e-Library of Evidence for Nutrition Actions (eLENA)

Multiple micronutrient powders for point-of-use fortification of foods consumed by infants and children

Guidance summary*

WHO recommendations

Infants and young children aged 6–23 months

In populations where the prevalence of anaemia in children under 2 years of age or under 5 years of age is 20% or higher, point-of-use fortification of complementary foodsa with iron-containing micronutrient powders in infants and young children aged 6–23 months is recommended, to improve iron status and reduce anaemia.

aAccording to the WHO publication, Complementary feeding: report of the global consultation, appropriate complementary feeding should start from the age of 6 months, with continued breast feeding up to 2 years or beyond. Further guidance on complementary feeding may assist the implementation of this guideline, including the WHO/PAHO publication, Guiding principles for complementary feeding of the breastfed child and the WHO publication, Guiding principles for feeding non-breastfed children 6–24 months of age.

Suggested scheme for point-of-use fortification with multiple micronutrient powders of foods consumed by infants and children 6–23 months of age
Composition per sachet Iron: 10 to 12.5 mg of elemental irona
Vitamin A: 300 µg of retinol
Zinc: 5 mg of elemental zinc
With or without other micronutrients to achieve 100% of the RNIb,c
Regimen Programme target of 90 sachets/doses over a 6-month period
Target group Infants and children 6–23 months of age
Settings Areas where the prevalence of anaemia in children aged under 2 years of age or under 5 years of age is 20% or higher

a12.5 mg of elemental iron equals 37.5 mg of ferrous fumarate or 62.5 mg of ferrous sulfate heptahydrate or equivalent amounts in other iron compounds. In children aged 6–12 months, sodium iron EDTA (NaFeEDTA) is generally not recommended. If NaFeEDTA is selected as a source of iron, the EDTA intake (including other dietary sources) should not exceed 1.9 mg EDTA/kg/day.
b Recommended nutrient intake (RNI). Multiple micronutrient powders can be formulated with or without other vitamin and minerals in addition to iron, vitamin A and zinc to achieve 100% of the RNI (1), and also taking into consideration the technical and sensory properties.
cWhere feasible, likely consumption from other sources, including home diet and fortified foods, should be taken into consideration for establishing the composition of the sachet.

Children 2–12 years of age

In populations where the prevalence of anaemia in school-age children is 20% or higher, point-of-use fortification of foods with iron-containing micronutrient powders in children aged 2–12 years is recommended, to improve iron status and reduce anaemia.

Suggested scheme for point-of-use fortification with multiple micronutrient powders of foods consumed by children 2-12 years of age
Composition per sachet Iron: 10 to 12.5 mg of elemental iron for children 2–4 years of age; and 12.5 to 30 mg elemental iron for children 5–12 years of agea
Vitamin A: 300 µg of retinol
Zinc: 5 mg of elemental zinc
With or without other micronutrients to achieve 100% of the RNIb,c
Regimen Programme target of 90 sachets/doses over a 6-month period
Target group Infants and children 6–23 months of age
Settings Areas where the prevalence of anaemia in children aged under 2 years of age or under 5 years of age is 20% or higher

a12.5 mg of elemental iron equals 37.5 mg of ferrous fumarate or 62.5 mg of ferrous sulfate heptahydrate or equivalent amounts in other iron compounds. If sodium iron EDTA (NaFeEDTA) is selected as a source of iron, the dose of elemental iron should be reduced by 3–6 mg due to its higher bioavailability. The appropriate range of NaFeEDTA is an area of research need.
b Recommended nutrient intake (RNI). Multiple micronutrient powders can be formulated with or without other vitamin and minerals in addition to iron, vitamin A and zinc to achieve 100% of the RNI (1), and also taking into consideration the technical and sensory properties.
cWhere feasible, likely consumption from other sources, including home diet and fortified foods, should be taken into consideration for establishing the composition of the sachet.

Remarks

  • The term “home fortification” has been substituted by the term “point-of-use fortification” because the process of fortification occurs not only at home but also at schools, nurseries, refugee camps or other places, where appropriate.

  • The use of multiple micronutrient powders is a preventive strategy for implementation at population level without screening. Children diagnosed with anaemia should be treated appropriately, according to WHO and national guidelines (2).

  • Anaemia is frequently caused by iron deficiency, but other factors may contribute to anaemia, including other micronutrient deficiencies (e.g. folic acid, zinc, vitamins A and B12), malaria, soil-transmitted helminths, other infections, and blood disorders (e.g. thalassaemias, sickle cell). The use of multiple micronutrient powders for the age groups indicated in the recommendations should be part of an integrated approach to address anaemia which should explicitly address inequities in the causes of micronutrient deficiencies (i.e. some population groups are more affected and/or vulnerable to micronutrient deficiencies than other groups when stratifying by, for instance, income level, place of residence or educational level, as well as when taking into account cultural practices, social norms around gender, or stigma suffered by groups that are discriminated against in each specific context).

