Impact of Food Fortification on Child Growth and Development during Complementary Feeding

Key Messages

• Effective feeding practices at early stages of life have a positive impact on the growth and development of a child as evidenced by a growing body of literature on negative growth outcome with inappropriate feeding practices.
• Fortification of commonly used food vehicles provides an opportunity for increasing nutrient intake during infancy and has the potential to improve growth. Fortification, however, depends on relevant food vehicles during complementary feeding programs. Those food vehicles include staple foods (e.g., rice), condiments (soy sauce and sugar), and processed foods (infant complementary foods).
• Most studies still reflect outcomes that do not demonstrate direct cause and effect relationships between fortification and growth but rather evidence of implied linkages.
• Important caution dwells on the fact that fortification should be evidence based and implemented based on initial screening processes or observable clinical signs for potential deficiencies. Key players in the intervention matrix should avoid blanket or mass fortification without informed choices backed by evidence.

Keywords 
Food · Fortification · Child growth · Development · Complementary feeding 

Abstract 
There appears to be increasing evidence of the relationship between infant feeding practices and growth during infan­cy. Effective complementary feeding has demonstrated an observable positive effect on the linear growth of a child within the first 24 months of life. It appears that improved complementary feeding is directly proportional to the linear growth of a child. Fortification of commonly used food ve­hicles provides an opportunity for increasing nutrient intake during infancy and has the potential to improve growth and development dimensions. This review scanned through 186 articles from common search engines, mainly PubMed, BioMed Central, and Google Scholar. The result based on a systematic review of articles which met the minimum selec­tion criteria identified milk, iodine, maize meal porridge, and vegetable oils as recurring fortification vehicles in the con­text of complementary feeding. A significant impact of forti­fication on linear and cognitive growth was demonstrated recurrently across the included empirical studies. However, the review reflects outcomes that still do not demonstrate direct cause and effect relationships but rather implied meaning in the relationship matrix. 
 
Introduction 
Effective feeding practices at early stages of life have a positive impact on the growth and development of a child. There is a growing body of literature that signifi­cantly demonstrates a negative growth outcome with in­appropriate feeding practices [1, 2] . Introducing addi­tional foods other than breast milk poses a high risk of deficiencies at the early stage of life [3] and more specific for 1,000 days. 

A causal link between infant feeding practices and growth during infancy is unquestionable and many stud­ies have had significant proof of the relationship [4–6] . These linkages have been demonstrated particularly in both cross-sectional studies [7, 8] and longitudinal mod­els [9] . Both designs have strong weight behind determi­nation of causation and had a significant confirmation of the link between feeding practices and growth of a child leading to strong internal consistency. 

Growth faltering is widespread during the critical for­mative years of child growth [10–12] leading to both short-term and long-term consequences in relation to physical and mental development [13] . Effective comple­mentary feeding has demonstrated an observable positive effect on the linear growth of a child within the first 24 months of life [14] . Somehow, empirical attestations con­firm the need for interventions that target growth en­hancement during complementary feeding. 

Existing literature confirms that growth impairment can be experienced first immediately after birth and may continue all through 18 months [16, 17] . This period in­cludes the complementary feeding phase characterized by variations across households. Growth failure may be caused by an inadequate intake of macronutrients and micronutrients [18], which is sometimes found to be common during complementary feeding. Many causes of growth retardation which occur during complemen­tary feeding often reflected as stunting have demonstrat­ed reversibility. The provision of multiple micronutrient supplementation during 12 months corrected child growth in Mexican children [11] . This outcome was also reflected in cognitive development [19] , where micronu­trient supplementation could improve cognitive indices with characteristics of impairment.
 
Fortification of commonly used food vehicles pro­vides an opportunity for increasing nutrient intake dur­ing infancy and has the potential to improve growth [20] . Fortification, however, depends on relevant food vehi­cles during complementary feeding programs. Those food vehicles include staple foods (e.g., rice), condiments (soy sauce and sugar), and processed foods (infant com­plementary foods) [21] . In infants and young children, fortification has demonstrated more effectiveness than supplementation [22] . This review examines the effec­tiveness and impact of fortification on the growth and development of children during complementary feeding. Focus is given to physical growth, differential growth, and development parameters during infancy and child­hood. 

