Effects of micronutrient fortified milk and cereal food for infants and children: a systematic review

BMC Public Health

Urs Brügger¹  Isabelle Rüthemann¹  Simon Wieser¹  Klaus Eichler¹ 

[1]Institute of Health Economics, Zurich University of Applied Sciences, St. Georgenstrasse, 70 P.O. Box, Winterthur 8401, CH, Switzerland

关键词: Cereals;    Milk;    Fortification;    Micronutrients;   

Others  :  1163469
DOI  :  10.1186/1471-2458-12-506

 received in 2012-02-09, accepted in 2012-07-06,  发布年份 2012

【 摘 要 】

Background

Micronutrient deficiency is a common public health problem in developing countries, especially for infants and children in the first two years of life. As this is an important time window for child development, micronutrient fortified complementary feeding after 6 months of age, for example with milk or cereals products, in combination with continued breastfeeding, is recommended. The overall effect of this approach is unclear.

Methods

We performed a Systematic Review and Meta-analysis to assess the impact of micronutrient fortified milk and cereal food on the health of infants and little children (aged 6 months to 5 years) compared to non-fortified food. We reviewed randomized controlled trials using electronic databases (MEDLINE and Cochrane library searches through FEB 2011), reference list screening and hand searches. Three reviewers assessed 1153 studies for eligibility and extracted data. One reviewer assessed risk of bias using predefined forms.

Results

We included 18 trials in our analysis (n = 5’468 children; range of mean hemoglobin values: 9.0 to 12.6 g/dl). Iron plus multi micronutrient fortification is more effective than single iron fortification for hematologic outcomes. Compared to non-fortified food, iron multi micronutrient fortification increases hemoglobin levels by 0.87 g/dl (95%-CI: 0.57 to 1.16; 8 studies) and reduces risk of anemia by 57% (relative risk 0.43; 95%-CI 0.26 to 0.71; absolute risk reduction 22%; number needed to treat 5 [95%-CI: 4 to 6]; 6 Studies). Compared to non-fortified food, fortification increases serum levels of vitamin A but not of zinc. Information about functional health outcomes (e.g. weight gain) and morbidity was scarce and evidence is inconclusive. Risk of bias is unclear due to underreporting, but high quality studies lead to similar results in a sensitivity analysis.

Conclusions

Multi micronutrient fortified milk and cereal products can be an effective option to reduce anemia of children up to three years of age in developing countries. On the basis of our data the evidence for functional health outcomes is still inconclusive.

