Effects of early childhood supplementation with and without stimulation on later development in stunted Jamaican children

Cost-effectiveness of a radio intervention to stimulate early childhood development: protocol for an economic evaluation of the SUNRISE trial in Burkina Faso

INTRODUCTION

Approximately 250 million children under 5 years of age are at risk of poor development in low-income and middle-income countries. However, existing early childhood development (ECD) interventions can be expensive, labour intensive and challenging to deliver at scale. Mass media may offer an alternative approach to ECD intervention. This protocol describes the planned economic evaluation of a cluster-randomised controlled trial of a radio campaign promoting responsive caregiving and opportunities for early learning during the first 3 years of life in rural Burkina Faso (SUNRISE trial).

METHODS AND ANALYSIS

The economic evaluation of the SUNRISE trial will be conducted as a within-trial analysis from the provider's perspective. Incremental costs and health outcomes of the radio campaign will be compared with standard broadcasting (ie, 'do nothing' comparator). All costs associated with creating and broadcasting the radio campaign during intervention start-up and implementation will be captured. The cost per child under 3 years old reached by the intervention will be calculated. Incremental cost-effectiveness ratios will be calculated for the trial's primary outcome (ie, incremental cost per SD of cognitive gain). A cost-consequence analysis will also be presented, whereby all relevant costs and outcomes are tabulated. Finally, an analysis will be conducted to assess the equity impact of the intervention.

ETHICS AND DISSEMINATION

The SUNRISE trial has ethical approval from the ethics committees of the Ministry of Health, Burkina Faso, University College London and the London School of Hygiene and Tropical Medicine. The results of the economic evaluation will be disseminated in a peer-reviewed journal and presented at a relevant international conference.

TRIAL REGISTRATION NUMBER

The SUNRISE trial was registered with ClinicalTrials.gov on 19 April 2019 (identifier: NCT05335395).

8-Year Follow-up of a Maternal Education Trial in a Low-Resource Setting

OBJECTIVES

Nutrition and stimulation interventions promote early childhood development, but little is known about their long-term benefits in low- and middle-income countries. We conducted a follow-up study of a cluster-randomized maternal education trial performed in children aged 6 to 8 months to assess the sustainability of developmental benefits after 8 years.

METHODS

The education intervention lasted 6 months and consisted of nutrition, hygiene, sanitation, and child stimulation aspects. We assessed child processing and cognitive abilities using the Kaufman Assessment Battery for Children Second Edition (KABC-II) and attention and inhibitory control using the Test of Variables of Attention after 8 years. The original trial included 511 mother-child pairs (intervention, n = 263; control, n = 248), whereas in the current study, 361 (71%; intervention, n = 185; control, n = 176) pairs were available for analyses.

RESULTS

The intervention group scored higher than the controls (all P < .001) on all 5 KABC-II subscales and on the KABC-II global score (mean difference: 14; 95% confidence interval, 12-16; P < .001). For all 5 Test of Variables of Attention variables, the intervention group scored higher than the controls on both the visual and auditory tasks (all P < .05). Because the intervention was delivered as a package, a limitation is that we cannot pinpoint the individual contribution of each component (nutrition, hygiene, and stimulation) to the developmental benefits.

CONCLUSIONS

The intervention group consistently scored markedly higher on both neuropsychological tests. Thus, even 8 years after the original maternal education intervention, the developmental benefits that we observed at child age of 1, 2, and 3 years, were sustained.

Effectiveness of a government-led, multiarm intervention on early childhood development and caregiver mental health: a study protocol for a factorial cluster-randomised trial in rural China

INTRODUCTION

The high incidences of both the developmental delay among young children and the mental health problems of their caregivers are major threats to public health in low-income and middle-income countries. Parental training interventions during early childhood have been shown to benefit early development, yet evidence on strategies to promote caregiver mental health remains limited. In addition, evidence on the optimal design of scalable interventions that integrate early child development and maternal mental health components is scarce.

METHODS AND ANALYSIS

We design a single-blind, factorial, cluster-randomised controlled, superiority trial that will be delivered and supervised by local agents of the All China Women's Federation (ACWF), the nationwide, government-sponsored social protection organisation that aims to safeguard the rights and interests of women and children. We randomise 125 villages in rural China into four arms: (1) a parenting stimulation arm; (2) a caregiver mental health arm; (3) a combined parenting stimulation and caregiver mental health arm and (4) a pure control arm. Caregivers and their children (aged 6-24 months at the time of baseline data collection) are selected and invited to participate in the 12-month-long study. The parenting stimulation intervention consists of weekly, one-on-one training sessions that follow a loose adaptation of the Reach Up and Learn curriculum. The caregiver mental health intervention is comprised of fortnightly group activities based on an adaptation of the Thinking Healthy curriculum from the WHO. Primary outcomes include measures of child development and caregiver mental health. Secondary outcomes include a comprehensive set of physical, psychological and behavioural outcomes. This protocol describes the design and evaluation plan for this programme.

ETHICS AND DISSEMINATION

This study received approval from the Institutional Review Board of Stanford University (IRB Protocol #63680) and the Institutional Review Board of the Southwestern University of Finance and Economics in Chengdu, Sichuan, China. Informed oral consent will be obtained from all caregivers for their own and their child's participation in the study. The full protocol will be publicly available in an open-access format. The study findings will be published in economics, medical and public health journals, as well as Chinese or English policy briefs.

TRIAL REGISTRATION NUMBER

AEA RCT Registry (AEARCTR-0010078) and ISRCTN registry (ISRCTN84864201).

International differences in the speed of cognitive development: A systematic examination of the existence of the Simber Effect

The Simber Effect refers to the phenomenon whereby, in Arabic countries, young children have an IQ that is little different from that of Western children but that these differences increase throughout childhood culminating in a difference of around 20 points by adulthood. The true nature of this phenomenon is revealed by an examination of 125 samples from all around the globe measured with Raven's Progressive Matrices. We show that in many cases different speeds of cognitive development increase the IQ score differences between countries mostly between 4 and 9 years of age, and that these increases can in part be explained by poor environmental conditions. However, the patterns are not completely clear, either in terms of regularity or strengths. Methodological problems, in particular the cross-sectional designs of the included samples, as well as the significance of the Simber Effect for country comparisons in intelligence are discussed.

Pathways to scale up early childhood programs: A scoping review of Reach Up and Care for Child Development

Evidence-based early childhood development (ECD) programs that strengthen nurturing parenting skills and promote early stimulation, such as Reach Up (RU) and Care for Child Development (CCD), are critical investments for interrupting cycles of intergenerational poverty; however, the implementation impact of these programs varies greatly globally. Analyzing systematically the evidence on the implementation pathways based on contexts (i.e., external and internal influences on intervention implementation), implementation strategies (i.e., mechanisms used to promote program initiation, design, and delivery with existing systems), and implementation outcomes (i.e., related to the implementation goals) can increase the likelihood of implementation success. Our scoping review aimed to identify implementation pathways of RU and CCD programs in low- and middle-income countries. A search in English, Spanish, and Portuguese of grey literature and five databases of peer reviewed literature; from inception through July 16, 2022, yielded 2,267 publications. Using predetermined eligibility criteria, 75 records yielded implementation details for 33 programs across 23 low- and middle-income countries. Two reviewers independently extracted program data on context, implementation strategies, and implementation outcomes following a program theory. A thematic analysis identified 37 implementation strategies across six "building blocks of implementation": program emergence, intersectoriality, intervention characteristics, workforce, training, and monitoring systems. Implementation pathways across building blocks are highly influenced by contextual factors, such as infrastructure, social norms, and the target population's demand and interest, which may shape different implementation outcomes. Six 'building blocks' shaping implementation pathways of CCD and RU in LMICs were identified. The careful consideration of context and use of intentional evidence-based planning can enable the successful implementation of ECD nurturing care interventions. We recommend the use of the ECD Implementation Checklist for Enabling Program Scale Up to guide decision-making regarding context and implementation strategies to support implementation outcomes and subsequent ECD program success.

Maternal time investment in caregiving activities to promote early childhood development: evidence from rural India

Introduction

Intervention strategies that seek to improve early childhood development outcomes are often targeted at the primary caregivers of children, usually mothers. The interventions require mothers to assimilate new information and then act upon it by allocating sufficient physical resources and time to adopt and perform development promoting behaviours. However, women face many competing demands on their resources and time, returning to familiar habits and behaviours. In this study, we explore mothers' allocation of time for caregiving activities for children under the age of 2, nested within a cluster randomised controlled trial of a nutrition and care for development intervention in rural Haryana, India.

