What is home fortification?
Home fortification is used in situations where local diets - or, in the case of emergencies, food aid baskets -do not provide enough micronutrients. Home fortification puts technology into the caregiver's hands, empowering them to improve the quality of their family's diet by adding micronutrients to the locally available foods they prepare at home. The process involves adding specialized ingredients such as multi-micronutrient powders (ie Sprinkles®), lipid-based nutrient supplements (LNS) and other nutritious foods to the local meals that people eat every day.
What is the Home Fortification Technical Advisory Group?
The Home Fortification Technical Advisory Group (HF-TAG) is a global network of stakeholders engaged in home fortification, comprised of members from governmental, UN, NGO, private and academic sectors.
The HF-TAG's vision is improving nutrition for health and development and its mission is to provide leadership by advocating and supporting well-designed and effective home fortification interventions at scale for children and women, based on sound technical guidance and best practices. The initiative aims to scale up home fortification and to improve delivery, whether through public or market-based channels, for home fortification by providing standards, guidelines and resources to implementers of programs, producers of home fortification products and supporting entities. The network seeks to represent all these key stakeholder groups and address the most important and feasible barriers to home fortification.
What services does the HF-TAG provide?
The HF-TAG website serves as a central, online hub for home fortification. By aggregating and connecting existing resources and building a shared space for discussion, the HF-TAG will increase the intra-sector and multi-sector collaboration necessary to improve health outcomes. The HF-TAG is built on the principle of inclusion and expands home fortification information/guidance within the public domain. Prescriptive nutrition science guidance provided is evidence-based and other guidance based on best practice and experience.
What is the purpose of the HF-TAG?
The initiative aims to provide standards, guidelines and resources to policymakers, non-governmental organizations, international organizations, corporations (manufacturers and suppliers), innovators/social entrepreneurs, academia and media interested in home fortification. The group seeks to represent all key stakeholder groups and address the most important and feasible barriers to home fortification.
What is SickKids Centre for Global Child Health's role in the group?
SickKids Centre for Global Child Health (C-GCH) serves as the Secretariat, providing its technical expertise to set the group's strategy, maintain the HF-TAG website, support working groups around priority topics and the creation of HF-TAG resources, facilitate conference calls and in-person meetings and coordinate the activities of the Executive Committee. The C-GCH is taking over from GAIN, which served as the Secretariat from the start of the HF-TAG in 2009 up until the end of 2014.
Lipid-Based Nutrient Supplements
What are Lipid-Based Nutrient Supplements (LNS)?
Lipid-based nutrient supplements (LNS) are a family of products designed to deliver nutrients to vulnerable people. They are considered “lipid-based” because the majority of the energy provided by these products is from lipids (fats). All LNS provide a range of vitamins and minerals, but unlike most other multiple micronutrient supplements, LNS also provide energy, protein, and essential fatty acids (EFA). LNS formulations and doses can be tailored to meet the nutrient needs of specific groups (for example, children under 2 years of age) and to fit in particular programmatic contexts (for example, preventive or therapeutic programs, emergency programs).
What are some examples of LNS?
The best known LNS are the ready-to-use therapeutic foods (RUTF) such as Plumpy'nut®. RUTF are now widely used in treating severe acute malnutrition (SAM), including in community-based programs. RUTF are designed to achieve specific daily weight gains of in order to reach a target weight-for-height consistent with nutritional recovery. RUTF thus temporarily replace most or all foods other than breast milk. There is substantial evidence that programs using RUTF result in better outcomes and fewer deaths, compared to the previous standard care.1-3.
More recently, LNS products such as Nutributter®, which provide significantly less daily energy than RUTF but a full complement of micronutrients, were shown to prevent child stunting and support normal motor development in trials in Malawi and Ghana4-7. These lower dose products are designed to enrich and not replace locally available foods. Additional efficacy trials are underway to improve the formulations and extend knowledge about the potential of lower-dose LNS products to contribute to prevention of under-nutrition.
1.Briend A, Lacsala R, Prudhon C, Mounier B, Grellety Y, Golden MH. Ready-to-use therapeutic food for treatment of marasmus. Lancet 1999;353:1767-8.
