The effect of eggs on early child growth in rural Malawi: the Mazira Project randomized controlled trial

An Egg Intervention Improves Ponderal But Not Linear Growth Among Infants 6-12 mo of Age in Rural Bangladesh

BACKGROUND

Animal source foods are rich in multiple nutrients. Regular egg consumption may improve infant growth in low- and middle-income countries.

OBJECTIVES

To assess the impact of daily egg consumption on linear growth among 6-12-mo olds in rural Bangladesh.

METHODS

We conducted a 2 × 4 factorial cluster-randomized controlled trial allocating clusters (n = 566) to treatment for enteric pathogens or placebo and a daily egg, protein supplement, isocaloric supplement, or control. All arms received nutrition education. Here, we compare the effect of the egg intervention versus control on linear growth, a prespecified aim of the trial. Infants were enrolled at 3 mo. We measured length and weight at 6 and 12 mo and visited households weekly to distribute eggs and monitor compliance. We used linear regression models to compare 12-mo mean length, weight, and z-scores for length-for-age (LAZ), weight-for-length, and weight-for-age (WAZ), and log-binomial or robust Poisson regression to compare prevalence of stunting, wasting, and underweight between arms. We used generalized estimating equations to account for clustering and adjusted models for baseline measures of outcomes.

RESULTS

We enrolled 3051 infants (n = 283 clusters) across arms, with complete 6 and 12 mo anthropometry data from 1228 infants (n = 142 clusters) in the egg arm and 1109 infants (n = 141 clusters) in the control. At baseline, 18.5%, 6.0%, and 16.4% were stunted, wasted, and underweight, respectively. The intervention did not have a statistically significant effect on mean LAZ (β: 0.05, 95% confidence interval [CI]: -0.01, 0.10) or stunting prevalence (β: 0.98, 95% CI: 0.89, 1.13) at 12 mo. Mean weight (β: 0.07 kg, 95% CI: 0.02, 0.11) and WAZ (β: 0.06, 95% CI: 0.02, 0.11) were significantly higher in the egg compared with control arms.

CONCLUSIONS

Provision of a daily egg for 6 mo to infants in rural Bangladesh improved ponderal but not linear growth.

TRIAL REGISTRATION NUMBER

NCT03683667, https://clinicaltrials.gov/ct2/show/NCT03683667.

Childhood growth during recovery from acute illness in Africa and South Asia: a secondary analysis of the childhood acute illness and nutrition (CHAIN) prospective cohort

Background

Growth faltering is well-recognized during acute childhood illness and growth acceleration during convalescence, with or without nutritional therapy, may occur. However, there are limited recent data on growth after hospitalization in low- and middle-income countries.

Methods

We evaluated growth following hospitalization among children aged 2-23 months in sub-Saharan Africa and South Asia. Between November 2016 and January 2019, children were recruited at hospital admission and classified as: not-wasted (NW), moderately-wasted (MW), severely-wasted (SW), or having nutritional oedema (NO). We describe earlier (discharge to 45-days) and later (45- to 180-days) changes in length-for-age [LAZ], weight-for-age [WAZ], mid-upper arm circumference [MUACZ], weight-for-length [WLZ] z-scores, and clinical, nutritional, and socioeconomic correlates.

Findings

We included 2472 children who survived to 180-days post-discharge: NW, 960 (39%); MW, 572 (23%); SW, 682 (28%); and NO, 258 (10%). During 180-days, LAZ decreased in NW (-0.27 [-0.36, -0.19]) and MW (-0.23 [-0.34, -0.11]). However, all groups increased WAZ (NW, 0.21 [95% CI: 0.11, 0.32]; MW, 0.57 [0.44, 0.71]; SW, 1.0 [0.88, 1.1] and NO, 1.3 [1.1, 1.5]) with greatest gains in the first 45-days. Of children underweight (<-2 WAZ) at discharge, 66% remained underweight at 180-days. Lower WAZ post-discharge was associated with age-inappropriate nutrition, adverse caregiver characteristics, small size at birth, severe or moderate anaemia, and chronic conditions, while lower LAZ was additionally associated with household-level exposures but not with chronic medical conditions.

Interpretation

Underweight and poor linear growth mostly persisted after an acute illness. Beyond short-term nutritional supplementation, improving linear growth post-discharge may require broader individual and family support.

Funding

Bill & Melinda Gates FoundationOPP1131320; National Institute for Health ResearchNIHR201813.

Associations of fish and meat intake with iron and anaemia in Malawian children

Animal flesh foods are rich in bioavailable iron but infrequently consumed by young children. We aimed to determine whether flesh food intake was associated with iron and anaemia status among 585 Malawian infants enroled in a 6-month egg-feeding trial. The percentage of days of small fish, large fish and meat consumption were assessed through weekly 7-day animal-source food screeners. Grams of intake were assessed through 24-h recalls conducted at 6-9, 9-12 and 12-15 months of age. Plasma ferritin, soluble transferrin receptor (sTfR) and haemoglobin concentrations were measured at 6-9 and 12-15 months of age. Iron biomarkers were adjusted for inflammation during analysis. At enrolment, each flesh food category was consumed by <5% of children in the past 24 h. Over the next 6 months, small fish, large fish and meat were consumed on 25%, 8% and 6% of days, respectively, with mean usual intakes of <5 g/day. More frequent small fish consumption was associated with lower sTfR (geometric mean ratio [95% CI]: 0.98 mg/L [0.96, 1.00] per 10 percentage point difference) but not ferritin (1.03 µg/L [0.98, 1.07]) or haemoglobin (1.01 g/dL [1.00, 1.01]). Large fish consumption was associated with higher anaemia (prevalence ratio [95% CI]: 1.09 [1.01, 1.19]) and lower iron deficiency (0.96 [0.93, 1.00]) prevalence. Gram intakes of flesh food categories were not associated with any iron or anaemia indicators. Small fish were a primary contributor to flesh food intake in this cohort of Malawian children, although usual portions were small. Fish was associated with modest improvements to iron status, but meat was too infrequent to be associated with anaemia and iron deficiency.

Eggs for Improving Nutrition, cognitive development and reducing linear growth retardation among Infants and young Children (ENRICH): protocol of an egg supplementation trial among children aged 9-18 months in Hyderabad, India

INTRODUCTION

Evidence on the impact of nutrient-rich animal source foods such as eggs for improving child growth and cognition is inconsistent. This study aims to examine the impact of an egg intervention in children, along with behaviour change communication (BCC) to the mother, on linear growth and cognition, and nutritional status in children aged 9-18 months.

METHODS AND ANALYSIS

A 9-month open-labelled randomised controlled trial will be conducted in three urban slums in Hyderabad, India, as a substudy of an observational cohort study (n=350) following pregnant women and their children until 18 months of age in a population at risk of stunting. The children born to women enrolled during the third trimester of pregnancy will be block randomised in a 1:4 ratio into the intervention (n=70) and control (n=280) groups. Children in the intervention group will be supplemented with one egg per day starting from 9 months until 18 months of age. BCC designed to enhance adherence to the intervention will be used. The control group will be a part of the observational cohort and will not receive any intervention from the study team. The primary outcome will be length-for-age z-scores, and the secondary outcomes will include cognition, blood biomarkers of nutritional status including fatty acid profile and epigenetic signatures linked with linear growth and cognition. Multivariate intention-to-treat analyses will be conducted to assess the effect of the intervention.

ETHICS AND DISSEMINATION

The study is approved by the Institutional ethics committees of ICMR-National Institute of Nutrition, Hyderabad, India and London School of Hygiene and Tropical Medicine, UK. The results will be published in peer-reviewed journals and disseminated to policy-makers. Findings will also be shared with study participants and community leaders.

TRIAL REGISTRATION NUMBER

CTRI/2021/11/038208.

Egg consumption and growth in children: a meta-analysis of interventional trials

Introduction

Stunting and wasting are prevalent in low- and middle-income countries, putting children at risk for disease and disability. Eggs are a nutrient-rich food that can potentially facilitate growth.

Purpose

The aim of this meta-analysis was to evaluate the potential beneficial effect of egg supplementation on growth in children.

Methods

Following the PRISMA guidelines, PubMed and Healthline (Ovid) were systematically searched for interventional studies on egg supplementation for growth in children aged 6 months to 18 years, with no restrictions on date. Studies were evaluated for quality using Cochrane's GRADE technique. Data were pooled and reported as means and 95% confidence intervals.

Results

Seven studies reporting on 9 unique interventions in 3,575 male and female participants were included in the meta-analysis. Participants in the intervention groups experienced significantly greater increases in height/length (by 0.47 [0.13, 0.80] cm, p < 0.01) and weight (by 0.07 [0.01, 0.13] kg, p = 0.03) when compared to those in the control groups.

Conclusion

Eggs are an affordable, nutritious option for improving growth in children, though more studies with longer interventions are warranted.Systematic review registration: PROSPERO (CRD42021289609: https://www.crd.york.ac.uk/prospero/).