Methods

We collected quantitative maternal time use data at two time points in rural Haryana, India, using a bespoke survey instrument. Data were collected from 704 mothers when their child was 12 months old, and 603 mothers when their child was 18 months old. We tested for significant differences in time spent by mothers on different activities when children are 12 months of age vs. 18 months of age between arms as well as over time, using linear regression. As these data were collected within a randomised controlled trial, we adjusted for clusters using random effects when testing for significant differences between the two time points.

Results

At both time points, no statistically significant difference in maternal time use was found between arms. On average, mothers spent most of their waking time on household chores (over 6 h and 30 min) at both time points. When children were aged 12 months, approximately three and a half hours were spent on childcare activities for children under the age of 2 years. When children were 18 months old, mothers spent more time on income generating activities (30 min) than when the children were 12 years old, and on leisure (approximately 4 h and 30 min). When children were 18 months old, less time was spent on feeding/breastfeeding children (30 min less) and playing with children (15 min). However, mothers spent more time talking or reading to children at 18 months than at 12 months.

Conclusion

We find that within a relatively short period of time in early childhood, maternal (or caregiver) time use can change, with time allocation being diverted away from childcare activities to others. This suggests that changing maternal time allocation in resource poor households may be quite challenging, and not allow the uptake of new and/or optimal behaviours.

Adverse childhood experiences and lifelong health

With the advent of the sustainable development goals, the field of global child health has shifted its focus from reducing mortality to improving health, nutrition and development outcomes - often measured as human capital. A growing knowledge of the biology of development and neuroscience has highlighted the importance of adverse environmental exposures, collectively termed adverse childhood experiences (ACEs) on health outcomes. ACEs are associated with short-term, medium-term and long-term negative consequences for health and development and their effects may be multiplicative, especially during critical periods of sensitivity and developmental plasticity. Some of these effects are compounded by emerging global threats such as climate change, conflict and population displacement. In this Review, we discuss the key mechanisms linking ACEs to health outcomes and consider promising strategies to prevent and mitigate their effects, highlighting evidence from programs in low-income and middle-income countries. Finally, we emphasize the need for early recognition of ACEs and delivery of packages of interventions spanning key sectors such as health, education, women's empowerment and social protection.

Parenting Promotes Social Mobility Within and Across Generations

This paper compares early childhood enrichment programs that promote social mobility for disadvantaged children within and across generations. Instead of conducting a standard meta-analysis, we present a harmonized primary data analysis of programs that shape current policy. Our analysis is a template for rigorous syntheses and comparisons across programs. We analyze new long-run life-cycle data collected for iconic programs when participants are middle-aged and their children are in their twenties. The iconic programs are omnibus in nature and offer many services to children and their parents. We compare them with relatively low-cost more focused home-visiting programs. Successful interventions target both children and their caregivers. They engage caregivers and improve the home lives of children. They permanently boost cognitive and non-cognitive skills. Participants in programs that enrich home environments grow up with better skills, jobs, earnings, marital stability, and health, as well as reduced participation in crime. Long-run monetized gains are substantially greater than program costs for the iconic programs. We investigate the mechanisms promoting successful family lives for participants and report intergenerational effects on their children. A study of focused home-visiting programs that target parents enables us to isolate a crucial component of successful programs: they activate and promote parenting skills of child caregivers. The home-visiting programs we analyze produce outcomes comparable to those of the iconic omnibus programs. National implementation of the programs with long-run follow up that we analyze would substantially shrink the overall US Black-White earnings gap.

Structured, multicomponent, community-based programme for women's health and infant health and development in rural Vietnam: a parallel-group cluster randomised controlled trial

BACKGROUND

Interventions to improve early childhood development have previously addressed only one or a few risk factors. Learning Clubs is a structured, facilitated, multicomponent programme designed to address eight potentially modifiable risk factors, and offered from mid-pregnancy to 12 months post partum; we aimed to establish whether this programme could improve the cognitive development of children at 2 years of age.

METHODS

For this parallel-group cluster-randomised controlled trial, 84 of 116 communes (the clustering unit) in HaNam Province in rural Vietnam were randomly selected and randomly assigned to receive the Learning Clubs intervention (n=42) or usual care (n=42). Women aged at least 18 years who were pregnant (gestational age <20 weeks) were eligible for inclusion. Data sources were standardised, and study-specific questionnaires assessing risks and outcomes were completed in interviews in mid-pregnancy (baseline), late pregnancy (after 32 weeks of gestation), at 6-12 months post partum, and at the end of the study period when children were 2 years of age. Mixed-effects models were used to estimate trial effects, adjusting for clustering. The primary outcome was the cognitive development of children at 2 years of age, assessed by the Bayley Scales of Infant and Toddler Development Third Edition (Bayley-III) cognitive score. This trial is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12617000442303).

FINDINGS

Between April 28, 2018, and May 30, 2018, 1380 women were screened and 1245 were randomly assigned (669 to the intervention group and 576 to the control group). Data collection was completed on Jan 17, 2021. Data at the end of the study period were contributed by 616 (92%) of 669 women and their children in the intervention group, and by 544 (94%) of 576 women and their children in the control group. Children aged 2 years in the intervention group had significantly higher mean Bayley-III cognitive scores than those in the control group (99·6 [SD 9·7] vs 95·6 [9·4]; mean difference 4·00 [95% CI 2·56-5·43]; p<0·0001). At 2 years of age, 19 (3%) children in the intervention group had Bayley-III scores less than 1 SD, compared with 32 (6%) children in the control group, but this difference was not significant (odds ratio 0·55 [95% CI 0·26-1·17]; p=0·12). There were no significant differences between groups in maternal, fetal, newborn, or child deaths.

INTERPRETATION

A facilitated, structured, community-based, multicomponent group programme improved early childhood development to the standardised mean in rural Vietnam and could be implemented in other similarly resource-constrained settings.

FUNDING

Australian National Health and Medical Research Council and Grand Challenges Canada Saving Brains Initiative.

TRANSLATION

For the Vietnamese translation of the abstract see Supplementary Materials section.

Early Childhood Development and Social Determinants

In human beings, the development of a child involves biological, emotional, and psychological changes that happen between birth and the conclusion of adolescence. Childhood is divided into three stages: early childhood, middle childhood, and late childhood (preadolescence). Early childhood is typically from infancy to six years of age. The methods for maintaining health and dealing with already-existing sicknesses and the social and economic settings in which children are born, grow up, live, and eventually work are referred to as the social determinants of health. Despite advances in health, child malnutrition remains a problem salutariness (severe) issue with massive human and economic resource implications. There is currently a growing corpus of research on how early development influences a child’s success later in life. From conception to two years of age, the first 1,000 days of life are becoming more well-recognized as important for the development of brain circuits that lead to linguistic, cognitive, and socio-emotional abilities, all of which are predictors of later-life labor market outcomes. The social patterning of health, sickness, and illness can be influenced by the social determinants of a child's health. This can also influence a person's overall well-being and functioning throughout their lifetime factors of a child's health, early childhood care, and development from an ecological standpoint, and as planned, a participatory approach in early childhood care and development is implemented. The social determinants of health are the elements that cause positive or negative changes in health or alter disease risks. The social determinants of health, which are different from medical treatment, can be altered by social policy. Social gradients and health equality are ideas that are related to understanding how social factors impact health.

Cognitive, psychosocial, and behaviour gains at age 31 years from the Jamaica early childhood stimulation trial

BACKGROUND

There is little evidence on adult benefits from early childhood interventions in low and middle-income countries. We assessed adult cognition, psychosocial skills and behaviour from a stimulation trial conducted in Jamaica.

METHODS

Children with stunted growth (height-for age <-2SD of references) aged 9-24 months were enrolled in a two-year randomised-controlled trial of nutritional supplementation and/or stimulation. At mean age 31.79 (SD 0.40) years, 95 of 127 participants (74.8%; 53.7% male) were assessed. Children without stunted growth were also followed as a comparison group (64 of 84 participants, 76.2%). Measurements included IQ, executive function, mental health, psychosocial skills, personality traits and risk behaviours. A block permutation test, valid for small sample sizes, was used. Analyses accounted for the randomisation protocol, multiple hypothesis testing and attrition.