2.Ciliberto MA, Sandige H, Ndekha MJ, et al. Comparison of home-based therapy with ready-to-use therapeutic food with standard therapy in the treatment of malnourished Malawian children: a controlled, clinical effectiveness trial. Am J Clin Nutr 2005;81:864-70.
3.WHO, WFP, SCN, UNICEF. Community-based management of severe malnutrition. A joint statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition, and the United Nations Childrens Fund., 2007.
4.Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007;86:412-20.
5.Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana. Am J Clin Nutr 2008;87:929-38.
6.Phuka JC, Maleta K, Thakwalakwa C, et al. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-month-old rural Malawians. Arch Pediatr Adolesc Med 2008;162:619-26.
7.Phuka JC, Maleta K, Thakwalakwa C, et al. Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr 2009;89:382-90.
What is the difference between LNS and Ready-to-use Food (RUF)?
LNS are one example of a ready-to-use food (RUF). RUF include any foods that do not require preparation in the home. RUF also refers to products that are safe to store without refrigeration. RUF have low moisture content and do not require dilution or cooking, so risk of contamination is low.
What is the food base for LNS?
LNS recipes can include a variety of ingredients, but typically have included vegetable fat, peanut/groundnut paste, milk powder and sugar. Alternative recipes and formulations are currently being explored in efforts to develop affordable and culturally acceptable products for a range of settings. Other ingredients have included whey, soy protein isolate, and sesame, cashew, and chickpea paste, among others.
Where do LNS fit alongside other products/programmatic approaches to address under-nutrition?
Currently, several approaches and products are being used to address infant and child under-nutrition. Approaches include promotion and support for breastfeeding, and behavior change communication encouraging enrichment of porridges with locally available and nutrient-dense foods. Other products include fortified blended foods to replace local staple foods, fortified full-fat soy flour, other complementary food supplements, and micronutrient powders such as Sprinkles® 1. Choices among approaches and/or products depend on many factors including the nature and underlying prevalence of malnutrition, the food security situation, and cultural preferences, as well as program or policy objectives. Cost and available resources also shape choices. On-going research will help clarify where LNS may best fit among the available options2-3. This research should include consideration of operational and implementation issues, as well as cost and comparative cost-effectiveness4.
- Ten Year Strategy to Reduce Vitamin and Mineral Deficiencies M, Infant and Young Child Nutrition Working Group: Formulations Subgroup. Formulations for fortified complementary foods and supplements: Review of successful products for improving the nutritional status of infants and young children. Food and Nutrition Bulletin 2009;30:17.
- WFP. Ten minutes to learn about nutrition programming. A joint initiative of the World Food Programme and DSM. Sight and Life Magazine 2008;2008:43.
- Dewey KG, Yang Z, Boy E. Systematic review and meta-analysis of home fortification of complementary foods. Maternal and Child Nutrition 2009;forthcoming.
- Neufeld LM. Ready-to-use therapeutic food for the prevention of wasting in children. JAMA 2009;301:327-8.
Does LNS replace other food?
LNS should not take the place of a diverse diet. RUTF temporarily replaces other foods for children treated for SAM. Otherwise, diets of infants and young children should gradually become more diverse, to include a variety of available fruits, vegetables, and animal-source foods. All infants need to learn to eat and enjoy locally available nutrient-dense foods. Additional supplements such as LNS may be necessary because of limited availability and quantity of such foods, especially animal-source foods.
Does LNS replace breastmilk?
LNS should not replace breastmilk. Good breastfeeding practices, including exclusive breastfeeding to 6 months and continued breastfeeding to 2 years or beyond, are critical to child survival and health. Two studies have shown that breast milk intake did not differ between children supplemented with LNS and those supplemented with a fortified blended food (FBF)1,2. Absolute breast milk intakes were slightly higher than the global average in both groups, despite consumption of LNS or FBF2. Four other studies did not assess breast milk intake but reported that frequency of breastfeeding was not decreased for infants given LNS3-6. Nevertheless, because breastfeeding is critical to child survival and continues to provide nutrient-dense, high-quality nourishment for infants to two years and beyond, additional studies across various age groups and settings are needed to confirm that LNS does not displace or decrease breast milk intake. Breast milk intake and breastfeeding practices are being assessed in iLiNS studies.
