Effectiveness of home-based fortification of complementary foods with Sprinkles in an integrated nutrition program to address rickets and anemia

Home-based fortification, through the use of ‘Sprinkles’(an innovative multiple-micronutrient food fortificant) has been shown to be efficacious in preventing and treating anemia in children under 5 years of age (Zlotkin et al., 2005). However, there has been little experience in the scale-up of Sprinkles programming and a lack of evaluation of large-scale programs. To address this gap, World Vision Canada and World Vision Mongolia in collaboration with the Mongolian Ministry of Health, and with technical support from the Hospital for Sick Children implemented and evaluated the first large-scale implementation of Sprinkles in the context of an integrated nutrition program. This report presents the findings of this evaluation. Rickets and anemia are the most prevalent forms of childhood malnutrition in Mongolia. The levels are unacceptably high, according to World Health Organization (WHO) standards, with anemia prevalence classifying it as a major public health problem. To address these needs, World Vision designed an integrated Nutrition Program (NP) to improve child and maternal levels of Vitamin D and iron, as a means of preventing and treating rickets (vitamin D deficiency) and anemia (iron deficiency) in WVM’s area development programs (ADPs). The NP included home-based fortification (Sprinkles), supplementation, social marketing, and community nutrition education. Sprinkles were distributed to children age 6-35 months in two regions of Mongolia from 2001-2003. Community nutrition workers (NWs) distributed Sprinkles to children 6-35 months of age, achieving 88% coverage. The Sprinkles were well accepted and the average duration of use was 13 months. Children in the 36-59 months age group who had anemia or rickets received iron syrup or vitamin D supplements, from NWs and family doctors. Pregnant and lactating women were supplemented with vitamin D and iron tablets, although coverage of these interventions was much lower than targeted. The program effectiveness was evaluated using cross-sectional surveys which compared key indicators at baseline (2000/1) and end of program (2003). The surveys included a household questionnaire, hemoglobin measure for anemia status, clinical assessment for signs of rickets, and anthropometric measurements. Anemia dramatically decreased in all NP areas, from 46% at baseline to 25% at final among children 6-59 months of age. This success is attributed primarily to Sprinkles intervention. Through NGO/MOH collaboration, Sprinkles were effectively distributed in this sparsely populated country and were accepted by caregivers and used with the traditional complementary foods of young children. The major limitation of the intervention was that parents did not start giving Sprinkles to their children until an average age of 13 months, even though the entire 6-35 month age group was targeted. Anemia prevalence did decline in children age 6-18 months, but remained in the range of a severe public health problem (>40%) at the end of the program. The need to ensure adequate iron intake to infants as soon as they begin complementary feeding the youngest children (6-11 months) was not effectively addressed by this intervention. In contrast to the reduction in anemia, the prevalence of rickets did not change overall, although in one NP area it decreased significantly, from 36% to 31%. The lack of success in decreasing rickets is likely due to insufficient levels of vitamin D in the Sprinkles (400 IU/day) to prevent deficiency or to replete children who were deficient. In addition, the fact that most children did not receive Sprinkles in the first year of life may have led to the intervention being too late to prevent the onset of clinical vitamin D deficiency. The experience of the World Vision Mongolia Nutrition Program demonstrates that home fortification through Sprinkles is an effective intervention for anemia control in young children. Expansion of this intervention within Mongolia and in other contexts where anemia prevalence is high is recommended. Increasing the dose of vitamin D in the Sprinkles formulation, re-emphasizing vitamin D treatment for all children < 5 with rickets and improving supplementation coverage to pregnant and lactating women are all recommended to address the ongoing issue of rickets in Mongolian children