throughout the continuum from pre and peri-conception until early childhood. The findings will increase our scientific understanding and provide guidance to nutrition programs in low- and middle-income settings.

Adequate nutrition during pregnancy is crucial to both mother and child. Maternal malnutrition can be the cause of stillbirth or lead to poor birth outcomes such as preterm delivery and small-for-gestational age newborns. There is a probable positive effect of providing pregnant women a balanced energy-protein (BEP) food supplement, but more evidence is needed. The Micronutriments pour la SAnte de la Mere et de l’Enfant (MISAME) III project aims to improve birth outcomes and infant growth by testing a BEP supplement during pregnancy and lactation in rural Burkina Faso. This paper describes the study protocol. MISAME-III is a four-arm individually randomised efficacy trial implemented in six rural health centre catchment areas in the district of Hounde. Women were randomly assigned to one of the four study groups: (1) prenatal intervention only, (2) postnatal intervention only, (3) prenatal and postnatal intervention or (4) no prenatal or postnatal intervention. The intervention group received the BEP supplement and iron/folic acid (IFA) tablets, while the control group only received the IFA tablets following the national health protocol. Consumption was supervised by trained village women on a daily basis by means of home visits. The primary outcomes are small-for-gestational age at birth and length-for-age z-score at 6 months of age. Secondary outcomes were measured at birth and during the first 6months of the infants’ life.