A good egg: An evaluation of a social and behavior change communication campaign to increase egg consumption among children in Rwanda

Childhood malnutrition, which is endemic in rural areas of low-income countries, leads to a host of deleterious outcomes such as poor cognitive development, low educational attainment and lower lifetime wages. Promoting the consumption of eggs among young children has emerged as a promising strategy to combat childhood malnutrition, though pathways to scale remain unclear. In this paper, we evaluate the impact of a social and behaviour change communication (SBCC) campaign combined with a program in which rural families purchased chickens on credit (poultry + SBCC; n = 769) relative to an arm in which families only received the poultry intervention (poultry only; n = 750), using a difference-in-difference estimation strategy with propensity score matching. The SBCC consisted of radio messages, in-person training, text message reminders and posters. We found a relatively modest but statistically significant increase in the number of times per week respondents in the poultry + SBCC arm reported feeding eggs to children of 0.28 (p = 0.02) compared to the poultry-only arm. The increase in egg feeding, however, was more pronounced for boys (0.42, p < 0.01) than for girls (0.14, p = 0.26). In addition, the campaign increased egg feeding more for those who were already feeding eggs to children (0.63, p < 0.01) than those who were not engaging in those practices at baseline (0.26, p < 0.01). However, the difference in these differences was not statistically significant. Future campaigns should ensure higher saturation of messaging and include specific messaging around the importance of feeding girls as well as boys. Campaigns seeking to scale up egg feeding quickly could potentially target the easier-to-reach segment of caregivers who already occasionally feed eggs to children though these might not be the neediest group.

Effects of egg as an early complementary food on growth of 6- to 9-month-old infants: a randomised controlled trial

OBJECTIVE

To assess the effect of daily egg consumption for six months on linear growth (primary outcome), weight-for-age, weight-for-length, mid-upper arm circumference-for-age, head circumference-for-age Z-scores, gross motor milestones development, anaemia and iron status (secondary outcomes) in a low socioeconomic community.

PARTICIPANTS

Infants aged 6 to 9 months living in the peri-urban Jouberton area, in the Matlosana Municipality, South Africa.

DESIGN

A randomised controlled trial with a parallel design was implemented. Eligible infants were randomly allocated to the intervention (n 250) receiving one egg/day and the control group (n 250) receiving no intervention. The participants were visited weekly to monitor morbidity and gross motor development, with information on adherence collected for the intervention group. Trained assessors took anthropometric measurements, and a blood sample was collected to assess anaemia and iron status. There was blinding of the anthropometric assessors to the groups during measurements and the statistician during the analysis.

RESULTS

Baseline prevalence of stunting, underweight, wasting, overweight and anaemia was 23·8 %, 9·8 %, 1·2 %, 13·8 % and 29·2 %, respectively, and did not differ between groups. Overall, 230 and 216 participants in the intervention and control groups completed the study, respectively. There was no intervention effect on length-for-age, weight-for-age, weight-for-length Z-scores, gross motor milestone development, anaemia and iron status.

CONCLUSIONS

Daily egg intake did not affect linear growth, underweight, wasting, motor milestones development, anaemia and iron status. Other interventions are necessary to understand the effect of animal-source food intake on children's growth and development. This trial was registered at https://clinicaltrials.gov/ (NCT05168085).

Precision Nutrition Opportunities to Help Mitigate Nutrition and Health Challenges in Low- and Middle-Income Countries: An Expert Opinion Survey

Precision nutrition involves several data collection methods and tools that aim to better inform nutritional recommendations and improve dietary intake, nutritional status, and health outcomes. While the benefits of collecting precise data and designing well-informed interventions are vast, it is presently unclear whether precision nutrition is a relevant approach for tackling nutrition challenges facing populations in low- and middle-income countries (LMIC), considering infrastructure, affordability, and accessibility of approaches. The Swiss Food & Nutrition Valley (SFNV) Precision Nutrition for LMIC project working group assessed the relevance of precision nutrition for LMIC by first conducting an expert opinion survey and then hosting a workshop with nutrition leaders who live or work in LMIC. The experts were interviewed to discuss four topics: nutritional problems, current solutions, precision nutrition, and collaboration. Furthermore, the SFNV Precision Nutrition for LMIC Virtual Workshop gathered a wider group of nutrition leaders to further discuss precision nutrition relevance and opportunities. Our study revealed that precision public health nutrition, which has a clear focus on the stratification of at-risk groups, may offer relevant support for nutrition and health issues in LMIC. However, funding, affordability, resources, awareness, training, suitable tools, and safety are essential prerequisites for implementation and to equitably address nutrition challenges in low-resource communities.

The impact of livestock interventions on nutritional outcomes of children younger than 5 years old and women in Africa: a systematic review and meta-analysis

Background

Nutrition-sensitive livestock interventions have the potential to improve the nutrition of communities that are dependent on livestock for their livelihoods by increasing the availability and access to animal-source foods. These interventions can also boost household income, improving purchasing power for other foods, as well as enhance determinants of health. However, there is a lack of synthesized empirical evidence of the impact and effect of livestock interventions on diets and human nutritional status in Africa.

Objective

To review evidence of the effectiveness of nutrition-sensitive livestock interventions in improving diets and nutritional status in children younger than 5 years old and in pregnant and lactating women.

Methods

Following PRISMA guidelines, we conducted a systematic review and meta-analysis of published studies reporting on the effect of livestock interventions on maternal and child nutrition in Africa. Data were extracted, synthesized, and summarized qualitatively. Key outcomes were presented in summary tables alongside a narrative summary. Estimation of pooled effects was undertaken for experimental studies with nutritional outcomes of consumption of animal-source foods (ASFs) and minimum dietary diversity (MDD). Fixed effects regression models and pooled effect sizes were computed and reported as odds ratios (ORs) together with their 95% confidence intervals (CI).

Results

After the screening, 29 research papers were included in the review, and of these, only 4 were included in the meta-analysis. We found that nutrition-sensitive livestock interventions have a significant positive impact on the consumption of ASFs for children < 5 years (OR = 5.39; 95% CI: 4.43-6.56) and on the likelihood of meeting minimum dietary diversity (OR = 1.89; 95% CI: 1.51-2.37). Additionally, the impact of livestock interventions on stunting, wasting, and being underweight varied depending on the type of intervention and duration of the program/intervention implementation. Therefore, because of this heterogeneity in reporting metrics, the pooled estimates could not be computed.

Conclusion

Nutrition-sensitive livestock interventions showed a positive effect in increasing the consumption of ASFs, leading to improved dietary diversity. However, the quality of the evidence is low, and therefore, more randomized controlled studies with consistent and similar reporting metrics are needed to increase the evidence base on how nutrition-sensitive livestock interventions affect child growth outcomes.

Campylobacter vaccination reduces diarrheal disease and infant growth stunting among rhesus macaques

Campylobacter-associated enteric disease is estimated to be responsible for more than 160 million cases of gastroenteritis each year and is linked to growth stunting of infants living under conditions of poor sanitation and hygiene. Here, we examine naturally occurring Campylobacter-associated diarrhea among rhesus macaques as a model to determine if vaccination could reduce severe diarrheal disease and infant growth stunting. Compared to unvaccinated controls, there are no Campylobacter diarrhea-associated deaths observed among vaccinated infant macaques and all-cause diarrhea-associated infant mortality is decreased by 76% (P = 0.03). By 9 months of age, there is a 1.3 cm increase in dorsal length that equaled a significant 1.28 LAZ (Length-for-Age Z score) improvement in linear growth among vaccinated infants compared to their unvaccinated counterparts (P = 0.001). In this work, we show that Campylobacter vaccination not only reduces diarrheal disease but also potentially serves as an effective intervention that improves infant growth trajectories.

Timing of Allergenic Food Introduction and Risk of Immunoglobulin E-Mediated Food Allergy: A Systematic Review and Meta-analysis

Importance

Earlier egg and peanut introduction probably reduces risk of egg and peanut allergy, respectively, but it is uncertain whether food allergy as a whole can be prevented using earlier allergenic food introduction.

Objective

To investigate associations between timing of allergenic food introduction to the infant diet and risk of food allergy.

Data Sources

In this systematic review and meta-analysis, Medline, Embase, and CENTRAL databases were searched for articles from database inception to December 29, 2022. Search terms included infant, randomized controlled trial, and terms for common allergenic foods and allergic outcomes.

Study Selection

Randomized clinical trials evaluating age at allergenic food introduction (milk, egg, fish, shellfish, tree nuts, wheat, peanuts, and soya) during infancy and immunoglobulin E (IgE)-mediated food allergy from 1 to 5 years of age were included. Screening was conducted independently by multiple authors.

Data Extraction and Synthesis

The Preferred Reporting Items for Systematic Reviews and Meta-analyses guideline was used. Data were extracted in duplicate and synthesized using a random-effects model. The Grading of Recommendations, Assessment, Development, and Evaluation framework was used to assess certainty of evidence.

Main Outcomes and Measures

Primary outcomes were risk of IgE-mediated allergy to any food from 1 to 5 years of age and withdrawal from the intervention. Secondary outcomes included allergy to specific foods.

