Health and nutrition interventions for infant development
Authors: Frances E Aboud, Aisha K Yousafzai
Journal: The Lancet Child & Adolescent Health (2018)

Nurturing care embodies activities of caregivers and providers that promote health, growth, and development of young children,1Britto PR Lye SJ Proulx K et al.Nurturing care: promoting early childhood development.Lancet. 2017; 389: 91-102Summary Full Text Full Text PDF PubMed Scopus (678) Google Scholar and increased attention has been paid to integrated packages of care that bundle specific interventions together (eg, handwashing promotion and nutrition supplementation) or through coordinated services (eg, conditional cash transfers linking poverty alleviation with participation in child health services) in low-income and middle-income countries to improve such care. To improve the effectiveness of these, the independent and combined effects of interventions and the mechanisms mediating their outcomes need to be understood. The cluster-randomised trials from Kenya by Christine Stewart and colleagues2Stewart CP Kariger P Pickering AJ et al.Effects of water, sanitation, handwashing, and nutritional interventions on child development: a cluster-randomised controlled trial in rural Kenya.Lancet Child Adolesc Health. 2018; (published online Feb 12.)http://dx.doi.org/10.1016/S2352-4642(18)30025-7Summary Full Text Full Text PDF Scopus (46) Google Scholar and Bangladesh by Fahmida Tofail and colleagues3Tofail F Fernald LC Das KK et al.The effects of single and combined water, sanitation, handwashing and nutrition interventions on developmental outcomes of young children in rural Bangladesh: A cluster randomised trial.Lancet Child Adolesc Health. 2018; (published online Feb 12.)http://dx.doi.org/10.1016/S2352-4642(18)30031-2Summary Full Text Full Text PDF PubMed Scopus (40) Google Scholar examined the effect of single and combined water, sanitation, and handwashing (WASH) interventions and lipid-based nutrition supplementation on children's early cognitive and language development. The two studies report on similar interventions in two different settings, making them ideal companion pieces. The six-group intervention design is especially strong because every input is assessed separately and in combinations of WASH and combined WASH and nutrition. The WASH interventions are relatively new, since most attempts have aimed at addressing diarrhoea and parasites and thereby nutrition, but when studied have rarely found effects on children's mental development.4Walker CLF Lamberti L Adair L et al.Does childhood diarrhea influence cognition beyond the diarrhea-stunting pathway?.PLoS One. 2012; 7: e47908Crossref PubMed Scopus (49) Google Scholar However, with increasing interest in environmental contamination and its chronic effects on children's guts, it is important to revisit these questions with stronger inputs to change parental behaviours. More studies have assessed the effects of nutrition supplements on motor and mental development, but findings are mixed.5Larson LM Yousafzai AK A meta-analysis of nutrition interventions on mental development of children under-two in low- and middle-income countries.Matern Child Nutr. 2017; : 13DOI: 10.1111/mcn.12229Google Scholar Results of many nutrition studies do not show effects on linear growth, although the timeframe might be short. It is important when designing and testing multiple intervention packages that researchers have a conceptual framework in mind; for example, when testing the effects of nutrition on mental development, potential mediators could be illness, linear growth, and fine or gross motor exploration. It is not clear whether combined WASH interventions will have synergistic effects with nutrition by reducing illness, or affect mental development directly by encouraging more frequent verbal and physical interactions between mother and child.6Aboud FE Yousafzi AK Very early childhood development.in: Black RE Laxminarayan L Walker N Temmerman M Disease control priorities 3rd edn. Volume 2. Reproductive, maternal, newborn and child health. World Bank, Washington, DC2016: 241Crossref Google Scholar Without such a conceptual framework, child development specialists will be unconvinced that putting a child on a potty or chlorinating tubewell water will enhance mental development. The Bangladeshi and Kenyan studies measured children at age 1 year using gross motor milestones and found effects on standing and walking. This effect was most clearly related to nutrition supplements, which also enhanced linear growth. At age 2 years, the Extended Ages and Stages Questionnaire (EASQ), which combined caregiver reports and some direct tests, was used to assess language development, personal social behaviours, and gross motor skills. Here the findings diverged: the Kenyan results showed no differences between the intervention and control groups, whereas the Bangladeshi findings showed significant benefits of the individual and combined interventions compared with control. The conclusion is that any one of these interventions by itself would work in Bangladesh, but not in Kenya, to improve motor, language, and personal social behaviours. The differences in findings are puzzling but instructive for future research. The studies differed in the number of visits received by families, adherence to intervention instructions, masking of assessors, and the control groups used. In Bangladesh, more than 60 community health promoter visits were provided to families, and adherence throughout the 2 years was more than 80%. In Kenya, health promoters were expected to provide 24 visits over 2 years, but at the end of year 2 less than 40% of families were receiving visits. Nutrition supplements had high rates of adherence in both countries, so adherence cannot explain mental development differences between the Bangladeshi and Kenyan nutrition groups, but could explain similarities in gross motor development. Consequently, the study in Bangladesh is more like an efficacy design with high levels of promoter contact, messaging, adherence, and social influence; whereas the study in Kenya is more like an effectiveness trial where promoters made fewer visits and were given a monthly pay of US$15 for the first 6 months and $9 afterwards, as opposed to $20. Studies have shown that outcomes are also poor in Bangladesh when combined WASH promoters make only 47% of the expected home visits.7Benjamin-Chung J Sultana S Halder AK et al.Scaling up a water, sanitation, and hygiene program in rural Bangladesh: the role of program implementation.Am J Public Health. 