- Galpin L, Thakwalakwa C, Phuka J, et al. Breast milk intake is not reduced more by the introduction of energy dense complementary food than by typical infant porridge. J Nutr 2007;137:1828-33.
- Owino VO, et al. Breast-milk intake of 9-10-mo-old rural infants given a ready-to-use complementary food in South Kivu, Democratic Republic of Congo. Am J Clin Nutr. 2011 Jun; 93(6):1300-4. Epub 2011 Mar 30.
- Adu-Afarwuah S, et al. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007; 86(2):412-20.
- Flax VL, et al. Feeding patterns of underweight children in rural Malawi given supplementary fortified spread at home. Matern Child Nutr. 2008 Jan; 4(1):65-73.
- Flax VL, et al. Feeding patterns and behaviors during home supplementation of underweight Malawian children with lipid-based nutrient supplements or corn-soy blend. Appetite. 2010 Jun; 54(3):504-11. Epub 2010 Feb 11.
- Paul KH et al. Complementary feeding messages that target cultural barriers enhance both the use of lipid-based nutrient supplements and underlying feeding practices to improve infant diets in rural Zimbabwe. Matern Child Nutr. Article first published online: 4 Aug 2010. DOI: 10.1111/j.1740-8709.2010.00265.x
What about peanut allergy?
Peanut is a common ingredient in LNS and is an ingredient in iLiNS Project supplements. Allergic reactions to peanut can be severe. However, even in the United States - where there is much attention given to peanut allergy - severe allergies to peanut are uncommon among infants under two years of age. Both the overall prevalence of allergy and the prevalence of severe allergy are very similar to those for milk (1.4-2.0% for any allergy and 0.6-0.7% for severe allergy)1.
There is very little information available on peanut allergies in developing countries, but prevalence may be lower than in the U.S.2.
A recent systematic review concluded that there is no clear evidence that either maternal exposure or timing of introduction of peanuts into infant and toddler diets has an impact on later development of allergy3. Currently, both the American Academy of Pediatrics and the National Institute of Allergy and Infectious Diseases advise no avoidance of potential allergens by the mother during pregnancy or lactation. They also advise no general restriction on introduction of potentially allergenic foods in infancy (after 6 months of age, when complementary feeding is recommended to commence)4,5.
- Gupta RS, Springston EE, Warrier MR, Smith B, Kumar R, Pongracic J, Holl JL. The prevalence, severity, and distribution of childhood food allergy in the United States. Pediatrics. 2011 Jul;128(1):e9-17. Epub 2011 Jun 20.
- Yang Z. Are peanut allergies a concern for using peanut-based formulated foods in developing countries? Food Nutr Bull. 2010 Jun;31(2 Suppl):S147-53.
- Thompson RL, Miles LM, Lunn J, Devereux G, Dearman RJ, Strid J, Buttriss JL. Peanut sensitisation and allergy: influence of early life exposure to peanuts.Br J Nutr. 2010 May;103(9):1278-86. Epub 2010 Jan 26.
- Greer FR, Sicherer SH, Burks AW; American Academy of Pediatrics Committee on Nutrition; American Academy of Pediatrics Section on Allergy and Immunology. Effects of early nutritional interventions on the development of atopic disease in infants and children: the role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008 Jan;121(1):183-91.
- Burks AW, Jones SM, Boyce JA, Sicherer SH, Wood RA, Assa’ad A, Sampson HA. NIAID-sponsored 2010 guidelines for managing food allergy: applications in the pediatric population. Pediatrics. 2011 Nov;128(5):955-65. Epub 2011 Oct 10.
Why investigate LNS for prevention of under-nutrition?
Several studies have suggested that LNS may have the potential to prevent stunting and developmental delays before they occur1-3. One study also showed sustained impacts on growth two years after the end of a 12-mo supplementation trial4. In considering the role of LNS (or other interventions) in preventing stunting, it is useful to recognize that the concept of “prevention” is complicated in the presence of widespread and chronic under-nutrition.
