• Mean z-scores (height-for-age, weight-for-age, weight-for-height) two years after intervention implemented
• Prevalence of undernutrition (stunting, wasting, underweight) two years after implementation of intervention

• Maternal knowledge about child feeding practices recommended through behavioral intervention at 2 years after implementation of intervention;
• Feeding practices and other caregiving practices at 2 years after implementation of intervention

The objective of this study is to compare two approaches to targeting donated supplementary food to young children. The study compares the effectiveness of the widely-used curative approach where targeting is based on the child’s poor nutritional status to a preventive approach which targets children in poor communities solely on the basis of age and provides supplementary food to all children aged 6-23 months. Cost-effectiveness of the two targeting approaches will also be assessed.

Under-nutrition is widespread among young children in poor countries. In many countries one of the programmatic responses has been distribution of supplementary food to under-nourished children and, often, their families. Traditionally, children under five years have been identified based on low weight-for-age or other anthropometric indicators, and those below a certain cut-off have received supplements. Typically this results in supplementation of many children in the 3-5 year age range, since they are most likely to display cumulative deficits in height and weight, and thus fall below the chosen cut-off.

However, there has been increasing evidence that the most effective period to ensure benefit from supplementary food is when children are 6 to 24 months of age. This is the period of highest growth velocity among humans and thus a period when most growth faltering occurs.

Based on this evidence, the current study aims to assess the effectiveness and cost-effectiveness of a preventive approach that targets children under 24 months as compared to the traditional “curative” approach that targets malnourished (and usually older) children under the age of 5 years.

The comparison is made in the programmatic context of a US Title II food aid distribution program implemented by an international non-governmental organization in rural Haiti. This programmatic context is common in many countries that receive assistance from the United States Agency for International Development and other donors. The study has also involved development of new nutrition education materials and tools, aimed at enabling caregivers to prevent malnutrition. In addition, a range of program operational issues will be studied in order to yield results useful to other implementers of similar interventions.

Comparison: Comparisons will be made at the level of the program site, with service delivery points randomized either to target food supplements as in the past, based on the child’s nutritional status, or to target preventively based on age. Pregnant women and lactating women with infants under 6 months of age will receive supplements under both targeting models. Effectiveness will be assessed based on two cross-sectional surveys, at baseline and two years after full implementation of the program.

• Behavioral: Fortified food rations
• Behavioral: Education and communication to improve feeding practices

• Ruel MT, Menon P, Loechl C, Pelto G. Donated fortified cereal blends improve the nutrient density of traditional complementary foods in Haiti, but iron and zinc gaps remain for infants. Food Nutr Bull. 2004 Dec;25(4):361-76.
• Lutter CK, Mora JO, Habicht JP, Rasmussen KM, Robson DS, Herrera MG. Age-specific responsiveness of weight and length to nutritional supplementation. Am J Clin Nutr. 1990 Mar;51(3):359-64.
• Rivera JA, Habicht JP. The recovery of Guatemalan children with mild to moderate wasting: factors enhancing the impact of supplementary feeding. Am J Public Health. 1996 Oct;86(10):1430-4.
• Rivera JA, Habicht JP. Effect of supplementary feeding on the prevention of mild-to-moderate wasting in conditions of endemic malnutrition in Guatemala. Bull World Health Organ. 2002;80(12):926-32. Epub 2003 Jan 23.
• Ruel MT, Menon P, Habicht JP, Loechl C, Bergeron G, Pelto G, Arimond M, Maluccio J, Michaud L, Hankebo B. Age-based preventive targeting of food assistance and behaviour change and communication for reduction of childhood undernutrition in Haiti: a cluster randomised trial. Lancet. 2008 Feb 16;371(9612):588-95.

Inclusion Criteria:

• Family resides in community served by World-Vision Haiti's Maternal and Child Health and Nutrition Program

Exclusion Criteria:

• None

• Cornell University
• Food and Nutrition Technical Assistance Project
• United States Agency for International Development (USAID)
• World Vision-Haiti
• Government of Germany
• World Food Programme