2017; 107: 694-701Crossref PubMed Scopus (10) Google Scholar The other differences were that the Kenyan study included an active control group in which families received health promoter visits (with arm circumference measured in the child) but no other intervention; this controlled for attention. There was also more effort to mask assessors. These two features might have removed a certain bias that was likely to affect results in Bangladesh. Mothers receiving an intervention in Bangladesh might be more responsive to the social attention of the promoter, given that mothers remain at home and are somewhat socially isolated. They were very motivated to adhere to instructions of the promoter and might also have been motivated to report their child achieving more milestones on the EASQ. The issues raised here beg for implementation research into the process by which the interventions were delivered. Health and nutrition researchers have reporting guidelines8Hales S Lesher-Trevino A Ford N Maher D Ramsay A Tran N Reporting guidelines for implementation and operational research.Bull World Health Organ. 2016; 94: 58-64Crossref PubMed Scopus (37) Google Scholar and frameworks9Habicht J-P Pelto GH Multiple micronutrient interventions are efficacious, but research on adequacy, plausibility, and implementation needs attention.J Nutr. 2012; 142: 205S-209SCrossref PubMed Scopus (19) Google Scholar to plan ahead and inform their descriptions and evaluations of how the programme was actually implemented. Some contextual differences between Bangladesh and Kenya, such as social density and conformity to norms, as well as the education level of parents and promoters are important. Training, supervision, and stipends for promoters are relevant, as are the curriculum, delivery of messages, and intensity of contact. Usually the quality of the promoter–parent interaction is observed and rated by an independent researcher. A report on the implementation of these studies will be helpful to inform future attempts to apply the interventions. Integrated programmes may be cost-effective and beneficial for families who tend to see health, growth, and development as unitary and not as silos.10DiGirolamo AM Stansbery P Lung'aho M Advantages and challenges of integration: opportunities for integrating early childhood development and nutrition programming.Ann N Y Acad Sci. 2014; 1308: 46-53Crossref PubMed Scopus (22) Google Scholar In particular, combining water, sanitation, and hygiene is crucial because of their interconnections. However, we could not fail to notice one important missed opportunity here—the addition of messages about the need to love, talk, and play with the child. Although more research evaluating additive or synergistic effects of stimulation is needed, especially with combined WASH interventions, there is a general consensus, supported by a robust conceptual framework, that stimulation inputs result in larger effect sizes on mental development than nutrition inputs alone.6Aboud FE Yousafzi AK Very early childhood development.in: Black RE Laxminarayan L Walker N Temmerman M Disease control priorities 3rd edn. Volume 2. Reproductive, maternal, newborn and child health. World Bank, Washington, DC2016: 241Crossref Google Scholar Whenever there is interpersonal contact with parents, programme designers should consider including messages about emotional warmth and stimulation through talk and play. In conclusion, we commend the strong design and integration of WASH and nutrition interventions in these two studies. Positive and negative findings are equally important in moving the field forward. Implementation and contextual differences are useful in identifying factors that enable and interfere with positive outcomes. Inclusion of theory-based and evidence-based behaviour change strategies11Briscoe C Aboud F Behaviour change communication targeting four health behaviours in developing countries: a review of change techniques.Soc Sci Med. 2012; 75: 612-621Crossref PubMed Scopus (96) Google Scholar and promotion of warm and stimulating care should be included in all such interventions. We declare no competing interests. Effects of water quality, sanitation, handwashing, and nutritional interventions on child development in rural Kenya (WASH Benefits Kenya): a cluster-randomised controlled trialThe handwashing and combined water, sanitation, handwashing, and nutrition interventions might have improved child motor development after 1 year, although after 2 years there were no other differences between groups. Future research should examine ways to make community health and nutrition programmes more effective at supporting child development. Full-Text PDF Open AccessEffect of water quality, sanitation, hand washing, and nutritional interventions on child development in rural Bangladesh (WASH Benefits Bangladesh): a cluster-randomised controlled trialImprovements in water quality, handwashing, sanitation, or nutrition supported by intensive interpersonal communication, when delivered either individually or in combination, contributed to improvements in child development. A crucial next step is to establish whether similar effects can be achieved with reduced intensity of promoter contacts that could be supported in large-scale interventions. Full-Text PDF Open Access