Person:

Ali, Nazia Binte

Background: High-quality early childhood care and education (ECCE) programs can positively impact children's development. However, as an unintended consequence, ECCE attendance may also affect children's nutritional status.

Objective: We evaluated the effect of a center-based ECCE intervention on child nutritional outcomes in rural Pakistan.

Methods: This study utilized data from a stepped-wedge cluster randomized controlled trial of a center-based ECCE program that trained female youth to run high-quality preschools for children aged 3.5-5.5 years (LEAPS program) in rural Sindh, Pakistan. The program did not include any school meals. A total of 99 village clusters were randomized to receive the LEAPS intervention in three steps, and repeated cross-sectional surveys were conducted to assess the impact on children (4.5-5.5 years old) at four time points. Intention-to-treat analyses with multi-level mixed-effect models were used to estimate the effect of the intervention on child anthropometric outcomes.

Results: The analysis included 3,858 children with anthropometric data from four cross-sectional survey rounds. The LEAPS intervention was found to have a positive effect on child HAZ (mean difference: 0.13 z-scores; 95% confidence interval (CI): 0.02, 0.24). However, there was a negative effect on weight-based anthropometric indicators, -0.29 WHZ (95% CI: -0.42, -0.15), -0.13 BMIZ (95% CI: -0.23, -0.03), and -0.16 MUACZ (95% CI: -0.25, -0.05). An exploratory analysis suggested that the magnitude of the negative effect of LEAPS on WHZ, BMIZ, and WAZ was greater in the survey round during the COVID-19 lockdown.

Discussion: The LEAPS intervention positively affected child linear growth but had negative effects on multiple weight-based anthropometric measures. ECCE programs in low- and middle-income country settings should evaluate the integration of nutrition-specific interventions (e.g., school lunch, counseling on healthy diets) and infection control strategies to promote children's healthy growth and development.

Context: The association between linear growth faltering and child development outcomes is generally well-recognized; however, the relationship between metrics of acute undernutrition and development has received less attention. Objectives: We aimed to quantify the association between acute undernutrition in childhood with development outcomes in low- and middle-income countries (LMIC). Methods: We conducted a systematic literature review of observational studies that assessed the association between metrics of acute undernutrition, including body mass index-for-age z-score (BMIZ), mid-upper arm circumference (MUAC), weight-for-height/length z-score (WHZ/WLZ), wasting (WHZ/ WLZ <-2), and severe acute malnutrition (SAM) among children under 5 years of age with cognitive, motor, language, and socio-emotional development assessed to 19 years of age. We estimated the pooled correlation and standardized mean difference (SMD) for cross-sectional and longitudinal studies. Results: A total of 113 studies from 40 LMICs were identified. Metrics of acute undernutrition were associated with lower cognitive and motor development outcomes. In longitudinal studies that reported multivariable-adjusted estimates for the cognitive domain, SAM was associated with -1.06 SD lower scores (95% CI: -1.41, -0.72) as compared to non-SAM children. SAM was also associated with lower motor scores in longitudinal studies with unadjusted estimates (SMD: -0.42; 95% CI: -0.68, -0.15). In longitudinal studies with multivariable estimates, wasting was associated with lower motor scores (SMD: -0.30; 95% CI: -0.54, -0.06), but there was no association with language (SMD: -0.08; 95% CI: -0.24, 0.07) and prosocial development scores (SMD: -0.18; 95% CI: -0.38, 0.02). Conclusion: Metrics of acute undernutrition in childhood were consistently associated with lower development scores, and the magnitude appeared stronger for children with SAM or wasting.

Introduction: Iron-folic acid (IFA) and calcium supplementation are recommended during pregnancy; however, calcium may inhibit iron absorption. While recent trials have shown daily low-dose 500 mg calcium supplementation to be noninferior to the recommended high-dose 1500 mg regimen for prevention of preeclampsia, its effects on maternal anaemia and iron status remain unclear. Methods: We conducted two individually randomized, non-inferiority trials in India and Tanzania (N=11,000 each) comparing daily 500 mg to 1500 mg calcium supplementation during pregnancy. All participants received standard IFA (60 mg iron) and were counselled to take calcium supplements several hours apart from the IFA. All participants had haemoglobin measured at baseline and at 32 weeks of gestation, while a random subset of participants had ferritin quantified at the same time points. Using an intention-to-treat approach, we assessed effects of 500 mg compared to 1500 mg calcium supplementation on mean haemoglobin and inflammation-adjusted serum ferritin concentrations using generalised linear models, and on anaemia, and iron deficiency anaemia using log-binomial models. Results: Third-trimester haemoglobin and serum ferritin were measured in 8,953 and 1,336 participants in India, respectively. In Tanzania, 8,496 participants had haemoglobin and 882 had ferritin assessed. In both trials, there was no difference between 500 and 1500 mg calcium supplementation on third-trimester haemoglobin [India: mean difference (MD) 0.01 (95% confidence intervals (CIs): -0.03, 0.04); Tanzania: MD -0.02 (95% CIs: -0.07, 0.03)], anaemia [India: relative risk (RR) 1.01 (95% CIs: 0.95, 1.07); Tanzania: RR 1.00 (95% CIs: 0.96, 1.05)], or iron deficiency anaemia [India: RR 1.20 (95% CIs: 0.93, 1.57); Tanzania: RR 0.94 (95% CIs: 0.77, 1.15)]. Conclusion: Low and high-dose calcium supplementation showed no differences in third-trimester hematologic outcomes. Future studies should assess co-administering or combining calcium and IFA into a single tablet on adherence and maternal iron status.