Acceptability and Effectiveness of a Locally-Produced Ready-to-Use Supplementary Food (RUSF) for Prevention of Undernutrition in Children Under Two Years in Cambodia

We tested a locally-produced, fish-based multiple micronutrient fortified lipid-based nutrient supplement (LNS) snack as a ready-to-use supplementary food (RUSF) to prevent undernutrition in Cambodian children under 2 years. Our first trial assessed the RUSF’s acceptability as a snack or mixed with borbor (white rice porridge) compared to Corn-Soy Blend Plus Plus (CSB++), and micronutrient powders (MNP) with borbor. The second assessed its effectiveness in reducing growth faltering compared to CSB++, MNP, and an unsupplemented control group. The acceptability trial with 92 children aged 9-23 months assessed children’s consumption, caregivers’ assessment of children’s preferences and caregivers’ ranking of foods. The cluster-randomised controlled effectiveness trial allocated 485 healthy children aged 6-17 months to RUSF, CSB++, MNP or control groups for 6 months. Outcomes were weight-for-age (WAZ), height-for-age (HAZ), weight- for-height (WHZ), and mid-upper arm circumference (MUAC). In acceptability testing, odds of children consuming >50% were greatest for MNP-borbor versus RUSF snack. Caregivers reported that children had the highest preference for MNP-borbor, then for the RUSF snack. Caregivers ranked the RUSF snack highest. In the effectiveness trial, growth faltered from baseline to endline, with no significant differences between interventions and control. In unadjusted analysis, the RUSF group had greater increases in MUAC than CSB++ or the control. For other outcomes, the RUSF did not differ significantly from the control, which had decreased WAZ and HAZ and no significant change in WHZ. In adjusted analysis, high consumers of RUSF had increased MUAC compared to control, but no statistically significant differences to CSB++ or MNP. Low consumers of RUSF had increased WAZ, WHZ and MUAC. Our trials demonstrated that the novel RUSF is acceptable and slowed, but did not prevent, growth faltering

Estimating the prevalence of exclusive breastfeeding with data from household surveys : measurement issues and options

The importance of breastfeeding for infant and maternal health is well established. The World Health Organization recommends that all infants be exclusively breastfed until they reach 6 months of age. The standard indicator to measure adherence to this criterion is the percentage of children aged 0–5 months who are currently being exclusively breastfed. This paper proposes supplementary measures that are easily calculated with existing survey data. First, for an accurate assessment of the WHO recommendation, we estimate the percentage of infants who are being exclusively breastfed at the exact age of 6 months. Second, an adjustment is proposed for prelacteal feeding. These two modifications, separately and in combination, are applied to data from 31 low-and middle-income countries that have participated in the Demographic and Health Surveys Program since 2015. There is considerable variation in the effects across countries. The modifications use existing data to provide a more accurate estimate than the standard indicator of the achievement of the exclusive breastfeeding until 6 months recommendation

Innovative financing for a gender-equitable first-food system to mitigate greenhouse gas impacts of commercial milk formula: investing in breastfeeding as a carbon offset

Women’s contributions to food production and food security are often overlooked, thus perpetuating inequitable and unsustainable globalized commercial food systems. Women’s role as producers in the first-food system, breastfeeding, is largely invisible and underfunded, encouraging the production and consumption of environmentally unsustainable commercial milk formula (CMF). This policy brief highlights opportunities for including and funding interventions enabling breastfeeding under carbon offset schemes such as the United Nations Clean Development Mechanism (CDM). A Green Feeding Tool is being developed to account for the national carbon and water footprints of CMF. The tool will help ensure that women’s contributions to a sustainable first-food system are not ignored by the CDM and other mechanisms funding greenhouse gas emissions reductions

Association between early initiation of breastfeeding and reduced risk of respiratory infection: Implications for nonseparation of infant and mother in the COVID-19 context

Early initiation of breastfeeding, within 1 h of birth, is vital for the health of newborns and reduces morbidity and mortality. Secondary analysis of the 2016 Nepal Demographic and Health Survey (DHS) showed that early initiation of breastfeeding significantly reduced the risk of acute respiratory infection (ARI) in children under 2 years. Early initiation of breastfeeding requires maternal proximity. Separation of infant and mother inhibits early initiation of breastfeeding and increases the risk that infants will suffer from ARIs. However, during the COVID-19 pandemic, guidance varied, with some recommending that infants and mothers with SARS-CoV-2 be isolated from one another. Nepal's Ministry of Health and Population recommended nonseparation, but the adherence to this guidance was inconsistent. Maternal proximity, nonseparation and early initiation of breastfeeding should be promoted in all birthing facilities

Crossover trial to test the acceptability of a locally produced lipid-based nutrient supplement (LNS) for children under 2 years in Cambodia: A study protocol

