Review
Effective interventions to address maternal and child malnutrition: an update of the evidence

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Summary

Malnutrition—consisting of undernutrition, overweight and obesity, and micronutrient deficiencies—continues to afflict millions of women and children, particularly in low-income and middle-income countries (LMICs). Since the 2013 Lancet Series on maternal and child nutrition, evidence on the ten recommended interventions has increased, along with evidence of newer interventions. Evidence on the effectiveness of antenatal multiple micronutrient supplementation in reducing the risk of stillbirths, low birthweight, and babies born small-for-gestational age has strengthened. Evidence continues to support the provision of supplementary food in food-insecure settings and community-based approaches with the use of locally produced supplementary and therapeutic food to manage children with acute malnutrition. Some emerging interventions, such as preventive small-quantity lipid-based nutrient supplements for children aged 6–23 months, have shown positive effects on child growth. For the prevention and management of childhood obesity, integrated interventions (eg, diet, exercise, and behavioural therapy) are most effective, although there is little evidence from LMICs. Lastly, indirect nutrition strategies, such as malaria prevention, preconception care, water, sanitation, and hygiene promotion, delivered inside and outside the health-care sector also provide important nutritional benefits. Looking forward, greater effort is required to improve intervention coverage, especially for the most vulnerable, and there is a crucial need to address the growing double burden of malnutrition (undernutrition, and overweight and obesity) in LMICs.

Introduction

Despite a recent focus on maternal and child undernutrition, no country is ready to meet all ten of the 2025 nutrition targets set by the World Health Assembly in 2012.1 Globally, there are 149 million children younger than 5 years whose growth is stunted, 49·5 million who are wasted, and 40·1 million who are overweight, with notable disparities between countries and regions.1 The 2008 Lancet Series on maternal and child undernutrition and the 2013 Lancet Series on maternal and child nutrition were important publications that summarised the effect of evidence-based interventions in reducing maternal and child undernutrition.2, 3 Since, many countries and agencies have scaled up the ten core interventions outlined in these Series (preventive zinc supplementation; promotion of breastfeeding; appropriate complementary feeding; periconceptual folic acid supplementation or fortification; maternal balanced energy protein supplementation; maternal multiple micronutrient [MMN] supplementation; maternal calcium supplementation; vitamin A supplementation; management of moderate and severe acute malnutrition). However, there is a need to periodically revisit the evidence-base of these interventions with newer evidence and assess areas that need further investigation.

Maternal and child nutrition research has had a rapid development over the last decade with large-scale effectiveness studies, and developments in innovations and improved commodities. The nutrition programme community now recognises the co-occurrence of conditions (eg, stunting and overweight, or stunting and wasting, in children) and the need for double-duty or triple-duty actions.4 There is also a growing awareness of the importance of targeting certain populations (eg, adolescents and school-aged children) that have been ignored until now. Additionally, the very nature of evidence synthesis is evolving, with emphasis being placed on good quality and effectiveness studies that assess how an intervention will fare in real life conditions that are not optimal.5 The inappropriate inclusion of low-quality studies in systematic reviews has also been highlighted.6

The 2013 Lancet Series showed a conceptual framework that categorised nutrition actions into those that were either nutrition-specific or nutrition-sensitive, depending on the nutrition determinant they addressed.7 This framework has triggered multisectoral planning in many countries, and has posed challenges in terms of coordination and affixing responsibility for nutrition oversight, especially for the traditional health and nutrition sectors.8, 9, 10, 11 We have proposed a revision of the framework, categorising nutrition actions into direct and indirect health and non-health-care sector interventions alongside cross-cutting strategies for nutrition support and integration (figure 1).12 With the revised framework as a guide, this Review builds upon previous research through a comprehensive set of systematic reviews and review updates to provide a new overview of what works to improve undernutrition in low-income and middle-income countries (LMICs; panel 1). We also discuss potential actions that could be taken to mitigate the rising double burden of malnutrition.

Key messages

  • Evidence-based interventions for improving maternal and child nutrition continue to be a combination of interventions that are direct (eg, delayed cord clamping, micronutrient supplementation, breastfeeding promotion, and counselling) and indirect (eg, malaria prevention, and water, sanitation, and hygiene promotion)

  • Nutritional interventions delivered within and outside the health-care sector are equally crucial for preventing and managing malnutrition

  • New evidence supports the use of preventive lipid-based nutrient supplementation for reducing childhood stunting, wasting, and underweight, and the use of antenatal multiple micronutrient supplementation for preventing adverse pregnancy and birth outcomes

  • Evidence gaps remain for strategies to address malnutrition among schoolchildren and adolescents

  • The drivers of undernutrition are diverse, and novel evidence synthesis methods underscore the need for multisectoral action and coordination

Section snippets

Direct health-care sector nutritional interventions for women of reproductive age and during pregnancy

Proper nutrition that can support maternal health and fetal growth and development is important to maintain. This section details the evidence for micronutrient and food supplementation in the preconception period and during pregnancy (table 1; appendix pp 2–5).

Direct health-care sector nutritional interventions in neonates

This section details the evidence for delayed cord clamping, vitamin K supplementation, vitamin A supplementation, kangaroo mother care, emollient use, and probiotics (appendix pp 6–7)—interventions that might improve neonatal vitamin and mineral stores, and reduce infections.

Direct health-care sector nutritional interventions in infants and children younger than 5 years

This section (table 1; appendix pp 8–10) details the evidence for breastfeeding and complementary feeding promotion, single and multiple micronutrient, and food supplementation interventions that promote optimal micronutrient intakes and diets among infants and children younger than 5 years. We also summarise the evidence on interventions to manage malnutrition.

Direct health-care sector nutritional interventions in school-aged children and adolescents

Although adolescence is a crucial period to maintain proper nutrition to support growth and development, large-scale nutrition programmes targeting this subgroup in LMICs are scarce, despite global guidance by WHO to provide additional micronutrients to adolescents in the preconception period in some contexts—eg, when the prevalence of anaemia is between 20–39%, intermittent iron–folic acid supplementation for adolescent girls who are menstruating is recommended.62 Of existing trials in LMICs

Family planning and birth spacing

Findings from national-level data show the positive association between contraceptive use and nutrition outcomes, including anaemia among women of reproductive age, child stunting, and underweight, highlighting some of the consequences of unplanned and poorly spaced pregnancies.71 Given data limitations, there are some questions around the link between interpregnancy intervals and maternal nutrition. However, birth spacing is associated with better maternal nutrition indicators and lower

Implications of the current evidence

This comprehensive evidence synthesis has reviewed the nutrition actions outlined in the 2013 Lancet Series on maternal and child nutrition along with several additional interventions that have been developed since (table 2). Although there has been a dearth of evidence for school-aged children and adolescents, and outside of pregnancy, we were able to assess various delivery strategies and platforms that could improve the reach of nutrition actions (panel 2). Taken together, several novel

Conclusion

Our overall interpretation of the effects remained consistent for most interventions and outcomes examined, and most of the ten Lancet priority interventions recommended in 2013 remain valid. These ten recommended interventions—previously nutrition-specific—are now considered direct health and nutrition-sector strategies, with the exception of salt iodisation, which is delivered outside the health-care system and requires coordinated action by the agricultural sector, private producers,

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