“Prevention” vs. treatment in the context of chronic under-nutrition
In high risk populations with chronic under-nutrition and a high prevalence of nutritional stunting, the line between prevention and treatment is not always clear. In such populations, “prevention” of stunting can also be seen as treatment for an on-going process of undernourishment. Children who are identified as stunted have been undernourished for some time, with long-lasting consequences5-6. High levels of stunting result from some combination of small maternal size and maternal under-nutrition, repeated infections during infancy, poor breastfeeding or care practices, and inadequate quantity and/or quality of complementary food. LNS and other products that improve home diets may play a role in ensuring the adequacy of complementary food. LNS formulated for pregnant and lactating women could also have potential to contribute to improvements in maternal and newborn nutrition.
Prevention of acute malnutrition (wasting)
LNS may also have a role to play in prevention of moderate or severe acute malnutrition, for example in food-insecure settings where acute malnutrition peaks seasonally7-8.
- Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Randomized comparison of 3 types of micronutrient supplements for home fortification of complementary foods in Ghana: effects on growth and motor development. Am J Clin Nutr 2007;86:412-20.
- Adu-Afarwuah S, Lartey A, Brown KH, Zlotkin S, Briend A, Dewey KG. Home fortification of complementary foods with micronutrient supplements is well accepted and has positive effects on infant iron status in Ghana. Am J Clin Nutr 2008;87:929-38.
- Phuka JC, Maleta K, Thakwalakwa C, et al. Complementary feeding with fortified spread and incidence of severe stunting in 6- to 18-month-old rural Malawians. Arch Pediatr Adolesc Med 2008;162:619-26.
- Phuka JC, Maleta K, Thakwalakwa C, et al. Postintervention growth of Malawian children who received 12-mo dietary complementation with a lipid-based nutrient supplement or maize-soy flour. Am J Clin Nutr 2009;89:382-90.
- World Bank. Repositioning nutrition as central to development: A strategy for large scale action. Washington, DC: The World Bank, 2005.
- Hoddinott J, Maluccio JA, Behrman JR, Flores R, Martorell R. Effect of a nutrition intervention during early childhood on economic productivity in Guatemalan adults. Lancet 2008;371:411-6.
- Isanaka S, Nombela N, Djibo A, et al. Effect of preventive supplementation with ready-to-use therapeutic food on the nutritional status, mortality, and morbidity of children aged 6 to 60 months in Niger: a cluster randomized trial. JAMA 2009;301:277-85.
- Defourny I, Minetti A, Harczi G, et al. A large-scale distribution of milk-based fortified spreads: evidence for a new approach in regions with high burden of acute malnutrition. PLoS One. 2009;4(5):e5455.
Micronutrient powders (MNP)
What are Micronutrient Powders (MNPs)?
MNPs are sachets (like small packets of sugar) containing a blend of micronutrients (vitamins and minerals) in powder form, which are easily added to semi-solid foods prepared in the home. Single serving sachets allow families to fortify a young child's food at an appropriate and safe level with needed vitamins and minerals for healthy physical and cognitive development.
Why were MNP developed?
In 1996, a group of UNICEF consultants determined that the standard iron drops were not effective, as adherence to treatment remained poor. They called for a simple, inexpensive and potentially viable new method to provide micronutrients (including iron) to populations at risk. The MNP concept was based on two observations from the ‘West’ where micronutrient deficiencies are rare: (a) fortification of commercially available food provides essential micronutrients and (b) no change in the color, texture or taste of the food ensures compliance. Responding to the challenge, the Sprinkles Global Health Initiative at The Hospital for Sick Children, University of Toronto, developed Sprinkles® utilizing encapsulated iron that could be added directly to food.
Where are MNPs used?
