Powerful tool for the prevention of child malnutrition: SQ-LNS

When Dr. Kathryn G. Dewey, Distinguished Professor Emerita at the University of California at Davis, was searching for ways to improve nutrition for 6 to 24-month-old children, her research took her back more than ten thousand years.

“That’s how long-standing the problem of poor nutrition is among this age group,” said Dr. Dewey. “My first eureka moment was recognizing that it started when humans transitioned from hunter-gatherer to agricultural societies and reduced their intake of animal-source foods.”

“On average, humans became shorter when we settled and adopted agriculture and a mostly cereal-based diet,” added Dr. Dewey. “The populations that have regained that lost height are mainly in high-income countries where diets rich in animal- source foods are more common, and infectious diseases are less common.”

Reversing this ancient pattern has been one of the most stubborn challenges in global health. That’s because children in that age group require extremely nutrient dense foods, especially high in iron and zinc. Consider the fact that, for every 100 calories of non-breast milk foods consumed, infants 6-8 months of age need 4 times as much zinc and 9 times as much iron as an adult male.

In most geographies today, and especially in low- and middle-income countries (LMICs), the foods parents feed this age group to complement breast milk (which does not contain high levels of iron) fall far short of what’s needed for proper growth and good health. Indeed, around the world only 29% of children between the ages of 6 and 24 months have diets that meet the minimum dietary diversity requirements. The consequences, including wasting, stunting, and developmental delays, are devastating for children, their families, and our economic development.

A few innovations over the last 40 years moved us closer to closing this nutritional gap, including fortified porridges, micronutrient powders, and fish powder. But none consistently led to increased growth.

Looking for a solution that would fill nutrient gaps and support optimal growth, Dr. Dewey, who served as the Director of the Program in International & Community Nutrition (now named Institute for Global Nutrition) from 2007 to 2018, examined hunter-gatherer diets. She found them to be highly nutritious compared to modern diets and more likely to meet the nutrient needs of infants and children at 6-24 months of age. But those types of diets, containing large amounts of iron-rich animal-source foods, are expensive. That high price point typically puts them out of reach for struggling families in LMICs.

She had her second eureka moment in the 1990s when she learned about Plumpy’nut – a lipid-based, ready-to-eat food that revolutionized the treatment of malnutrition. Dr. Dewey and her colleagues recognized a potential path forward based on the same types of ingredients but using a much smaller serving size designed for the prevention rather than treatment of malnutrition.

Over the next 20 years they designed and tested a version to be used for complementary feeding among 6 to 24-month- olds who are likely to have multiple micronutrient deficiencies despite regular breastfeeding.

Their formulation, called small-quantity lipid-based nutrient supplements (SQ-LNS), threads a tricky needle by mixing nutrient dense foods, such as peanuts, chickpeas, or lentils together with milk powder, the recommended daily amounts of essential fatty acids, and 22 vitamins and minerals, in a shelf-stable serving small enough (about 4 teaspoons or 20 grams) to allow for continued breastfeeding and other complementary foods.

“There isn’t a lot of wiggle room in the matrix for this type of product, which needs to be lipid-based in order to ensure the desired doses of essential fatty acids in a total daily serving of less than 120 kilocalories,” added Dr. Dewey. “We aimed to keep the amount small to make sure that the child can eat the entire serving, to get the recommended doses of key nutrients, without displacing breast milk or other locally available complementary foods.”

Distributed in small packets that include a precisely measured daily serving, SQ-LNS does not need to be hydrated, can easily be mixed with other foods, or consumed as is.

The impact on vulnerable populations, thus far, has been remarkable.

A 2021 meta-analysis of 14 randomized controlled trials of SQ-LNS provided to more than 37,000 children 6-24 months of age in LMICs found that the supplement reduces wasting by 14% and severe wasting by 31%; stunting by 12% and severe stunting by 17%; iron-deficiency anemia by 64%; and developmental delays by 16 to 19%. What’s more, it reduces all- cause mortality in this age group by 27%.

