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The lack of counselling tools and aids and the poor health personnel knowledge of infant and young child feeding practices in Ghanaian growth monitoring and promotion (GMP) services impede efforts to address mild (-2 ≤ weight-for-length z score (WLZ) < -1) to moderate (-3 ≤ WLZ < -2) wasting. A cluster-randomized intervention was used to compare three treatments targeted at children less than 24 months: (i) control group, use of the standard-of-care (SOC) weight measurements, weight-for-age z-score (WAZ) chart, and the Ghana Health Service counselling cards; (ii) algorithm group, use of a newly-developed algorithm and SOC; and (iii) length group, measurement of length, use of WLZ chart, and SOC. Thirty clusters of rural communitybased GMP clinics were randomly assigned to the three treatment groups (n = 10 per group). Using crosssectional surveys at baseline (n = 661) and one year later (n = 666), we tested differences in prevalence of low WLZ (WLZ < -1) in children from 0 to 24 months. Analyses were by intention-to-treat, adjusting for clustering effect. There was no significant effect of the intervention on low WLZ (p = 0.66). However, the quality of GMP implementation differed among the treatments. The algorithm and length groups had a significantly higher (mean difference: 2.7 [95% CI: 0.01 - 5.40] and 2.93 [95% CI: 0.55 – 5.31], respectively) number of GMP sessions held compared to the control. Compared to the length group, the algorithm and control groups had higher (mean difference: 0.24 [95% CI: 0.17 – 0.31] and 0.23 [95% CI: 0.15 – 0.31], respectively) proportions of mothers receiving individual counselling at sessions. Having a simple focused tool may improve the frequency of GMP sessions and quality of nutrition counselling provided. There is a need for an evaluation of rural GMP programs to identify bottlenecks and how these can be addressed for higher program impact.

BackgroundPrevious literature suggests a U-shaped relation between hemoglobin concentration and adverse birth outcomes. There is less evidence on associations between iron status and birth outcomes.ObjectiveOur objective was to determine the associations of maternal hemoglobin concentration and iron status with birth outcomes.MethodsWe conducted a secondary data analysis of data from 2 cohorts of pregnant women receiving iron-containing nutritional supplements (20-60 mg ferrous sulfate) in Ghana (n=1137) and Malawi (n=1243). Hemoglobin concentration and 2 markers of iron status [zinc protoporphyrin and soluble transferrin receptor (sTfR)] were measured at ≤20 weeks and 36 weeks of gestation. We used linear and Poisson regression models and birth outcomes included preterm birth (PTB), newborn stunting, low birth weight (LBW), and small-for-gestational-age.ResultsPrevalence of iron deficiency (sTfR >6.0 mg/L) at enrollment was 9% in Ghana and 20% in Malawi. In early pregnancy, iron deficiency was associated with PTB (9% compared with 17%, adjusted RR: 1.63; 95% CI: 1.14, 2.33) and stunting (15% compared with 23%, adjusted RR: 1.44; 95% CI: 1.09, 1.94) in Malawi but not Ghana, and was not associated with LBW in either country; replete iron status (sTfR

Background: Small-quantity (SQ) lipid-based nutrient supplements (LNSs) provide many nutrients needed for brain development. Objectives: We aimed to generate pooled estimates of the effect of SQ-LNSs on developmental outcomes (language, social-emotional, motor, and executive function), and to identify study-level and individual-level modifiers of these effects. Methods: We conducted a 2-stage meta-analysis of individual participant data from 14 intervention against control group comparisons in 13 randomized trials of SQ-LNSs provided to children age 6-24 mo (total n = 30,024). Results: In 11-13 intervention against control group comparisons (n = 23,588-24,561), SQ-LNSs increased mean language (mean difference: 0.07 SD; 95% CI: 0.04, 0.10 SD), social-emotional (0.08; 0.05, 0.11 SD), and motor scores (0.08; 95% CI: 0.05, 0.11 SD) and reduced the prevalence of children in the lowest decile of these scores by 16% (prevalence ratio: 0.84; 95% CI: 0.76, 0.92), 19% (0.81; 95% CI: 0.74, 0.89), and 16% (0.84; 95% CI: 0.76, 0.92), respectively. SQ-LNSs also increased the prevalence of children walking without support at 12 mo by 9% (1.09; 95% CI: 1.05, 1.14). Effects of SQ-LNSs on language, social-emotional, and motor outcomes were larger among study populations with a higher stunting burden (≥35%) (mean difference: 0.11-0.13 SD; 8-9 comparisons). At the individual level, greater effects of SQ-LNSs were found on language among children who were acutely malnourished (mean difference: 0.31) at baseline; on language (0.12), motor (0.11), and executive function (0.06) among children in households with lower socioeconomic status; and on motor development among later-born children (0.11), children of older mothers (0.10), and children of mothers with lower education (0.11). Conclusions: Child SQ-LNSs can be expected to result in modest developmental gains, which would be analogous to 1-1.5 IQ points on an IQ test, particularly in populations with a high child stunting burden. Certain groups of children who experience higher-risk environments have greater potential to benefit from SQ-LNSs in developmental outcomes. publishedVersion