【 授权许可】

   
2012 Eichler et al.; licensee BioMed Central Ltd.

【 图 表 】

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【 参考文献 】

• [1]Horton S: Alderman H. Rivera JA: Hunger and Malnutrition. Copenhagen Consensus Challenge Paper. Copenhagen Consensus Center; 2008.
• [2]Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J: Maternal and child undernutrition: global and regional exposures and health consequences. Lancet 2008, 371(9608):243-260.
• [3]Dewey KG, Begum K: Long-term consequences of stunting in early life. Matern Child Nutr 2011, 7(Suppl 3):5-18.
• [4]Word Health Organisation: Conclusions and recommendations of the WHO consultation on prevention and control of iron deficiency in infants and young children in malaria-endemic areas. Food and Nutrition Bulletin 2007, 28(4):S621-S631.
• [5]Allen L, de Benoist B: Dary O. Hurrel R: Guidelines on food fortification with micronutritients. Edited by WHO Food and Agricultural Organization of the United Nations. Geneva; 2006.
• [6]Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, et al.: What works? Interventions for maternal and child undernutrition and survival. Lancet 2008, 371(9610):417-440.
• [7]World Health Assembly Resolution: Infant and young child nutrition. In WHA Resolution 2001., 542
• [8]Sazawal S, Dhingra U, Dhingra P, Hiremath G, Sarkar A, Dutta A, Menon VP, Black RE: Micronutrient fortified milk improves iron status, anemia and growth among children 1–4 years: a double masked, randomized, controlled trial. PLoS One 2010, 5(8):e12167.
• [9]Oelofse A, Van Raaij JM, Benade AJ, Dhansay MA, Tolboom JJ, Hautvast JG: The effect of a micronutrient-fortified complementary food on micronutrient status, growth and development of 6- to 12-month-old disadvantaged urban South African infants. Int J Food Sci Nutr 2003, 54(5):399-407.
• [10]Rivera JA, Shamah T, Villalpando S, Monterrubio E: Effectiveness of a large-scale iron-fortified milk distribution program on anemia and iron deficiency in low-income young children in Mexico. Am J Clin Nutr 2010, 91(2):431-439.
• [11]NHS Centre for Reviews and Dissemination: CRD’s guidance for undertaking reviews in health care. York: University of York; 2008.
• [12]Higgins JP, Green S: Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration 2011.
• [13]Moher D, Liberati A, Tetzlaff J, Altman DG: Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med 2009, 151(4):264-269.
• [14]Heird WC: Progress in promoting breast-feeding, combating malnutrition, and composition and use of infant formula, 1981–2006. J Nutr 2007, 137(2):499S-502S.
• [15]Food and Agricultural Organization of the United Nations: Standard for infant formula and formulas for special medical purposes intended for infants. In CODEX STAN 2007, 72-1981.
• [16]International Clinical Epidemiology Network. http://www.inclentrust.org/ webcite
• [17]Global Alliance for Improved Nutrition. http://www.gainhealth.org/ webcite
• [18]The Micronutrient Initiative. http://www.micronutrient.org/english/view.asp?x=1 webcite
• [19]Bill & Melinda Gates Foundationhttp://www.gatesfoundation.org/Pages/home.aspx webcite
• [20]Allen LH, Peerson JM, Olney DK: Provision of multiple rather than two or fewer micronutrients more effectively improves growth and other outcomes in micronutrient-deficient children and adults. J Nutr 2009, 139(5):1022-1030.
• [21]Altman DG, Machin D, Bryant TN, Gardner JM: Statistics with confidence. Bristol: BMJ Books; 2001.
• [22]Khan KS, Kunz R, Kleijnen J, Antes G: Systematic reviews to support evidence-based medicine. London: Royal Society of Medicine Press; 2003.
• [23]Higgins JP, Thompson SG, Deeks JJ, Altman DG: Measuring inconsistency in meta-analyses. BMJ 2003, 327(7414):557-560.
• [24]Gill DG, Vincent S, Segal DS: Follow-on formula in the prevention of iron deficiency: a multicentre study. Acta Paediatr 1997, 86(7):683-689.
• [25]Maldonado Lozano J, Baro L, Ramirez-Tortosa MC, Gil F, Linde J, Lopez-Huertas E, Boza JJ, Gil A: Intake of an iron-supplemented milk formula as a preventive measure to avoid low iron status in 1–3 year-olds. An Pediatr (Barc) 2007, 66(6):591-596.
• [26]Morley R, Abbott R, Fairweather-Tait S, MacFadyen U, Stephenson T, Lucas A: Iron fortified follow on formula from 9 to 18 months improves iron status but not development or growth: a randomised trial. Arch Dis Child 1999, 81(3):247-252.
• [27]Villalpando S, Shamah T, Rivera JA, Lara Y, Monterrubio E: Fortifying milk with ferrous gluconate and zinc oxide in a public nutrition program reduced the prevalence of anemia in toddlers. J Nutr 2006, 136(10):2633-2637.
• [28]Virtanen MA, Svahn CJ, Viinikka LU, Raiha NC, Siimes MA, Axelsson IE: Iron-fortified and unfortified cow's milk: effects on iron intakes and iron status in young children. Acta Paediatr 2001, 90(7):724-731.
• [29]Brown KH, López de Romaña D, Arsenault JE, Peerson JM, Penny ME: Comparison of the effects of zinc delivered in a fortified food or a liquid supplement on the growth, morbidity, and plasma zinc concentrations of young Peruvian children. Am J Clin Nutr 2007, 2:538-547.
• [30]Walter T, Pino P, Pizarro F, Lozoff B: Prevention of iron-deficiency anemia: comparison of high- and low-iron formulas in term healthy infants after six months of life. J Pediatr 1998, 4:635-640.
• [31]Daly A, MacDonald A, Aukett A, Williams J, Wolf A, Davidson J, Booth IW: Prevention of anaemia in inner city toddlers by an iron supplemented cows' milk formula. Arch Dis Child 1996, 1:9-16.
• [32]Stevens D, Nelson A: The effect of iron in formula milk after 6 months of age. Arch Dis Child 1995, 3:216-220.
