Micronutrient powders (MNP)

• What are micronutrient powders (MNP)?

  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 children's food at an appropriate and safe level with needed vitamins and minerals for healthy physical and cognitive development.

• Why were MNPs developed?

  In 1996, a group of UNICEF consultants determined that the standard iron drops were not as effective as they could be, as adherence to the recommended regime remained poor. They called for a simple, inexpensive, and new method to provide micronutrients (including iron) to populations at risk. The MNPs 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 MNPs (branded at the time as Sprinkles®) utilizing encapsulated iron that could be added directly to food. MNPs additionally provide an alternative supplementation method to address the inability of infants and young children to 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 additionally tend to stain the teeth unless they are carefully placed at the back of the infant's' 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. Furthermore, general food fortification, though suitable for preventing micronutrient deficiencies in the adult population, does not meet the micronutrient needs of infants and young children, who ingest smaller amounts of food than adults.

• Who should use MNPs?

  MNPs should be considered for 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 often do not meet the nutrient density/adequacy for this period of rapid growth and development. WHO recommends MNPs for children 6-23 months of age in populations where the prevalence of anemia in children under two or under five is ≥20%, and for children 2-12 years of age in populations where the prevalence of anemia among schoolchildren is ≥20%.  Generally, MNPs are recommended where foods do not provide enough essential micronutrients. This occurs where one or more of the following apply:

  1. Dietary diversity is low (due to limited availability or affordability). Complementary foods prepared for small children often have insufficient nutrient content and density (for example, watery porridges and foods with too low micronutrient content); 
  2. There is a limited availability and a low consumption of fortified foods; 
  3. The bioavailability of micronutrients is poor due to absorption inhibitors in the diet (fiber, phytate, tannin), this is quite common in many communities consuming plant-based diets; and 
  4. Stunting levels (a proxy indicator for micronutrient deficiencies) are high. 

• Who should not use MNPs?

  Children who are severely malnourished should not be given MNPs while being 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 after the first 7 days of treatment).

   

• Can MNPs be used in infants younger than 6 months of old, older children, adolescents, or other individuals?

  MNPs are intended for used in infants and young children aged 6-23 months as well as preschool and school-aged children aged 2-12 years¹. MNPs occupy a unique niche for young children. The use of MNPs 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, MNPs can be used in the other age groups without fear of toxicity. Further research for the use of MNPs during pregnancy has been conducted however, it not recommended in lieu of multiple micronutrient supplements (MMS) and iron folic acid (IFA) supplementation³. 

  1. WHO guideline: Use of multiple micronutrient powders for point-of-use fortification of foods consumed by infants and young children aged 6-23 months and children aged 2-12 years. Geneva: World Health Organization; 2016. Licence: CC BY-NC-SA 3.0 IGO. 
  2. Use of multiple micronutrient powders for point-of-use fortification of foods consumed by pregnant women. Geneva: World Health Organization; 2016  
  3. Choudhury N, Aimone A, Hyder SMZ, Zlotkin SH. Relative Efficacy of Micronutrient Powders versus Iron—Folic Acid Tablets in Controlling Anemia in Women in the Second Trimester of Pregnancy. Food and Nutrition Bulletin. 2012;33(2):142-149.

• When should MNP use begin and for how long should use continue?

  The current recommendation from the World Health Organization (WHO) is that exclusive breastfeeding should last until 6 months of age. Young children should receive 60-180 sachets consumed over 60-180 days (no more than one sachet per day). Afterwards, complementary feeding begins and MNPs can be given. MNPs are designed to be safely taken one/day for 60 days, then 4 months of no use. However, as a daily regime for two months and 4 months off can be difficult in a programme setting. The WHO recommends a programme target of 90 sachets per six months period (equivalent to 15 sachets per month, or 3-4 per week), which is likely to be reasonable for most situations. This equates to a single sachet every second day for six months. 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.

   

• What is the benefit/advantage to using MNPs?

  MNPs have proven to be both efficacious and effective; studies in several countries have found they reduce anemia by 18% and iron deficiency by 53% in young children aged 6 months to 2 years¹. Given that iron is needed for optimal physical and cognitive development in young children, the impact of reducing iron-deficiency anemia on economic productivity of a nation has been modeled. 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. They continue to show success in interventions for 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 in most settings. 