Methodology 
The study design adopted the use of a mini systematic review critically assessing previous empirical studies ( Fig. 1 ). PubMed, Google Scholar, and BioMed Central were the main databases used to search for relevant arti­cles using keywords such as “food fortification and growth” and “food fortification, growth and compensa­tory feeding”. Objective evaluation was applied in critical scanning of each article based on the thematic focus of the articles in relation to the topic of the study. Issues that were weighted for purposes of inclusion surrounded the complementary feeding, fortification in the context of young child feeding as well as physical and cognitive growth. The review scanned through 186 articles closely related to the topic and out of these a few articles were selected after meeting the threshold of set criteria to argue on the em­pirical case. The results identified milk, iodine, maize meal, and vegetable oil as the commonly used food ve­hicles for fortification. 

Results and Discussion 
Child Growth during Complementary Feeding 
Introduction of complementary foods after 6 months of exclusive breastfeeding is crucial for optimal growth and development of a child within the 1,000 golden days [23]. Complementary feeding contributes to child growth and development between 6 and 24 months [24] , making it a critical factor in the etiology of malnutrition. Some studies have confirmed the existence of problems char­acterized by suboptimal complementary feeding practic­es in West Africa posing a major challenge towards the achievement of a minimally acceptable diet [25] . Given the importance of complementary feeding in the physical growth and cognitive development of a child, there ap­pear to be serious gaps when normal diet provisions be­come a usual practice.
 

Fig. 1. Systematic review matrix in the con­text of fortification and growth of a child. Keywords used: fortification + growth; fortification + development; fortification + growth + development; fortification + growth + development + children. 

During complementary feeding, the high incidence of growth faltering is probably the result of questionable meal quality, quantity, and frequency [26] . These compo­nents of complementary feeding attempt to suggest a crit­ical focus on the quality and adequacy of complementary foods for maximum supply of required nutrients. These results may exhibit adverse consequences on growth and development. Somehow a study of this nature seems to demonstrate a persistent positive effect on intelligence development [27] . In addition, this reaffirms the contri­bution of fortification to the cognitive development of children. 

Fortification during Complementary Feeding: Growth and Development Concept 
Fortification is one of the many public health interven­tions towards mitigating micronutrient malnutrition as well as poor growth and development of children [28] . Fortification refers to the deliberate addition of nutrients to food to meet the demand of increased intake require­ments of a targeted population. In many cases, fortifica­tion targets restoring nutrients lost during processing, enhancing nutrients lost during processing, enhancing nutrient levels of food vehicles that have limited content than what is required, and adding nutrients not usually present in food to some commonly consumed food ve­hicles for the purposes of boosting intake of that particu­lar nutrient [29, 30].  

Successful fortification during complementary feed­ing depends on food vehicles commonly used as comple­ments. Nearly all food vehicles used as basic minimum for complementary feeding reviewed from previous litera­ture focus on micronutrient fortification [31–33] . How­ever, it is widely known in science that vitamins and min­erals play a major role in metabolic processes and are very critical in macronutrient metabolism. Therefore, the hid­den role in growth is unquestionable. 

Impact of Fortification on Growth and Development: Systematic Review 
Complementary feeding has a significant attributable effect on child growth and thus opens up a gateway for fortification [34] . Many studies have demonstrated the impact of fortification on the physical and emotional de­velopment of children. 

A study conducted to investigate whether multi-mi­cronutrient food fortification could improve the cogni­tion of school children through a systematic review pro­cess revealed a positive correlation and subsequent effect 
[35]. Similarly, another study made an attempt to test the effect of milk fortified with iodine on the cognitive ability of children, where a considerable favorable impact was realized on cognitive function of school children [36] . This relationship is not far from the truth as iodine is needed for the production of thyroid hormone that is es­sential for growth. 

A randomized controlled study involving 419 infants aged 6 months was conducted for 9 months with a single-blind technique to establish the effect of animal source food and micronutrient fortification in complementary food products on linear growth [37] . The final outcome of this study revealed the potential of micronutrient for­tification. The outcome somehow concurred with anoth­er study which demonstrated a positive effect on linear growth driven by multi-micronutrient home fortification among refugee children [38] . These two studies ap­pear to confirm the impact fortification has on the linear growth of children during complementary feeding. However, fortification not only contributes positively to linear growth and physical development. Some studies have focused on home fortification of complementary feeding and its effect on intellectual development of chil­dren in a large sample survey (n = 1,478). In Table 1 , rel­evant selected studies are shown to demonstrate the ex­isting relationship between fortification, growth, and de­velopment. 