BackgroundPrevious reviews have identified 44 risk factors for poor early child development (ECD) in low- and middle-income countries. Further understanding of their relative influence and pathways is needed to inform the design of interventions targeting ECD.MethodsWe conducted path analyses of factors associated with 18-month language and motor development in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements (iLiNS) Project in Ghana (n=1,023), Malawi (n=675 and 1,385), and Burkina Faso (n=1,122). In two cohorts, women were enrolled during pregnancy. In two cohorts, infants were enrolled at 6 or 9months. In multiple linear regression and structural equationmodels (SEM), we examined 22 out of 44 factors identified in previous reviews, plus 12 additional factors expected to be associated with ECD.ResultsOut of 42 indicators of the 34 factors examined, 6 were associated with 18-month language and/or motor development in 3 or 4 cohorts: child linear and ponderal growth, variety of play materials, activities with caregivers, dietary diversity, and child hemoglobin/iron status. Factors that were not associated with child development were indicators of maternal Hb/iron status, maternal illness and inflammation during pregnancy, maternal perceived stress and depression, exclusive breastfeeding during 6months postpartum, and child diarrhea, fever, malaria, and acute respiratory infections. Associations between socioeconomic status and language development were consistently mediated to a greater extent by caregiving practices than by maternal or child biomedical conditions, while this pattern for motor development was not consistent across cohorts.ConclusionsKey elements of interventions to ensure quality ECD are likely to be promotion of caregiver activities with children, a variety of play materials, and a diverse diet, and prevention of faltering in linear and ponderal growth and improvement in child hemoglobin/iron status.

© Author(s) (or their employer(s)) 2019. Stunting prevalence is an indicator of a country's progress towards United Nations' Sustainable Development Goal 2, which is to end hunger and achieve improved nutrition. Accelerating progress towards reducing stunting requires a deeper understanding of the factors that contribute to linear growth faltering. We conducted path analyses of factors associated with 18-month length-for-Age z-score (LAZ) in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements Project in Ghana (n=1039), Malawi (n=684 and 1504) and Burkina Faso (n=2619). In two cohorts, women were enrolled during pregnancy. In two other cohorts, infants were enrolled at 6 or 9 months. We examined the association of 42 indicators of environmental, maternal, caregiving and child factors with 18-month LAZ. Using structural equation modelling, we examined direct and indirect associations through hypothesised mediators in each cohort. Out of 42 indicators, 2 were associated with 18-month LAZ in three or four cohorts: maternal height and body mass index (BMI). Six factors were associated with 18-month LAZ in two cohorts: length for gestational age z-score (LGAZ) at birth, pregnancy duration, improved household water, child dietary diversity, diarrhoea incidence and 6-month or 9-month haemoglobin concentration. Direct associations were more prevalent than indirect associations, but 30%-62% of the associations of maternal height and BMI with 18-month LAZ were mediated by LGAZ at birth. Factors that were not associated with LAZ were maternal iron status, illness and inflammation during pregnancy, maternal stress and depression, exclusive breast feeding during 6 months post partum, feeding frequency and child fever, malaria and acute respiratory infections. These findings may help in identifying interventions to accelerate progress towards reducing stunting; however, much of the variance in linear growth status remained unaccounted for by these 42 individual-level factors, suggesting that community-level changes may be needed to achieve substantial progress.