RESULTS

Treatment group participants (stimulation intervention with or without supplementation, n = 48) had significantly greater IQ (Hedges g effect size 0. 57; 95%CI 0.20, 0.95) and cognitive flexibility (0.61; 0.25, 0.98) compared with no-treatment (no-intervention and supplementation only, n = 47). They also had reduced depressive symptoms (0.61; 0.28, 1.00), increased grit (0.53; 0.16, 0.92) and conscientiousness (0.66; 0.31, 1.07), lower substance use (rank mean score, 0.45; 0.08, 0.81) and risk taking related to health and work (0.64; 0.27, 1.00). There were 18 significant outcomes of 33 assessed. Comparison participants had higher IQ than no-treatment (1.17; 0.81, 1.54) and treatment groups (0.62; 0.18, 1.07); and better executive function, lower social inhibition and risk taking than the no-treatment group.

CONCLUSIONS

The wide-ranging benefits at 31 years from the stimulation intervention supports investment in larger scale programmes to promote early childhood development in disadvantaged children. The lower IQ in the treatment group compared with comparison participants, emphasises the need for continued efforts to prevent early childhood growth retardation.

Grandi Byen-supporting child growth and development through integrated, responsive parenting, nutrition and hygiene: study protocol for a randomized controlled trial

BACKGROUND

Poor child growth and development outcomes stem from complex relationships encompassing biological, behavioral, social, and environmental conditions. However, there is a dearth of research on integrated approaches targeting these interwoven factors. The Grandi Byen study seeks to fill this research gap through a three-arm longitudinal randomized controlled trial which will evaluate the impact of an integrated nutrition, responsive parenting, and WASH (water, sanitation and hygiene) intervention on holistic child growth and development.

METHODS

We will recruit 600 mother-infant dyads living in Cap-Haitien, Haiti and randomize them equally into one of the following groups: 1) standard well-baby care; 2) nutritional intervention (one egg per day for 6 months); and 3) multicomponent Grandi Byen intervention (responsive parenting, nutrition, WASH + one egg per day for 6 months). Primary outcomes include child growth as well as cognitive, language, motor, and social-emotional development. The study also assesses other indicators of child health (bone maturation, brain growth, diarrheal morbidity and allergies, dietary intake, nutrient biomarkers) along with responsive parenting as mediating factors influencing the primary outcomes. An economic evaluation will assess the feasibility of large-scale implementation of the interventions.

DISCUSSION

This study builds on research highlighting the importance of responsive parenting interventions on overall child health, as well as evidence demonstrating that providing an egg daily to infants during the complementary feeding period can prevent stunted growth. The multicomponent Grandi Byen intervention may provide evidence of synergistic or mediating effects of an egg intervention with instruction on psychoeducational parenting and WASH on child growth and development. Grandi Byen presents key innovations with implications for the well-being of children living in poverty globally.

TRIAL REGISTRATION

NCT04785352 . Registered March 5, 2021 at https://clinicaltrials.gov/.

Short-term, medium-term and long-term effects of early parenting interventions in low- and middle-income countries: a systematic review

INTRODUCTION

Parenting interventions during early childhood are known to improve various child development outcomes immediately following programme implementation. However, less is known about whether these initial benefits are sustained over time.

METHODS

We conducted a systematic literature review of parenting interventions in low- and middle-income countries (LMICs) that were delivered during the first 3 years of life and had completed a follow-up evaluation of the intervention cohort at least 1 year after the primary postintervention endpoint. We summarized intervention effects over time by child-level and parent-level outcomes as well as by timing of follow-up rounds in the short-term (1-3 years after programme completion), medium-term (4-9 years), and long-term (10+ years). We also conducted exploratory meta-analyses to compare effects on children's cognitive and behavioral development by these subgroups of follow-up rounds.

RESULTS

We identified 24 articles reporting on seven randomised controlled trials of parenting interventions delivered during early childhood that had at least one follow-up study in seven LMICs. The majority of follow-up studies were in the short-term. Three trials conducted a medium-term follow-up evaluation, and only two trials conducted a long-term follow-up evaluation. Although trials consistently supported wide-ranging benefits on early child development outcomes immediately after programme completion, results revealed a general fading of effects on children's outcomes over time. Short-term effects were mixed, and medium-term and long-term effects were largely inconclusive. The exploratory meta-analysis on cognitive development found that pooled effects were significant at postintervention and in the short-term (albeit smaller in magnitude), but the effects were not significant in the medium-term and long-term. For behavioural development, the effects were consistently null over time.

CONCLUSIONS

There have been few longer-term follow-up studies of early parenting interventions in LMICs. Greater investments in longitudinal intervention cohorts are needed in order to gain a more comprehensive understanding of the effectiveness of parenting interventions over the life course and to improve the design of future interventions so they can have greater potential for achieving and sustaining programme benefits over time.

Growth and Development of Preschool Children (12-60 Months): A Review of the Effect of Dairy Intake

Undernutrition in young children is a global health issue. The ability to meet energy and nutrient needs during this critical stage of development is necessary, not only to achieve physical and mental potential but also socio-economic achievement later in life. Given ongoing discussions regarding optimization of dietary patterns to support achievement of the Sustainable Development Goals established by the United Nations, it is important to identify foods/food groups that have shown efficacy in reducing the negative impacts of undernutrition in young children. This narrative review addresses the impact of dairy intake, with a focus on linear growth, cognitive development and weight gain in early childhood (12-60 months). The impact of country economic status is also examined, to help elucidate regional specific recommendations and/or future research needs. Overall, the body of research addressing this age group is somewhat limited. Based on the data available, there is a positive association between dairy intake and linear growth. The impact of milk or dairy products on cognitive development is less clear due to a lack of evidence and is a gap in the literature that should be addressed. Regarding the impact on body weight, the majority of evidence suggests there is either no association or an inverse association between milk intake by preschool children on overweight and obesity later in life. This evidence is exclusively in high income countries, however, so additional work in lower income countries may be warranted.

The association between under-nutrition, school performance and perceptual motor functioning in first-grade South African learners: The North-West Child Health Integrated with Learning and Development study

BACKGROUND

Early childhood is characterised by an immense spurt of growing and learning where under-nutrition can have adverse effects on the neuro-developmental health and school performance of children. A full understanding of the relationship between school performance and motor functioning skills and malnourishment in school beginners is still lacking.

AIM

To determine the association between indices of under-nutrition and how it relates to school performance and motor functioning skills of first-grade learners.

SETTING

North West province (NWP) of South Africa (SA).

METHOD

The baseline data of the stratified, randomised North-West Child Health Integrated with Learning and Development (NW-CHILD) longitudinal study were used. Grade 1 learners (N = 816, 420 boys, 396 girls, mean age 6.78+ years) from four school districts in the NWP of SA took part in the study. Indices of under-nutrition were determined by Z-scores (-2 standard deviation [s.d.]) for stunting (height-for-age [HAZ]) and wasting and underweight (Z-score for body mass index) using the 2007 World Health Organization reference sample. The Bruininks-Oseretsky Test of Motor Proficiency Short Form and the Visual Motor Integration fourth edition were used to assess different aspects of motor functioning, while school performance in mathematics, reading and writing was assessed by teachers according to the National South African standards of assessments.

RESULTS

Both HAZ and Z-score for weight-for-age correlated significantly with school performance and motor functioning skills (r > 2.0, p < 0.05), while visual perception was moderately associated (r < 0.30) with mathematics in HAZ and Z-score for weight-for-height (WHZ) children. Motor functioning of HAZ and WHZ children was significantly poorer (p < 0.05) compared to typical children, while underweight was not associated with any outcome variables.

CONCLUSION

Moderate forms of stunting and wasting influence school performance and motor functioning of school beginners negatively, while an association between visual perceptual abilities and inferior mathematics, reading and writing suggests a close link with inferior cognitive information processing in stunted and wasted children. These barriers should be addressed as poor scholastic success in Grade 1 may influence future school performance and the subsequent well-being of children.

Effect of play-based family-centered psychomotor/psychosocial stimulation on the development of severely acutely malnourished children under six in a low-income setting: a randomized controlled trial

BACKGROUND

The World Health Organization (WHO) recommends incorporating psychosocial stimulation into the management of severe acute malnutrition (SAM). However, there is little evidence about the effectiveness of these interventions for SAM children, particularly when serious food shortages and lack of a balanced diet prevail. The objective of this study was to examine whether family-based psychomotor/psychosocial stimulation in a low-income setting improves the development, linear growth, and nutritional outcomes in children with SAM.