Results

Of 9283 titles screened, data were extracted from 23 eligible trials (56 articles, 13 794 randomized participants). There was moderate-certainty evidence from 4 trials (3295 participants) that introduction of multiple allergenic foods from 2 to 12 months of age (median age, 3-4 months) was associated with reduced risk of food allergy (risk ratio [RR], 0.49; 95% CI, 0.33-0.74; I2 = 49%). Absolute risk difference for a population with 5% incidence of food allergy was -26 cases (95% CI, -34 to -13 cases) per 1000 population. There was moderate-certainty evidence from 5 trials (4703 participants) that introduction of multiple allergenic foods from 2 to 12 months of age was associated with increased withdrawal from the intervention (RR, 2.29; 95% CI, 1.45-3.63; I2 = 89%). Absolute risk difference for a population with 20% withdrawal from the intervention was 258 cases (95% CI, 90-526 cases) per 1000 population. There was high-certainty evidence from 9 trials (4811 participants) that introduction of egg from 3 to 6 months of age was associated with reduced risk of egg allergy (RR, 0.60; 95% CI, 0.46-0.77; I2 = 0%) and high-certainty evidence from 4 trials (3796 participants) that introduction of peanut from 3 to 10 months of age was associated with reduced risk of peanut allergy (RR, 0.31; 95% CI, 0.19-0.51; I2 = 21%). Evidence for timing of introduction of cow's milk and risk of cow's milk allergy was very low certainty.

Conclusions and Relevance

In this systematic review and meta-analysis, earlier introduction of multiple allergenic foods in the first year of life was associated with lower risk of developing food allergy but a high rate of withdrawal from the intervention. Further work is needed to develop allergenic food interventions that are safe and acceptable for infants and their families.

Plasma mineral status after a six-month intervention providing one egg per day to young Malawian children: a randomized controlled trial

Mineral deficiencies are common in children living in low-resource areas. Eggs are a rich source of essential nutrients and have been shown to improve growth in young children, although little is known about their impact on mineral status. Children aged 6-9 months (n = 660) were randomized to receive either one egg/day for 6-months or no intervention. Anthropometric data, dietary recalls, and venous blood were collected at baseline and 6-months follow-up. Quantification of plasma minerals (n = 387) was done using inductively coupled plasma-mass spectroscopy. Difference-in-difference mean plasma mineral concentrations was determined from baseline and follow-up values and assessed between groups by intention-to-treat using ANCOVA regression models. Prevalence of zinc deficiency was 57.4% at baseline and 60.5% at follow-up. Mean difference (MD) of plasma magnesium, selenium, copper, and zinc levels were not different between groups. Plasma iron concentrations were significantly lower in the intervention compared to the control group (MD = - 9.29; 95% CI: - 15.95, - 2.64). Zinc deficiency was widely prevalent in this population. Mineral deficiencies were not addressed with the egg intervention. Further interventions are needed to improve the mineral status of young children.

The association between plasma choline, growth and neurodevelopment among Malawian children aged 6-15 months enroled in an egg intervention trial

Choline is an essential micronutrient that may influence growth and development; however, few studies have examined postnatal choline status and children's growth and development in low- and middle-income countries. The aim of this observational analysis was to examine associations of plasma choline with growth and development among Malawian children aged 6-15 months enrolled in an egg intervention trial. Plasma choline and related metabolites (betaine, dimethylglycine and trimethylamine N-oxide) were measured at baseline and 6-month follow-up, along with anthropometric (length, weight, head circumference) and developmental assessments (the Malawi Developmental Assessment Tool [MDAT], the Infant Orienting with Attention task [IOWA], a visual paired comparison [VPC] task and an elicited imitation [EI] task). In cross-sectional covariate-adjusted models, each 1 SD higher plasma choline was associated with lower length-for-age z-score (-0.09 SD [95% confidence interval, CI -0.17 to -0.01]), slower IOWA response time (8.84 ms [1.66-16.03]) and faster processing speed on the VPC task (-203.5 ms [-366.2 to -40.7]). In predictive models, baseline plasma choline was negatively associated with MDAT fine motor z-score at 6-month follow-up (-0.13 SD [-0.22 to -0.04]). There were no other significant associations of plasma choline with child measures. Similarly, associations of choline metabolites with growth and development were null except higher trimethylamine N-oxide was associated with slower information processing on the VPC task and higher memory scores on the EI task. In this cohort of children with low dietary choline intake, we conclude that there were no strong or consistent associations between plasma choline and growth and development.

The Effects of One Egg Per Day on Vitamin A Status Among Young Malawian Children: A Secondary Analysis of a Randomized Controlled Trial

Background

Vitamin A deficiency (VAD) is common in populations with limited dietary diversity and access to vitamin A-rich foods.

Objectives

This analysis aimed to determine the impact of supplementing children's diets with 1 egg/d on the concentration of plasma retinol and RBP and the prevalence of VAD.

Methods

Children age 6-9 mo living in the Mangochi district of Malawi were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329) in the Mazira trial (clinicaltrials.gov; NCT03385252). This secondary analysis measured plasma retinol by HPLC and RBP, CRP, and α-1-acid glycoprotein (AGP) by ELISA techniques at enrollment and 6 mo follow-up. Retinol and RBP were adjusted for inflammation, and mean concentrations were compared between groups using linear regression models. In addition, prevalence ratios of VAD (retinol <0.7 μmol/L) were compared between groups using log-binomial or modified Poisson regression models.

Results

After 6 mo of study participation, 489 were assessed for retinol (egg: n = 238; control: n = 251), and 575 (egg: n = 281; control: n = 294) were assessed for RBP. Prevalence of inflammation (CRP >5 mg/L or AGP >1 g/L: 62%) and inflammation-adjusted VAD (7%) at enrollment did not differ between groups. At follow-up, the egg intervention group did not differ from the control in inflammation-adjusted retinol [geometric mean (95% CI); egg: 1.10 μmol/L (1.07, 1.13); control: 1.08 (1.05, 1.12)], RBP [egg: 0.99 μmol/L (0.96, 1.02); control: 0.97 (0.94, 1.00)], or prevalence of VAD [egg: 6%; control: 3%; prevalence ratio: 1.87 (0.83, 4.24)].

Conclusions

Provision of 1 egg/d did not impact VAD, plasma retinol, or RBP among young children in rural Malawi, where the prevalence of VAD was low. Curr Dev Nutr 2023;x:xx.This trial was registered at [clinicaltrials.gov] as [NCT03385252].

Differences in wasting assessment through Middle-Upper Arm Circumference (MUAC) adjusted by sex, age and geographic origin for children aged 6-59 months: New reference based on anthropometric surveys from 22 low-and-middle-income countries

OBJECTIVES

The Middle Upper Arm Circumference (MUAC) bracelet is a widely used instrument in public health assessments and humanitarian assistance projects. The WHO guidelines present a universal cut-off point of 115 mm to determine whether a child has severe acute malnutrition. The objective of this study is to analyze the existing differences in the MUAC for boys and girls aged between 6 and 59 months, from 22 countries distributed in three different continents, in contrast to the use of this single cut-off point. In addition, the creation of MUAC growth charts is presented for reference use.

MATERIALS AND METHODS

This study was carried out with a database developed by Action Against Hunger, composed, after the data pre-processing phase, of 97 921 individuals without anthropometric failure from African, Asian, and American continents. MUAC measurements were compared between countries, dividing by sex and age groups. A k-means method was used to create country clusters to allow comparisons and the variability was resumed using a Principal Component Analysis. For each cluster, growth curves were created and smoothed using the LOESS method.

RESULTS

Our research has revealed the existence of differences in the MUAC between countries in both, males and females, although with different trends. The evidence was confirmed with the creation of two clusters using the k-means method, which, when graphically represented by the Principal Component Analysis, showed that the MUAC was clearly different. There were also differences between males and females within each cluster, where growth curves did not overlap in any age group.

CONCLUSIONS

All statistical analysis indicate that there are differences in the MUAC values for children without anthropometric failure between countries, but also between sexes. With this research, a new reference is proposed that consider the existing variability between human populations to improve the precision in the determination of severe acute malnutrition in children.

An Egg Intervention Improves Dietary Intakes but Does Not Fill Intake Gaps for Multiple Micronutrients among Infants in Rural Bangladesh

BACKGROUND

Eggs are nutrient-rich. Strengthening evidence of the impact of egg consumption on dietary quality can inform complementary feeding guidance.

OBJECTIVES

We aimed to assess the effect of an egg intervention on dietary intakes among infants aged 6-12 mo in rural Bangladesh.

METHODS

We conducted a cluster-randomized controlled trial allocating clusters (n = 566) to enteric pathogen control or placebo treatment, with daily provision of a protein-rich meal, isocaloric meal, egg, or control. Nutrition education was provided to all arms. Our focus here is on the egg and control arms. Infants were enrolled at 3 mo. From 6 mo, we visited households weekly to distribute eggs and measure compliance. A semistructured feeding questionnaire assessed 24-h intake at 6, 9, and 12 mo. Assessments were repeated in ∼10% of subjects 2-29 d later. Using NCI SAS macros, we estimated usual intake distributions for energy, protein, fat, and 18 micronutrients and the proportion meeting intake recommendations. We compared the outcomes between the arms using clustered bootstrapping.

RESULTS

Data were available from 757 infants (137 clusters) and 943 infants (141 clusters) in the egg and control arms, respectively. In the egg arm compared with the control arm, the mean usual intakes were higher for energy (610 compared with 602 kcal/d, 9 mo; 669 compared with 658 kcal/d, 12 mo), crude protein (2.2 compared with 1.7 g/(kg·d), 9 mo; 2.4 compared with 1.9 g/(kg·d), 12 mo), available protein (2.0 compared with 1.6 g/(kg·d), 9 mo; 2.1 compared with 1.8 g/(kg·d), 12 mo), and for 13 and 14 micronutrients at 9 and 12 mo, respectively. The proportion meeting intake recommendations for most micronutrients was higher in the egg arm but remained <50% for 15 and 13 micronutrients at 9 and 12 mo, respectively.