Use of MNPs is recommended where foods do not provide enough essential micronutrients. This occurs where one or more of the following apply:
a) Dietary diversity is low (due to limited availability or affordability). Complementary foods prepared for small children have insufficient nutrient content and density (for example, watery porridges and foods with too low micronutrient content);
b) There is a limited availability and a low consumption of fortified foods;
c) The bioavailability of micronutrients is poor due to absorption inhibitors in the diet (fiber, phytate, tannin), which is especially the case in plant-source based meals; and
d) Stunting levels (a proxy indicator for micronutrient deficiencies) are high.
A total of 12 million children in the age range of 6 to 59 months were reached with MNP in 2011.
Who should use MNPs?
The target group should be those who are at risk of having an inadequate intake of micronutrients; evidence from multiple countries suggests that the period of highest vulnerability is 6 to 23 months of age. This is the time period where the variety, quality and/or quantity of foods provided to young children do not meet the nutrient density/adequacy for this period of rapid growth and development. WHO recommends the home fortification of foods with MNPs for children 6 to 23 months of age to improve iron status and reduce anemia in populations where the prevalence of anemia in children under 2 or 5 years is 20% or higher. This is quite common in many communities consuming plant-based diets.
Other target groups at risk of inadequate intake of micronutrients include; a) Children 24 to 59 months of age, b) School-age children.
What is the benefit/advantage of using MNPs?
MNPs have proven to be both efficacious and effective; studies have found they reduce anemia in young children by as much as 45 per cent. Compared to other vitamin and mineral supplements in syrup or tablet form, MNPs are particularly attractive due to their generally higher acceptability in field settings and especially for interventions targeting young children due to their limited gastro-intestinal side effects and limited to zero effect on the taste and colour of the food to which they are added. Use of MNPs for improving the quality of complementary feeding is one of the most promising nutrition interventions that contributes to improved nutrition status of children.Evaluation of MNP programs in several countries has shown they reduce iron deficiency anemia. Due to the need for iron for optimal physical and cognitive development in young children, the impact of reducing iron-deficiency anemia has been found to affect the economic productivity of a nation. Due to the vast-reaching impact as well as the affordable cost of the product and intervention, the benefit:cost ratio for MNPs has been estimated at 37:1.
Which key messages are given to caregivers when they receive MNP for the first time?
Caregivers are provided with the following key messages
Key Message 1: In the first few days of taking MNPs, darkening of child's stool may be observed. This is completely normal. The dark stool testifies to the fact that iron is being absorbed into the child's body normally. Therefore, continued use of MNPs is advised. In addition, during the first days of taking MNPs the child may have softer stools - mild diarrhea or a mild form of constipation, which usually passes in a period of 4-5 days. This does not happen to all children. This is also normal, and it should not be a cause for concern. If the diarrhea is severe, bloody, or with mucous, care should be sought as it would have been without concurrent use of MNP.
Key Message 2: Children already consuming other products containing a similar or higher amount of micronutrients, should not be given MNPs, until the child is no longer consuming these products. These products include RUTF (ready-to-use therapeutic food) for treatment of SAM (severe acute malnutrition), RUSF (ready-to-use supplementary food) or fortified blended foods such as WSB++ (wheat-soy blend) or CSB++ (corn-soy blend), also known as Super Cereal Plus, for treatment of MAM (moderate acute malnutrition), or small-quantity LNS (lipid-based nutrient supplement, <= 20 g/d, providing <=120 kcal/d). Key Message 3: MNP can be safely provided in addition to twice-yearly high-dose of vitamin A capsule, iodized salt and general food fortification. Key Message 4: Use of MNPs is an integral part of the infant and young child feeding to improve the quality of complementary food. Therefore, along with good childcare, health care and nutrition, MNPs can help prevent micronutrient deficiencies and anemia. During an illness, children need to continue to eat regularly. After an illness, children need at least one extra meal every day for at least a week. MNPs should continue being provided during illness.
Who should not use MNPs?
Children who are severely malnourished should not be given MNPs when treated with Ready to use Therapeutic Foods (RUTF) such as Plumpy'Nut®, as these products already provide the vitamins and minerals they need.
According to WHO guidance, they should also not be used for severely malnourished children during the initial period of treatment of electrolyte imbalance. MNPs can be used effectively and safely after this period (usually the first 7 days of treatment).
Are MNPs safe?