Table 1. Selected studies showing the impact of food fortification on growth [39–52] 

Table 1 (continued)


Conclusion and Recommendation 
A close analysis of these studies reviewed demonstrat­ed convergence, with a common understanding of the positive correlation between food fortification and the growth of children. Growth parameters consistently range from physical, motor, to cognitive development across the studies. This review demonstrates the growing literature on the impact of fortification on growth and development during complementary feeding. It identi­fied growth from the perspective of physical and cogni­tive dimensions. Micronutrients are major fortifiers in common food vehicles, which justifies that fortification is rather a metabolic process in growth and development. 

The result based on articles which met the minimum selection criteria identified milk, iodine, maize meal por­ridge, and vegetable oils as recurring fortification vehicles in the context of complementary feeding. However, the review reflects outcomes that still do not demonstrate di­rect cause and effect relationships between fortification and growth but rather evidence of implied linkages. Therefore, fortification should be evidence based and im­plemented based on initial screening processes. Key play­ers in the intervention matrix should avoid blanket or mass fortification without informed choices. 

Disclosure Statement 
The author of this publication received an honorarium from Nestlé Nutrition Institute. The terms of this arrangement have been reviewed and approved by the Kenya Nutritionists and Dieti­cians Institute in accordance with its policy on objectivity in re­search. 


