Micronutrient supplementation is widely used to prevent stunting in children under 5 years in low‐ and middle‐income countries (LMIC), but the impact of treatment has been disappointing, possibly due to non‐compliance. Our aim was to deliver long‐term micronutrient supplementation via a novel, culturally acceptable liquid food to improve linear growth in a high stunting prevalence region. In a randomised control trial, 971 children aged 6–72 months received either ‘Chispuditos®’ (n = 681), a hot drink (atole) fortified with micronutrients (atole + MN) (9 mg/zinc, 12.5 mg/iron), or lactose‐free milk (n = 290) for 18 months. Primary outcomes were changes in length/height‐for‐age (HAZ) score and the prevalence of stunting at 18‐month follow‐up. Adherence was monitored monthly, and 73% children in atole + MN group consumed at least half their daily zinc and iron requirement. At 18 months, there was no difference between the treatments in growth [mean change in HAZ −0.02 (95% CI −0.12, 0.08)] or stunting [atole + MN 41%, milk 41%; RR 0.99 (95% CI 0.84, 1.19)]. There were no differences in haemoglobin (HB), ferritin or zinc. No children had iron deficiency anaemia (IDA) at outcome, but zinc deficiency remained equally prevalent in both groups: atole + MN 35%, milk 35% [RR 1.02 (95% CI 0.83, 1.24)]. There was no difference in morbidity between the groups, and micronutrient status was unrelated to HAZ. Long‐term micronutrient supplementation via a culturally acceptable food had no impact on stunting or morbidity, raising the question of whether large‐scale micronutrient supplementation is worthwhile.

Objectives Undernutrition risk increases when children transition to complementary feeding in lower/middle income countries. Our newly developed ICFET assesses feeding and eating behavior (FEB); we aimed to test its performance in different countries and assess FEB in wasted and healthy infants. Methods Healthy and malnourished children aged 6–24 months were sampled from child health and malnutrition clinics in urban slums in Nairobi, Kenya (n = 157), peri-urban Lahore, Pakistan (n = 108), rural Retalhuleu, Guatemala (n = 125) and playgroups in Glasgow, United Kingdom (UK, n = 97). Children were measured and parents surveyed using the ICFET, which comprises standardized questions on meal frequency and self-feeding, and 5-point scores for enthusiasm for eating (Avidity), food refusal (Avoidance) and Force-feeding. Results Of 487 children, mean (SD) age 14.2 (5.3) months, 77 (16%) were wasted (body mass index < −2SD). Complementary feeding started earliest in the UK, with 91% starting before 6 m, and latest in Pakistan, where 27% started ≥ 8 m. In 336 healthy weight children, median (Q1, Q3) Avidity was higher (3.67; 2.8–4.2) than Avoidance (2.0; 1.6–2.6); Kenyan children had highest avoidance (2.4; 1.8–3.0) and Pakistani children lowest avidity (2.2; 2–2.8). Force feeding was rare in the UK (17%) and Guatemala (15%), but common in Pakistan (76%) and Kenya (82%). In LMIC children, wasted infants had lower median Avidity (2.7) than healthy (3.5; P < 0.001), but similar Avoidance and Force-feeding. Healthy children were offered 3 (2–3) plated meals and 1 (0–3) energy dense snacks daily. Compared to healthy, wasted children had fewer meals (2; vs 3; P = 0.006) and more milk (3 vs 2; P = 0.016). Conclusions Malnourished children were less hungry and ate fewer meals, but still refused food. The ICFET identified between country variation in complementary feeding behavior. It will be valuable for the identification of poor feeding and eating practices and informing intervention. Funding Sources Scottish Funding Council (Global Challenges Research Fund).

Undernutrition and a lack of learning opportunities can jeopardize long-term growth and development among infants in low- and middle-income countries. We conducted a 6-month 2 × 2 cluster-randomized trial to assess the effects of multiple micronutrient-fortified beverages and responsive caregiving interventions among infants 6–18 months in 72 community sectors in southwest Guatemala. We administered baseline and endline assessments of childhood development (Bayley Scales of Infant and Toddler Development) and socioemotional development (Brief Infant Toddler Socio-Emotional Assessment) and measured ferritin and hemoglobin on a subsample. The trial was analyzed using linear mixed models. At the baseline, the mean age (SD) was 13.0 (4.6) months, including 49% males, 32% who were stunted, 55% who were anemic, and 58% who were iron deficient. At the endline (n = 328/386, 85% retention), there was no synergistic effect on the fortified beverage and responsive caregiving intervention. Compared to the non-fortified beverage group, socioemotional development improved in the fortified beverage group. There were no intervention effects on other measures of child development, hemoglobin, or ferritin. In a setting with high rates of anemia and iron deficiency, a multiple micronutrient-fortified beverage improved infants’ socioemotional development.

Objectives To determine the long-term impact of a micronutrient fortified supplement on stunting rates and micronutrient status in young children living in rural Guatemala, which has the highest stunting prevalence in Latin America. Methods A parallel, open label randomised control trial in rural children aged 6–72 months (Registration NCT01643187). After growth screening, all children < 1SD for either weight for height (WHZ), height for age (HAZ), or weight for age (WAZ) were randomly allocated using 7:3 ratio, stratified by locality and age to receive either the test drink, Chispuditos®, a corn/soy beverage fortified with 21 vitamins or de-lactosed milk (control). Both drinks were isoproteic (4g/drink) and had similar energy content (test drink 147 kcal, milk 117 kcal) but the tst drink had higher micronutrient content (e.g., 9 mg zinc, 12.5 mg iron vs 1.5 mg zinc, 1.9 mg iron in control). They were supplied for 18 months and monthly visits were conducted to test for adherence. Results A total of 1238 children were screened, 971 met the criteria and 681 were allocated to test drink and 290 to control. At baseline, malnutrition prevalence of stunting (HAZ < -2SD), for test vs control was 48.4% vs 47.9%, 5.5% vs 6.7% for wasting (WHZ < -2SD) and 19.9% vs 18.7% for underweight (WAZ < -2SD). 73% of children reported to consume at least half of allocated drinks/day. After 18 months of intervention, the prevalence and relative risks [RR (95% CI)] for stunting in the test: control were 40.6:40.7% [RR 0.99 (0.84, 1.19)]; similarly, no differences were seen in WAZ, WHZ nor micronutrient status. Conclusions In this trial in rural Guatemalan children, long term supplementation with a micronutrient enriched drink had no impact on either stunting or micronutrient status. These results differ form long-term studies in urban Guatemalan nurseries. The present study suggest that fortified foods alone are not enough to reduce stunting rates in this setting when fed during an 18 month period. Funding Sources The Mathile Institute for the Advancement of Human Nutrition funded this study.

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