Abstract
Background: Child survival is improving in Cambodia, nevertheless, 40% of Cambodian children under-five years of age are stunted and 55% are anaemic, with a peak anaemia prevalence in late infancy of 86%. In efficacy trials in Cambodia and elsewhere, micronutrient powders (Sprinkles) have significantly reduced anaemia. Whether this could be achieved by delivering Sprinkles through existing government health services was less certain.
Methods: A cluster-randomized trial in one rural health district of Cambodia evaluating the effectiveness of daily multi-micronutrient Sprinkles mixed with complementary foods along with infant and young child feeding (IYCF) education in infants (N = 3112) from aged 6 to 11 months, compared to IYCF education alone. We followed a randomly selected sub-sample of 1350 children at 6 monthly intervals to aged 24 months via biomarkers and anthropometry, to establish whether any observed effects on anaemia, deficiencies of iron, vitamin A, zinc, and growth were sustained.
Results:Anaemia prevalence (haemoglobin (Hb) < 110g/L) was reduced in the intervention arm compared with the control arm at the end of the intervention [aged 12 months], by 20.6% (95% CI, 9.4 to 30.2; P = 0.001), and prevalence of moderate anaemia (Hb < 100g/L) was reduced by 27.1% (95% CI, 21.0 to 31.8, P < 0.001).
The risk of anaemia (Hb < 110 g/L) and moderate anaemia (Hb < 100 g/L) was reduced by 24%, (Rate Ratio (RR) 0.76, 95% CI 0.64 to 0.89, P = 0.001), and 57% (RR 0.43, 95% CI 0.33 to 0.56, P < 0.001), respectively. At later follow-up time points there were no significant differences in anaemia between groups.
At 12 and 18 months, iron deficiency was reduced by 23.5% (95% CI, 15.6 to 29.1; P < 0.001) and 11.6% (95% CI, 2.6 to 17.9; P = 0.02), respectively. The risk of iron deficiency was reduced by 57% (RR 0.43, 95% CI 0.32 to 0.58, P < 0.001), and iron deficiency anaemia (IDA) and non-IDA, were reduced for moderate anaemia at 12 months in the intervention group.
The mean serum zinc concentration was increased at 12 months (0.44 μmol/L, 95% CI 0.04 to 0.83, P = 0.028).
There were no statistically significant differences in zinc or vitamin A deficiency, or growth at any time. Compared to national surveys, we found a slowing of stunting and underweight at 12 and 18 months, and an increase in meeting World Health Organization (WHO) recommended IYCF practices for adequate feeding at 6, 12 and 18 months.
Conclusion: Sprinkles, delivered through government health services, reduced anaemia and iron deficiency, and increased mean serum zinc concentration in Cambodian infants. These effects were in addition to IYCF education alone, but the effects on anaemia and serum zinc concentration did not persist beyond the intervention period. This study provides clear evidence supporting the roll out of Sprinkles as a micronutrient intervention in Cambodia and similar settings. The duration should be extended to at least 18 months, and preferably 24 months of age. This study also provides indirect evidence that Sprinkles should be accompanied by IYCF education.