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Background: Preventive vitamin A supplementation (VAS) is an essential child survival intervention. In India, VAS program coverage has remained relatively low, with wide interstate variation., Objective: To review the VAS program in India, particularly in Bihar and Odisha, the two states that have had the most successful VAS programs, to define best practices and identify critical success factors., Methods: A thorough review of existing relevant literature was carried out, supplemented by field visits and interviews with selected partners., Results: Both states have adopted a biannual approach to reach out to children 1 to 5 years of age with VAS every 6 months, while infants below 1 year of age receive their first VAS dose with the measles immunization at 9 months. The critical success factors for the VAS program in the two states include strong leadership and ownership by the state government; close coordination between the two departments that are involved in the VAS program; effective microplanning prior to each biannual round; flexible dosing mechanisms that enhance coverage in hard-to-reach areas; a stable procurement and distribution mechanism to ensure an adequate, timely, and sustainable supply of VAS; intensive social mobilization and communication; and appropriate training and supervision of staff., Conclusions: The governments of Bihar and Odisha have demonstrated that it is feasible to implement a successful and inclusive VAS program in India. The challenge now is to reach out to the remaining 30% to 40% of children who are undoubtedly the hardest to reach and potentially the most vulnerable.

Background: In 1981 the World Health Assembly (WHA) adopted the International Code of Marketing of Breastmilk Substitutes out of concern that inappropriate marketing of breastmilk substitutes was contributing to the alarming decline in breastfeeding worldwide and the increase in child malnutrition and mortality, particularly in developing countries., Objective: To document progress, challenges, and lessons learned in the implementation of the International Code in West and Central Africa., Methods: Data were obtained by literature review and interviews with key informants., Results: Twelve of the 24 countries have laws, decrees, or regulations that implement all or most of the provisions of the Code, 6 countries have a draft law or decree that is awaiting government approval or have a government committee that is studying how best to implement the Code, 3 countries have a legal instrument that enacts a few provisions of the Code, and 3 countries have not taken any action to implement the Code. International declarations and initiatives for child nutrition and survival have provided impetus for national implementation of the Code. National action to regulate the marketing of breastmilk substitutes needs to be linked to national priorities for nutrition and child survival. A clearly defined scope is essential for effective implementation of national legislation. Leadership and support by health professionals is essential to endorse and enforce national legislation. Training on Code implementation is instrumental for national action; national implementation of the Code requires provisions and capacity to monitor and enforce the legislative framework and needs to be part of a multipronged strategy to advance national child nutrition and survival goals., Conclusions: Nations in West and Central Africa have made important progress in implementing the International Code. More than 25 years after its adoption by the WHA, the Code remains as important as ever for child survival and development in West and Central Africa.

Background: Micronutrient deficiencies during pregnancy are associated with adverse pregnancy outcomes, including reduced birthweight. Low birthweight is associated with increased risk of infant mortality and growth failure., Objectives: To assess the effects of prenatal supplementation with UNIMMAP (United Nations International Multiple Micronutrient Preparation) compared with iron/folic acid on average birthweight and incidence of low birthweight., Methods: Pregnant women from 78 villages in Niger were included in a cluster-randomized, double-blinded, controlled supplementation trial. Baseline, monthly follow-up, and birth data were collected. Cluster analysis was conducted to assess differences in mean birthweight and incidence of low birthweight between groups using multiple linear regression models. Analyses were stratified by nutrition status and duration of supplementation., Results: Of the 3,670 women recruited, 2,550 completed the study and provided complete birthweight data (1,328 received multiple micronutrients and 1,222 received iron/folic acid). Mean birthweight was significantly higher (67 g, p < .001) with multiple micronutrients (3,092 +/- 190 g) than with iron/folic acid (3,025 +/- 205 g); this corresponded to a 14% fall in the incidence of low birthweight (from 8.4% with multiple micronutrients to 7.2% with folic acid fortification). The impact of multiple micronutrients was greater when the supplements were taken for more than 150 days. The incidence of low birthweight was further reduced in women who entered pregnancy with a poorer nutrition status., Conclusions: Prenatal supplementation with multiple micronutrients had a greater positive impact on birthweight than supplementation with iron/folic acid. Our data suggest that prenatal supplementation with multiple micronutrients as part of a prenatal care package in addition to interventions to promote improved maternal prepregnancy nutrition status is an important strategy to increase birthweight and reduce the incidence of low birthweight.

