Adding Small Quantity Lipid-Based Nutrient Supplements to an Enhanced Homestead Food Production Program Improves Child Hemoglobin, Iron and Vitamin A Status in Rural Burkina Faso: A Cluster-Randomized Controlled Trial

BACKGROUND: Enhanced homestead food production programs (EHFP) including nutrition behavior change communication and women's empowerment activities have limited impacts on child nutrition. This may be due to short program duration or the absence of interventions to improve water, sanitation, and hygiene (WASH), as well as access to nutritious foods. OBJECTIVES: We assessed impacts on child anemia, micronutrient status, and anthropometry of prior village exposure to an EHFP, and of adding WASH alone or WASH with daily small quantity-lipid based nutrient supplements (SQ-LNS). METHODS: This 2-y longitudinal cluster-randomized controlled trial (2014-2016) included 60 villages in Burkina Faso randomized to 4 groups (15 per group): 1) EHFP-2014; 2) EHFP-2014+WASH; 3) EHFP-2010+WASH; and 4) EHFP-2010+WASH+SQ-LNS. Groups 3 and 4 had previously received EHFP (2010-2012). We assessed impacts on child anemia and micronutrient status (n = 1704; 3-12.9 mo at baseline) and anthropometry (n = 2308; 0-12.9 mo at baseline) using difference-in-difference (DID) specifications. We controlled for covariates, adjusted for clustering, and assessed interactive effects by child age at baseline. The trial was registered with clinicaltrials.gov (NCT02236468). RESULTS: We found no impact of prior exposure to EHFP (groups 2 compared with 3) on the outcomes examined. Adding WASH (groups 1 compared with 2) reduced anemia [hemoglobin (Hb) <11 g/dL] (DID = 9.43 pp, P < 0.01) and led to a decline in weight-for-age Z-score (DID -0.11 ± 0.04, P = 0.01). Adding SQ-LNS (groups 3 compared with 4) increased Hb (DID = 0.26 ± 0.13 g/dL, P < 0.05), plasma ferritin (DID = 7.61 ± 2.69 μg/L, P < 0.01), and retinol binding protein (DID = 0.07 ± 0.02 μmol/L, P < 0.01) concentrations. Effects were larger in children <6 mo at baseline, where providing SQ-LNS (>6 mo) positively impacted Hb, plasma ferritin, height-for-age Z-score, weight-for-age Z-score, and underweight. CONCLUSIONS: Using EHFP to deliver WASH and SQ-LNS reduced child anemia and improved micronutrient status. Anthropometric improvements were found in children who joined the program before 6 mo of age and were exposed for the whole complementary feeding period.