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Table 3 Summary of results regarding adherence to and acceptability and side effects of home fortification with multiple micronutrients in powder (MNP)

From: Adherence to and acceptability of home fortification with vitamins and minerals in children aged 6 to 23 months: a systematic review

Source study (n = 17) Adherence (or percentage of use) and acceptability Side effects and/or limitations
Soofi et al. (2013) [20] Adherence: The mean number of micronutrient powder sachets consumed each month was 16.8 (SD 11.7) in the MNP without zinc group and 15.2 (11.9) in the MNP with zinc group.
Acceptability: No data given.
Side effects: Increased proportion of days with diarrhoea in MNP without zinc group (OR 1.15; 95 % CI 1.00–1.33) and in MNP with zinc group (OR 1.31; 95 % CI 1.13–1.51), p = 0.001. Increased incidence of bloody diarrhoea in MNP without zinc group (IRR 1.63; 95 % CI 1.12–2.39) and in MNP with zinc group (IRR 1.88; 95 % CI 1.29–2.74), p = 0.003.
Espino et al. (2012) [8] Adherence: 5.4 % of children did not receive the intervention; 60.3 % consumed 60 or more sachets and only 49.0 % consumed them adequately (sachets consumed fully and with semisolid food).
Acceptability: Among those who received the intervention, 4.5 % reported that they stopped giving sachets to children (of these, 70.0 % of the children not want to eat food with sachets) and 30.4 % of children did not consume the sachets adequately (of these, 84.0 % did not like the MNP flavor).
Side effects: No data given.
Jack et al. (2012) [17] Adherence: 93.3 % of eligible children used MNP; the median number of MNP sachets consumed per month per child was 23.8 (range, 0–30).
Acceptability: No data given
Side effects: No data given.
Inayati et al. (2012) [15] Adherence: The proportion of children who consumed MNP daily was higher in the intensive nutrition education + MNP group than in the non-intensive nutrition education + MNP group (83.0 % vs 62.0 %).
Acceptability: The main reasons given for not regularly consuming MNP included: perceived bitter taste of foods when mixed with MNP, monotonous taste when consumed daily, and occasionally forgetting to add MNP supplement to the lunch of a mildly wasted child. However, the majority of caregivers stated that they regularly added the MNP to the child’s meal, but the child several times refused to consume it (data not shown).
Side effects: No data given.
Sampaio et al. (2012) [7] Adherence: The mean percentage of consumption, in days, of the entire contents of the sachets was 95.7 % (SD = 4.9) in the test group supplemented with MNP with zinc, and 96.4 % (SD = 6.2) in the control group supplemented with MNP without zinc.
Acceptability: No data given
Side effects: No data given.
Avula et al. (2011) [13] Adherence: No data given.
Acceptability: No data given.
Side effects: In this qualitative study, two of the five health workers said that there were some complaints from mothers regarding instances of diarrhoea; when MNP were administered, the children started losing weight. No data shown for the control group.
Bilukha et al. (2011) [14] Adherence: Over 90.0 % of children in each of the surveys from 2008 to 2010 were reported to currently consume MNP.
Acceptability: 40.0 % of caregivers reported changes to food after mixing it with MNP.
In 2010, 80.0 % to 85.0 % of caregivers reported perceived positive changes in children’s health after receiving MNP.
Side effects: The percentage of total of caregivers that reported any perceived negative health effects (diarrhoea, vomiting, constipation, etc.) attributed to multiple micronutrients was 11.6 % in 2008, 5.6 % in 2009, and 2.9 % in 2010. This study had no control group.
Kounnavong et al. (2011) [18] Adherence: All children in the twice-weekly group consumed two sachets of MNP per week. In the daily group, 72.7 % of children consumed five or more sachets per week and 43.6 % consumed all seven sachets per week for all 24 weeks.
Acceptability: 42.1 % of mothers reported that MNP changed the colour of their children’s food and 43.9 % reported that it had an unpleasant smell or taste. However, some mothers mixed the MNP in liquids such as juice or milk. Many of the mothers felt that the MNP had increased their child’s appetite (31.7 %) and playfulness (48.4 %).
Side effects: There were no significant differences in reports of illness (diarrhoea or cough) among the control, daily, and twice weekly groups (32.7 %, 39.1 %, and 34.2 %, respectively; p = 0.587).
Tripp et al. (2011) [23] Adherence: No data given.
Acceptability: MNP sachets were found to be acceptable and beneficial by mothers. Mothers said that MNP were easy to use, and several liked that the product had no taste or smell and did not change the taste of the food. Almost all mothers, regardless of the product they used, reported some increase in appetite or weight gain in their child (data not shown).
Side effects: Several mothers reported diarrhoea in their children at the start of the study (data not shown).
Jefferds et al. (2010) [22] Adherence: At midway (at 2 weeks of 1 month-study), observations of sachets in 24 households showed an average of 15 sachets used per child per household (range, 5 to 25). Five families reported
giving away MNP to children living in other households or older children taking and consuming MNP without permission.