Introduction The acceptability and efficacy of existing ready-to-use supplementary and therapeutic foods has been low in Cambodia, thus limiting success in preventing and treating malnutrition among Cambodian children. In that context, UNICEF and IRD have developed a locally produced, multiple micronutrient fortified lipid-based nutrient supplement. This food is innovative, in that it uses fish instead of milk as the animal source food. Very few supplementary foods have non-milk animal source foods, and in addition they have not been widely tested. This trial will assess the novel food's acceptability to children and caregivers. Methods and analysis This is a cluster-randomised, incomplete block, 4×4 crossover design with no blinding. It will take place in four sites in a community setting in periurban Phnom Penh. Healthy children aged 9-23 months (n=100) will eat each of four foods for 3 days at a time. The amount they consume will be measured, and at the end of each 3-day set, caregivers will assess how well their child liked the food. After 12 days, caregivers themselves will do a sensory test of the 4 foods and will rank them in terms of preference. Ethics and dissemination Ethical clearance was received from the University of Queensland Medical Research Ethics Committee (2014001070) and from Cambodia's National Ethics Committee for Health Research (03/8 NECHR). Registration ClinicalTrials.gov, identifier: LNS-CAMB-INFANTS; NCT02257437. Pre-results

Acceptability of locally-produced Ready-to-Use Supplementary Food (RUSF) for children under two years in Cambodia: A cluster randomised trial

In Cambodia, existing food products for treating or preventing undernutrition have met with limited success. Therefore, in 2014, alternative ready-to-use foods were developed. This trial aimed to assess the acceptability of the novel ready-to-use supplementary food (RUSF) as a snack or mixed with borbor (white rice porridge), compared with corn–soy blend plus plus (CSB++) and borbor fortified with micronutrient powder (MNP). The nonblinded, randomised 4\ua0×\ua04 crossover trial recruited 95 children aged 9–23\ua0months from communities in peri-urban Phnom Penh. Small quantities (100\ua0g for porridges, 42\ua0g for snack) of each food were offered for three consecutive days at testing sites (homes of health volunteers). Main outcomes were children's consumption, caregivers' assessment of children's preferences, and caregivers' ranking of the foods. Median percentage consumed of the test food servings ranged from 21 to 50% (p\ua0=\ua00.003). The odds of children consuming over 50% were greatest for borbor fortified with MNP versus RUSF snack (unadjusted OR\ua0=\ua06.79, CI\ua0=\ua02.80–16.47, p\ua

Effectiveness of a locally produced ready-to-use supplementary food in preventing growth faltering for children under 2 years in Cambodia: a cluster randomised controlled trial

This cluster randomised controlled trial tested the effectiveness of a locally produced, fish-based, ready-to-use supplementary food (RUSF) to prevent growth faltering (decline in z-scores). Cambodian infants (n= 485), aged 6 to 11 months, were randomised by site to receive the RUSF, Corn-Soy Blend++ (CSB++), micronutrient powders (MNP), or no supplement (control). The intervention was for 6 months. In unadjusted analysis, the control group had statistically significantly decreased weight-for-age z-scores (WAZ; -0.02, 95%CI = -0.03 - -0.01, P= 0.001) and height-for-age z-scores (HAZ; -0.07, 95%CI = -0.09 - -0.05, P < 0.001), and increased mid-upper arm-circumference (MUAC; 0.02cm, 95%CI = 0.01 - 0.04, P = 0.010), but no statistically significant change in weight-for-height z-scores (WHZ). The RUSF group did not differ significantly from the control for WAZ, HAZ or WHZ (in other words, WAZ and HAZ decreased and WHZ did not change), but had increased MUAC in comparison to the control (0.04cm, 95%CI = 0.01 - 0.06, P = 0.008). There were no statistically significant differences between the RUSF group and the CSB++ or MNP groups with respect to WAZ, HAZ, WHZ or MUAC. Interestingly, in adjusted analysis, low consumers of RUSF had increased WAZ, WHZ and MUAC (0.03, 95%CI = 0.01-0.06, P = 0.006; 0.04, 95%CI = 0.01-0.08, P = 0.026; and 0.05cm, 95%CI = 0.02-0.09, P = 0.004, respectively) compared with the control. The novel RUSF, particularly in small quantities, protected against ponderal growth faltering, but the improvements were of limited clinical significance

Development and testing of locally-produced ready-to-use therapeutic and supplementary foods (RUTFs and RUSFs) in Cambodia: Lessons learned

Background: Rates of childhood undernutrition are persistently high in Cambodia. Existing ready-to-use supplementary and therapeutic foods (RUSFs and RUTFs) have had limited acceptance and effectiveness. Therefore, our project developed and trialled a locally-produced, multiple micronutrient fortified lipid-based nutrient supplement (LNS) with therapeutic and supplementary versions. This ready-to-use food (RUF) is innovative in that, unlike many RUFs, it contains fish instead of milk. Development began in 2013 and the RUF was finalised in 2015. From 2015 until the present, both the RUTF and the RUSF versions were trialled for acceptability and effectiveness. Methods: This paper draws on project implementation records and semi-structured interviews to describe the partnership between the Cambodian Ministries of Health and Agriculture, Forestry and Fisheries, UNICEF, the French National Research Institute for Sustainable Development (IRD), universities, and Vissot factory. It discusses the project implementation and lessons learned from the development and trialling process, and insights into positioning nutrition on the health agenda in low and middle-income countries. Results: The lessons learned relate to the importance of project planning, management, and documentation in order to seize opportunities in the research, policy, advocacy, and programming environment while ensuring adequate day-to-day project administration and resourcing. Conclusions: We conclude that projects such as ours, that collaborate to develop and test novel, locally-produced RUTFs and RUSFs, offer an exciting opportunity to respond to both local programmatic and broader research needs