MNPs are formulated to contain one recommended nutrient intake (RNI) per child per day, which is the amount that should normally come from the diet. Because of the low dosage and the single-dose packaging, there is little risk of overdosing (i.e. several sachets would need to be opened and consumed - unlikely to happen). Even if taken in amounts of up to 4 sachets a day, intakes are safe according to international recommendations of overdosing - the single-dose packaging and bland taste of the micronutrient powder prevent this. Typically, most programs provide 1 sachet for every 2 or 3 days, thereby reducing the risk of too high intakes.
Can MNPs lead to diarrhea or other side effects?
To date more than 16 scientific studies have evaluated the efficacy and effectiveness of micronutrient powders in thousands of children in Africa, Asia and the Americas. Overall, fewer than 1% of caregivers have reported an increase in vomiting, stomach upset, hard stools, dark stools or diarrhea. A survey undertaken in Nepal in 2009 found that fewer than 3% of mothers reported that they stopped giving micronutrient powder because they associated it with diarrhea. Studies conducted in Bangladesh and Haiti have shown no differences in diarrhea symptoms between children who consumed micronutrient powder and those who did not consume the powder. A study conducted in Pakistan (other than the publication by Soofi et al, 2013) found that children who consumed micronutrient powder had less frequent episodes of diarrhea compared to those who did not consume the micronutrient powder. It is important to note that these side effects typically occur at the start of the intervention and will become less prevalent afterwards.
Do MNP programs currently monitor side effects?
Countries initiating and implementing MNP programs are encouraged to have monitoring systems in place which track all program indicators including information on MNP provision, coverage, adherence and side effects. Among the 22 countries implementing MNP programs, information on reported adverse effects is available from 16 countries that have some type of monitoring system in place for MNP program indicators including side effects. Apart from some reporting of expected, self-perceived side effects, which include stool darkening, mild constipation and diarrhea, no other adverse, or severe, side effects have been reported by these programs. In addition, implementing agencies have not received any reports of exceptionally high incidence of side effects that caused concern or warranted interruption of MNP programs.
Can MNP be used to treat vitamin D deficiency rickets?
The vitamin D dose in MNP is meant to meet the RNI for vitamin D, rather than provide a therapeutic intervention. Thus, for rickets treatment, the recommended dose of vitamin D is significantly higher than the dose present in MNP. The vitamin D dose in MNP, however, is adequate to prevent rickets.
Can MNP be used to treat anemia or is it only used to prevent anemia?
MNP can be used both in the treatment and prevention of anemia.
Should a person with thalassemia trait avoid iron supplements, such as iron-fortified vitamins or MNP?
Thalassemia and iron metabolism are closely linked. Iron deficiency and mild forms of thalassemia (e.g., thalassemia trait) are often confused. Both are associated with mild to moderate anemia and microcytosis (small red cells). At the other end of the spectrum, severe forms of thalassemia frequently produce iron overload. Excess iron accumulates due to a combination of enhanced iron absorption, repeated blood transfusions or both. People with thalassemia trait (thalassemia minor) are not at greater risk of complications from iron in the diet than anyone else in the general population. In the absence of concomitant iron deficiency, iron supplementation will neither correct nor improve anemia due to thalassemia. For people with both iron deficiency and thalassemia, iron replacement will lessen the severity of the anemia until the iron deficiency is corrected. The blood count will then level off and no further improvement will occur.
Can MNP be used in infants younger than 6 months of age, older children, adolescents or other individuals?
MNP were originally developed for infants and young children between 6-24 months of age. Infants and young children cannot safely ingest tablets or pills. Syrups and drops have been used for many years, but compliance has been documented to be poor (for iron) because of the strong unpleasant taste of the drops. The drops tend to stain the teeth unless they are carefully placed at the back of the infants’ mouth, and for parents who cannot read, it is often difficult to measure the appropriate amount of liquid iron, which is often supplied in a bottle with a dropper calibrated in milliliters. General food fortification, though suitable for preventing micronutrient deficiencies in the adult population, does not meet the micronutrient needs of young children, who ingest smaller amounts of food than adults.