BackgroundInterventions are needed to address iron deficiency in low-income settings.ObjectiveThis secondary outcome analysis aimed to compare the hemoglobin (Hb) and iron status [zinc protoporphyrin (ZPP)] of children born to women enrolled in the iLiNS-DYAD trial in Ghana.MethodsWomen ≤20 wk pregnant (n=1320) were assigned to receive 60 mg Fe/d and 400 µg folic acid/d until delivery and placebo thereafter, and no supplementation for infants (IFA group); or multiple micronutrients containing 20 mg Fe/d until 6 mo postpartum and no supplementation for infants (MMN); or small-quantity lipid-based nutrient supplements (SQ-LNSs) containing 20 mg Fe/d until 6 mo postpartum, and SQ-LNSs for infants from 6 to 18 mo of age (LNS). We compared infants' Hb (g/L) and ZPP (µmol/mol heme) at 6 and 18 mo of age.ResultsAt 6 mo of age, groups did not differ in mean±SD Hb (overall: 113±9.9 g/L) or geometric mean (95% CI) ZPP [overall: 62.6 (60.6, 64.7)]. At 18 mo of age, mean±SD Hb (overall: 112±10.4 g/L) did not differ significantly between groups, whereas geometric mean (95% CI) ZPP was lower (P=0.031) in the LNS group [53.9 (50.7, 57.3)] than the IFA [60.4 (56.7, 64.3)] but not the MMN [58.8 (55.6, 62.2)] group. Further, the LNS group, compared with the IFA and MMN groups combined, had a lower prevalence of elevated (>70) ZPP (27.5% compared with 35%; P=0.02) and a marginally lower prevalence of anemia (38.7% compared with 44.9%; P=0.06). These results generally remained unchanged when controlling for prespecified covariates or correcting for inflammation.ConclusionsIn this setting, providing SQ-LNSs or multiple micronutrients with 20 mg Fe/d, compared with iron (60 mg/d) and folic acid, to pregnant women does not affect their infants' Hb or iron status at 6 mo of age, but maternal and infant supplementation with SQ-LNSs increases infants' iron status at 18 mo of age. This trial was registered at clinicaltrials.gov as NCT00970866.

Background: Childhood stunting usually begins in utero and continues after birth; therefore, its reduction must involve actions across different stages of early life. Objective: We evaluated the efficacy of small-quantity, lipid-based nutrient supplements (SQ-LNSs) provided during pregnancy, lactation, and infancy on attained size by 18 mo of age. Design: In this partially double-blind, individually randomized trial, 1320 women at ≤20 wk of gestation received standard iron and folic acid (IFA group), multiple micronutrients (MMN group), or SQ-LNS (LNS group) daily until delivery, and then placebo, MMNs, or SQ-LNS, respectively, for 6 mo postpartum; infants in the LNS group received SQ-LNS formulated for infants from 6 to 18 mo of age (endline). The primary outcome was child length by 18 mo of age. Results: At endline, data were available for 85% of 1228 infants enrolled; overall mean length and length-for-age z score (LAZ) were 79.3 cm and −0.83, respectively, and 12% of the children were stunted (LAZ

There is little information on whether prenatal multiple micronutrient (MMN) supplements containing iodine affect women's iodine status. In the International Lipid-based Nutrient Supplements DYAD-Ghana trial, we aimed to assess women's urinary iodine concentration (UIC, μg/L) during pregnancy, as one of the planned secondary outcomes. Women (n=1,320)

Objectives. \ud To estimate the impact of hypothetical antimalarial and nutritional interventions (which reduce the prevalence of low midupper arm circumference [MUAC]) on the incidence of low birth weight (LBW).\ud \ud Methods. \ud We analyzed data from 14 633 pregnancies from 13 studies conducted across Africa and the Western Pacific from 1996 to 2015. We calculated population intervention effects for increasing intermittent preventive therapy in pregnancy (IPTp), full coverage with bed nets, reduction in malaria infection at delivery, and reductions in the prevalence of low MUAC.\ud \ud Results. \ud We estimated that, compared with observed IPTp use, administering 3 or more doses of IPTp to all women would decrease the incidence of LBW from 9.9% to 6.9% (risk difference = 3.0%; 95% confidence interval = 1.7%, 4.0%). The intervention effects for eliminating malaria at delivery, increasing bed net ownership, and decreasing low MUAC prevalence were all modest.\ud \ud Conclusions. \ud Increasing IPTp uptake to at least 3 doses could decrease the incidence of LBW in malaria-endemic countries. The impact of IPTp on LBW was greater than the effect of prevention of malaria, consistent with a nonmalarial effect of IPTp, measurement error, or selection bias.

