Consumption of multiple micronutrient supplements (MMS) during pregnancy offers additional benefits compared with iron‐folic acid (IFA) supplementation, but the tablets are more expensive. We estimated the effects, costs, and cost‐effectiveness of hypothetically replacing IFA supplements with MMS for 1 year in Bangladesh and Burkina Faso. Using baseline demographic characteristics from LiST and effect sizes from a meta‐analysis, we estimated the marginal effects of replacing IFA with MMS on mortality, adverse birth outcomes, and disability‐adjusted life years (DALYs) averted. We calculated the marginal tablet costs of completely replacing MMS with IFA (assuming 180 tablets per covered pregnancy). Replacing IFA with MMS could avert over 15,000 deaths and 30,000 cases of preterm birth annually in Bangladesh and over 5000 deaths and 5000 cases of preterm birth in Burkina Faso, assuming 100% coverage and adherence. We estimated the cost per death averted to be US$175–185 in Bangladesh and $112–125 in Burkina Faso. Cost per DALY averted ranged from $3 to $15, depending on the country and consideration of subgroup effects. Our estimates suggest that this policy change would cost‐effectively save lives and reduce life‐long disabilities. Improvements in program delivery and supplement adherence would be expected to improve the cost‐effectiveness of replacing IFA with MMS.

BackgroundAdequate nutrition is necessary for brain development during pregnancy and infancy. Few randomized controlled trials of supplementation during these periods have measured later developmental outcomes.ObjectiveOur objective was to investigate the effects of provision of prenatal and postnatal lipid-based nutrient supplements (LNS) on child development at preschool age.MethodsWe conducted a follow-up study of 966 children aged 4–6 y in 2016, born to women who participated in the International Lipid-Based Nutrient Supplements-DYAD trial conducted in Ghana in 2009–2014, representing 79% of eligible children. Women ≤20 weeks of gestation were randomized to daily LNS or multiple micronutrient (MMN) capsules during pregnancy through 6 mo postpartum or iron and folic acid (IFA) capsules during pregnancy and calcium placebo capsules during 6 mo postpartum. Children in the LNS group received LNS from 6 to 18 mo. Primary outcomes of this follow-up study were (1) a cognitive factor score based on a test battery adapted from several standard tests, 2) fine motor score (9-hole pegboard test), and (3) social-emotional difficulties (Strengths and Difficulties Questionnaire; SDQ). Eight secondary outcomes were calculated in specific domains (e.g., language, SDQ prosocial). Analysis was by a complete case intention to treat in a 2-group comparison: LNS compared with non-LNS (MMN + IFA).ResultsChildren in the LNS group had significantly lower social-emotional difficulties z-scores than children in the non-LNS group (adjusted for child age β = −0.12, 95% CI: −0.25, 0.02, P = 0.087; fully adjusted β = −0.16, 95% CI: −0.29, −0.03, P = 0.013). The effect of LNS on social-emotional difficulties score was larger among children living in households with lower home environment scores (P-interaction = 0.081). No other outcomes differed between the 2 intervention groups.ConclusionsProvision of LNS during the first 1000 d of development improved behavioral function, particularly for children from low nurturing and stimulation households, but did not affect cognition at preschool age in this setting. Trial Registration: clinicaltrials.gov, Identifier NCT00970866.

Background Few studies have evaluated the long-term effects of nutritional supplementation during the first 1000 d of life. We previously reported that maternal and child lipid-based nutrient supplements (LNS) increased child length by 18 mo. Objective The aim of this study was to examine the effects of LNS on later growth and body composition at 4–6 y of age. Design This was a follow-up of children in the International Lipid-based Nutrient Supplements (iLiNS)-DYAD trial in Ghana. Women (n = 1320) at ≤20 weeks of gestation were randomly assigned to: 1) iron and folic acid during pregnancy and 200 mg calcium/d for 6 mo postpartum, 2) multiple micronutrients (1–2 RDA of 18 vitamins and minerals) during both periods, or 3) maternal LNS during both periods plus child LNS from 6 to 18 mo. At 4–6 y, we compared height, height-for-age z score (HAZ), and % body fat (deuterium dilution method) between the LNS group and the 2 non-LNS groups combined. Results Data were available for 961 children (76.5% of live births). There were no significant differences between LNS compared with non-LNS groups in height [106.7 compared with 106.3 cm (mean difference, MD, 0.36; P = 0.226)], HAZ [−0.49 compared with −0.57 (MD = 0.08; P = 0.226)], stunting (< -2 SD) [6.5 compared with 6.3% (OR = 1.00; P = 0.993)], or % body fat [15.5 compared with 15.3% (MD = 0.16; P = 0.630)]. However, there was an interaction with maternal prepregnancy BMI (kg/m2) (P-interaction = 0.046 before correction for multiple testing): among children of women with BMI < 25 , LNS children were taller than non-LNS children (+1.1 cm, P = 0.017), whereas there was no difference among children of women with BMI ≥ 25 (+0.1 cm; P = 0.874). Conclusions There was no overall effect of LNS on height at 4–6 y in this cohort, which had a low stunting rate, but height was greater in the LNS group among children of nonoverweight/obese women. There was no adverse impact of LNS on body composition. This trial was registered at clinicaltrials.gov as NCT00970866.