• [33]Faber M, Kvalsvig JD, Lombard CJ, Benadé AJ: Effect of a fortified maize-meal porridge on anemia, micronutrient status, and motor development of infants. Am J Clin Nutr 2005, 5:1032-1039.
• [34]Lartey A, Manu A, Brown KH, Peerson JM, Dewey KG: A randomized, community-based trial of the effects of improved, centrally processed complementary foods on growth and micronutrient status of Ghanaian infants from 6 to 12 mo of age. Am J Clin Nutr 1999, 70(3):391-404.
• [35]Gibson RS, Kafwembe E, Mwanza S, Gosset L, Bailey KB, Mullen A, Baisley K, Filteau S: A Micronutrient-Fortified Food Enhances Iron and Selenium Status of Zambian Infants but Has Limited Efficacy on Zinc. J Nutr 2011, 141:935-943.
• [36]Nesamvuni AE, Vorster HH, Margetts BM, Kruger A: Fortification of maize meal improved the nutritional status of 1-3-year-old African children. Public Health Nutr 2005, 8(5):461-467.
• [37]Liu DS, Bates CJ, Yin TA, Wang XB, Lu CQ: Nutritional efficacy of a fortified weaning rusk in a rural area near Beijing. Am J Clin Nutr 1993, 57(4):506-511.
• [38]Schumann K, Romero-Abal ME, Maurer A, Luck T, Beard J, Murray-Kolb L, Bulux J, Mena I, Solomons NW: Haematological response to haem iron or ferrous sulphate mixed with refried black beans in moderately anaemic Guatemalan pre-school children. Public Health Nutr 2005, 8(6):572-581.
• [39]Williams J, Wolff A, Daly A, MacDonald A, Aukett A, Booth IW: Iron supplemented formula milk related to reduction in psychomotor decline in infants from inner city areas: randomised study. BMJ 1999, 318(7185):693-697.
• [40]Chilenje Infant Growth Nutrition Infection Study Team: Micronutrient fortification to improve growth and health of maternally HIV-unexposed and exposed Zambian infants: a randomised controlled trial. PloS one 2010, 6:e11165.
• [41]Manno D, Kowa PK, Bwalya HK, Siame J, Grantham-McGregor S, Baisley K, De Stavola BL, Jaffar S, Filteau S: Rich micronutrient fortification of locally produced infant food does not improve mental and motor development of Zambian infants: a randomised controlled trial. Br J Nutr 2011, 1-11.
• [42]Sazawal S, Dhingra U, Dhingra P, Hiremath G, Kumar J, Sarkar A, Menon VP, Black RE: Effects of fortified milk on morbidity in young children in north India: community based, randomised, double masked placebo controlled trial. BMJ 2007, 334(7585):140.
• [43]Dewey KG, Adu-Afarwuah S: Systematic review of the efficacy and effectiveness of complementary feeding interventions in developing countries. Matern Child Nutr 2008, 4(Suppl 1):24-85.
• [44]Gera T, Sachdev HP, Nestel P, Sachdev SS: Effect of iron supplementation on haemoglobin response in children: systematic review of randomised controlled trials. J Pediatr Gastroenterol Nutr 2007, 44(4):468-486.
• [45]Ojukwu JU, Okebe JU, Yahav D, Paul M: Oral iron supplementation for preventing or treating anaemia among children in malaria-endemic areas. Cochrane Database Syst Rev 2009., 3CD006589
• [46]Bhutta ZA, Black RE, Brown KH, Gardner JM, Gore S, Hidayat A, Khatun F, Martorell R, Ninh NX, Penny ME, et al.: Prevention of diarrhea and pneumonia by zinc supplementation in children in developing countries: pooled analysis of randomized controlled trials. Zinc Investigators' Collaborative Group. J Pediatr 1999, 135(6):689-697.
• [47]Mayo-Wilson E, Imdad A, Herzer K, Yakoob MY, Bhutta ZA: Vitamin A supplements for preventing mortality, illness, and blindness in children aged under 5: systematic review and meta-analysis. BMJ 2011, 343:d5094.
• [48]Haider Batool A, Bhutta Zulfiqar A: Neonatal vitamin A supplementation for the prevention of mortality and morbidity in term neonates in developing countries (Review). Cochrane Library 2011, 10:CD006980.
• [49]De-Regil LM, Suchdev PS, Vist GE, Walleser S, Pena-Rosas JP: Home fortification of foods with multiple micronutrient powders for health and nutrition in children under two years of age. Cochrane Database Syst Rev 2010, 12:CD008524. CD006980
• [50]Ramakrishnan U, Aburto N, McCabe G, Martorell R: Multimicronutrient interventions but not vitamin a or iron interventions alone improve child growth: results of 3 meta-analyses. J Nutr 2004, 134(10):2592-2602.
• [51]Hess SY, Brown KH: Impact of zinc fortification on zinc nutrition. Food Nutr Bull 2009, 30(1 ):79-107.
• [52]Bhutta Zulfiqar A, Das JK, Dean SV, Salam RA: Effectiveness of Food Fortification with Micronutrients. A Review. Geneva: Nestle; 2012.
• [53]Imdad A, Herzer K, Mayo-Wilson E, Yakoob M, Bhutta Z: Vitamin A supplementation for preventiing morbidity and mortality in children six months to five years of age. Cochrane Database of Systematic Reviews 2010., 5
• [54]Sazawal S, Black RE, Ramsan M, Chwaya HM, Stoltzfus RJ, Dutta A, Dhingra U, Kabole I, Deb S, Othman MK, et al.: Effects of routine prophylactic supplementation with iron and folic acid on admission to hospital and mortality in preschool children in a high malaria transmission setting: community-based, randomised, placebo-controlled trial. Lancet 2006, 367(9505):133-143.
• [55]World Health Organisation: Iron supplementation of young children in regions where malaria transmission is intense and infectious disease higly prevalent. Geneva: World Health Organisation; 2007.
• [56]Bryce J, Coitinho D, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P: Maternal and child undernutrition: effective action at national level. Lancet 2008, 371(9611):510-526.
• [57]Darnton-Hill I, Nalubola R: Fortification strategies to meet micronutrient needs: successes and failures. Proc Nutr Soc 2002, 61(2):231-241.
• [58]Scaling up Nutrition: Road Map Implementation. http://www.unscn.org/sacling_up_nutrition_sun/ webcite