We examined the impact on depression at 6months postpartum of maternal supplementation with small-quantity lipid-based nutrient supplement (SQ-LNS) compared to supplementation with iron and folic acid (IFA) or multiple micronutrients (MMN). In this partially double-blinded randomized controlled trial, pregnant women ≤20weeks gestation (n=1320) were recruited from antenatal clinics and randomly assigned to receive either (1) SQ-LNS during pregnancy and for 6months postpartum, or (2) IFA during pregnancy only, or (3) MMN during pregnancy and for 6months postpartum. Maternal depressive symptoms were measured at 6months postpartum using the Edinburgh Postnatal Depression Scale (EPDS). Women who scored 12 or more on the EPDS were considered to show symptoms of depression. One thousand one hundred fifty-one women were included in this analysis (LNS=382, IFA=387 and MMN=382). Characteristics of the three groups were similar at baseline, and there were no significant differences between women who were included in the analysis (n=1151) and those who were not (n=169). At 6months postpartum, 13% of the women overall showed symptoms of depression, and this did not differ by group (LNS=13.1%, IFA=11.2% and MMN=14.7%. P=0.36). The median (25, 75 percentile) EPDS score did not differ by group (LNS 4.0 (1.0, 8.0), IFA 4.0 (1.0, 8.0), MMN 5.0 (2.0, 9.0), P transformed=0.13). Adjustment for covariates did not alter these findings. Maternal supplementation with SQ-LNS compared to MMN or IFA did not affect postnatal depressive symptoms in this sample of Ghanaian women.

Appendix: Equations used in estimating reliability. Eq. 1 for calculating Intra-observer TEM, Eq. 2. for Inter-observer TEM, Eq. 3. for Average bias from the expert, and Eq. 4. for the calculation of Coefficient of reliability (R) (DOCX 20 kb)

Table S1. Preschool Developmental Assessment Methods in Ghana. Table S2. Maternal and Household Characteristics Descriptive Statistics for Developmental Scores. (DOCX 38Â kb)

Background Since the adoption of United Nations’ Sustainable Goal 4.2 to ensure that all children have access to quality early child development (ECD) so that they are ready for primary education, the demand for valid ECD assessments has increased in contexts where they do not yet exist. The development of early language ability is important for school readiness. Our objective was to evaluate the validity of a method to develop vocabulary checklists in new languages to assess early language development, based on the MacArthur-Bates Communicative Development Inventories. Methods Through asking mothers of young children what words their children say and through pilot testing, we developed 100-word vocabulary checklists in multilingual contexts in Malawi and Ghana. In Malawi, we evaluated the validity of the vocabulary checklist among 29 children age 17–25 months compared to three language measures assessed concurrently: Developmental Milestones Checklist-II (DMC-II) language scale, Malawi Developmental Assessment Tool (MDAT) language scale, and the number of different words (NDW) in 30-min recordings of spontaneous speech. In Ghana, we assessed the predictive validity of the vocabulary checklist at age 18 months to forecast language, pre-academic, and other skills at age 4–6 years among 869 children. We also compared the predictive validity of the vocabulary checklist scores to that of other developmental assessments administered at age 18 months. Results In Malawi, the Spearman’s correlation of the vocabulary checklist score with DMC-II language was 0.46 (p = 0.049), with MDAT language was 0.66 (p = 0.016) and with NDW was 0.50 (p = 0.033). In Ghana, the 18-month vocabulary checklist score showed the strongest (rho = 0.12–0.26) and most consistent (8/12) associations with preschool scores, compared to the other 18-month assessments. The largest coefficients were the correlations of the 18-month vocabulary score with the preschool cognitive factor score (rho = 0.26), language score (0.25), and pre-academic score (0.24). Conclusions We have demonstrated the validity of a method to develop vocabulary checklists in new languages, which can be used in multilingual contexts, using a feasible adaptation process requiring about 2 weeks. This is a promising method to assess early language development, which is associated with later preschool language, cognitive, and pre-academic skills. Electronic supplementary material The online version of this article (10.1186/s41043-018-0145-1) contains supplementary material, which is available to authorized users.