METHOD

Children with SAM (N = 339) admitted for treatment to the Jimma University Specialized Hospital, Ethiopia, were randomized to a control (n = 170) or intervention (n = 169) group. Both groups received routine medical care and nutritional treatment at the hospital. The intervention group additionally received play-based psychomotor/psychosocial stimulation during their hospital stay, and at home for 6 months after being discharged from hospital. The fine motor (FM) and gross motor (GM) functions, language (LA) and personal-social (PS) skills of the children were assessed using adapted Denver II, the social-emotional (SE) behavior was assessed using adapted Ages and Stages Questionnaires: Social-Emotional, and the linear growth and nutritional status were determined through anthropometric assessments. All outcomes were assessed before the intervention, upon discharge from hospital, and 6 months after discharge (as end-line). The overtime changes of these outcomes measured in both groups were compared using Generalized Estimating Equations.

RESULTS

The intervention group improved significantly on GM during hospital follow-up by 0.88 points (p < 0.001, effect size = 0.26 SD), and on FM functions during the home follow-up by 1.09 points (p = 0.001, effect size = 0.22 SD). Both young and older children benefited similarly from the treatment. The intervention did not contribute significantly to linear growth and nutritional outcomes.

CONCLUSION

Psychomotor/psychosocial stimulation of SAM children enhances improvement in gross motor functions when combined with standard nutrient-rich diets, but it can enhance the fine motor functions even when such standard dietary care is not available.

TRIAL REGISTRATION

The trial was retrospectively registered on 30 January 2017 at the US National Institute of Health (ClinicalTrials.gov) # NCT03036176 .

Implementation of Reach Up early childhood parenting program: acceptability, appropriateness, and feasibility in Brazil and Zimbabwe

Young children need nurturing care, which includes responsive caregiver-child interactions and opportunities to learn. However, there are few extant large-scale programs that build parents' abilities to provide this. We have developed an early childhood parenting training package, called Reach Up, with the aim of providing an evidence-based, adaptable program that is feasible for low-resource settings. Implementation of Reach Up was evaluated in Brazil and Zimbabwe to inform modifications needed and identify challenges that implementers and delivery agents encountered. Interview guides were developed to collect information on the program's appropriateness, acceptability, and feasibility from mothers, home visitors, and supervisors. Information on adaptation was obtained from country program leads and Reach Up team logs, as well as quality of visits from observations conducted by supervisors. The program was well accepted by mothers and visitors, who perceived benefits for the children; training was viewed as appropriate, and visitors felt well-prepared to conduct visits. A need for expansion of supervisor training was identified and the program was feasible to implement, although challenges were identified, including staff turnover; implementation was less feasible for staff with other work commitments (in Brazil). However, most aspects of visit quality were high. We conclude that the Reach Up program can expand capacity for parenting programs in low- and middle-income countries.

Adaptation of a mental development assessment tool for the evaluation of the long-term effect of a successful nutrition intervention in Ghana

This study adapted a cognitive assessment tool to be used in evaluating nutrition interventions in developing countries and assessed its reliability and validity in Ghana. The tool was used to evaluate the long-term effect of the Enhancing Child Nutrition through Animal Source Food Management (ENAM) project. The former ENAM participants' children were contacted (now 13 to 15 years old). The items in the Wechsler Abbreviated Scale of Intelligence-II were adapted, pretested, refined, and pretested again. Cross-sectional data collection was conducted with former ENAM participants (60 interventions and 51 comparison families) in one of ENAM's three sites (the Guinea Savanna zone). Data on participants' socio-economic status and food insecurity were collected, along with their children's intellectual functioning, dietary intake, school attainment, anthropometry, and symptoms of depression. Alpha coefficient of the verbal subscale improved between the first and second pretest (from .34 to .80). After controlling for age, the intelligence scores of the children were associated with their grade (r = .35, p = .001) and academic performance (r = .26 to .33, p < .05). The verbal scale was associated with their anthropometry (r = .24 to .27, p < .05). The intervention children still recorded a better dietary diversity score than controls (6.8 vs 5.8, p = .0001); however, significance was lost after adjusting for confounders. There were no significant group differences in growth or intellectual functioning. The adapted Wechsler Abbreviated Scale of Intelligence-II tool performed well in evaluating adolescent intellectual functioning in rural Ghana, and there were no long-term effects of ENAM intervention on child growth and development.

Prenatal and postnatal lipid-based nutrient supplementation and cognitive, social-emotional, and motor function in preschool-aged children in Ghana: a follow-up of a randomized controlled trial

Background

Adequate nutrition is necessary for brain development during pregnancy and infancy. Few randomized controlled trials of supplementation during these periods have measured later developmental outcomes.

Objective

Our objective was to investigate the effects of provision of prenatal and postnatal lipid-based nutrient supplements (LNS) on child development at preschool age.

Methods

We conducted a follow-up study of 966 children aged 4-6 y in 2016, born to women who participated in the International Lipid-Based Nutrient Supplements-DYAD trial conducted in Ghana in 2009-2014, representing 79% of eligible children. Women ≤20 weeks of gestation were randomized to daily LNS or multiple micronutrient (MMN) capsules during pregnancy through 6 mo postpartum or iron and folic acid (IFA) capsules during pregnancy and calcium placebo capsules during 6 mo postpartum. Children in the LNS group received LNS from 6 to 18 mo. Primary outcomes of this follow-up study were (1) a cognitive factor score based on a test battery adapted from several standard tests, 2) fine motor score (9-hole pegboard test), and (3) social-emotional difficulties (Strengths and Difficulties Questionnaire; SDQ). Eight secondary outcomes were calculated in specific domains (e.g., language, SDQ prosocial). Analysis was by a complete case intention to treat in a 2-group comparison: LNS compared with non-LNS (MMN + IFA).

Results

Children in the LNS group had significantly lower social-emotional difficulties z-scores than children in the non-LNS group (adjusted for child age β = -0.12, 95% CI: -0.25, 0.02, P = 0.087; fully adjusted β = -0.16, 95% CI: -0.29, -0.03, P = 0.013). The effect of LNS on social-emotional difficulties score was larger among children living in households with lower home environment scores (P-interaction = 0.081). No other outcomes differed between the 2 intervention groups.

Conclusions

Provision of LNS during the first 1000 d of development improved behavioral function, particularly for children from low nurturing and stimulation households, but did not affect cognition at preschool age in this setting. Trial Registration: clinicaltrials.gov, Identifier NCT00970866.

Community-based supplementary feeding for food insecure, vulnerable and malnourished populations - an overview of systematic reviews

BACKGROUND

Supplementary feeding may help food insecure and vulnerable people by optimising the nutritional value and adequacy of the diet, improving quality of life and improving various health parameters of disadvantaged families. In low- and middle-income countries (LMIC), the problems supplementary feeding aims to address are entangled with poverty and deprivation, the programmes are expensive and delivery is complicated.

OBJECTIVES

1. To summarise the evidence from systematic reviews of supplementary feeding for food insecure, vulnerable and malnourished populations, including children under five years of age, school-aged children, pregnant and lactating women, people with HIV or tuberculosis (or both), and older populations.2. To describe and explore the effects of supplementary feeding given to people in these groups, and to describe the range of outcomes between reviews and range of effects in the different groups.

METHODS

In January 2017, we searched the Cochrane Database of Systematic Reviews, MEDLINE, Embase and nine other databases. We included systematic reviews evaluating community-based supplementary feeding, and concerning food insecure, vulnerable and malnourished populations. Two review authors independently undertook selection of systematic reviews, data extraction and 'Risk of bias' assessment. We assessed review quality using the AMSTAR tool, and used GRADEpro 'Summary of findings' tables from each review to indicate the certainty of the evidence for the main comparisons. We summarised review findings in the text and reported the data for each outcome in additional tables. We also used forest plots to display results graphically.

