Home fortification with multiple micronutrient powders improves infant and young child development in Bihar, India
Authors: Larson Leila , Young Melissa , Bauer Patricia , Rukshan Mehta , Girard Amy Webb , Ramakrishnan Usha , Verma Pankaj , Chaudhuri Indrajit , Srikantiah Sridhar , Martorell Reynaldo 
Published: November 2023

Estimates based on stunting and extreme poverty show that, in South Asia, approximately 88 million children under five years of age fail to fulfill their developmental potential. Children in Bihar, India may be at particularly high risk because many experience chronic malnutrition with implications for brain development. This study examined the impacts of home fortification with multiple micronutrient powders (MMPs) (including iron, zinc, iodine, folic acid, and vitamins A, C and B12) on motor and mental development, memory, and executive function of children 6–18 months of age living in West Champaran, Bihar.Seventy health sub‐centers from West Champaran district were randomized to either MMPs and nutrition counseling (intervention) or nutrition counselling alone (control) for 12 months. Frontline health workers delivered MMPs and/or nutrition counseling to all households in study communities with a child 6–18 months of age. Data were collected using cross‐sectional household surveys at study baseline (N=4359) and endline (N=4292) with households selected from intervention and control communities using a 2‐stage cluster randomized sampling strategy. The Developmental Milestones Checklist‐II was used to assess motor and mental development, Elicited Imitation tasks were used to assess memory, and the A‐Not‐B test was used to assess executive function. Impacts of the intervention on child development outcomes were estimated with linear mixed models adjusted for clustering, using restricted maximum likelihood estimation.At baseline, 72% of children were anemic and 33% were stunted. In adjusted analyses, children in the intervention group had a significantly (P<0.01) larger increase from baseline to endline compared to those in the control group on scores for gross motor (difference in difference=0.47, SE=0.13), language (DiD=0.25, SE=0.09), and personal‐social development (DiD=0.37, SE=0.14) after adjusting for clustering, age of the child, baseline hemoglobin, and baseline household stimulation score. However, we noted significant effect modification of MMP impacts on language and personal‐social development (PSD) by household stimulation scores at baseline such that impacts were greater for children from households with higher stimulation scores at baseline compared to those from households with lower stimulation scores at baseline (Cohen's d, language =0.13 v. 0.07; Cohen's d, PSD=0.09 v. 0.07; P‐interaction <0.05). No significant impacts were seen for MMP on memory or executive function.Home fortification with multiple micronutrient powders through the existing health infrastructure in Northern India was effective in improving child motor and mental development and should be considered in combination with other household stimulation initiatives.Support or Funding InformationFunding for this work was obtained from the Bill and Melinda Gates Foundation and the Thrasher Research Fund. NCT02593136