  1. Suchdev, P. S., Jefferds, M., Ota, E., da Silva Lopes, K., & De-Regil, L. M. (2020). Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. The Cochrane database of systematic reviews, 2(2).

   

• What key messages are given to caregivers when they receive MNPs 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 MNPs. 

  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.

• 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 in accordance with the WHO recommendations. There was previous speculation surrounding iron supplementation leading to an increased risk of malaria and death in children living in malaria-endemic regions¹. However, the most recent evidence indicates that when malaria surveillance and treatment options are consistently implemented and available, iron supplementation or the use of iron containing MNPs, do not contribute to an increase in incidence of malaria in children^1,2. Therefore, in regions where anaemia is a public health concern and children aged 6 months to 12 years are already at a higher risk for morbidity and malnutrition, the WHO recommends iron supplementation in any form, including micronutrient powders for home fortification, should be provided in conjunction with measures to prevent, diagnose, and treat malaria for these children³.

  1. World Health Organization. (2016, February 29). Intermittent iron supplementation in preschool and school-age children in malaria-endemic areas. World Health Organization. Retrieved from https://www.who.int/elena/titles/iron_infants_malaria/en/  
  2. Zlotkin S, Newton S, Aimone AM, Azindow I, Amenga-Etego S, Tchum K, Mahama E, Thorpe KE, Owusu-Agyei S. Effect of iron fortification on malaria incidence in infants and young children in Ghana: a randomized trial. JAMA. 2013 Sep 4;310(9):938-47. doi: 10.1001/jama.2013.277129. PMID: 24002280. 
  3. Home Fortification Technical Advisory Group. Technical Brief on the Use of Home Fortification with Micronutrient Powders Containing Iron in Malaria Endemic Regions. Home Fortification Technical Advisory Group, 2018. 

• Can MNPs lead to diarrhea or other side effects?

  Stool consistency does not change in the majority of infants and children receiving MNPs.  Loose stools may be caused by a change in bowel flora (microorganisms) associated with the introduction of complementary foods containing micronutrients such as 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). 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. Parents have reported that diarrhea quickly disappears in these young infants, if 1/3 - 1/2 of a MNP sachet is used. Although this form of diarrhea lasts for approximately one week and does not lead to dehydration, it is a valid concern to parents and health care providers. Stool colour changes to a dark or black colour in all infants receiving MNPs 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. 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. 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 programmes currently monitor side-effects?

  Reaching more than 10 million children aged 6-59 months, a total of 65 countries are implementing MNP programs.¹ These 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. 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.

  1. UNICEF. NutriDash: Facts and Figures - Nutrition Programme Data for the SDGs (2015-2030), UNICEF, New York, 2017

• Can MNPs be used to treat Vitamin D deficiency rickets?

  The vitamin D dose in MNPs 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 MNPs. The vitamin D dose in MNPs, however, is adequate to prevent rickets.

   

• Is vitamin A toxicity of concern for children who receive MNPs and high dose vitamin A?

  There is no risk of toxicity, and the two interventions are complimentary. High dose vitamin A capsules given to children 6-59 months of age every four to six months apart are recommended in populations where vitamin A deficiency is a public health problem to protect children from preventable illness and death due to their deficiency, and MNPs containing vitamin A are formulated to help children meet their daily vitamin A requirement (RNI) thus reducing their risk over time. It is proven to be safe to use the two supplements together, no upper toxic limit is reached if consumed on the same day, and the supplements are not competitive. With the distribution of high dose capsules, the WHO recommends an age-appropriate diet which should contain all micronutrients, including vitamin A.

   

• Can MNPs be used to treat anaemia or is it to only prevent anaemia?

  MNPs can be used both in the treatment and prevention of anemia.^1,2

  1. Hirve S, Bhave S, Bavdekar A, Naik S, Pandit A, Schauer C, Christofides A, Hyder Z, Zlotkin S. Low dose 'Sprinkles'-- an innovative approach to treat iron deficiency anemia in infants and young children. Indian Pediatr. 2007 Feb;44(2):91-100.

  2. Zlotkin S, Arthur P, Schauer C, Antwi KY, Yeung G, Piekarz A. Home fortification with iron and zinc sprinkles or iron sprinkles alone successfully treats anemia in infants and young children. J Nutr. 2003 Apr;133(4):1075-80.