  • The evidence considered in the systematic reviews (3, 4) included trials with intakes of multiple micronutrient powders ranging from 60 to 360 sachets (or doses) in a 12-month period. The recommendation of providing 90 sachets (or doses) was based on the judgment of the members of the guideline development group, considering the quality of the diet in low- and middle-income countries, as well as desirable and undesirable effects of the intervention, values and preferences, and costs. The number of sachets or doses may be adjusted if data on iron status or other micronutrient status of the vulnerable population are known. Those implementing should also consider the number of sachets that are provided to the caretaker each time, in order to promote adherence and proper use.

  • Countries should have a national strategy for prevention and control of micronutrient malnutrition. The choice of intervention (e.g. point-of-use fortification with multiple micronutrient powders, fortified foods, iron supplements, lipid-based nutrient supplements) should be considered in the context of a national strategy for control and prevention of micronutrient deficiency, including consideration of costs, cost effectiveness, feasibility and acceptability.

  • Programmes of point-of-use fortification with micronutrient powders should include a behaviour-change strategy that promotes awareness and correct use of this product, proper and hygienic preparation, feeding of complementary foods for children older than 6 months and a healthy diet for children older than 2 years of age. Recommended breastfeeding practices, hand washing with soap, prompt attention to fever in malaria settings, and measures to manage diarrhoea should also be included. Further, these programmes should include training for health-care workers on how to adequately provide nutrition counselling and demonstrate the correct use of multiple micronutrient powders.

  • In malaria-endemic areas, the provision of iron in any form, including micronutrient powders for pointof-use fortification, should be implemented in conjunction with measures to prevent, diagnose and treat malaria (5). Provision of iron through these interventions should not be made to children who do not have access to malaria-prevention strategies (e.g. provision of insecticide-treated bednets and vector-control programmes), prompt diagnosis of malaria illness, and treatment with effective antimalarial drug therapy.

  • If sugar is fortified with vitamin A, vitamin A should be excluded from the multiple micronutrient powders. If other staple foods regularly consumed by children (e.g. oil) are fortified with vitamin A, the risk of inadequate and high intakes of vitamin A should be assessed and the decision to include or exclude vitamin A from the multiple micronutrient powders should be based on that assessment prior to programme implementation, with regular review to permit adjustment of vitamin A as needed. Ideally, any public health nutrition interventions distributing micronutrients (e.g. food fortification and micronutrient supplementation) should be designed and implemented in a coordinated manner.
  • High-dose vitamin A supplements are a child-survival intervention in populations at risk of vitamin A deficiency (6), and do not provide a regular source of vitamin A in the diet. Therefore, multiple micronutrient powders are not a replacement for this programme. The appropriate combination of interventions to address vitamin A and other deficiencies should be based on the local context and articulated in a national micronutrient strategy.
  • For comparability, it is important that outcomes are measured and reported using standard definitions where they exist, e.g. diarrhoea, as defined by WHO (7, 8).
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* This is an extract from the relevant guideline (9). Additional guidance information can be found in this document.


References

1. WHO/FAO. Vitamin and mineral requirements in human nutrition, 2nd ed. Geneva: World Health Organization; 2004 (http://www.who.int/nutrition/publications/micronutrients/9241546123/en/).

2. Guideline: Daily iron supplementation in infants and children. Geneva: World Health Organization; 2016. (http://www.who.int/nutrition/publications/micronutrients/guidelines/daily_iron_supp_childrens/en/).

3. De-Regil LM, Suchdev PS, Vist GE, Walleser S, Peña-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. 2011;(9):CD008959.

4. De-Regil LM, Jefferds MED, Peña-Rosas JP. Point-of-use fortification of foods with micronutrient powders containing iron in children of preschool and school age (protocol). Cochrane Database Syst Rev. 2012;(2):CD009666.

5. Guidelines for the treatment of malaria, 3rd ed. Geneva: World Health Organization; 2015 (http://www.who.int/malaria/publications/atoz/9789241549127/en/).

6. Guideline: Vitamin A supplementation for infants and children 6–59 months of age. Geneva: World Health Organization; 2011 (http://www.who.int/nutrition/publications/micronutrients/guidelines/vas_6to59_months/en/).

7. The treatment of diarrhoea. A manual for physicians and other senior health workers. Geneva: World Health Organization; 2005 (http://www.who.int/maternal_child_adolescent/documents/9241593180/en/).

8. Ending preventable child deaths from pneumonia and diarrhoea by 2025. The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD). Geneva: World Health Organization/United Nations Children's Fund; 2013 (http://www.who.int/maternal_child_adolescent/documents/global_action_plan_pneumonia_diarrhoea/en/).

9. Guideline: Use of multiple micronutrient powders for point-of-use fortification of foods consumed by infants and young children aged 6–23 months and children aged 2–12 years. Geneva: World Health Organization; 2016 (http://www.who.int/nutrition/publications/micronutrients/ guidelines/mmpowders-infant6to23mons-children2to12yrs/en/)