MAIN RESULTS

This overview included eight systematic reviews (with last search dates between May 2006 and February 2016). Seven were Cochrane Reviews evaluating interventions in pregnant women; children (aged from birth to five years) from LMIC; disadvantaged infants and young children (aged three months to five years); children with moderate acute malnutrition (MAM); disadvantaged school children; adults and children who were HIV positive or with active tuberculosis (with or without HIV). One was a non-Cochrane systematic review in older people with Alzheimer's disease. These reviews included 95 trials relevant to this overview, with the majority (74%) of participants from LMIC.The number of included participants varied between 91 and 7940 adults, and 271 and more than 12,595 children. Trials included a wide array of nutritional interventions that varied in duration, frequency and format, with micronutrients often reported as cointerventions. Follow-up ranged from six weeks to two years; three trials investigated outcomes at four to 17 years of age. All reviews were rated as high quality (AMSTAR score between eight and 11). The GRADE certainty ratings ranged from very low to moderate for individual comparisons, with the evidence often comprising only one or two small trials, thereby resulting in many underpowered analyses (too small to detect small but important differences). The main outcome categories reported across reviews were death, anthropometry (adults and children) and other markers of nutritional status, disease-related outcomes, neurocognitive development and psychosocial outcomes, and adverse events.Mortality data were limited and underpowered in meta-analysis in all populations (children with MAM, in children with HIV, and in adults with tuberculosis) with the exception of balanced energy and protein supplementation in pregnancy, which may have reduced the risk of stillbirth (risk ratio (RR) 0.60, 95% confidence interval (CI) 0.39 to 0.94; 5 trials, 3408 women). Supplementation in pregnancy also improved infant birth weight (mean difference (MD) 40.96 g, 95% CI 4.66 to 77.26; 11 trials, 5385 participants) and reduced risk of infants born small-for-gestational age (RR 0.79, 95% CI 0.69 to 0.90; 7 trials, 4408 participants). These effects did not translate into demonstrable long-term benefits for children in terms of growth and neurocognitive development in the one to two trials reporting on longer-term outcomes. In one study (505 participants), high-protein supplementation was associated with increased risk of small-for-gestational age babies.Effects on growth in children were mixed. In children under five years of age from LMIC, one review found that supplementary feeding had a little or no effect on child growth; however, a more recent review in a similar population found that those who received food supplementation gained an average of 0.12 kg more in weight (MD 0.12 kg, 95% CI 0.05 to 0.18; 9 trials, 1057 participants) and 0.27 cm more in height (MD 0.27 cm, 95% CI 0.07 to 0.48; 9 trials, 1463 participants) than those who were not supplemented. Supplementary food was generally more effective for younger children (younger than two years of age) and for those who were poorer or less well-nourished. In children with MAM, the provision of specially formulated food improved their weight, weight-for-height z scores and other key outcomes such as recovery rate (by 29%), as well as reducing the number of participants dropping out (by 70%). In LMIC, school meals seemed to lead to small benefits for children, including improvements in weight z scores, especially in children from lower-income countries, height z scores, cognition or intelligence quotient tests, and maths and spelling performance.Supplementary feeding in adults who were HIV positive increased the daily energy and protein intake compared to nutritional counselling alone. Supplementation led to an initial improvement in weight gain or body mass index but did not seem to confer long-term benefit.In adults with tuberculosis, one small trial found a significant benefit on treatment completion and sputum conversion rate. There were also significant but modest benefits in terms of weight gain (up to 2.60 kg) during active tuberculosis.The one study included in the Alzheimer's disease review found that three months of daily oral nutritional supplements improved nutritional outcomes in the intervention group.There was little or no evidence regarding people's quality of life, adherence to treatment, attendance at clinic or the costs of supplementary feeding programmes.

AUTHORS' CONCLUSIONS

Considering the current evidence base included, supplementary food effects are modest at best, with inconsistent and limited mortality evidence. The trials reflected in the reviews mostly reported on short-term outcomes and across the whole of the supplementation trial literature it appears important outcomes, such as quality of life and cost of programmes, are not systematically reported or summarised.

A Combined Dietary and Cognitive Intervention in 3⁻5-Year-Old Children in Indonesia: A Randomized Controlled Trial

Early childhood nutritional interventions typically combine nutritional and psychosocial stimulation. Such combined interventions result in long-lasting improvements of cognitive abilities in children who are malnourished. Here, we investigated potential cognitive abilities in normally developing children in Indonesia who were, however, at risk for suboptimal cognitive development due to little psychosocial stimulation in their home environment. In a randomized controlled intervention, children of the experimental group received nutritional supplementation combined with cognitive stimulation. Pre- and post-intervention measurements included cognitive development and functioning, behavior, and mother–child interaction. The experimental and control group received nutritional supplementation in the form of a fortified or unfortified milk powder, respectively. Additionally, the children and parents of the experimental group jointly engaged in daily learning activities at home and performed iPad-based tasks designed to foster cognitive abilities. The experimental group compared to the control group displayed a significantly higher increase in intelligence quotient as well as a significantly larger reduction in attentional problems after the intervention. These results indicate that low-level cognitive stimulation in combination with nutritional supplementation during early childhood can be an effective intervention that improves global cognitive functioning in healthy developing children. ClinicalTrials.gov Identifier: NCT02359669.

Nutrition (Micronutrients) in Child Growth and Development: A Systematic Review on Current Evidence, Recommendations and Opportunities for Further Research

OBJECTIVE

An important aspect of malnutrition is deficiency of different micronutrients during pregnancy or early childhood. We systematically reviewed the role of nutrition in child growth (weight or height gain) and development.

METHODS

A comprehensive literature search was done on PubMed/Cochrane Library browsing through 38,795 abstracts until December 31, 2016 to select systematic reviews/meta-analyses and individual randomized controlled trials (RCTs) of micronutrient supplementation.

RESULTS

Micronutrients studied included iron, iodine, folate, zinc, calcium, magnesium, selenium, vitamin D, vitamin A, vitamin B complex, and multiple micronutrients. We summarize evidence with details and results of RCTs, highlight strengths/weaknesses, and critically interpret findings. Effects of breastfeeding-promotion, food-supplementation (complementary and school feeding), conditional-cash-transfers, and integrated nutrition/psychosocial interventions are discussed.

CONCLUSION

Based on this evidence we make policy and programmatic recommendations for supplementation to mothers and children at high-risk of deficiency.

The Nexus Between Nutrition and Early Childhood Development

This article looks at both nutrition and early childhood stimulation interventions as part of an integrated life cycle approach to development. We build on recent systematic reviews of child development, which are comprehensive in regard to what is currently known about outcomes reported in key studies. We then focus particularly on implementation, scaling, and economic returns, drawing mainly on experience in low- and middle-income countries where undernutrition and poor child development remain significant public health challenges with implications across the life course.

Nurturing care: promoting early childhood development

The UN Sustainable Development Goals provide a historic opportunity to implement interventions, at scale, to promote early childhood development. Although the evidence base for the importance of early childhood development has grown, the research is distributed across sectors, populations, and settings, with diversity noted in both scope and focus. We provide a comprehensive updated analysis of early childhood development interventions across the five sectors of health, nutrition, education, child protection, and social protection. Our review concludes that to make interventions successful, smart, and sustainable, they need to be implemented as multi-sectoral intervention packages anchored in nurturing care. The recommendations emphasise that intervention packages should be applied at developmentally appropriate times during the life course, target multiple risks, and build on existing delivery platforms for feasibility of scale-up. While interventions will continue to improve with the growth of developmental science, the evidence now strongly suggests that parents, caregivers, and families need to be supported in providing nurturing care and protection in order for young children to achieve their developmental potential.

Iodine status and associations with feeding practices and psychomotor milestone development in six-month-old South African infants

Iodine is important for normal growth and psychomotor development. While infants below 6 months of age receive iodine from breast milk or fortified infant formula, the introduction of complementary foods poses a serious risk for deteriorating iodine status. This cross-sectional analysis assessed the iodine status of six-month-old South African infants and explored its associations with feeding practices and psychomotor milestone development. Iodine concentrations were measured in infant (n = 386) and maternal (n = 371) urine (urinary iodine concentration [UIC]), and in breast milk (n = 257 [breast milk iodine concentrations]). Feeding practices and psychomotor milestone development were assessed in all infants. The median (25th-75th percentile) UIC in infants was 345 (213-596) μg/L and was significantly lower in stunted (302 [195-504] μg/L) than non-stunted (366 [225-641] μg/L) infants. Only 6.7% of infants were deficient. Maternal UIC (128 [81-216] μg/L; r_s  = 0.218, p < 0.001) and breast milk iodine concentrations (170 [110-270] μg/kg; r_s  = 0.447, p < 0.0001) were associated with infant UIC. Most infants (72%) were breastfed and tended to have higher UIC than non-breastfed infants (p = 0.074). Almost all infants (95%) consumed semi-solid or solid foods, with commercial infant cereals (60%) and jarred infant foods (20%) being the most common solid foods first introduced. Infants who reported to consume commercial infant cereals ≥4 days weekly had significantly higher UIC (372 [225-637] μg/L) than those reported to consume commercial infant cereals seldom or never (308 [200-517] μg/L; p = 0.023). No associations between infant UIC and psychomotor developmental scores were observed. Our results suggest that iodine intake in the studied six-month-old infants was adequate. Iodine in breast milk and commercial infant cereals potentially contributed to this adequate intake.