Background: Children with vitamin A deficiency have higher risk of morbidity and mortality than vitamin A-sufficient children. Estimates on the potential child survival benefits of vitamin A deficiency control are needed for policy and program advocacy., Objective: To determine the current prevalence of children at risk for vitamin A deficiency in sub-Saharan Africa in order to estimate the potential child-survival benefits of effective and sustained policies and programs for the control of vitamin A deficiency in this region., Methods: Estimates of the prevalence of vitamin A deficiency generated in 1998, data from 11 nationally representative vitamin A deficiency surveys conducted in sub-Saharan Africa between 1997 and 2003, and the measured effects of vitamin A deficiency on child mortality were combined to estimate the prevalence of children at risk for vitamin A deficiency in sub-Saharan Africa and the potential child-survival benefits of effective and sustained policies and programs for the control of vitamin A deficiency in this region., Results: Our analysis shows that in the absence of effective and sustained policies and programs for the control of vitamin A deficiency, an estimated 42.4% of children 0 to 59 months of age in sub-Saharan Africa (43.2 million children) are at risk for vitamin A deficiency. Such effective and sustained policy and program action for the control of vitamin A deficiency can bring about a potential 25% reduction in mortality in children 0 to 59 months with respect to 1995 mortality levels (i.e., before the onset of large-scale vitamin A supplementation programs in sub-Saharan Africa)., Conclusions: Effective and sustained control of vitamin A deficiency has the potential to be among the most cost-effective and high-impact child-survival interventions in sub-Saharan Africa. A stronger political commitment and a more appropriate level of investment in the effective control of vitamin A deficiency could make a large contribution toward the attainment of the Millennium Development Goal for the reduction of child mortality rates by two-thirds between 1990 and 2015. Among the many challenges that Africa will need to face in the coming years, vitamin A deficiency is one that can be overcome. The need is urgent, and the solutions are known, effective, and affordable.

Background: The 1997 Demographic and Health Survey in Mozambique shows that 47% of girls 15 to 19 years old living in Manica province (west-central Mozambique) are pregnant or have already had a child. A recent survey also shows that 45% of girls 10 to 18 years old attending school are anemic. Strategies are needed to build iron stores before pregnancy and to control seasonal and chronic iron deficiency and anemia in school-aged girls., Objective: To assess the program effectiveness of two school-based weekly iron and folic acid (IFA) supplementation regimes (5-month supplementation vs. 8-month supplementation) in girls 10 to 18 years old attending school in Manica province., Methods: Twelve schools were included in the study. Schools were ordered by descending mean hemoglobin concentration, and assigned alternately to study group 5 (six schools; 5-month supplementation) or study group 8 (six schools; 8-month supplementation). In both study groups, the weekly supplement contained 60 mg of elemental iron and 400 microg of folic acid. All girls received a single dose of mebendazol (500 mg) twice--once at the beginning of the study (T0) and once six months later (T6). Supplementation was implemented and supervised by the teachers of the schools included in the study. Between T0 and T3, girls in study group 8 received IFA supplements weekly whereas girls in study group 5 did not. Between T3 and T8, all girls in both groups received weekly IFA supplements., Results: At T0, mean hemoglobin concentration and anemia prevalence were comparable in study groups 8 and 5 (125.3 +/- 12.6 g/L vs. 123.8 +/- 12.8 g/L; 28% vs. 29%, respectively). At T3, the mean hemoglobin concentration in study group 8 was significantly higher (126.3 +/- 14.3 g/L vs. 121.5 g/dL +/- 11.9 g/L, p < .001) and the prevalence of anemia was lower (28% vs. 35%, p = .076) than in study group 5. At T8, after an additional 5-month supplementation period in both study groups, mean hemoglobin concentration and anemia prevalence in study groups 8 and 5 were not significantly different (126.5 +/- 12.6 g/L vs. 124.9 +/- 12.3 g/L; 23% vs. 27%, respectively)., Conclusion: In Manica Province, school-based weekly IFA supplementation is a feasible and effective intervention to prevent seasonal drops in hemoglobin concentration and increases in anemia prevalence. Short supplementation periods can have an important impact on girls' hematological status. However, the size of girls' hematological response in this study was significantly lower that that observed in studies with similar population groups, initial anemia prevalence, supplement dosing, and/or supplementation regime.

In 1997, the reduction of child mortality became a policy priority for the Government of Niger because Niger's child mortality rate was the highest in the world. The Ministry of Public Health, Helen Keller International (HKI), and UNICEF spearheaded a coalition-building process linking vitamin A deficiency (VAD) control to national child survival goals. An evidence-based advocacy strategy was developed around the child survival benefits of adequate and sustained VAD control with one unambiguous message: "VAD control can avert over 25,000 child deaths per year." As a result, in 1997 Niger became one of the first countries in Africa to effectively integrate vitamin A supplementation into National Immunization Days (NIDs) for polio eradication. The challenge was then to provide children with a second annual dose of vitamin A. This led in 1999 to the first ever National Micronutrient Days (NMDs) in Africa. NMDs are mobilization campaigns in which caregivers are actively encouraged to take their children for the delivery of vitamin A supplements. Since 1999, the combination of NIDs and NMDs has ensured that over 80% of children 6 to 59 months of age receive two vitamin A doses annually. The success of NIDs/NMDs has relied on five pillars: leadership and ownership by the Ministry of Public Health; district-level planning and implementation; effective training and flexible delivery mechanisms; effective social information, communication, and mobilization; and responsiveness and flexibility of Ministry of Public Health and development partners. This successful approach has been widely disseminated, notably through the West African Nutrition Focal Points Network.