References 

• Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, et al: What works? In­terventions for maternal and child undernu­trition and survival. Lancet 2008;371:417– 440.
• Kumar D, Goel NK, Mittal PC, Misra P: Influ­ence of infant-feeding practices on nutrition­al status of under-five children. Indian J Pedi­atr 2006;73:417–421.
• Brown KH, Creed-Kanashiro H, Dewey KG: Optimal complementary feeding practices to prevent childhood malnutrition in develop­ing countries. Food Nutr Bull 1995;16:164e.
• Ruel MT, Menon P: Child feeding practices are associated with child nutritional status in Latin America: innovative uses of the demo­graphic and health surveys. J Nutr 2002;132: 1180–1187.
• Sawadogo PS, Martin-Prevel Y, Savy M, et al: An infant and child feeding index is associ­ated with the nutritional status of 6- to 23­month-old children in rural Burkina Faso. J Nutr 2006;136:656–663.
• Ntab B, Simondon KB, Milet J, et al: A young child feeding index is not associated with height-for-age or height velocity in rural Sen­egalese children. J Nutr 2005;135:457–464.
• Marquis GS, Habicht J-P, Lanata CF, Black RE, Rasmussen K: Association of breastfeed­ing and stunting in Peruvian toddlers: an ex­ample of reverse causality. Int J Epidemiol 1998;26:349–356.
• Marquis GS, Diaz J, Bartolini R, De Kanashiro HC, Rasmussen K. Recognizing the reversible nature of child-feeding decisions: breastfeed­ing, weaning, and re-lactation patterns in a shanty town community in Lima. Soc Sci Med 1998;47:645–646.
• Hop LT, Gross R, Giay T, Sastroamidjojo S, Schultink W, Lang NT: Premature comple­mentary feeding is associated with poorer growth of Vietnamese children. J Nutr 2000; 130:2683–2690.
• Shrimpton R, Victora CG, de Onis M, Lima RC, Blossner M, Glugston G: Worldwide tim­ing of growth faltering: implications for nutri­tion interventions. Pediatr 2001;107:1–7.
• Rivera JA, Gonzalez-Cossio T, Flores M, Rome­ro M, Rivera M, Tellez-Rojo MM, Rosado JL, Brown KH: Multiple micronutrient supple­mentation increases the growth of Mexican in­fants. Am J Clin Nutr 2001;74:657–663.
• Scrimshaw NS: Community-Based Longitu­dinal Nutrition and Health Studies: Classical Examples from Guatemala, Haiti and Mexico. Boston, International Foundation for Devel­oping Countries, 1995.
• Lozoff B, Georgieff MK: Iron deficiency and brain development. Semin Pediatr Neurol 2006;13:158–165.
• Lartey A, Manu A, Brown KH, Peerson JM, Dewey KG: A randomized, community-based trial of the effects of improved, centrally pro­cessed complementary foods on growth and micronutrient status of Ghanaian infants from 6 to 12 mo of age. Am J Clin Nutr 1999; 70:391–404.
• Penny ME, Creed-Kanashiro HM, Robert RC, Narro MR, Caulfield LE, Black RE: Effective­ness of an educational intervention delivered through the health services to improve nutri­tion in young children: a cluster-randomized controlled trial. Lancet 2005;365:1863–1872.
• Waterlow JC: Post-neonatal mortality in the Third World. Lancet 1988;ii:1303.
• Martorell R, Khan LK, Schroeder DG: Revers­ibility of stunting: epidemiological findings in children from developing countries. Eur J Clin Nutr 1994; 48(suppl 1):S45–S57.
• Golden MH: The role of individual nutrient deficiencies in growth retardation of children as exemplified by zinc and protein; in Water-low JC (ed): Linear Growth Retardation in Less Developed Countries. New York, Raven Press, 1988, pp 143–163.
• Grantham-McGregor S, Walker S, Powell C: Nutritional supplementation and mental de­velopment. Lancet 1991;338:758.
• Angeles-Agdeppa I, Magsadia CR, Capanza­na MV: Fortified juice drink improved iron and zinc status of schoolchildren. Asia Pac J Clin Nutr 2011;20535–543.
• Das JK, Salam RA, Kumar R, Bhutta ZA: Mi-cronutrient fortification of food and its im­pact on woman and child health: a systematic review. Syst Rev 2013;2:67.
• Bhandari N, Taneja S, Mazumder S, Bahl R, Fontaine O, Bhan MK: Adding zinc to supple­mental iron and folic acid does not affect mor­tality and severe morbidity in young children. J Nutr 2007;137:112–117.
• Pem D: factors affecting early childhood growth and development: golden 1,000 days. Adv Practice Nurs 2015;1:101.
• National Statistics Bureau: Bhutan Multiple Indicator Survey, 2010. Thimphu, National Statistics Bureau, 2011.
• Issaka AI, Agho KE, Page AN, Burns PL, Ste­vens GJ, Dibley MJ. The problem of subopti­mal complementary feeding practices in West Africa: what is the way forward? Matern Child Nutr 2015; 11(suppl 1): 53–60.
• Awogbenja MD, Ugwuona FU: Feeding prac­tices and nutritional status of under-five chil­dren in Nasarawa State, Nigeria. PAT 2010;6: 23–35.
• Chen CM, Wang YY, Chang SY: Effect of in-home fortification of complementary feeding on intellectual development of Chinese chil­dren. Biomed Environ Sci 2010;23:83–91.
• Mannar MG, Sankar R: Micronutrient fortifi­cation of foods-rationale, application and im­pact. Indian J Pediatr 2004;71:997–1002.
• Meenakshi JV, Johnson NL, Manyong VM, Degroote H, Javelosa J, et al: How cost-effec­tive is biofortification in combating micronu­trient malnutrition? an ex ante assessment. World Dev 2010;38:64–75.
• Ottaway PB: Food Fortification and Sup­plementation: Technological, Safety and Reg­ulatory Aspects. Cambridge, Woodhead Pub­lishing Ltd, 2008.
• Caballero B, Allen L, Prentice A: Encyclope­dia of Human Nutrition, ed 2. Oxford, Else-vier Ltd, 2005.