Development of norms for executive functions in typically-developing Indian urban preschool children and its association with nutritional status

Executive functions (EFs) are essential and important for achieving success in children's everyday lives and play a fundamental role in children's cognitive, academic, social, emotional and behavioral functioning. A cross-sectional study was carried out to develop age- and sex-specific norms for EFs using the Behavior Rating Inventory of Executive Function - Preschool Version (BRIEF-P) among 2- to 5-year-olds from urban Bangalore, India. In addition, the association between EFs and anthropometric measures, a marker of nutritional status, is also examined. Primary caregivers of 412 children, equally distributed by age and sex, participated. Raw scores for each domain and indices were converted to standard t-scores and percentiles were computed. A t-score at or above 63 corresponding to the 90th percentile was considered as the cutoff for executive dysfunction in this sample. The prevalence of executive dysfunction is 10% based on the Global Executive Composite score of the BRIEF-P. The cutoff score for identifying executive dysfunction using existing United States (US) norms is higher compared to the cutoff score obtained in the current study. Therefore, using US norms for Indian children could result in the prevalence of executive dysfunction been underestimated. Multiple linear regression analysis revealed that stunted and underweight children have significantly elevated EF scores after adjusting for age, sex and socioeconomic status (SES; p < .01). A greater understanding of EFs in preschool children is important for the early identification of executive dysfunction and implementing interventions to improve their future prospects. This study also shows that undernourished children are more likely to have executive dysfunction.

Overview of Early Child-Care and Education Programmes and Jamaican Case Studies

The extent to which early childhood programmes can produce long-term benefits to children's cognitive and social-emotional development continues to be a major concern of policy makers. This paper examines some of the model intervention programmes for children under four years of age that have been carried out in the United States and some developing countries, with emphasis on our experience in Jamaica. in general, programme participants have shown concurrent gains in IQ during the intervention. These have been sustained into the early school years, after which there is a tendency for the gains to decline. However, some programmes have reported persistence of IQ gains to the age of 12 years. Long-term gains in educational progress include fewer placements in special education classes and less grade retention. Programmes of greater duration and intensity were more likely to be successful.

Effects of Health and Nutrition on Cognitive and Behavioural Development in Children in the First Three Years of Life: Part 1: Low Birthweight, Breastfeeding, and Protein-Energy Malnutrition

The following paper and its accompanying paper (Grantham-McGregor SM, et al. Effects of health and nutrition on cognitive and behavioural development in children in the first three years of life. Part 2: Infections and micronutrient deficiencies: iodine, iron, and zinc. Food Nutr Bull 1999;20:76–99) review the literature on the conditions that are prevalent and considered to be likely to affect child development and are therefore of public health importance. the reviews are selective, and we have generally focused on recent work, particularly in areas that remain controversial. the reviews are restricted to nutritional and health insults that are important in the first three years of life. Where possible, we have discussed the better studies. This paper considers the effects of low birthweight (focusing on small-for-gestational-age babies) and early childhood protein-energy malnutrition on mental, motor, and behavioural development. We have also included a section on breastfeeding because of its importance to child health and nutrition programmes.

The pediatrician's role in the first thousand days of the child: the pursuit of healthy nutrition and development

OBJECTIVES

To describe the concept of the first 1000 days, its importance for health, and actions to be implemented, particularly by pediatricians, in order to attain healthy nutrition and development.

SOURCES

A nonsystematic review was carried out in the SciELO, LILACS, MEDLINE, Scopus, and Web of Science databases, encompassing the last decade, using the terms 1000 days, child nutrition, child development, childhood, and child. A non-systematic search was performed online for organizations that use the 1000-day concept and give recommendations on children's health.

SUMMARY OF THE FINDINGS

The first 1000 days range from conception to the end of the second year of life. It represents an important period to implement interventions to ensure healthy nutrition and development, which will bring benefits throughout life. Children should receive adequate nutrition, through proper prenatal diet, exclusive breastfeeding for the first 6 months, addition of adequate complementary foods, and continued breastfeeding up to 2 years of life. Given the condition of absolute dependence on an adult's care, it is crucial to establish an enabling and friendly environment, necessary for the development of strong bonds with caregivers, laying the groundwork for a full and healthy development.

CONCLUSIONS

The pediatrician, together with other professionals, can act by promoting actions emphasizing the concept of the first 1000 days to ensure healthy nutrition and development. Focusing on actions in this period may increase the child's chance of having a healthy and productive life in the future, strengthening family and community ties, helping to break the intergenerational cycle of poverty.

Parenting begets parenting: A neurobiological perspective on early adversity and the transmission of parenting styles across generations

The developing brains of young children are highly sensitive to input from their social environment. Nurturing social experience during this time promotes the acquisition of social and cognitive skills and emotional competencies. However, many young children are confronted with obstacles to healthy development, including poverty, inappropriate care, and violence, and their enhanced sensitivity to the social environment means that they are highly susceptible to these adverse childhood experiences. One source of social adversity in early life can stem from parenting that is harsh, inconsistent, non-sensitive or hostile. Parenting is considered to be the cornerstone of early socio-emotional development and an adverse parenting style is associated with adjustment problems and a higher risk of developing mood and behavioral disorders. Importantly, there is a growing literature showing that an important predictor of parenting behavior is how parents, especially mothers, were parented themselves. In this review, we examine how adversity in early-life affects mothering behavior in later-life and how these effects may be perpetuated inter-generationally. Relying on studies in humans and animal models, we consider evidence for the intergenerational transmission of mothering styles. We then describe the psychological underpinnings of mothering, including responsiveness to young, executive function and affect, as well as the physiological mediators of mothering behavior, including hormones, brain regions and neurotransmitters, and we consider how development in these relevant domains may be affected by adversity experienced in early life. Finally, we explore how genes and early experience interact to predict mothering behavior, including the involvement of epigenetic mechanisms. Understanding how adverse parenting begets adverse parenting in the next generation is critical for designing interventions aimed at preventing this intergenerational cycle of early adversity.

Linear growth and child development in low- and middle-income countries: a meta-analysis

BACKGROUND AND OBJECTIVE

The initial years of life are critical for physical growth and broader cognitive, motor, and socioemotional development, but the magnitude of the link between these processes remains unclear. Our objective was to produce quantitative estimates of the cross-sectional and prospective association of height-for-age z score (HAZ) with child development.

METHODS

Observational studies conducted in low- and middle-income countries (LMICs) presenting data on the relationship of linear growth with any measure of child development among children <12 years of age were identified from a systematic search of PubMed, Embase, and PsycINFO. Two reviewers then extracted these data by using a standardized form.

RESULTS

A total of 68 published studies conducted in 29 LMICs were included in the final database. The pooled adjusted standardized mean difference in cross-sectional cognitive ability per unit increase in HAZ for children ≤ 2 years old was +0.24 (95% confidence interval [CI], 0.14-0.33; I(2) = 53%) and +0.09 for children > 2 years old (95% CI, 0.05-0.12; I(2) = 78%). Prospectively, each unit increase in HAZ for children ≤ 2 years old was associated with a +0.22-SD increase in cognition at 5 to 11 years after multivariate adjustment (95% CI, 0.17-0.27; I(2) = 0%). HAZ was also significantly associated with earlier walking age and better motor scores (P < .05).

CONCLUSIONS

Observational evidence suggests a robust positive association between linear growth during the first 2 years of life with cognitive and motor development. Effective interventions that reduce linear growth restriction may improve developmental outcomes; however, integration with environmental, educational, and stimulation interventions may produce larger positive effects.