Objectives To explore the potential for bouillon as a micronutrient fortification vehicle in northern Ghana, we assessed market availability, household purchase and consumption of bouillon products, and perceptions of bouillon and salt. Methods We selected 28 clusters in the Tolon and Kumbungu districts of the Northern region of Ghana (7 urban, 4 semi-urban, and 3 rural clusters per district). Among 369 randomly selected households, women of reproductive age (15–49 y; WRA) were interviewed about household bouillon purchasing habits, its use in food preparation, and perceptions about the positive/negative effects of bouillon consumption. Twenty focus groups of 5–6 participants each were held in 11 clusters (10 WRA, 5 men, 5 women &gt; 49y). We also assessed availability of bouillon products for sale from vendors in clusters (n = 11) and major markets (n = 4). Results In the survey, almost all (99%) respondents had ever cooked with bouillon, and 77% reported typically cooking with bouillon at least twice per day. Seven brands and three flavors of bouillon products were for sale. Most households (87%) reported consuming shrimp flavor without other spice most frequently. On average, households purchased bouillon cubes weekly, most from open markets (74%) or kiosks (22%). Most common reasons for bouillon use included taste (98%) and family preference (46%). Economic access was also important: 59% reported purchasing less bouillon or switching bouillon brands (28%) or flavors (11%) when they had less money available. About two-thirds of respondents perceived having bouillon in a person's diet was “good” (vs 43% for salt); reasons provided included: “gives more energy” (43%) and “makes you stronger” (41%). Among the 18% of respondents who perceived having bouillon in a person's diet was “bad”, reasons included: stomach upset (63%) and high blood pressure (39%). High blood pressure (85%) was the most common concern among the 32% perceiving salt as “bad”. Focus groups revealed seasonal variation in quantity of bouillon used. Conclusions Bouillon consumption is common and frequent in northern Ghana, indicating good potential as a micronutrient fortification vehicle. Understanding perceptions of bouillon by different household members will inform research and program messaging. Funding Sources Funded by a grant to the University of California, Davis from Helen Keller International.

Background Whether consuming sweet foods early in life affects sweet food preferences and consumption later in childhood is unknown. Objective We tested the hypothesis that exposure to a slightly sweet lipid-based nutrient supplement (LNS) early in life would not increase preference for or consumption of sweet items at preschool age. Methods We followed up children who had participated in a randomized trial in Ghana in which LNS was provided to 1 group of women during pregnancy and 6 mo postpartum and to their infants from ages 6–18 mo (LNS group). The control group (non-LNS group) received iron and folic acid during pregnancy or multiple micronutrients during pregnancy and 6 mo postpartum, with no infant supplementation. At 4–6 y, we obtained data from caregivers on children's food and beverage preferences and consumption (n = 985). For a randomly selected subsample (n = 624), we assessed preference for sweet items using a photo game (range in potential scores, 0–15). For the photo game and reported consumption of sweet items, we examined group differences using predetermined noninferiority margins equivalent to an effect size of 0.2. Results Median (quartile 1, quartile 3) reported consumption of sweet items (times in previous week) was 14 (8, 23) in the LNS group and 16 (9, 22) in the non-LNS group; in the photo game, the number of sweet items selected was 15 (11, 15) and 15 (11, 15), respectively. The upper level of the 95% CI of the mean difference between LNS and non-LNS groups did not exceed the noninferiority margins for these outcomes. Caregiver-reported preferences for sweet items also did not differ between groups (P = 0.9). Conclusion In this setting, where child consumption of sweet foods was common, exposure to a slightly sweet LNS early in life did not increase preference for or consumption of sweet foods and beverages at preschool age. This trial was registered at clinicaltrials.gov as NCT00970866.