CONCLUSIONS

Daily egg consumption improved dietary intakes among Bangladeshi infants, but was insufficient to meet multiple micronutrient intake recommendations, demonstrating the need to be coupled with other strategies.

Sustainability and scalability of egg consumption in Burkina Faso for infant and young child feeding

Introduction

Malnutrition is a significant challenge to the health of women and children in Burkina Faso. Given the critical role of animal source food on the health of infants and young children (IYC), interventions continue to explore the potential for eggs to prevent malnutrition.

Methods

Using data from the Un Oeuf intervention, which significantly increased IYC egg consumption, combined with quantitative and qualitative data from endline and 3-month follow-up, we explore the barriers and facilitating factors to IYC egg consumption and the sustainability and scalability of the intervention.

Results

Child egg consumption was high at follow-up in the Control, Partial, and Full Intervention arms (83.3, 88.2%, and 100, respectively). The Full Intervention arm had the highest mean number of eggs consumed (2.9, 2.6, and 5.7), which reflected a slight reduction from endline (6.2). All participants owned chickens at follow-up (100%), however, flock size varied. The Full Intervention arm had more chickens (mean 8.8) than the Control (5.1) or Partial Intervention (6.2) arms, which was a 50% reduction in below endline (18.5 chickens). Qualitative results indicate that chicken ownership, education about the nutritional value of eggs, and spousal support facilitated IYC egg consumption. Barriers included egg production, cultural taboos, and animal health. Motivational factors reported included the observed improvement in child health, increased availability of mothers' time, and mothers' financial independence. Knowledge sharing within the Full and Partial Intervention groups was widely reported, and the sustainability of IYC egg consumption was reinforced by accountability among mothers and to community leaders, flipbooks distributed during the project, and high motivation.

Discussion

Main findings indicate that mothers who received the full Un Oeuf intervention were able to overcome barriers to feeding their child an egg daily, were able to improve their livelihood, were motivated to continue feeding their child eggs, and saw the addition of eggs into the child's diet as sustainable. Future nutrition sensitive agriculture interventions should consider tailoring this approach for other LMIC contexts. Future research is needed to explore a possible threshold in the number of household chickens necessary to continuously feed a child an egg a day.

Relationship between Animal Sourced Food Consumption and Early Childhood Development Outcomes

Early-childhood development (ECD) is an important determinant of a child’s cognitive ability, learning, productivity, and lifetime earnings. Animal-sourced food (ASF), which is a rich source of high-quality protein and micronutrients, has been linked with ECD outcomes. This study investigates the relationship between the number, frequency, and cumulative consumption of ASF at 6, 9, 12, and 18 months of age and ECD outcomes at 24 months of age, controlling for physical growth. The study uses data collected from 701 mother−child pairs from an observational birth cohort study carried out in Banke, Nepal. ECD outcomes were assessed through a standardized ages and stages questionnaire (ASQ-3) tool. Separate multivariable ordinary least squares regression models were used to test for associations. Significant positive association was seen between total ASQ-3 score at 24 months of age and any ASF consumption at 18 months (β = 8.98, p-value < 0.01), controlling for growth outcomes. The study findings highlight the positive contribution and the accumulating benefit of consistent ASF consumption on ECD outcomes. This study recommends support and promotion of ASF intake among young children in Nepal through policy and programming actions relevant to female education; nutrition knowledge; quality ASF production; improved market access; cold storage; and poverty reduction.

Animal-source foods as a suitable complementary food for improved physical growth in 6 to 24-month-old children in low- and middle-income countries: a systematic review and meta-analysis of randomised controlled trials

Although animal-source foods are suitable complementary food for child growth in low- and middle-income countries (LMICs), their efficacy is still under discussion. This systematic review and meta-analysis was done to investigate the suitability of animal-source foods intake on child physical growth in LMICs. A systematic literature search was done using electronic databases and scanning the reference list of included studies, previous meta-analysis and systematic reviews. Paper selection was based on the PICO (ST) criteria. Papers were selected if based on 6 to 24-month-old children, if they were randomised controlled trials evaluating the effect of complementary animal-based food supplementation of any natural origin, if reporting at least a measure of body size and published after 2000. The PRISMA guidelines for reporting systematic review was followed in the paper selection. Fourteen papers were included in the systematic review and eight were considered for the meta-analysis. Animal-based food supplementation resulted in a higher length-for-age LAZ and weight-for-age (WAZ) Z-scores compared with the control group with random effect size of 0·15 (95 % CI 0·02, 0·27) and 0·20 (95 % CI 0·03, 0·36), respectively. Results were confirmed after influence analyses, and publication bias resulted as negligible. An increased effect on LAZ and WAZ was observed when the food supplementation was based on egg with effect size of 0·31 (95 % CI = -0·03, 0·64) and 0·36 (95 % CI = -0·03, 0·75), respectively. Animal-source foods are a suitable complementary food to improve growth in 6 to 24-month-old children in LMICs.

A comprehensive intervention package improves the linear growth of children under 2-years-old in rural Bangladesh: a community-based cluster randomized controlled trial

Approximately one-third of children under the age of five are stunted in developing countries and many of them are micronutrient-deficient. We designed a comprehensive intervention package including egg/milk-based snacks to improve linear growth and dietary diversity among 6 to 12-month-old children in rural Bangladesh. In this 1-year community-based cluster randomized controlled longitudinal experiment, 412 mother-infant pairs were randomly assigned to receive either monthly food vouchers (for eggs, milk, semolina, sugar, and oil) to prepare egg and milk-based snacks for their children, along with multiple micronutrient powder (MNP), counseling on child feeding and handwashing, or regular government health communication alone (control; n = 206, treatment; n = 206). The trial was conducted in 12 clusters (small administrative units of sub-district). The primary inclusion criteria were ultra-poor households with limited resources and having children under 2-years-old. The primary and secondary outcomes were differences in children's length gain and dietary diversity. The effect of intervention on child growth was examined using a mixed effect linear regression model. Mean weight and length of the children did not significantly differ between groups at baseline. Around 90% of the children in both groups were breastfed. After receiving intervention for 12 months, LAZ score increased by 0.37 (CI 0.24, 0.51, p < 0.001) and risk of stunting reduced by 73% (OR: 0.27, CI 0.13, 0.58, p = 0.001). This comprehensive intervention package improved the growth and dietary diversity of children in extremely poor Bangladeshi households. A scaling-up of this intervention in contexts with limited resources should be taken into consideration.Trial registration: This trial registered retrospectively at ClinicalTrials.gov as NCT03641001, 21/8/2018.

Effect of a Child-Owned Poultry Intervention Providing Eggs on Nutrition Status and Motor Skills of Young Children in Southern Ethiopia: A Cluster Randomized and Controlled Community Trial

Eggs are highly nutritious foods, yet intake by children in Ethiopia is low. We hypothesized that a nutrition-sensitive poultry intervention improves nutritional status of children 6-18 months using a 6-month cluster randomized controlled community trial. Intervention group (IG) children received a gift of two egg-laying hens in a ceremony where children's ownership of the chickens was declared by community leaders. Parents promised to add more hens and feed the owner-child one-egg-a-day. Trained community workers reinforced egg feeding, environmental sanitation and poultry husbandry. Control group (CG) mothers received usual nutrition education on child feeding. At baseline 29.6% of children were stunted, 19.4% underweight and 8.6% wasted. Egg consumption significantly increased only in IG, at 6 months. The intervention increased weight-for-age and weight-for-height z-scores by 0.38 (95% CI = 0.13-0.63) and 0.43 (95% CI = 0.21-0.64), respectively. Binary logit model indicated IG children were 54% (Odds ratio [OR] = 0.46; 95% CI = 0.26-0.84) and 42% (OR = 0.58; 95% CI = 0.37-0.91) less likely to be underweight and stunted, respectively, compared to CG. IG children attained the milestone of running (p = 0.022; AHR = 1.43; 95% CI = 1.05-1.95), kicking a ball (p = 0.027; AHR = 1.39; 95% CI = 1.04-1.87) and throwing a ball (p = 0.045; AHR = 1.37; 95% CI = 1.01-1.86) earlier than CG. This nutrition-sensitive child-owned poultry approach should be implemented where animal-source food intake is low.