Performance of a receptive language test among young children in Madagascar

Language tests developed and validated in one country may lose their desired properties when translated for use in another, possibly resulting in misleading estimates of ability. Using Item Response Theory (IRT) methodology, we assess the performance of a test of receptive vocabulary, the U.S.-validated Peabody Picture Vocabulary Test-Third Edition (PPVT-III), when translated, adapted, and administered to children 3 to 10 years of age in Madagascar (N = 1372), in the local language (Malagasy). Though Malagasy is considered a single language, there are numerous dialects spoken in Madagascar. Our findings were that test scores were positively correlated with age and indicators of socio-economic status. However, over half (57/96) of items evidenced unexpected response variation and/or bias by local dialect spoken. We also encountered measurement error and reduced differentiation among person abilities when we used the publishers' recommended stopping rules, largely because we lost the original item ordering by difficulty when we translated test items into Malagasy. Our results suggest that bias and testing inefficiency introduced from the translation of the PPVT can be significantly reduced with the use of methods based on IRT at both the pre-testing and analysis stages. We explore and discuss implications for cross-cultural comparisons of internationally recognized tests, such as the PPVT.

Food supplementation for improving the physical and psychosocial health of socio-economically disadvantaged children aged three months to five years

BACKGROUND

Undernutrition contributes to five million deaths of children under five each year. Furthermore, throughout the life cycle, undernutrition contributes to increased risk of infection, poor cognitive functioning, chronic disease, and mortality. It is thus important for decision-makers to have evidence about the effectiveness of nutrition interventions for young children.

OBJECTIVES

Primary objective1. To assess the effectiveness of supplementary feeding interventions, alone or with co-intervention, for improving the physical and psychosocial health of disadvantaged children aged three months to five years.Secondary objectives1. To assess the potential of such programmes to reduce socio-economic inequalities in undernutrition.2. To evaluate implementation and to understand how this may impact on outcomes.3. To determine whether there are any adverse effects of supplementary feeding.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, PsycINFO, and seven other databases for all available years up to January 2014. We also searched ClinicalTrials.gov and several sources of grey literature. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs, controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that provided supplementary food (with or without co-intervention) to children aged three months to five years, from all countries. Adjunctive treatments, such as nutrition education, were allowed. Controls had to be untreated.

DATA COLLECTION AND ANALYSIS

Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data, and assessed risk of bias. We conducted meta-analyses for continuous data using the mean difference (MD) or the standardised mean difference (SMD) with a 95% confidence interval (CI), correcting for clustering if necessary. We analysed studies from low- and middle-income countries and from high-income countries separately, and RCTs separately from CBAs. We conducted a process evaluation to understand which factors impact on effectiveness.

MAIN RESULTS

We included 32 studies (21 RCTs and 11 CBAs); 26 of these (16 RCTs and 10 CBAs) were in meta-analyses. More than 50% of the RCTs were judged to have low risk of bias for random selection and incomplete outcome assessment. We judged most RCTS to be unclear for allocation concealment, blinding of outcome assessment, and selective outcome reporting. Because children and parents knew that they were given food, we judged blinding of participants and personnel to be at high risk for all studies.Growth. Supplementary feeding had positive effects on growth in low- and middle-income countries. Meta-analysis of the RCTs showed that supplemented children gained an average of 0.12 kg more than controls over six months (95% confidence interval (CI) 0.05 to 0.18, 9 trials, 1057 participants, moderate quality evidence). In the CBAs, the effect was similar; 0.24 kg over a year (95% CI 0.09 to 0.39, 1784 participants, very low quality evidence). In high-income countries, one RCT found no difference in weight, but in a CBA with 116 Aboriginal children in Australia, the effect on weight was 0.95 kg (95% CI 0.58 to 1.33). For height, meta-analysis of nine RCTs revealed that supplemented children grew an average of 0.27 cm more over six months than those who were not supplemented (95% CI 0.07 to 0.48, 1463 participants, moderate quality evidence). Meta-analysis of seven CBAs showed no evidence of an effect (mean difference (MD) 0.52 cm, 95% CI -0.07 to 1.10, 7 trials, 1782 participants, very low quality evidence). Meta-analyses of the RCTs demonstrated benefits for weight-for-age z-scores (WAZ) (MD 0.15, 95% CI 0.05 to 0.24, 8 trials, 1565 participants, moderate quality evidence), and height-for-age z-scores (HAZ) (MD 0.15, 95% CI 0.06 to 0.24, 9 trials, 4638 participants, moderate quality evidence), but not for weight-for-height z-scores MD 0.10 (95% CI -0.02 to 0.22, 7 trials, 4176 participants, moderate quality evidence). Meta-analyses of the CBAs showed no effects on WAZ, HAZ, or WHZ (very low quality evidence). We found moderate positive effects for haemoglobin (SMD 0.49, 95% CI 0.07 to 0.91, 5 trials, 300 participants) in a meta-analysis of the RCTs.Psychosocial outcomes. Eight RCTs in low- and middle-income countries assessed psychosocial outcomes. Our meta-analysis of two studies showed moderate positive effects of feeding on psychomotor development (SMD 0.41, 95% CI 0.10 to 0.72, 178 participants). The evidence of effects on cognitive development was sparse and mixed.We found evidence of substantial leakage. When feeding was given at home, children benefited from only 36% of the energy in the supplement. However, when the supplementary food was given in day cares or feeding centres, there was less leakage; children took in 85% of the energy provided in the supplement. Supplementary food was generally more effective for younger children (less than two years of age) and for those who were poorer/ less well-nourished. Results for sex were equivocal. Our results also suggested that feeding programmes which were given in day-care/feeding centres and those which provided a moderate-to-high proportion of the recommended daily intake (% RDI) for energy were more effective.

AUTHORS' CONCLUSIONS

Feeding programmes for young children in low- and middle-income countries can work, but good implementation is key.

Highlighting the evidence gap: how cost-effective are interventions to improve early childhood nutrition and development?

There is growing evidence of the effectiveness of early childhood interventions to improve the growth and development of children. Although, historically, nutrition and stimulation interventions may have been delivered separately, they are increasingly being tested as a package of early childhood interventions that synergistically improve outcomes over the life course. However, implementation at scale is seldom possible without first considering the relative cost and cost-effectiveness of these interventions. An evidence gap in this area may deter large-scale implementation, particularly in low- and middle-income countries. We conduct a literature review to establish what is known about the cost-effectiveness of early childhood nutrition and development interventions. A set of predefined search terms and exclusion criteria standardized the search across five databases. The search identified 15 relevant articles. Of these, nine were from studies set in high-income countries and six in low- and middle-income countries. The articles either calculated the cost-effectiveness of nutrition-specific interventions (n = 8) aimed at improving child growth, or parenting interventions (stimulation) to improve early childhood development (n = 7). No articles estimated the cost-effectiveness of combined interventions. Comparing results within nutrition or stimulation interventions, or between nutrition and stimulation interventions was largely prevented by the variety of outcome measures used in these analyses. This article highlights the need for further evidence relevant to low- and middle-income countries. To facilitate comparison of cost-effectiveness between studies, and between contexts where appropriate, a move towards a common outcome measure such as the cost per disability-adjusted life years averted is advocated. Finally, given the increasing number of combined nutrition and stimulation interventions being tested, there is a significant need for evidence of cost-effectiveness for combined programmes. This too would be facilitated by the use of a common outcome measure able to pool the impact of both nutrition and stimulation activities.

Labor market returns to an early childhood stimulation intervention in Jamaica

A substantial literature shows that U.S. early childhood interventions have important long-term economic benefits. However, there is little evidence on this question for developing countries. We report substantial effects on the earnings of participants in a randomized intervention conducted in 1986-1987 that gave psychosocial stimulation to growth-stunted Jamaican toddlers. The intervention consisted of weekly visits from community health workers over a 2-year period that taught parenting skills and encouraged mothers and children to interact in ways that develop cognitive and socioemotional skills. The authors reinterviewed 105 out of 129 study participants 20 years later and found that the intervention increased earnings by 25%, enough for them to catch up to the earnings of a nonstunted comparison group identified at baseline (65 out of 84 participants).

Early childhood nutritional status in CARICOM countries: an overview with respect to five nutrition related millennium development goals

Previous reviews of nutritional status in children under 5 years describe the Caribbean grouped with Latin America. This paper focuses specifically on the Caribbean and the goals and targets of the Millennium Declaration that have bearing on childhood development. The results indicate that CARICOM countries have made progress in terms of child health as assessed by gross health indicators. Yet, the millennium generation experiences coexistence of undernutrition and overweight in early childhood. The associations of GNI with markers such as poverty indices are somewhat inconsistent with traditional findings and highlight a need to reassess the causes of infant mortality and low birth weight. However, a lack of systematic local data has hampered progress on an individual country basis. Interventions that deal more pointedly with country specific needs are required including those targeting obesity if the MDGs are to be attained by all member states.

