Nutrition is essential for a child's growth, brain development, and protection from disease. While breastmilk provides the best nutrition for young infants, children older than six months may not get all the nutrients they need from breastmilk and regular foods alone. For this reason, some children receive special nutrient supplements to support healthy growth.

Lipid-based nutrient supplements (LNS) are one type of supplement that provides important vitamins and minerals. These supplements are used in many countries to help prevent undernutrition in young children. In Pakistan, the government social safety net program currently provides medium-quantity LNS to children starting at six months of age. However, it is not known whether a smaller-quantity LNS could provide similar benefits for children in this age group from under-resourced communities that have limited access to nutritious foods.

The goal of this trial is to learn whether small-quantity lipid-based nutrient supplements (SQ-LNS) work as well as medium-quantity lipid-based nutrient supplements (MQ-LNS) in preventing undernutrition in children aged six to twelve months.

The main questions this study aims to answer are:

• Does SQ-LNS work as well as MQ-LNS in supporting healthy growth, including reducing stunting, wasting, and underweight?
• Does SQ-LNS work as well as MQ-LNS in reducing anemia?

Researchers will compare SQ-LNS and MQ-LNS to see if SQ-LNS is as good as MQ-LNS in preventing undernutrition.

Participants will:

• Receive either SQ-LNS or MQ-LNS once daily for 6 months
• Have their length, weight and mid-upper arm circumference (MUAC) measured monthly
• Have their blood tested for anemia at the start and end of supplementation

Inclusion Criteria:

• Children aged 6 months (26 weeks) to 7 months and 15 days (33 weeks) with weight-for-length z-score (WLZ) ≥ -2 standard deviation (SD) and mid-upper arm circumference (MUAC) ≥125 mm, born to mothers who are beneficiaries of the Benazir Income Support Programme and registered with the Benazir Nashonuma Programme (BNP) at any point during their pregnancy.
• Permanent residents of the selected districts, with no plan to relocate or migrate within the next 6 months.
• Written informed consent provided by the child's caregivers.

Exclusion Criteria:

• Children with moderate acute malnutrition (MAM), defined as WLZ ≥ -3 to < -2 SD, or MUAC ≥115 mm to <125 mm.
• Children with severe acute malnutrition (SAM), defined as WLZ < -3 SD or MUAC <115 mm or presence of bilateral pitting edema, who require therapeutic feeding.
• Children with known congenital anomalies, chronic illness, or conditions affecting growth or feeding (for example, cerebral palsy or congenital heart disease).
• Children already enrolled in any nutritional supplementation other than BNP or another clinical trial.
• Children whose families will be unwilling to provide informed consent, or likely to be unavailable for follow-up.

De-identified individual participant data (IPD) underlying the results reported in publications will be shared.

May 2027 - May 2034

Access to de-identified IPD will be provided to researchers upon reasonable request. Data access will be subject to approval by the Principal Investigator and the ethical review committee of Aga Khan University. Data will be shared through a secure data transfer mechanism.

The statistical analysis team will remain blinded to the intervention allocation to minimize the risk of bias.