Background: Small birth size, often associated with insufficient maternal nutrition, contributes to a large share of global child undernutrition, morbidity, and mortality. We developed a small-quantity lipid-based nutrient supplement (SQ-LNS) to enrich the diets of pregnant women. Objective: The objective was to test a hypothesis that home fortification of pregnant women's diets with SQ-LNS would increase birth size in an African community. Design: We enrolled 1391 women with uncomplicated pregnancies (,20 gestational weeks) in a randomized controlled trial in Malawi. The women were provided with one daily iron-folic acid (IFA) capsule, one capsule containing multiple micronutrients (MMNs), or one 20-g sachet of SQ-LNS (LNS, containing 118 kcal, protein, carbohydrates, essential fatty acids, and 21 micronutrients). Primary outcomes were birth weight and newborn length. Secondary outcomes included newborn weight, head and arm circumference, and pregnancy duration. Analysis was by intention to treat. Results: The mean 6 SD birth weight and newborn length were 2948 6 432, 2964 6 460, and 3000 6 447 g (P = 0.258) and 49.5 6 2.4, 49.7 6 2.2, and 49.9 6 2.1 cm (P = 0.104) in the IFA, MMN, and LNS groups, respectively. For newborn weight-for-age, head circumference, and arm circumference, the point estimate for the mean was also highest in the LNS group, intermediate in the MMN group, and lowest in the IFA group, but except for midupper arm circumference (P = 0.024), the differences were not statistically significant. The prevalence of low birth weight (,2500 g) was 12.7%, 13.5%, and 12.1% (P = 0.856), respectively; newborn stunting (length-for-age z score , 22) was 19.2%, 14.0%, and 14.9% (P = 0.130), respectively; and newborn small head circumference (head circumference-for-age z score , 22) was 5.8%, 3.0%, and 3.1% (P = 0.099), respectively. The associations between the intervention and the outcomes were not modified by maternal parity, age, or nutritional status (P . 0.100). Conclusion: The study findings do not support a hypothesis that provision of SQ-LNS to all pregnant women would increase the mean birth size in rural Malawi. The trial was registered at clinicaltrials.gov as NCT01239693.

Objective To compare growth and incidence of malnutrition among infants receiving long-term dietary complementation with ready-to-use fortified spread (FS) or micronutrient fortified maize-soy flour (LP). Design Randomized, controlled, single-blind trial Setting Rural Malawian population with high incidence of malnutrition Participants 182 six-month-old infants. Intervention Participants were randomized to receive 1-year-long daily supplementation with either 71g of LP (282 kcal energy / day), 50g FS50 (256 kcal), or 25g FS25 (127 kcal). Main outcome measures Weight and length gain, incidence of severe stunting, underweight, and wasting. Results The mean weight and length gains in LP, FS50 and FS25 groups were 2.37, 2.47, and 2.37 kg (p= 0.658) and 12.7, 13.5, and 13.2 cm (p=0.234), respectively. In the same groups, cumulative 12-month incidence of severe stunting was 14.0%, 0.0% and 4.0% (p=0.011), severe underweight 15.0%, 22.5% and 16.9% (p=0.706), and severe wasting 1.8%, 1.9% and 1.8% (p=0.999). Compared to LP-supplemented infants, those given FS50 gained on average (95%CI;p) 100 g (−143 to 343; p=0.419) more weight and 0.8 cm (−0.1 to 1.7; p=0.091) more length. There was a significant interaction between baseline length and intervention (p=0.042); among children with below-median length at enrolment, those given FS50 gained on average 1.9 cm (0.3 to 3.5; p=0.020) more than individuals receiving LP. Conclusions One-year-long complementary feeding with FS does not have significantly larger effect than maize-soy flour on the average weight gain of all infants, but it seems to boost linear growth in the disadvantaged individuals and hence decrease the incidence of severe stunting.

Our results do not support the hypothesis that LNS supplementation during infancy and childhood promotes length gain or prevents stunting between 6 and 18 mo of age in Malawi. This trial was registered at clinicaltrials.gov as NCT00945698.

Selenium (Se) is an essential human micronutrient. Deficiency of Se decreases the activity of selenoproteins and can compromise immune and thyroid function and cognitive development, and increase risks from non-communicable diseases. The prevalence of Se deficiency is unknown in many countries, especially in sub-Saharan Africa (SSA). Here we report that the risk of Se deficiency in Malawi is large among a nationally representative population of 2,761 people. For example, 62.5% and 29.6% of women of reproductive age (WRA, n = 802) had plasma Se concentrations below the thresholds for the optimal activity of the selenoproteins glutathione peroxidase 3 (GPx3; <86.9 ng mL −1 ) and iodothyronine deiodinase (IDI; <64.8 ng mL −1 ), respectively. This is the first nationally representative evidence of widespread Se deficiency in SSA. Geostatistical modelling shows that Se deficiency risks are influenced by soil type, and also by proximity to Lake Malawi where more fish is likely to be consumed. Selenium deficiency should be quantified more widely in existing national micronutrient surveillance programmes in SSA given the marginal additional cost this would incur.