Complementary feeding 6–23 months: specially formulated and fortified foods/ products to fill nutrient gaps in food insecure populations

Provision of targeted specially formulated and fortified foods/ products to fill nutrient gaps and improve the quality of the complementary diet can be delivered using the following platforms:

• Blanket supplementary feeding to all 6–23 months.
• Additional targeted ration provided as part of household support/general food assistance.
• IYCF support through health services/programmes.

• The most common specially formulated and fortified foods/ products include:

  • Multiple micronutrient powders (MNPs) are single– dose packets or sachets that contain multiple vitamins and minerals in powdered form and are designed to be mixed with semi–solid foods for children six months of age and older. They can provide additional amounts of selected vitamins and minerals without displacing other foods in the diet 

    (see micronutrients).

  • For populations already consuming grain–based complementary foods and blended flours, fortification of these cereals (eg, supercereals, CSB+, CSB++) can improve micronutrient and protein intakes.
  • Small–quantity lipid–based nutrient supplements (SQ– LNS) provide 22 vitamins and minerals embedded in a small amount of food (~20g/d; 100–120 kcal/d). This supplement also provides energy, protein and essential fatty acids. SQ–LNS act as a form of home fortification, which consists of adding specialised, nutrient–filled products to locally available foods prepared at home or other settings such as daycare centers or schools.
• Linked WHO, 2023 recommendations include:
  • In areas of or during periods of high food insecurity, in addition to infant and young child feeding counselling, specially formulated foods (SFFs), including medium– quantity lipid–based nutrient supplements (MQ–LNS) or small–quantity lipid–based nutrient supplements (SQ–LNS), may be considered for the prevention of wasting and nutritional oedema for a limited duration for all infants and children 6–23 months of age, while continuing to enable access to adequate home diets for the whole family.
  • In areas of or during periods of high food insecurity, children living in the most vulnerable households should be prioritized for SFF interventions through a targeted approach. However, when targeting is not possible, these SFFs may need to be given to all households through a blanket approach for infants and children 6–23 months of age, while continuing to enable access to adequate home diets for the whole family and providing infant and young child feeding counselling.
• There is now good evidence that the risk of developing acute malnutrition and of mortality is higher amongst children under two years (than over two years), and some argue that this may justify targeting preventative services among children to this age group, particularly where resources are constrained.^{80, 81} However, in many humanitarian contexts, access to quality diet and good quality health and other nutrition sensitive services as well as household and family practices for nutrition can be severely disrupted such that those who would normally be relatively well protected from undernutrition, become vulnerable.
• Specially formulated/fortified foods often have to be imported and are often more costly (per unit) than local foods. Therefore, they are usually considered only in food insecure contexts where local foods/market systems cannot fill identified nutrient gaps in the diets of young children
• Households must be food secure to ensure that the impact of targeted nutritional support for children is not diluted. This may require household assistance in the form of food (in kind) or cash/vouchers to improve food security at this level (see household level response options).
• Given they are not part of the ‘normal’ diet for young children, duration of intervention is an important consideration. Provision of SFFs for the prevention of wasting and nutritional oedema should be stopped when the food insecurity situation improves and/or when the most vulnerable households can meet energy and nutrient needs using locally available nutrient-dense foods.
• For the prevention of wasting and stunting SQLNS currently has the strongest evidence base, but other SFFs such as CSB+ can also be effective. Choice of supplement must be decided based on cost, availability, cultural acceptability etc.
• In effectiveness trials, SQ–LNS was predominantly given for a duration of 12–18 months. Evidence suggests that three– six months during periods of vulnerability to increasing wasting prevalence (eg, before/during dry season rises in wasting) can also be an effective approach for the use of SFFs. Longer durations have seen improved effectiveness in some contexts. The optimal quantity and duration of SFFs for prevention of wasting and nutritional oedema is unknown based on the available evidence and therefore those implementing these interventions should consider what is most appropriate, feasible and equitable within their contexts based on careful planning.
• Potential undesirable and unintended consequences from providing SFFs for the prevention of wasting and nutritional oedema should be considered when planning implementation. Examples may include risk of displacing breastmilk and/or nutrient–dense home foods, diverting necessary resources from other important interventions and giving the perception that these interventions replace products for the management of wasting and nutritional oedema.
• Where anaemia is a public health problem, point–of–use fortification with iron–containing MNPs in infants and young children aged 6–23 months is recommended and should include at least iron, vitamin A and zinc. Use of MNPs alone are not effective as an approach to address/prevent stunting and wasting.
• Products should never be distributed as standalone interventions, rather they should always be accompanied by messaging and complementary counselling and SBC support to reinforce optimal infant and young child feeding practices.
• Screening and referral for wasting and nutritional oedema should be done alongside delivery of preventive interventions as part of a continuum of care.

⁸⁰ United Nations Children’s Fund (UNICEF). Key Issues Brief: Age prioritization of nutrition interventions for child survival, growth and development in resource-constrained contexts. UNICEF, 2024. UNICEF, New York. World Health Organization (WHO. Risk-differentiated care: a paradigm shift to improve child mortality. Webinar. Sept 2024. First results (childhealthtaskforce.org)

⁸¹ It is important to note that the extrapolation of this to individual treatment for wasting is not currently justified given that mortality risk in children who are already malnourished is not concentrated in those under 2. The risk is equal in under and over 2 years in these children (Thurstans, S., et al., Anthropometric deficits and the associated risk of death by age and sex in children aged 6-59 months: A meta-analysis. Matern Child Nutr, 2023. 19(1): p. e13431. doi: 10.1111/mcn.13431. https:// pubmed.ncbi.nlm.nih.gov/36164997/).