Social and economic factors influencing intrahousehold food allocation and egg consumption of children in Kaduna State, Nigeria

Adequate intake of high-quality nutritious foods during infancy and early childhood is critical to achieving optimal growth, cognitive and behavioural development, and economic productivity later in life. Integrating high-quality and nutrient-dense animal source foods (ASFs), a major source of protein and micronutrients, into children's diets is increasingly considered essential to reducing the global burden of malnutrition in low- and middle-income countries. While eggs are an ASF that shows promise for mitigating child undernutrition, interventions promoting egg consumption among children have had mixed results in improving egg intake and child growth outcomes. As part of an evaluation of a demand creation campaign promoting egg consumption, qualitative research was carried out in September 2019 to assess sociocultural and household factors affecting egg intake among young children living in Kaduna State, Nigeria, where a thriving egg industry and childhood stunting rates of 50% exist. Methods included freelisting exercises (11), key informant interviews (11), in-depth interviews (25) and FGDs (4). Results illuminated cultural rules that restrict egg consumption among children living in low-income households. These rules and norms reflect social and economic valuations that foster male dominance in household decision-making and guide food purchasing and intrahousehold food allocation that allow men to consume eggs more regularly. Study results highlight sociocultural considerations when selecting food interventions to address child malnutrition in low-income contexts. Interventions encouraging increased consumption of ASFs, and specifically eggs in young children, should be informed by formative research to understand sociocultural norms and beliefs guiding egg consumption.

Effectiveness of the Eggs Make Kids demand-creation campaign at improving household availability of eggs and egg consumption by young children in Nigeria: A quasi-experimental study

Using a quasi-experimental design, our study aimed to determine the effectiveness of the 'Eggs Make Kids Sharp & Bright and Strong & Active' demand-creation campaign in Nigeria. The intervention arm received emotionally compelling radio and television advertisements about eggs, and was exposed to promotional activities and advertising about eggs at points of purchase, schools and health facilities; the comparison arm received no intervention. Children 6-59 months of age (intervention: n = 1359; comparison: n = 1485) were assessed 14 months apart. Intent-to-treat analyses with analysis of covariance method assessed the impact of the intervention on caregivers' behaviour towards eggs, caregivers' willingness to pay for eggs, availability of eggs in households, and consumption of eggs by children 6-59 months of age. Analyses were adjusted for possible confounders and perceived effects of COVID-19 on finances and food consumption. Compared to the comparison arm, the intervention arm showed a greater prevalence of household egg acquisition (odds ratio = 1.34, p < 0.0001), and larger improvements in caregiver self-efficacy (β = 0.242, p = 0.004) and intent to feed eggs to children (β = 0.080, p = 0.021). No effects were found on children's egg consumption or caregivers' reported willingness to pay for eggs. The lack of impact on child egg consumption despite increased acquisition of eggs and caregiver self-efficacy suggests that other barriers to child consumption may exist. Additional research should further investigate factors that may influence intrahousehold distribution of eggs and whether these may also influence other nutritious foods.

Determinants of egg consumption by infants and young children in Ethiopia

OBJECTIVE

To identify determinants of egg consumption in infants and young children aged 6-23·9 months in Ethiopia.

DESIGN AND SETTING

Data used were from the cross-sectional baseline survey of an egg campaign in Ethiopia implemented by the Global Alliance for Improved Nutrition.

PARTICIPANTS

Children aged 6-23·9 months (n 453) were sampled. Data on socio-demographic characteristics, economic resources, caregiver's behaviour, child health and feeding practices, and egg consumption in the last 7 d were collected using interviewer-administered questionnaires. Multivariable ordinal logistic regression was used to examine the association between explanatory variables and egg consumption in the last 7 d.

RESULTS

About half of children (53·4 %) did not consume eggs in the last 7 d. The odds of children consuming eggs were 4·33 (P < 0·002) times higher when their caregivers had some college education compared with no education. Wealth was positively (OR, 1·13, P = 0·029) and household food insecurity was negatively (OR, 0·96, P = 0·117) associated with child egg consumption. Purchasing eggs (OR, 9·73, P < 0·001) and caregiver's positive behavioural determinants (OR, 1·37, P = 0·005) were associated with child egg consumption. The associations of socio-demographic characteristics and economic resources with egg consumption provide evidence of partial mediation through caregiver behaviour and child health.

CONCLUSIONS

About half of children aged 6-23·9 months consumed eggs. Availability of eggs in households, mainly through purchase, was strongly associated with egg consumption. Education of caregivers and household heads and economic resources were associated with egg consumption and may operate through caregiver behaviour.

Nationally representative estimates of the cost of adequate diets, nutrient level drivers, and policy options for households in rural Malawi

A growing literature uses least-cost diets to evaluate how effectively a food system supports access to nutritious foods. We identify the cost of meeting nutrient requirements for whole households in rural Malawi from and the nutrient-level drivers thereof. From 2013 to 2017, we can identify a household least-cost diet only 60% of the time with an average cost of $2.32/person/day (2011 US$ PPP). We illustrate that larger households have more diverse nutrient needs and face a higher cost for 1000 calories of a sufficiently nutrient dense diet. Shadow price analysis shows riboflavin to be the costliest nutrient in the market. We use policy scenarios to understand what drives the infeasibility and high cost. Simulating the impact of selenium soil biofortification of maize results in a feasible diet 94% of the time at half the cost ($1.22/person/day on average) and eliminates the shadow price of copper. This is explained by insufficient selenium from sources low in copper such that under baseline conditions it is impossible to get enough selenium without too much copper. Even when feasible, to avoid copper, more higher cost foods enter the diet than would be otherwise needed to meet remaining nutrient requirements. Other value chain scenarios to increase the availability and lower the cost of nutrient-dense foods did not meaningfully change the diet cost results. Of direct relevance to Malawi, this study demonstrates more broadly how least-cost diet methods can be used to assess barriers to accessing an adequate diet and the potential impacts of policy options.

Infant age at egg introduction and malnutrition‐related child growth in the United States

To evaluate the relationship between infant age of egg introduction and malnutrition‐related growth outcomes in the United States, we analysed secondary data of 1716 mother–child dyads in the Infant Feeding Practices Study II and its Year 6 Follow‐Up Study. Malnutrition‐related growth outcomes included body mass index z‐score (BMIZ), obesity (weight‐for‐height z‐score [WHZ] ≥3 or BMIZ ≥ 2), WHZ, wasting (WHZ < −2), height‐for‐age z‐score (HAZ), and stunting (HAZ < –2). Infant age at egg introduction was analysed as a continuous variable. We used generalised estimating equations to estimate the mean difference in continuous outcomes and relative risk [RR]) for binary outcomes, adjusting for related maternal and child confounders. We also explored interactions with child sex, maternal race/ethnicity, maternal educational level, ever breastfeeding, and formula feeding. In the total sample, a later infant age at egg introduction was associated with a lower mean difference in HAZ (confounder‐adjusted mean difference = −0.08, 95% confidence interval [CI]: −0.12 to −0.03 per month) and a higher risk of stunting (confounder‐adjusted RR = 1.17, 95% CI: 1.03–1.33 per month) at 6 years. The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Among females but not among males, later introduction of eggs was associated with a lower mean WHZ (−0.06 [−0.12 to 0.00] per month) at 12 months. Later egg introduction during infancy was associated with a lower mean HAZ and a higher risk of stunting in 6‐year‐old children. Besides this, it was associated with a lower WHZ among females at 12 months.

This secondary data analysis evaluated the relationship between infant age at egg introduction and malnutrition‐related growth outcomes among young US children within the Infant Feeding Practices Study II and its Year 6 Follow‐up Study.

In the total sample, a later infant age at egg introduction was associated with a lower mean 6‐year height‐for‐age z‐score and a higher risk of stunting at 6 years.

The associations between infant age at egg introduction and 12‐month growth outcomes differed by child sex. Later introduction of eggs was associated with a lower mean weight‐for‐height z‐score among females. However, this association was not observed among males.

Fish and Fish-Based Products for Nutrition and Health in the First 1000 Days: A Systematic Review of the Evidence from Low and Middle-Income Countries

Fish provide essential nutrients for the critical window of growth and development in the first 1000 d of life and are thus an attractive option for inclusion in nutrition-sensitive and nutrition-specific programming. We conducted a systematic review of the evidence for fish and fish-based products for nutrition and health outcomes during the first 1000 d of life in low- and middle-income countries, searching the peer-reviewed and gray literature from 1999 to 2020. Databases included PubMed, Web of Science, Embase, ProQuest, and the Clinical Trials repository. Our search returned 1135 articles, 39 of which met the inclusion criteria. All studies were dual evaluated for risk of bias. Of the included studies, 18 measured maternal health and nutrition outcomes and 24 measured infant/child outcomes (3 measured both). Our search uncovered 10 impact evaluations, all of which measured consumption of fish or fish-based complementary food products in children aged 6-24 mo. We did not find strong evidence for fish consumption in children improving child growth from the impact evaluations; however, the studies were highly heterogeneous in their design and likely underpowered to detect an effect. Results from observational studies were mixed but provided evidence that adding fish to maternal and child diets is associated with improved nutrition outcomes, such as reducing the risk of anemia and improving vitamin D status. Given the nutrient richness of fish and the fact that production is often more environmentally friendly as compared with other animal source foods, more robust evidence is needed on the role of fish consumption in nutrition interventions to inform policy and programming recommendations in low- and middle-income countries.

The Effects of 1 Egg per Day on Iron and Anemia Status among Young Malawian Children: A Secondary Analysis of a Randomized Controlled Trial

Background

Young children with diets lacking diversity with low consumption of animal source foods are at risk of iron deficiency anemia (IDA).

Objectives

Our objectives were to determine the impact of supplementing diets with 1 egg/d on 1) plasma ferritin, soluble transferrin receptor (sTfR), body iron index (BII), and hemoglobin concentrations and 2) the prevalence of iron deficiency (ID), anemia, and IDA.