Early stimulation and language development of economically disadvantaged young children

OBJECTIVE

To examine the effect of home stimulation on the language functioning of young children from low income families.

METHODS

The language functioning of 102 children (Mean age = 3.3 y, SD = 1.3) was assessed by the communication sub-scale of the Indian Developmental Inventory (IDI). Home visits were made to assess the quality of stimulation provided by parents to children. Seven items measuring stimulation of the child were selected from the Mohite Home Environment Inventory, a scale measuring the quality of home environment.

RESULTS

Nearly 16 % of children from economically disadvantaged homes had language delay. Children with language delay as compared to children with adequate language skills had significantly lower stimulation at home (t = 2.59, P = 0.01), specifically parents were significantly less likely to praise their child (25 % vs. 52 %, χ (2) = 4.03, P = 0.045) or provide verbal stimulation (44 % vs. 72 %, χ (2) = 4.95, P = 0.026). Multivariate stepwise regression analysis revealed that 18 % of the variance in the communication developmental quotient (DQs) of children was accounted by stimulation and age of the child (F = 10.47, P = 0.000).

CONCLUSIONS

Programs that seek to increase early stimulation for disadvantaged children by providing cognitive-linguistic enriched learning experiences would go a long way in paving the way for improved language, cognition and school performance in young children.

Measures and indicators for assessing impact of interventions integrating nutrition, health, and early childhood development

When implementing interventions integrating nutrition, health, and early childhood development, evaluation studies of effectiveness that assess the intermediate and ultimate impacts on the four domains of food and nutrition, family care, health, and child development are needed. Such studies should demonstrate impact, both benefits and potential harms, and understand mechanisms through which impact has been achieved. This article reviews and suggests measures and indicators suitable for use in evaluation studies of effectiveness of integrated interventions for children under 5 years of age. Within each of the four domains, multiple constructs and subconstructs were considered. For each construct and subconstruct, we identified measures and indicators, using several search processes, and reviewed them in relation to validity, responsiveness to intervention inputs and activities, equivalence in constructs and items across contexts with appropriate adaptation, and feasibility for use in effectiveness studies. Suggested measures and indicators for each domain, construct, and subconstruct are tabulated and described. We discuss the strengths and weaknesses of measures and indicators across domains and constructs, further research establishing validity, and guidance on adaptation of measures to particular contexts.

The role of health systems and policy in producing behavior and social change to enhance child survival and development in low- and middle-income countries: an examination of the evidence

Evidence-based behavior change interventions addressing health systems must be identified and disseminated to improve child health outcomes. Studies of the efficacy of such interventions were identified from systematic searches of the published literature. Two hundred twenty-nine of the initially identified references were judged to be relevant and were further reviewed for the quality and strength of the evidence. Studies were eligible if an intervention addressed policy or health systems interventions, measured relevant behavioral or health outcomes (e.g., nutrition, childhood immunization, malaria prevention and treatment), used at least a moderate quality research design, and were implemented in low- or middle-income countries. Policy or systems interventions able to produce behavior change reviewed included media (e.g., mass media, social media), community mobilization, educational programs (for caregivers, communities, or providers), social marketing, opinion leadership, economic incentives (for both caregiver and provider), health systems strengthening/policy/legislation, and others. Recommendations for policy, practice, and research are given based on fairly strong data across the areas of health service delivery, health workforce, health financing, governance and leadership, and research.

Effects of integrated child development and nutrition interventions on child development and nutritional status

We conducted a systematic review of studies that examined the effect of interventions combining a child development component with a nutrition one; in some cases the nutrition interventions also included health-promotion components. Only papers with both child development and nutrition outcomes and rated as moderate-to-good quality were included. Eleven efficacy and two nonrandomized trials, and eight program evaluations were identified. Only six trials examined interventions separately and combined. The trials showed nutritional interventions usually benefited nutritional status and sometimes benefited child development. Stimulation consistently benefited child development. There was no significant loss of any effect when interventions were combined, but there was little evidence of synergistic interaction between nutrition and stimulation on child development. Only three trials followed up the children after intervention. All at-scale program evaluations were combined interventions. Five benefited child development, but one did not, and two showed deficits. There was generally little benefit of at-scale programs to nutritional status. We found no rigorous evaluations of adding stimulation to health and nutrition services at scale and there is an urgent need for them. There is also a need to establish quality-control mechanisms for existing scaled-up programs and to determine their long-term effects. There is also a need to determine if there are any sustained benefits for the children after programs finish.

The long-term cognitive consequences of early childhood malnutrition: the case of famine in Ghana

We examine the role of early childhood health in human capital accumulation. Using a unique data set from Ghana with comprehensive information on individual, family, community, school quality characteristics and a direct measure of intelligence together with test scores, we examine the long-term cognitive effects of the 1983 famine on survivors. We show that differences in intelligence test scores can be robustly explained by the differential impact of the famine in different parts of the country and the impacts are most severe for children under two years of age during the famine. We also account for model uncertainty by using Bayesian Model Averaging.

Roles and effectiveness of lay community health workers in the prevention of mental, neurological and substance use disorders in low and middle income countries: a systematic review

Background

It has been suggested that lay community health workers (LHWs) could play a role in primary and secondary prevention of Mental, Neurological and Substance use (MNS) disorders in low resourced settings. We conducted a systematic review of the literature with the aim of assessing the existing evidence base for the roles and effectiveness of LHWs in primary and secondary prevention of MNS disorders in low and middle income countries (LMICs).

Methods

Internet searches of relevant electronic databases for articles published in English were done in August 2011 and repeated in June 2013. Abstracts and full text articles were screened according to predefined criteria. Authors were asked for additional information where necessary.

Results

A total of 15 studies, 11 of which were randomised, met our inclusion criteria. Studies were heterogeneous with respect to interventions, outcomes and LHWs’ roles. Reduction in symptoms of depression and improved child mental development were the common outcomes assessed. Primary prevention and secondary prevention strategies were carried out in 11 studies and 4 studies respectively .There was evidence of effectiveness of interventions however, most studies (n = 13) involved small sample sizes and all were judged to have an unclear or high risk of bias.

Conclusions

LHWs have the potential to provide psychosocial and psychological interventions as part of primary and secondary prevention of MNS disorders in LMICs, but there is currently insufficient robust evidence of effectiveness of LHW led preventive strategies in this setting. More studies need to be carried out in a wider range of settings in LMICs that control for risk of bias as far as possible, and that also collect indicators relating to the fidelity and cost of interventions.

Evaluating a community-based early childhood education and development program in Indonesia: study protocol for a pragmatic cluster randomized controlled trial with supplementary matched control group

Background

This paper presents the study protocol for a pragmatic cluster randomized controlled trial (RCT) with a supplementary matched control group. The aim of the trial is to evaluate a community-based early education and development program launched by the Government of Indonesia. The program was developed in collaboration with the World Bank with a total budget of US$127.7 million, and targets an estimated 738,000 children aged 0 to 6 years living in approximately 6,000 poor communities. The aim of the program is to increase access to early childhood services with the secondary aim of improving school readiness.

Methods/Design

The study is being conducted across nine districts. The baseline survey contained 310 villages, of which 100 were originally allocated to the intervention arm, 20 originally allocated to a 9-month delay staggered start, 100 originally allocated to an 18-month delay staggered start and 90 allocated to a matched control group (no intervention). The study consists of two cohorts, one comprising children aged 12 to 23 months and the other comprising children aged 48 to 59 months at baseline. The data collection instruments include child observations and task/game-based assessments as well as a questionnaire suite, village head questionnaire, service level questionnaires, household questionnaire, and child caretaker questionnaire. The baseline survey was conducted from March to April 2009, midline was conducted from April to August 2010 and endline conducted early 2013. The resultant participation rates at both the district and village levels were 90%. At the child level, the participation rate was 99.92%. The retention rate at the child level at midline was 99.67%.

Discussion

This protocol paper provides a detailed record of the trial design including a discussion regarding difficulties faced with compliance to the randomization, compliance to the dispersion schedule of community block grants, and procurement delays for baseline and midline data collections. Considering the execution of the program and the resultant threats to the study, we discuss our analytical plan and intentions for endline data collection.

Trials registration

Current Controlled Trials ISRCTN76061874