Acceptability: MNP’s acceptability was high and most families reported that the children ate food with MNP without problems. Perceived positive effects observed in children: increased appetite and improvements in immunity, strength, activity levels, and weight gain (data not shown).
Side effects: Infrequently mentioned by some caregivers were initial adjustments to MNP, including diarrhoea, softer stool, dark stool, and vomiting.
Lundeen et al. (2010) [19] Adherence: Adherence was high. Average consumption of 45 of the 60 sachets provided; 39.0 % of the children consumed all 60 sachets.
Acceptability: 67.0 % of caregivers reported that they liked using MNP, 73.0 % reported that the MNP was easy to use, and 57.0 % reported an improvement in their children’s appetite.
Side effects: Among participants in the intervention group, 32.0 % of caretakers reported diarrhoea on 3 or more days during the 2-month intervention, 29.0 % reported constipation, 9.0 % reported vomiting, 4.0 % reported an allergic reaction. No data shown for control group. Authors comment that these data must be cautiously interpreted because diarrhoea and other forms of gastrointestinal upset are quite common among young children in the Kyrgyz Republic.
Rosado et al. (2010) [12] Adherence: 84.6 % (95 % CI, 71.9 %–97.2 %) of children in the MNP group completed 80.0 % of treatment dose (adequate adherence) and 71.0 % (95 % CI, 57.7 %–84.4 %) in this group completed the 4 months of treatment.
Acceptability: In this study the MNP treatment had the lowest acceptability. In this group, 6.4 % (95 % CI, 5.5–7.2) of children had trouble taking the treatment and 7.4 % (95 % CI, 6.5–8.4) disliked the treatment.
Side effects: In the MNP group, the proportion of children experiencing any adverse event (allergies, infections, or viral diseases) was 10.9 %. In other groups this proportion was 4.3 % (iron supplement), 5.4 % (fortified food), 7.0 % (zinc and iron and acid ascorbic fortified water), and 4.9 % (iron and folic acid supplement).
Geltman et al. (2009) [11] Adherence: High adherence (5 to 7 sachets consumed per week) ranged from 30.0 % to 46.0 % in the group supplemented with MNP.
Acceptability: 12.0 % of caregivers in the MNP group reported concerns about using a new product, 14.0 % reported concerns about safety of the product for infants, and 17.0 % reported difficulty in integrating administration of the supplement into a daily routine.
Side effects: The main side effects in the MNP group were: constipation (15.0 % versus 26 % in iron drops group; p = 0.14); diarrhoea (11.0 % versus 12 % in iron drops group; p = 0.85), and vomiting (5.6 % versus 8.8 % in iron drops group; p = 0.51).
Adu-Afarwuah et al. (2008) [21] Adherence: At 12 months, median adherence (95 % CI) to treatment in the MNP group was 85.8 % (82.3–90.0). This adherence was determined as the percentage of scheduled days on which the supplement was added to the child’s food.
Acceptability: In the MNP group, 96.9 % of mothers liked giving the supplements to their children, 99.0 % of mothers believed that consumption of the supplements benefited their children’s health, 89.6 % of mothers said that the child easily accepted food mixed with the supplement, 95.9 % of mothers did not have major problems feeding the child the supplement, and 100.0 % of them had a good impression of the supplement.
Side effects: No significant side effects were reported (data not shown).
Ip et al. (2007) [16] Adherence: On average, children in the flexible 4-months group consumed 98.0 % of prescribed sachets. The flexible 3-months group consumed an average of 93.0 % and the daily 2-months group consumed 88.0 %. The proportion of children who consumed all prescribed sachets was 86.4 %, 58.4 %, and 13.5 % in the flexible 4-months, flexible 3-months, and daily 2-months groups, respectively.
Acceptability: Most mothers reported changes in their child’s behaviour (increased appetite and higher levels of activity and playfulness) after using MNP. MNPs were found to mix easily with food and had ‘no’ or ‘mild’ effects on the colour, taste, and smell of foods to which they were added. Almost all mothers preferred flexible administration over daily schedule (data not shown).
Side effects: No data given.
Menon et al. (2007) [9] Adherence: An estimated mean 57.6 of the planned 60 sachets were consumed (SD, 4.9; range, 27–60).
Acceptability: No data given.
Side effects: No data given.
Christofides
et al. (2005) [10]
Adherence: Average adherence was 59.6 % (SD, 27.7). Adherence was determined by first calculating a score for each individual based on the mean outcome over 12 monitoring visits, and then calculating the overall mean percentage in the study population.
Acceptability: Mothers said that the MNP did not create any appreciable change in colour, taste, or appearance of the complementary food and that they were easy to use, although they did have trouble remembering to give them daily. Participants agreed that if MNP were to become a commercially marketed product, they should be made available in their communities as an alternative to iron syrup.
Side effects: In the MNP group, the main side effects were diarrhoea (28.6 % versus 33.9 % in the placebo group; RR, 1.09; 95 % CI, 0.61–1.97) and vomiting (8.2 % versus 20.7 % in the placebo group; RR, 0.57; 95 % CI, 0.23–1.39).
  1. CI confidence interval, IRR incidence rate ratio, OR odds ratio, RR relative risk, SD standard deviation