Methods

Malawian 6-9-mo-old infants in the Mazira trial (clinicaltrials.gov; NCT03385252) were individually randomly assigned to receive 1 egg/d for 6 mo (n = 331) or continue their usual diet (n = 329). In this secondary analysis, hemoglobin, plasma ferritin, sTfR, C-reactive protein (CRP), and α-1-acid glycoprotein (AGP) were measured at enrollment and 6-mo follow-up. Iron biomarkers were corrected for inflammation. Ferritin, sTfR, BII, and hemoglobin were compared between groups using linear regression. Prevalence ratios (PRs) for anemia (hemoglobin <11 g/dL) and ID (ferritin <12 µg/L, sTfR >8.3 mg/L, or BII <0 mg/kg) between groups were compared using log binomial or modified Poisson regression.

Results

A total of 585 children were included in this analysis (Egg: n = 286; Control: n = 299). At enrollment, the total prevalence of anemia was 61% and did not differ between groups. At 6-mo follow-up, groups did not differ in geometric mean concentration of hemoglobin [mean (95% CI); Egg: 10.9 (10.7, 11.1) g/dL; Control: 11.1 (10.9, 11.2) g/dL] and inflammation-adjusted ferritin [Egg: 6.52 (5.98, 7.10) µg/L; Control: 6.82 (6.27, 7.42) µg/L], sTfR [Egg: 11.34 (10.92, 11.78) mg/L; Control: 11.46 (11.04, 11.89) mg/L] or BII [Egg: 0.07 (0.06, 0.09) mg/kg; Control: 0.07 (0.05, 0.08) mg/kg]. There were also no group differences in anemia [Egg: 46%; Control 40%; PR: 1.15 (95% CI: 0.96, 1.38)], ID [PR: 0.99 (0.94, 1.05)], or IDA [PR: 1.12 (0.92, 1.36)].

Conclusions

Providing eggs daily for 6 mo did not affect iron status or anemia prevalence in this context. Other interventions are needed to address the high prevalence of ID and anemia among young Malawian children. This trial is registered at http://www.clinicaltrials.gov as NCT03385252.

The Efficacy of Fish as an Early Complementary Food on the Linear Growth of Infants Aged 6-7 Months: A Randomised Controlled Trial

Fish is a good animal-source protein for growth and development. The main objective of the study was to assess the efficacy of fish during the early complementary feeding period on infants’ linear growth in the Samfya district of the Luapula Province of Zambia in 6 months randomised controlled trial. The study was conducted from April 2019 to January 2020. Infants aged 6–7 months (N = 238) were assigned to either the intervention (treatment) group or control (placebo) group to receive fish powder or sorghum powder, respectively. Participants were followed on a weekly basis to distribute the powder and record compliance/usage and any morbidities. Anthropometric measurements were taken monthly. A linear mixed-effects model showed that fish powder improved linear growth among infants over all the 6 months of the intervention period. The fish powder increased length-for-age z scores by 1.26 (95% CI: 0.94–1.57) and weight-for-age z score by 0.95 (95% CI 0.6–1.23). The addition of fish powder to the infant’s usual food during the early complementary feeding improves the infant’s linear growth outcome.

Effectiveness of an integrated agriculture, nutrition-specific, and nutrition-sensitive program on child growth in Western Kenya: a cluster-randomized controlled trial

BACKGROUND

Stunting rates remain unacceptably high in many regions, including sub-Saharan Africa. Agricultural programs have led to increased yields and household incomes but showed limited success in improving nutritional status.

OBJECTIVES

We assessed whether linear growth could be improved through a potentially scalable, integrated program adding nutrition-specific and nutrition-sensitive components to an existing agricultural program.

METHODS

In this cluster-randomized controlled trial in rural Western Kenya, we randomized children aged 6-35 months from farming families to an agricultural intervention without (control group) or with a bundle of interventions (intervention group), including distribution of micronutrient powders (MNP), poultry to increase egg consumption, seeds of greens and onions, and soap and chlorine solution, as well as provision of monthly behavior change trainings. The primary outcome was the change in height-for-age z-score (HAZ) over 2 years of follow-up. We assessed safety through active morbidity and passive adverse event monitoring. We conducted an intention-to-treat analysis, followed by per-protocol and prespecified subgroup analyses.

RESULTS

From March to April 2018, we enrolled 1927 children from 126 clusters (control, 942 children in 63 clusters; intervention, 985 children in 63 clusters). Data on HAZ were available for 1672 (86.6%) children after 2 years. Adherence was >80% for use of MNP, chlorine, and greens and receipt of soap, and ∼40% for egg and red onion consumption. The intention-to-treat analysis indicated a greater change in HAZ over 2 years in the intervention group (adjusted effect size, 0.11; 95% CI: 0.02-0.19). We found a slightly stronger effect in the per-protocol analysis (adjusted effect size, 0.15; 95% CI: 0.06-0.24). Dietary diversity and consumption of iron-rich foods were improved in the intervention group, and reported instances of fever, lower respiratory tract infections, and diarrheal episodes were lower in the intervention group.

CONCLUSIONS

This study found a modest improvement in linear growth, indicating the need for multiple, integrated interventions to achieve benefits. The trial was registered with clinicaltrials.gov as NCT03448484.

The role of nutrition‐sensitive agriculture combined with behavioral interventions in childhood growth in Ethiopia: An adequacy evaluation study

Objective

The study aimed to investigate the role of nutrition‐sensitive and specific interventions along with nutrition education on child stunting during the first 1000 days in Ethiopia.

Methods

An adequacy evaluation study was used to see changes between the baseline and end‐line data after following for 1 year. A sample of 170 mother‐child pairs who had a 1‐year followed up was used to detect differences. We performed structural equation modeling to elucidate changes in feeding behaviors, socioeconomic status, water, sanitation and hygiene on child linear growth. Furthermore, the independent effect of covariates on child linear growth was handled using a general linear model.

Results

A total of 170 and 270 mother‐child dyads were interviewed at baseline and end‐line surveys, respectively. After about 1 year of intervention, the annual rate of stunting prevalence declined from 29.3% (95% confidence interval [CI] = 18.6, 42.7) to 16.4% (95% CI = 10.7, 24.2). There was a significant change in the mean of length‐for‐age Z‐score which changed from −1.18 to −0.45 (P < .034). Adjusting for the different constructs of the health belief model, child sex, age, feeding behaviors, and dietary diversity, one egg consumption per day was responsible for the most significant variability explained (36%) for stunting reduction.

Conclusions

Sustainable access to egg consumption for children below 2 years experienced a substantial reduction in childhood stunting. A combination of nutrition‐sensitive agricultural and direct nutrition interventions along with behavioral‐based education is a sustainable strategy in reducing and preventing child growth from faltering in the early life stages.

Plasma Choline Concentration Was Not Increased After a 6-Month Egg Intervention in 6-9-Month-Old Malawian Children: Results from a Randomized Controlled Trial

BACKGROUND

Eggs are a rich source of choline, an essential nutrient important for child growth and development. In a randomized trial of 1 egg/d in young children in Ecuador, an egg intervention led to significant improvements in growth, which were partially mediated by increased plasma choline concentration. A similar trial in Malawi (clinicaltrials.gov: NCT03385252) found little improvement in child growth or development.

OBJECTIVES

We aimed to evaluate the effect of 1 egg/d for 6 mo on plasma choline concentrations in Malawian children enrolled in a randomized trial.

METHODS

Infants aged 6-9 mo in rural Malawi were randomly assigned to receive 1 egg/d (n = 331) or serve as a nonintervention control (n = 329) for 6 mo. Anthropometric, developmental, and dietary data were collected at baseline and 6-mo follow-up, along with a blood draw. Plasma choline, betaine, dimethylglycine, trimethylamine N-oxide (TMAO), and DHA were measured at both time points using ultrahigh performance liquid chromatography-tandem MS (n = 200 per group). Linear regression analysis was used to determine the difference in plasma choline and related metabolites between groups after 6 mo of intervention.

RESULTS

Plasma choline, betaine, dimethylglycine, and DHA concentrations did not differ between groups at 6-mo follow-up. Plasma TMAO was significantly (26%; 95% CI: 7%, 48%) higher in the egg intervention group in a fully adjusted model.

CONCLUSIONS

Provision of 1 egg/d for 6 mo did not result in increases in plasma choline or related metabolites, except TMAO. This could partially explain the lack of effect on growth and development. Additional interventions are needed to improve choline status, growth, and development in this population.

Non-Targeted Dried Blood Spot-Based Metabolomics Analysis Showed Rice Bran Supplementation Effects Multiple Metabolic Pathways during Infant Weaning and Growth in Mali

Rice bran contains essential nutrients, antioxidants, and bioactives with anti-inflammatory and diarrheal protective properties important for infants. This 6-month randomized controlled trial investigated the effects of heat-stabilized rice bran supplementation during Malian infant weaning. Fifty healthy 6-month-old infants were randomized to a rice bran intervention (N = 25) or non-intervention control group (N = 25). Intervention infants received dose-escalating rice bran supplementation for 6 months (1–5 g/day). Monthly infant dried blood spot and anthropometric measurements were collected. Dried blood spot metabolite abundances were compared monthly according to diet for six months. Supplementation resulted in favorable weight-for-age and weight-for-length z-score changes. Non-targeted dried blood spot-based metabolomics identified 796 metabolites, of which 33% had significant fold differences between groups (7–12 months). Lipids and amino acids represented 70.6% of the metabolites identified. Rice bran supplementation during infant weaning significantly modulated the metabolites involved in antioxidant defenses and with neuroactive properties including reduced glutathione, glycine, glutamate, cysteinylglycine, tryptophan betaine, and choline. These findings support rice bran as a weaning ingredient to meet infant nutritional requirements and with the potential to reduce oxidative stress and improve cognitive outcomes. This study provides evidence for dried blood spots as a cost-effective tool to detect infant biomarkers of nutritional and metabolic status.