Background: It is unknown whether self-reported measures of household food insecurity change in response to food-based nutrient supplementation. Objective: We assessed the impacts of providing lipid-based nutrient supplements (LNSs) to women during pregnancy and postpartum and/or to their children on self-reported household food insecurity in Malawi [DOSE and DYAD trial in Malawi (DYAD-M)], Ghana [DYAD trial in Ghana (DYAD-G)], and Bangladesh [Rang-Din Nutrition Study (RDNS) trial]. Methods: Longitudinal household food-insecurity data were collected during 3 individually randomized trials and 1 cluster-randomized trial testing the efficacy or effectiveness of LNSs (generally 118 kcal/d). Seasonally adjusted Household Food Insecurity Access Scale (HFIAS) scores were constructed for 1127 DOSE households, 732 DYAD-M households, 1109 DYAD-G households, and 3671 RDNS households. The impact of providing LNSs to women during pregnancy and the first 6 mo postpartum and/or to their children from 6 to 18–24 mo on seasonally adjusted HFIAS scores was assessed by using negative binomial models (DOSE, DYAD-M, and DYAD-G trials) and mixed-effect negative binomial models (RDNS trial). Results: In the DOSE and DYAD-G trials, seasonally adjusted HFIAS scores were not different between the LNS and non-LNS groups. In the DYAD-M trial, the average household food-insecurity scores were 14% lower (P = 0.01) in LNS households than in non-LNS households. In the RDNS trial, compared with non-LNS households, food-insecurity scores were 17% lower (P = 0.02) during pregnancy and the first 6 mo postpartum and 15% lower (P = 0.02) at 6–24 mo postpartum in LNS households. Conclusions: The daily provision of LNSs to mothers and their children throughout much of the “first 1000 d” may improve household food security in some settings, which could be viewed as an additional benefit that may accrue in households should policy makers choose to invest in LNSs to promote child growth and development. These trials were registered at clinicaltrials.gov as NCT00945698 (DOSE) NCT01239693 (DYAD-M), NCT00970866 (DYAD-G) and NCT01715038 (RDNS).

Optimal infant and young child feeding (IYCF) practices can help ensure nutrient adequacy and support healthy growth and development. Small-quantity lipid-based nutrient supplements (SQ-LNS) have been proposed to help fill nutrient gaps, but little is known about the impact of provision of SQ-LNS on breastfeeding or complementary feeding practices. In the context of four coordinated randomized controlled nutrient supplementation trials in diverse sites in Africa, we compared IYCF practices at infant age 18months (after 9-12months of supplementation) between those receiving and not receiving SQ-LNS. Practices were assessed by caregiver recall. Continued breastfeeding ranged from 74% (Ghana site) to 97% (Burkina Faso site) and did not differ between groups in any site; prevalence of frequent breastfeeding also did not differ. In two sites (Burkina Faso and Malawi), infants receiving SQ-LNS were more likely to meet the World Health Organization recommendations for frequency of feeding (percentage point differences of 12-14%, P&nbsp

Background: It is unclear whether maternal supplementation with small-quantity lipid-based nutrient supplements (SQ-LNSs; 118 kcal/d) affects maternal weight.Objective: We compared several secondary anthropometric measures between 3 groups of women in the iLiNS (International Lipid-based Nutrient Supplements)-DYAD trial in Ghana.Methods: Women (n = 1320

It is unknown whether a novel small-quantity lipid-based nutrient supplement (SQ-LNS) containing alpha-linolenic (ALA) and linoleic acids impacts maternal plasma lipids and fatty acid status. We measured plasma fatty acids (wt%) and lipid concentrations at 36 wk gestation and breast milk fatty acids (wt%) at 6 months postpartum in a subsample of women enrolled in a randomized controlled trial studying the effects of SQ-LNS on birth outcomes and child growth. Women≤20 wk gestation in Ghana (n=1,320) and Malawi (n=1,391) were assigned to receive daily either: 1) iron-folic acid (pregnancy); 2) multiple micronutrients (pregnancy and lactation); or 3) SQ-LNS (pregnancy and lactation). At 36 wk, plasma ALA levels were higher in those receiving SQ-LNS. SQ-LNS increased breast milk ALA in Ghana but not Malawi. There was no effect on plasma lipids or other selected fatty acids. SQ-LNS may impact plasma and breast milk ALA levels depending on the population.