MNP occupy a unique niche for young children. The use of MNP for infants under the age of six months is not recommended as they should be exclusively breastfed in accordance with WHO guidelines on breastfeeding. For other age groups, more choices for supplementation are available, including the use of fortified foods, pills and capsules. Nevertheless, MNP can be used in the other age groups without fear of toxicity. To date, research has focused on infants and children under age 5. The limited research on MNP for pregnant women does not support programmatic use of MNP during pregnancy.
When should MNP use begin and how long should MNP be used?
The current recommendation from the World Health Organization (WHO) is that exclusive breastfeeding should last until 6 months of age. Afterwards, complementary feeding begins and MNP can be given. Young children should receive 60-180 sachets consumed over 60-180 days (no more than one sachet per day). A target of 90 sachets per six months period (equivalent to 15 sachets per month, or 3-4 per week) is likely to be reasonable for most situations. Sachets should be made available throughout the year for the target groups until a variety of mixed foods (containing iron and other micronutrients) are being eaten.
Can MNP be used with fluids like milk or juice?
First and foremost, the aim of home fortification is to improve complementary feeding. MNP can be used in any food products and should be used with foods. When an MNP is added to a liquid, depending on the form of iron used, some of the iron will float to the top of the liquid and tend to stick to the side of the cup or glass, and hence some will be lost in the process.
Can MNP be used in emergency rations?
MNP is safe to use and recommended to improve micronutrient status in emergency situations. Emergency rations tend to include corn-soya blend (CSB) or wheat-soya blend (WSB) - two vehicles suitable for the addition of MNP. Both these rations produce a thick paste-like substance after cooking, to which MNP may be added after cooling to provide an additional source of micronutrients. A research study in rural Haiti showed a decrease of anemia prevalence by one-half when MNP was used with WSB, while anemia prevalence increased when WSB was used alone. MNP has been used in emergency relief aid in countries like Indonesia and Haiti.
Can MNP be used by Muslims and Jews who follow traditional food practices?
Yes. Neither alcohol nor porcine products are used in the production of MNP. They are therefore both Halal and Kosher and may be used as part of a traditional Muslim or Jewish diet.
Why does stool consistency (loose stools or constipation) and colour change in young children when they start taking MNP?
Stool consistency does not change in the majority of infants and children receiving MNP. Stool colour, however, changes to a dark or black colour in all infants receiving MNP on a regular basis. Iron itself is dark in colour. When some quantities are left unabsorbed, the iron is excreted in the stool and causes the change in colour. Some very young infants, who have not previously been exposed to any complementary foods containing micronutrients (i.e. who are exclusively breast-fed) may develop loose stools or even mild diarrhea. The diarrhea does not lead to dehydration, but is a valid concern to parents and health care providers. The diarrhea lasts for approximately one week and then will not recur. Parents have reported that diarrhea quickly disappears in these young infants, who are transitioning from breastfeeding to complementary feeding, if 1/3 – 1/2 of a MNP sachet is used.
Loose stools may be caused by a change in bowel flora (microorganisms) associated with the introduction of iron into the diet or possibly the impact of ascorbic acid on bowel peristalsis in infants, who previously had received only very small amounts of ascorbic acid in their diets (in breast milk). Since loose stools have only been observed in infants transitioning from exclusive breastfeeding to complementary feeding, loose stools may possibly be unrelated to MNP, and instead related to the change in stool pattern with the introduction of complementary foods.
Likely, the presence of food during MNP intake accounts for the fewer and less severe cases of diarrhea and constipation than other iron supplements.
Isn't MNP not supposed to change the taste and colour of food? Why does this happen?
In order to mask the strong metallic taste of the iron, the iron in some of the available MNPs is coated or encapsulated with a thin lipid-coat. The melting temperature for the lipid is around 60ºC. If MNP are added to food hotter than 60ºC, the lipid coating around the iron will melt and the food will be exposed to the iron. The iron can then change the colour of the food and will certainly have a strong taste.
To prevent changes in the taste and colour of food to which MNP is added, it is recommended that MNP be added to food after it is cooled to a temperature below 60ºC.