• Should a person with thalassemia trait avoid iron supplements, such as 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 MNPs be used with fluids like milk or juice?

  First and foremost, the aim of home fortification is to improve complementary feeding. MNPs can be used in any food products and should be used with foods. It is not recommended to add MNP to a liquid, because 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 MNPs be used in emergency rations?

  MNPs are safe to use and recommended to improve micronutrient status in emergency situations. In response to the 2004 Indian ocean earthquake and ensuing tsunamis, the provision of MNPs at large scale proved to be a feasible, beneficial, and cost-effective intervention in Aceh, Indonesia, saving numerous lives and preventing the outbreak of diseases1. Through quick product roll out, early establishment of partnerships, behaviour change communication and regular monitoring practices¹ this tsunami relief and recovery program led by Helen Keller International provided 28 million MNP sachets to more than 250,000 disaster displaced children. Further assessments by UNICEF revealed that individuals in emergency settings who received MNPs had lower rates of anaemia than those that did not². 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. MNPs combined with iron derived from the CSB, was assumed to help meet the iron needs of the young children at a refugee camp greatly impacted by a malaria endemic in Kakuma, Kenya³.

  1. Martini, E., van Hees, J., de Pee, S. Home fortification in emergency situations: Distributing a micronutrient powder to tsunami-affected children in Indonesia. Home Fortification Technical Advisory Group (HF-TAG). 10.

  2. UNICEF. Second health and nutrition assessment in Nanggroe Aceh Darussalam Province and Nias Island, September 2005. S.l. UNICEF, 2006 

  3. Jee Hyun Rah, Saskia dePee, Klaus Kraemer, Georg Steiger, Martin W. Bloem, Paul Spiegel, Caroline Wilkinson, Oleg Bilukha, Program Experience with Micronutrient Powders and Current Evidence, The Journal of Nutrition, Volume 142, Issue 1, 191S-196S. 2012

   

• Can MNPs 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.

   

• 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 MNPs 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 MNPs are added, it is recommended that MNPs be added to food after it is cooled to a temperature below 60ºC. Caregivers in eastern Uganda also reported a change in food colour when MNPs were added to food cooked with soda ash^1,2. In addition to organoleptic changes to food, studies have revealed that soda ash can affect the micronutrient bioavailability of MNPs by forming insoluble ternary compounds with iron and further reduce the absorption of iron due to changes in intestinal pH¹.

   

  1. Ford, N. D., Ruth, L. J., Ngalombi, S., Lubowa, A., Halati, S., Ahimbisibwe, M., Baingana, R., Whitehead, R. D., Mapango, C., & Jefferds, M. E. (2020). An integrated infant and young child feeding and micronutrient powder intervention does not affect anemia, iron status, or vitamin A status among children aged 12-23 months in eastern Uganda. The Journal of Nutrition, 150(4), 938-944. https://doi.org/10.1093/jn/nxz314

  2. Ford, N. D., Ruth, L. J., Ngalombi, S., Lubowa, A., Halati, S., Ahimbisibwe, M., Mapango, C., Whitehead Jr, R. D., & Jefferds, M. E. (2019). Predictors of micronutrient powder sachet coverage and recent intake among children 12-23 months in eastern Uganda. Maternal & Child Nutrition, 15(S5). https://doi.org/10.1111/mcn.12792

• Who owns the intellectual rights to Sprinkles®?

  In September 2007, the Sprinkles Global Health Initiative (SGHI) and its sponsor, the Heinz Foundation, formally announced that they were putting the Technical Specifications for the MNP Sprinkles® products into the public domain. 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. Please note that this open access does not extend to SGHI's Canadian trademark rights to the brands Sprinkles®. This brand 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.

   

• Are MNPs on the WHO Essential Medicines List?

  The WHO classifies Essential Medicines as those that respond to the priority healthcare needs of a population and are available at affordable cost and the appropriate dose and quality to functioning health systems. Essential Medicines are selected based on disease prevalence, public health relevance, efficacy and safety evidence and comparative cost-effectiveness. MNP were first added to the WHO Essential Medicines List in 2019 for prevention of iron deficiency anaemia in infants and young children. The list is updated every two years and MNP continues to maintain its essential medicine status. MNP can be found on the list under the ATC Code A11AA01 or here.