International audience; Background: Dietary diversity is a key element of diet quality, but diets of women of reproductive age (WRA; aged 15–49 y) in resource-poor settings are often deficient in a range of micronutrients. Previous work showed associations between simple food-group diversity indicators (FGIs) and micronutrient adequacy among WRA. For operational and advocacy purposes, however, there is strong demand for a dichotomous indicator reflecting an acceptable level of dietary diversity.Objective: The aim of the study was to develop a dichotomous indicator of dietary diversity in WRA.Methods: We performed a secondary analysis of 9 data sets containing quantitative dietary data from WRA in resource-poor settings (total n = 4166). From the raw dietary data, we calculated an individual “mean probability of adequacy” (MPA) across 11 micronutrients. Several candidate FGIs were constructed. Indicator performance in predicting an MPA >0.60 was assessed within each data set by using receiver-operating characteristic analysis and sensitivity and specificity analysis at various FGI cutoffs. The analysis was performed separately for nonpregnant and nonlactating (NPNL) women and for lactating women.Results: We identified 2 “best candidate” dichotomous indicators on the basis of 9- or 10-point food-group scores (FGI-9 and FGI-10) with a cutoff of ≥5 food groups. Both were significantly correlated to MPA in each site (P < 0.001). Areas under the curve were moderate, ranging from 0.62 to 0.82 among NPNL women and from 0.56 to 0.90 among lactating women. Comparisons of results slightly favored FGI-10 for all women.Conclusions: When resource-intensive dietary methods are not feasible, a simple dichotomous indicator based on a cutoff of ≥5 of 10 defined food groups reflects “minimum dietary diversity for women of reproductive age.” According to the conclusions of a consensus meeting of experts, this indicator is well suited for population-level assessment, advocacy, and possibly also for tracking of change in dietary diversity across time.

BackgroundChildhood stunting usually begins in utero and continues after birth; therefore, its reduction must involve actions across different stages of early life.ObjectiveWe evaluated the efficacy of small-quantity, lipid-based nutrient supplements (SQ-LNSs) provided during pregnancy, lactation, and infancy on attained size by 18 mo of age.DesignIn this partially double-blind, individually randomized trial, 1320 women at ≤20 wk of gestation received standard iron and folic acid (IFA group), multiple micronutrients (MMN group), or SQ-LNS (LNS group) daily until delivery, and then placebo, MMNs, or SQ-LNS, respectively, for 6 mo postpartum; infants in the LNS group received SQ-LNS formulated for infants from 6 to 18 mo of age (endline). The primary outcome was child length by 18 mo of age.ResultsAt endline, data were available for 85% of 1228 infants enrolled; overall mean length and length-for-age z score (LAZ) were 79.3 cm and -0.83, respectively, and 12% of the children were stunted (LAZ

We examined hemoglobin (Hb, g/L), iron status (zinc protoporphyrin, ZPP, µmol/mol heme, and transferrin receptor, TfR, mg/L) and inflammation (C‐reactive protein, CRP and alpha‐1 glycoprotein, AGP) in pregnant Ghanaian women who participated in a randomized controlled trial. Women (n = 1320) received either 60 mg Fe + 400‐µg folic acid (IFA); 18 micronutrients including 20‐mg Fe (MMN) or small‐quantity lipid‐based nutrient supplements (SQ‐LNS, 118 kcal/d) with the same micronutrient levels as in MMN, plus four additional minerals (LNS) daily during pregnancy. Intention‐to‐treat analysis included 349, 354 and 354 women in the IFA, MMN and LNS groups, respectively, with overall baseline mean Hb and anemia (Hb 60) [9.4% vs. 18.6% and 19.2%; P = 0.003] and elevated TfR (>6.0) [9.0% vs. 19.2% and 15.1%; P = 0.004]. CRP and AGP concentrations did not differ among groups. We conclude that among pregnant women in a semi‐urban setting in Ghana, supplementation with SQ‐LNS or MMN containing 20 mg iron resulted in lower Hb and iron status but had no impact on inflammation, when compared with iron (60 mg) plus folic acid (400 µg). The amount of iron in such supplements that is most effective for improving both maternal Hb/iron status and birth outcomes requires further evaluation. This trial was registered at http://ClinicalTrials.gov as: NCT00970866.