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/.

Fish Nutritional Value as an Approach to Children's Nutrition

Fish is a relatively cheap and accessible source of animal protein for human consumption even in rural communities. It is critical for global food and nutrition security, and its consumption continues to increase. As a highly nutritious food, fish consumption is highly recommended for children and expectant mothers for normal growth and development. The present paper explores the nutritional value of fish as approach to nutrition in children and its benefits. The findings reveal that fish is a valuable source of essential amino acids (EAA) and polyunsaturated fatty acids (PUFAs) that play important physiological functions for maintenance and development of fetuses, neonates, and infant brains. Therefore, it could be a valuable tool in the fight against food insecurity and malnutrition. However, fish and fish products are also highly susceptible to contamination by various organic and inorganic compounds that threaten public health. Particularly, heavy metals and biogenic amines (BAs) have shown adverse effects when contaminated fish is consumed, and the effects in children have been worse. Hence, while fish consumption is highly recommended for children's nutrition, the safety and quality of the product should always be checked to safeguard public health.

Choline and docosahexaenoic acid during the first 1000 days and children's health and development in low- and middle-income countries

Choline and DHA are nutrients that, when provided during the first 1000 days from conception to age 2 years, may have beneficial effects on child neurodevelopment as well as related health factors, including birth outcomes and child growth, morbidity, and inflammation. Because these nutrients are found mainly in animal-source foods, they may be lacking in the diets of pregnant and lactating women and young children in low- and middle-income countries, potentially putting children at risk for suboptimal development and health. Prior reviews of these nutrients have mainly focused on studies from high-income countries. Here, a narrative review is presented of studies describing the pre- and postnatal roles of choline, docosahexaenoic acid, and a combination of the 2 nutrients on child neurodevelopment, birth outcomes, growth, morbidity, and inflammation in low- and middle-income countries. More studies are needed to understand the specific, long-term effects of perinatal choline and docosahexaenoic acid intake in various contexts.

Impacts of an egg intervention on nutrient adequacy among young Malawian children

Eggs are a rich source of multiple nutrients that support child growth and development. Provision of eggs as a complementary food may improve dietary adequacy among young children at risk for undernutrition. Our objective was to test the impact of an egg intervention on the adequacy of total nutrient intakes and micronutrient density among 6- to 15-month-old Malawian children. Children 6 to 9 months old, living in Mangochi District, Malawi, were randomly assigned to the intervention group (n = 331) receiving an egg per day or a control group (n = 329) consuming their usual diet. Dietary intakes of macronutrients, vitamins and minerals were assessed using 24-h recalls at baseline, 3-month midline and 6-month endline, with repeat recalls in a subsample. Usual nutrient intake and micronutrient density distributions were modelled to estimate group means and prevalence of inadequacy. Group differences at midline and endline were tested using unequal variance t tests with bootstrapped standard errors. The egg intervention resulted in higher intakes of fat and protein and lower intakes of carbohydrates. The egg group had lower prevalence of inadequacy for selenium, vitamin A, riboflavin, vitamin B5 , vitamin B12 and choline. Micronutrient density inadequacy was lower in the egg group for vitamin A and choline at midline and endline, riboflavin at midline and vitamin B5 at endline. Inadequacy of nutrient intakes or density remained highly prevalent in both groups for multiple micronutrients. Though the egg intervention increased intakes of protein and several micronutrients, total intakes and micronutrient density of multiple micronutrients remained far below recommendations.

Academy of Nutrition and Dietetics Nutrition Research Network: The Saqmolo' Project Rationale and Study Protocol for a Randomized Controlled Trial Examining the Influence of Daily Complementary Feeding of Eggs on Infant Development and Growth in Guatemala

Adequate nutrition during the complementary feeding period is critical for optimal child growth and development and for promoting long-term educational attainment and economic potential. To prioritize limited public health resources, there is a need for studies that rigorously assess the influence of multicomponent integrated nutrition interventions in children younger than age 2 years in different contexts. This study aimed to describe the rationale and protocol for the Saqmolo' Project using the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. The Saqmolo' (ie, "egg" in the Mayan language, Kaqchiquel) Project is an individually randomized, partially blinded, controlled comparative effectiveness trial to evaluate the influence of adding delivery of a single whole egg per day to local standard nutrition care (ie, growth monitoring, medical care, deworming medication, multiple micronutrient powders for point-of-use food fortification [chispitas], and individualized complementary and responsive feeding education for caregivers) for 6 months, compared with the local standard nutrition care package alone, on child development, growth, and diet quality measures in rural indigenous Mayan infants aged 6 to 9 months at baseline (N = 1,200). The study is being executed in partnership with the Wuqu' Kawoq/Maya Health Alliance, a primary health care organization located in central Guatemala. Primary outcomes for this study are changes in global development scores, assessed using the Guide for Monitoring Global Development and the Caregiver Reported Child Development Instruments. Secondary outcomes include changes in infant hemoglobin, anthropometric measures (including z scores for weight for age, length for age, weight for length, and head circumference for age), and diet quality as measured using the World Health Organization's infant and young child feeding indicators. The results of the Saqmolo' Project may help to inform public health decision making regarding resource allocation for effective nutrition interventions during the complementary feeding period.

Mobilising evidence, data, and resources to achieve global maternal and child undernutrition targets and the Sustainable Development Goals: an agenda for action

As the world counts down to the 2025 World Health Assembly nutrition targets and the 2030 Sustainable Development Goals, millions of women, children, and adolescents worldwide remain undernourished (underweight, stunted, and deficient in micronutrients), despite evidence on effective interventions and increasing political commitment to, and financial investment in, nutrition. The COVID-19 pandemic has crippled health systems, exacerbated household food insecurity, and reversed economic growth, which together could set back improvements in undernutrition across low-income and middle-income countries. This paper highlights how the evidence base for nutrition, health, food systems, social protection, and water, sanitation, and hygiene interventions has evolved since the 2013 Lancet Series on maternal and child nutrition and identifies the priority actions needed to regain and accelerate progress within the next decade. Policies and interventions targeting the first 1000 days of life, including some newly identified since 2013, require renewed commitment, implementation research, and increased funding from both domestic and global actors. A new body of evidence from national and state-level success stories in stunting reduction reinforces the crucial importance of multisectoral actions to address the underlying determinants of undernutrition and identifies key features of enabling political environments. To support these actions, well-resourced nutrition data and information systems are essential. The paper concludes with a call to action for the 2021 Nutrition for Growth Summit to unite global and national nutrition stakeholders around common priorities to tackle a large, unfinished undernutrition agenda-now amplified by the COVID-19 crisis.

Sustained intake of animal-sourced foods is associated with less stunting in young children

The value of animal-sourced foods (ASFs) in providing key nutrients, particularly for child growth and where diets are of low quality, is understood mainly from cross-sectional assessment of current consumption. Longitudinal panel data from Nepal, Bangladesh and Uganda were used here to assess associations among previous (lagged) and contemporaneous ASF intake with linear growth of children aged 6-24 months. Lagged ASF consumption was significantly correlated with a 10% decline in stunting in Nepali children who consumed any ASF in the previous year, while current intake was associated with a 9% decline in stunting in Uganda. Previous consumption of two or more ASFs showed a stronger association, ranging from a 10% decline in stunting in Bangladesh to a 16% decline in Nepal. This novel lagged analysis emphasizes the need for regular and appropriate levels of ASF intake by young children to support healthy growth in resource-constrained settings.

The effect of bovine colostrum/egg supplementation compared with corn/soy flour in young Malawian children: a randomized, controlled clinical trial

BACKGROUND

Bovine colostrum with egg powder (BC/egg) is rich in essential amino acids and immunoactive compounds.

OBJECTIVES

This trial tested the hypothesis that a daily supplement of BC/egg would reduce linear growth faltering and environmental enteric dysfunction (EED) in Malawian infants when compared with an isoenergetic ration of corn/soy flour used as a control. EED was defined by a lactulose permeability test.

METHODS

This was a prospective, randomized, blinded, placebo-controlled clinical trial in which 9-mo-old infants received BC/egg or a control for 3 mo. The primary outcomes were change in length-for-age z-score (ΔLAZ) and urinary lactulose excretion (%L) at 12-mo-old. Secondary outcomes included episodes of diarrhea, stunting, EED, and the 16S configuration of the fecal microbiota.