Can MNP be provided to non-anemic young children without producing any toxicity?
Yes. The amount of micronutrients in the MNP sachets is high enough to meet the needs of young children with micronutrient deficiencies (e.g. iron deficiency anemia) but not too high for those who do not have deficiencies. A research study was conducted in China with 400 preschool children, a majority of whom were non-anemic (95%). MNP prevented anemia (when provided for 4 months) with no evidence of excessive iron stores. Serum ferritin values remained within the normal range in 100% of children included in the study.
Thus, MNP are safe to use, even in young children without micronutrient deficiencies. In fact, MNP were originally designed to prevent deficiencies in non-deficient children at risk of micronutrient deficiencies.
Is vitamin A toxicity of concern for children, who receive both MNP and high dose vitamin A capsules?
There is no risk of toxicity. MNP containing vitamin A are formulated to help children meet their daily vitamin A requirement (RNI). It is safe to use the two supplements together because MNP use is complementary to high dose vitamin A capsules and not competitive. With the distribution of high dose capsules, the WHO recommends an age-appropriate diet which would contain all micronutrients, including vitamin A.
What are the implications of the Pakistan study on MNP programming?
The recently published study by Soofi et al (2013) on the effect of MNP use among children 6-24 months old in Pakistan reported, amongst others, incidence and severity of side effects on using MNPs. A 5 micronutrient (MN) formulation MNP was used in the study. The caregiver-reported number of days with diarrhea was 5.7% in the non-intervention group and 6.5% and 6.7% in the two MNP groups. While the difference was statistically significant, the difference was small (on a yearly basis 21 vs 24 days with diarrhea), and there was no difference in persistent diarrhea, febrile episodes, hospitalizations or death. Meanwhile, there was a marked reduction of iron deficiency anemia and a small improvement of growth.
There are some challenges in interpreting the findings of this study:
a) the study used maternal recall of diarrhea and respiratory symptoms to assess morbidity, which could lead to over-reporting
b) without a placebo control, it is not possible to know whether mothers over-reported morbidity symptoms because they thought that MNP might lead to such symptoms, or if they used MNP to treat illness as has been reported in other settings
c) despite delivering a daily supply of MNP to households every 2 weeks, overall utilization of MNP was surprisingly low at ~50% of target. This could represent a poor behavioral programmatic component, and might be related to over-reporting of perceived negative impact of the MNP.
This study like other studies should be added to the evidence base and analyzed alongside other studies. The World Health Organization, being the normative agency, is tasked to do that. No decisions on programmatic change should be made based on this single study. Therefore, countries should continue providing this cost-effective and efficacious MNP intervention.
Who owns the intellectual rights to Sprinkles®?
SGHI controls the Canadian and American patent rights for the invention known and trade marked as Sprinkles®. These patent rights effectively extend to any micro-nutrient formulations which include micro-encapsulated iron and which are contained in single-dosage sachets, or other forms of packages which enable the user to sprinkle the formulation onto prepared foods. Therefore, the manufacture, distribution and/or marketing of such products in Canada and the United States of America are not allowed without SGHI's express, written permission.
Sprinkles® is not patented in the rest of the world. In September 2007, SGHI and its sponsor, the Heinz Foundation, formally announced that they were putting the Technical Specifications for the Sprinkles® products into the public domain outside of Canada and the United States of America. This announcement was made at a meeting attended by such organizations the Global Alliance for Improved Nutrition (GAIN), the Micronutrient Initiative (MI), UNICEF, USAID, and WFP. The Technical Specifications include information on formulations, ingredients, and packaging materials. Thus, manufacturers who are able to prove their commitment to quality control can now approach SGHI, or organizations such as GAIN, for these Technical Specifications.
Please note that this open access does not extend to SGHI's global trade mark rights to the brands Sprinkles®, Sprinkles Plus®, SuppleFer®, and SuppleFem®. These brands cannot be associated with any micro-nutrient powder product without SGHI's express, written permission, which will be granted only if SGHI is absolutely confident that the quality of the product meets or exceeds the standards set out in the Technical Specifications at all times.