Background Supplementing pregnant and lactating mothers with small quantity lipid-based nutrient supplements (SQ-LNS) has resulted in improvements in birth outcomes in some low-income settings. In order to be effective, SQ-LNS must be consumed regularly over sustained periods. Methods The objective was to assess and compare acceptability of and adherence to SQ-LNS consumption among pregnant and lactating women in Ghana and Malawi throughout 12 months of supplementation. We enrolled women before 20 gestation weeks into randomized trials in Ghana (n = 1320) and Malawi (n = 869). In the SQ-LNS group participants received a 20 g sachet of supplement per day during pregnancy and the first 6 months of lactation. In the control groups participants received multiple micronutrients (MMN) during pregnancy and lactation or iron and folic acid (IFA) during pregnancy and calcium during lactation. We used questionnaires to collect data on self-reported adherence to daily use of supplements and conducted in-depth interviews with women in the SQ-LNS group to examine acceptability. Results The mean self-reported adherence during the supplementation period was lower in Ghana (79.9 %) than in Malawi (91.7 %) for all supplements (difference 11.8 %, P

Objectives: Guided by the UNICEF framework for childcare, this study examined the association of childcare practices (CCP) with infant and young children’s growth (height-for-age Z-scores, HAZ), and investigated whether care practices are more important to growth in some sociodemographic subgroups of children. Design: Cross-sectional survey. Setting: Urban and rural Ghana. Participants: The study sample comprised 1187 dyads of mothers aged 15–49 years and their youngest child (aged 6–36 months). Results: The results showed that CCP was a significant predictor of HAZ, after controlling for covariates/confounders at child, maternal and household levels. Children with higher CCP scores had higher HAZ. A 1-unit increase in the CCP score was associated with a 0.17-unit increase in HAZ. Child’s and mother’s age, number of children under 5 years, place of residence, maternal weight and wealth index were also significantly associated with HAZ. Statistical interaction analyses revealed no subgroup differences in the CCP/HAZ relationship. Conclusions: This study found a significant, positive association between CCP and child growth, after accounting for other important determinants of child growth at maternal and household levels. This calls for research into the effects on growth of various CCP components, with longitudinal cohort study designs that can disentangle causal relationships. publishedVersion

Objectives Guided by the UNICEF framework for childcare, this study examined the association of childcare practices (CCP) with infant and young children's growth (height-for-age Z-scores, HAZ), and investigated whether care practices are more important to growth in some sociodemographic subgroups of children. Design Cross-sectional survey. Setting Urban and rural Ghana. Participants The study sample comprised 1187 dyads of mothers aged 15–49 years and their youngest child (aged 6–36 months). Results The results showed that CCP was a significant predictor of HAZ, after controlling for covariates/confounders at child, maternal and household levels. Children with higher CCP scores had higher HAZ. A 1-unit increase in the CCP score was associated with a 0.17-unit increase in HAZ. Child's and mother's age, number of children under 5 years, place of residence, maternal weight and wealth index were also significantly associated with HAZ. Statistical interaction analyses revealed no subgroup differences in the CCP/HAZ relationship. Conclusions This study found a significant, positive association between CCP and child growth, after accounting for other important determinants of child growth at maternal and household levels. This calls for research into the effects on growth of various CCP components, with longitudinal cohort study designs that can disentangle causal relationships.

The interplay of factors that affect post-partum loss or retention of weight gained during pregnancy is not fully understood. The objective of this paper is to describe patterns of weight change in the six sites of the World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) and explore variables that explain variation in weight change within and between sites. Mothers of 1743 breastfed children enrolled in the MGRS had weights measured at days 7, 14, 28 and 42 post-partum, monthly from 2 to 12 months and bimonthly thereafter until 24 months post-partum. Height, maternal age, parity and employment status were recorded and breastfeeding was monitored throughout the follow-up. Weight change patterns varied significantly among sites. Ghanaian and Omani mothers lost little or gained weight post-partum. In Brazil, India, Norway and USA, mothers on average lost weight during the first year followed by stabilization in the second year. Lactation intensity and duration explained little of the variation in weight change patterns. In most sites, obese mothers tended to lose less weight than normal-weight mothers. In Brazil and Oman, primiparous mothers lost about 1 kg more than multiparous mothers in the first 6 months. In India and Ghana, multiparous mothers lost about 0.6 kg more than primiparas in the second 6 months. Culturally defined mother-care practices probably play a role in weight change patterns among lactating women. This hypothesis should stimulate investigation into gestational weight gain and post-partum losses in different ethnocultural contexts.