RESULTS

Of the 277 children enrolled, 267 completed the intervention phase of the study. LAZ decreased in all children from 9 to 17 mo, although ΔLAZ was less in children receiving BC/egg from 9 to 12 mo (difference = 0.12 z-scores; P = 0.0011). This difference persisted after feeding was completed, with less ΔLAZ (difference = 0.09 z-scores). A lower prevalence of stunting was seen in the intervention group (n = 47/137) than the control group (n = 62/127) at 17 mo (RR = 0.70; 95% CI: 0.52, 0.94).The median %L at 12 mo of age in the children receiving BC/egg was 0.14%, compared with 0.17% in the control group (P = 0.74). In children with %L >0.45% at enrollment (severe EED), the BC/egg group had more children with normal %L at 12 mo of age (10/20, 50%) than was seen in controls (2/15, 13%; P = 0.024). Episodes of diarrhea and β-diversity of the 16S configuration of fecal microbiota did not differ between the 2 groups.

CONCLUSIONS

Addition of BC/egg to complementary feeding in Malawian infants resulted in less linear growth faltering. This trial was registered at clinicaltrials.gov as NCT03801317.

Impacts of an egg complementary feeding trial on energy intake and dietary diversity in Malawi

Complementary feeding diets in low- and middle-income countries are generally inadequate to meet requirements for growth and development. Food-based interventions may prevent nutrient inadequacies provided that they do not displace other nutrient-rich foods. We conducted a randomized controlled trial in rural Malawi in which 660 children aged 6 to 9 months were provided an egg a day for 6 months or assigned to a control group. Dietary intake of complementary foods and drinks was assessed at baseline, 3-month midline and 6-month endline visits using a tablet-based multipass 24-h recall. Up to two repeat recalls were collected at each time point in a subsample of 100 children per treatment group. At midline and endline, usual energy intake from eggs was about 30 kcal/day higher in the egg group compared with controls (p < 0.0001). Compared with controls, children in the egg group were over nine times more likely to consume eggs at midline and endline. There was a comparable, but nonsignificant, greater total usual energy intake from complementary foods of 30 kcal/day at midline (p = 0.128) and 36 kcal/day at endline (p = 0.087). There also was a displacement of 7 kcal/day in legumes and nuts in children at endline (p = 0.059). At midline and endline, more than 80% of children in the egg group consumed a minimally diverse diet compared with 53% at midline and 60% at endline in the control group. This study illustrates that mothers in the egg group fed eggs to young children on a regular basis without substantial displacement of other complementary foods.

Behavior Change, Egg Consumption, and Child Nutrition: A Cluster Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Malnutrition is a significant contributor to child morbidity and mortality globally. Egg consumption has been associated with improved child nutrition yet is rare in rural, resource-poor settings. We test the effects of a culturally tailored behavior change intervention to increase child egg consumption.

METHODS

A 3-arm cluster randomized controlled trial was conducted in rural Burkina Faso with 260 mother-child dyads. Children aged 4 to 17 months from 18 villages were included; those with reported history of malnutrition or egg allergy were excluded. Each child in the full intervention arm received 4 chickens, and mothers received the 10-month behavior change package. Participants in the partial intervention arm received only the behavior change package.

RESULTS

In this analysis of 250 children, the full (β = 4.3; P = 6.6 × 10^-12) and the partial (β = 1.0; P = .02) interventions significantly increased egg consumption. The full intervention also significantly increased poultry production (β = 11.6; 95% confidence interval 8.3-15; P = 1.1 × 10^-5) and women's decision-making about eggs (β = .66; P = .02), and significantly decreased wasting (β = .58; P = .03) and underweight (β = .47; P = .02).

CONCLUSIONS

The culturally tailored behavior change package significantly increased child egg consumption. When coupled with the gift of chickens, the behavior change intervention yielded a greater increase in egg consumption and significantly reduced wasting and underweight. Behavior change strategies to increase egg consumption should be considered among nutrition and health programs in resource-poor settings where poultry is available.

Baseline Characteristics of Study Participants in the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) Trial

Recurrent enteric infections and micronutrient deficiencies, including deficiencies in the tryptophan–kynurenine–niacin pathway, have been associated with environmental enteric dysfunction, potentially contributing to poor child growth and development. We are conducting a randomized, placebo-controlled, 2 × 2 factorial interventional trial in a rural population in Haydom, Tanzania, to determine the effect of 1) antimicrobials (azithromycin and nitazoxanide) and/or 2) nicotinamide, a niacin vitamer, on attained length at 18 months. Mother/infant dyads were enrolled within 14 days of the infant’s birth from September 2017 to September 2018, with the follow-up to be completed in February 2020. Here, we describe the baseline characteristics of the study cohort, risk factors for low enrollment weight, and neonatal adverse events (AEs). Risk factors for a low enrollment weight included being a firstborn child (−0.54 difference in weight-for-age z-score [WAZ] versus other children, 95% CI: −0.71, −0.37), lower socioeconomic status (−0.28, 95% CI: −0.43, −0.12 difference in WAZ), and birth during the preharvest season (November to March) (−0.22, 95% CI: −0.33, −0.11 difference in WAZ). The most common neonatal serious AEs were respiratory tract infections and neonatal sepsis (2.2 and 1.4 events per 100 child-months, respectively). The study cohort represents a high-risk population for whom interventions to improve child growth and development are urgently needed. Further analyses are needed to understand the persistent impacts of seasonal malnutrition and the interactions between seasonality, socioeconomic status, and the study interventions.

A Chicken Production Intervention and Additional Nutrition Behavior Change Component Increased Child Growth in Ethiopia: A Cluster-Randomized Trial

BACKGROUND

Chicken production in the context of nutrition-sensitive agriculture may benefit child nutrition in low-income settings.

OBJECTIVES

This study evaluated effects of 1) a chicken production intervention [African Chicken Genetic Gains (ACGG)], and 2) the ACGG intervention with nutrition-sensitive behavior change communication (BCC) [ACGG + Agriculture to Nutrition (ATONU)], on child nutrition and health outcomes and hypothesized intermediaries.

METHODS

Forty ACGG villages received 25 genetically improved chickens and basic husbandry guidance; of these, 20 ACGG + ATONU villages in addition received a nutrition-sensitive behavior change and homegardening intervention; 20 control clusters received no intervention. We assessed effects of the interventions on height-for-age z scores (HAZ), weight-for-age z scores (WAZ), and weight-for-height z scores (WHZ) at 9 (midline) and 18 mo (endline) through unadjusted and adjusted ordinary least squares (OLS) regressions. We examined the interventions' effects on hypothesized intermediaries including egg production and consumption, dietary diversity, women's empowerment, income, child morbidities, anemia, and chicken management practices through OLS and log binomial models.

RESULTS

Data included 829 children aged 0-36 mo at baseline. ACGG + ATONU children had higher midline HAZ [mean difference (MD): 0.28; 95% CI: 0.02, 0.54] than controls. The ACGG group had higher HAZ (MD: 0.28; 95% CI: 0.05, 0.50) and higher WAZ (MD: 0.18; 95% CI: 0.01, 0.36) at endline than controls; after adjusting for potential baseline imbalance, effects were similar but not statistically significant. At endline, differences in ACGG + ATONU children's HAZ and WAZ compared with controls were similar in magnitude to those of ACGG, but not statistically significant. There were no differences in anthropometry between the intervention groups. ACGG + ATONU children had higher dietary diversity and egg consumption than ACGG children at endline. Both interventions showed improvements in chicken management practices. The interventions did not increase anemia, diarrhea, fever, or vomiting, and the ACGG + ATONU group at midline showed reduced risk of fever.

CONCLUSIONS

A chicken production intervention with or without nutrition-sensitive BCC may have benefited child nutrition and did not increase morbidity.This trial was registered at clinicaltrials.gov as NCT03152227.

Early Child Development Outcomes of a Randomized Trial Providing 1 Egg Per Day to Children Age 6 to 15 Months in Malawi

BACKGROUND

Eggs are a rich source of nutrients important for brain development, including choline, riboflavin, vitamins B-6 and B-12, folate, zinc, protein, and DHA.

OBJECTIVE

Our objective was to evaluate the effect of the consumption of 1 egg per day over a 6-mo period on child development.

METHODS

In the Mazira Project randomized controlled trial, 660 children aged 6-9 mo were randomly allocated into an intervention or control group. Eggs were provided to intervention households during twice-weekly home visits for 6 mo. Control households were visited at the same frequency. At enrollment, blinded assessors administered the Malawi Developmental Assessment Tool (MDAT), and 2 eye-tracking tasks using a Tobii-Pro X2-60 eye tracker: a visual paired comparison memory task and an Infant Orienting with Attention task. At endline, 6-mo later, blinded assessors administered the MDAT and eye-tracking tasks plus an additional elicited imitation memory task.

RESULTS

At endline, intervention and control groups did not significantly differ in any developmental score, with the exception that a smaller percentage of children were delayed in fine motor development in the intervention group (10.6%) compared with the control group (16.5%; prevalence ratio: 0.59, 95% CI: 0.38-0.91). Among 10 prespecified effect modifiers for the 8 primary developmental outcomes, we found 7 significant interactions demonstrating a consistent pattern that children who were less vulnerable, for example, those with higher household wealth and maternal education, showed positive effects of the intervention. Given multiple hypothesis testing, some findings may have been due to chance.

CONCLUSION

The provision of 1 egg per day had no overall effect on child development in this population of children, however, some benefits may be seen among children in less vulnerable circumstances. This trial was registered at clinicaltrials.gov as NCT03385252.