“And kids love the taste,” said Shawn Baker, Chief Program Officer for Helen Keller Intl and member of the global SQ-LNS Task Force which is guiding efforts to scale SQ-LNS.

The potential impact goes beyond the direct impact on nutrition outlined above. Researchers have found that the supplement may serve as a powerful incentive, increasing uptake of other interventions, creating powerful synergies.

For example, in Honduras and Niger, researchers have noted that offering SQ-LNS increased health service utilization. In Honduras that took the form of more child consultation visits and in Niger, providing parents with SQ-LNS when they brought their children for immunization drove higher child vaccination rates.

In Burkina Faso and Mali, the distribution of SQ-LNS boosted attendance at nutrition screenings.

In Bangladesh, researchers found that community health workers were more likely to conduct scheduled home visits when they were provided the supplements to distribute.

In Nigeria’s Gombe State, distribution of SQ-LNS led to increased uptake in immunization, birth registration, and family planning.

A trial underway in Nigeria, managed by ALIMA, is adding to this body of evidence. There, researchers are evaluating whether caregivers are more likely to bring their children to receive routine vaccinations if they are provided with packets of the supplement at the time of vaccination.

“This supplement has a carrot effect that creates a virtuous cycle,” said Baker. “It isn’t a blanket solution. But it is an incredibly powerful solution that should be mainstream at a time when climate shocks are making it even more difficult for low-income families.”

SQ-LNS were recommended in the Lancet 2021 series on Maternal and Child Undernutrition for optimizing health and growth in children. The WHO recommended SQ-LNS in 2023 to prevent wasting and other adverse outcomes in areas with high food insecurity. Late last year, Innovations for Poverty Action added SQ-LNS to its list of “Best Bets” — "innovations that hold significant promise for making an impact at scale." And the World Bank is expected to include SQ-LNS in its updated investment framework for nutrition later this year.

SQ-LNS is not a stand-alone intervention. Best practices include distributing the supplements alongside nutrition education including promotion of breastfeeding and diverse and healthy diets. It should be incorporated into existing programs. For maximum impact it is best introduced as soon as a child turns six months old and should continue for at least six months. It should be accompanied by robust measurement and evaluation activities to allow for course corrections.

In Madagascar, SQ-LNS has been integrated into the provision of monthly community-based growth monitoring and promotion clinics for infants and young children. In Ethiopia, the Children’s Investment Fund Foundation in partnership with Gavi, the Vaccine Alliance, are supporting the integration of nutrition, social protection, and immunization programs with SQ-LNS. Pakistan, which has been distributing a larger dose (medium-quantity LNS) in a slightly different formulation, is currently shifting to SQ-LNS distribution as one part of a stunting prevention program for low-income households.

The cost of one sachet of the supplement is about 10 cents. A 12-month supply for one child would be about $36 per child (not including non-product program costs).

While the cost per child is one challenge, other challenges include ensuring the intervention is accompanied by effective nutrition education that emphasizes the importance of a nutritious diet and continued breastfeeding, and potential supply chain issues. UNICEF has demonstrated a path forward on this last issue by supporting local production in Nigeria.

Also, it should be noted that in some instances, children’s physical health may be so compromised that their growth doesn’t improve in response to the intervention.

Dr. Dewey explained, “children with the greatest potential to benefit sometimes have the lowest ability to respond in terms of increased growth.”

This occurred in one early study in Malawi, which found a burden of infection and inflammation in children so high that their growth response was limited. “Their bodies were busy fighting malaria, respiratory and other infections, and toxins. This signals to the body not to put much energy into growth, which is less critical than simply surviving,” explained Dr. Dewey.

That outcome in Malawi, which found no difference in height between the children who received the supplement and those who did not, appears to have been an outlier. Results from other geographies, thus far, have demonstrated reductions in both stunting and wasting.

“The research indicates that is a scalable and robust solution that should be a pillar of child survival and development,” said Baker.