• Vinodkumar M, Rajagopalan S: Multiple mi-cronutrient fortification of salt. Eur J Clin Nutr 2009;63:437–445.
• Melse-Boonstra A, de Pee S, Martini E, Ha-lati S, Sari M, et al: The potential of various foods to serve as a carrier for micronutrient fortification, data from remote areas in Indo­nesia. Eur J Clin Nutr 2000;54:822–827.
• Chang SY, He W Chen CM: Complementary feeding and growth of infant and young child in China. Biomed Environ Sci 2008;21:264– 268.
• Best C, Neufingerl N, Del Rosso JM, Transler C, van den Briel T, Osendarp S: Can multi-micronutrient food fortification improve the micronutrient status, growth, health, and cognition of schoolchildren? A systematic re­view. Nutr Rev 2011;69:186–204.
• Zahrou FE, Azlaf M, El Menchawy I, El Mzi­bri M, El Kari K, El Hamdouchi A, Mouzouni FZ, Barkat A, Aguenaou H: Fortified iodine milk improves iodine status and cognitive abilities in schoolchildren aged 7–9 years liv­ing in a rural mountainous area of Morocco. J Nutr Metab 2016;2016:8468594.
• Skau JK, Touch B, Chhoun C, Chea M, Unni US, Makurat J, Filteau S, Wieringa FT, Dijk­huizen MA, Ritz C, Wells JC, Berger J, Friis H, Michaelsen KF, Roos N: Effects of animal source food and micronutrient fortification in complementary food products on body com­position, iron status, and linear growth: a ran­domized trial in Cambodia. Am J Clin Nutr 2015;101:742–751.
• Bilukha O, Howard C, Wilkinson C, Bamrah S, Husain F: Effects of multimicronutrient home fortification on anemia and growth in Bhutanese refugee children. Food Nutr Bull 2011;32:264–276.
• Bouhouch RR, El-Fadeli S, Andersson M, Aboussad A, Chabaa L, Zeder C, Kippler M, Baumgartner J, Sedki A, Zimmermann MB: Effects of wheat-flour biscuits fortified with iron and EDTA, alone and in combination, on blood lead concentration, iron status, and cognition in children: a double-blind ran­domized controlled trial. Am J Clin Nutr 2016;104:1318–1326.
• Farebrother J, Naude CE, Nicol L, Andersson M, Zimmermann MB: Iodised salt and iodine supplements for prenatal and postnatal growth: a rapid scoping of existing systematic reviews. Nutr J 2015;14:89.
• Kuriyan R, Thankachan P, Selvam S, Pauline M, Srinivasan K, Kamath-Jha S, Vinoy S, Mis-ra S, Finnegan Y, Kurpad AV: The effects of regular consumption of a multiple micronu­trient fortified milk beverage on the micronu­trient status of school children and on their mental and physical performance. Clin Nutr 2016;35:190–198.
• Sazawal S, Dhingra P, Dhingra U, Gupta S, Iyengar V, Menon VP, Sarkar A, Black RE: Compliance with home-based fortification strategies for delivery of iron and zinc: its ef­fect on haematological and growth markers among 6–24 months old children in north In­dia. J Health Popul Nutr 2014;32:217–226.
• Semba RD, Moench-Pfanner R, Sun K, de Pee S, Akhter N, Rah JH, Campbell AA, Badham J, Bloem MW, Kraemer K: Consumption of micronutrient-fortified milk and noodles is associated with lower risk of stunting in pre-school-aged children in Indonesia. Food Nutr Bull 2011;32:347–353.
• Pérez-Expósito AB, Klein BP: Impact of forti­fied blended food aid products on nutritional status of infants and young children in devel­oping countries. Nutr Rev 2009;67:706–718.
• Muthayya S, Eilander A, Transler C, Thomas T, van der Knaap HC, Srinivasan K, van Klinken BJ, Osendarp SJ, Kurpad AV: Effect of fortification with multiple micronutrients and n-3 fatty acids on growth and cognitive performance in Indian schoolchildren: the CHAMPION (Children’s Health and Mental Performance Influenced by Optimal Nutri­tion) Study. Am J Clin Nutr 2009;89:1766– 1775.
• Silva MR, Dias G, Ferreira CL, Franceschini SC, Costa NM: Growth of preschool children was improved when fed an iron-fortified fermented milk beverage supplemented with Lactobacillus acidophilus. Nutr Res 2008;28:226–232.
• Manger MS, McKenzie JE, Winichagoon P, Gray A, Chavasit V, Pongcharoen T, Gowachirapant S, Ryan B, Wasantwisut E, Gibson RS: A micronutrient-fortified season­ing powder reduces morbidity and improves short-term cognitive function but has no ef­fect on anthropometric measures in primary school children in northeast Thailand: a ran­domized controlled trial. Am J Clin Nutr 2008;87:1715–1722.
• Faber M, Kvalsvig JD, Lombard CJ, Benadé AJ: Effect of a fortified maize-meal porridge on anemia, micronutrient status, and motor development of infants. Am J Clin Nutr 2005; 82:1032–1039.
• Nesamvuni AE, Vorster HH, Margetts BM, Kruger A: Fortification of maize meal im­proved the nutritional status of 1–3-year-old African children. Public Health Nutr 2005;8: 461–467.
• Mason JB, Deitchler M, Gilman A, Gillenwa­ter K, Shuaib M, Hotchkiss D, Mason K, Mock N, Sethuraman K: Iodine fortification is re­lated to increased weight-for-age and birth-weight in children in Asia. Food Nutr Bull 2002;23:292–308.
• Vaidya UV, Hegde VM, Bhave SA, Pandit AN: Vegetable oil fortified feeds in the nutri­tion of very low birthweight babies. Indian Pediatr 1992;29:1519–1527.
• Muhilal, Permeisih D, Idjradinata YR, Muherdiyantiningsih, Karyadi D: Vitamin A-fortified monosodium glutamate and health, growth, and survival of children: a controlled field trial. Am J Clin Nutr 1988;48:1271–1276. 

Impact of Food Fortification on Child Reprinted with permission from: Growth and Development Ann Nutr Metab 2018;73(suppl 1):7–13 DOI: 10.1159/000490087