Early childhood stunting is associated with poor psychological functioning in late adolescence and effects are reduced by psychosocial stimulation.

Stunting is associated with deficits in cognition and school achievement from early childhood to late adolescence; however, there has been little investigation of emotional and behavioral outcomes. The objective of this study was to determine whether linear growth retardation (stunting) in early childhood is associated with poorer psychological functioning in late adolescence. The study was a prospective cohort study of stunted and nonstunted children. Participants were identified at age 9-24 mo by a survey of poor neighborhoods in Kingston, Jamaica, and a 2-y intervention trial of supplementation and stimulation was conducted in the stunted children. Psychological functioning was assessed at age 17 y in 103 of 129 stunted children enrolled and 64 of 84 nonstunted participants. Anxiety, depressive symptoms, self-esteem, and antisocial behavior were reported by participants using interviewer-administered questionnaires and attention deficit, hyperactivity, and oppositional behavior were reported by parent interviews. The stunted participants reported significantly more anxiety (regression coefficient = 3.03; 95% CI = 0.99, 5.08) and depressive symptoms (0.37; 95% CI = 0.01, 0.72) and lower self-esteem (-1.67; 95% CI = -0.38, -2.97) than nonstunted participants and were reported by their parents to be more hyperactive (1.29; 95% CI = 0.12, 2.46). Effect sizes were 0.4-0.5 SD. Participants who received stimulation in early childhood differed from the nonstunted group in hyperactivity only. Children stunted before age 2 y thus have poorer emotional and behavioral outcomes in late adolescence. The findings expand the range of disadvantages associated with early stunting, which affects 151 million children <5 y old in developing countries.

Effects of psychosocial stimulation and dietary supplementation in early childhood on psychosocial functioning in late adolescence: follow-up of randomised controlled trial.

OBJECTIVE: To determine whether dietary supplementation or psychosocial stimulation given to growth retarded (stunted) children age 9-24 months has long term benefits for their psychosocial functioning in late adolescence. DESIGN: Sixteen year follow-up study of a randomised controlled trial. SETTING: Poor neighbourhoods in Kingston, Jamaica. PARTICIPANTS: Of 129 stunted children identified at age 9-24 months, 103 adolescents aged 17-18 were followed up. INTERVENTION: Supplementation with 1 kg milk based formula each week or psychosocial stimulation (weekly play sessions with mother and child), or both, for two years. MAIN OUTCOME MEASURES: Anxiety, depression, self esteem, and antisocial behaviour assessed by questionnaires administered by interviewers; attention deficit, hyperactivity, and oppositional behaviour assessed by interviews with parents. RESULTS: Primary analysis indicated that participants who received stimulation had significantly different overall scores from those who did not (F = 2.047, P = 0.049). Supplementation had no significant effect (F = 1.505, P = 0.17). Participants who received stimulation reported less anxiety (mean difference - 2.81, 95% confidence interval - 5.02 to - 0.61), less depression (- 0.43, - 0.78 to - 0.07), and higher self esteem (1.55, 0.08 to 3.02) and parents reported fewer attention problems (- 3.34, - 6.48 to - 0.19). These differences are equivalent to effect sizes of 0.40-0.49 standard deviations. CONCLUSIONS: Stimulation in early childhood has sustained benefits to stunted children's emotional outcomes and attention.

Zinc supplementation and psychosocial stimulation: effects on the development of undernourished Jamaican children.

BACKGROUND: Undernourished children have poor levels of development that benefit from stimulation. Zinc deficiency is prevalent in undernourished children and may contribute to their poor development. OBJECTIVE: We assessed the effects of zinc supplementation and psychosocial stimulation given together or separately on the psychomotor development of undernourished children. DESIGN: This was a randomized controlled trial with 4 groups: stimulation alone, zinc supplementation alone, both interventions, and control (routine care only). Subjects were 114 children aged 9-30 mo and below -1.5 z scores of the National Center for Health Statistics weight-for-age references who were recruited from 18 health clinics. Clinics were randomly assigned to receive stimulation or not; individual children were randomly assigned to receive zinc or placebo. The stimulation program comprised weekly home visits during which play was demonstrated and maternal-child interactions were encouraged. The supplementation was 10 mg Zn as sulfate daily or placebo. Development (assessed by use of the Griffiths Mental Development Scales), length, and weight were measured at baseline and 6 mo later. Weekly morbidity histories were taken. RESULTS: Significant interactions were found between zinc supplementation and stimulation. Zinc benefited the developmental quotient only in children who received stimulation, and benefits from zinc to hand and eye coordination were greater in stimulated children. Zinc supplementation alone improved hand and eye coordination, and stimulation alone benefited the developmental quotient, hearing and speech, and performance. Zinc supplementation also reduced diarrheal morbidity but did not significantly improve growth. CONCLUSION: Zinc supplementation benefits development in undernourished children, and the benefits are enhanced if stimulation is also provided.

Early childhood supplementation and cognitive development, during and after intervention

Studies of the effects of supplementation during childhood have been reviewed previously and a meta-analysis of the concurrent effects on development was recently conducted. This review looks at five studies in Latin America and the Caribbean, in which the effects of supplementation have been assesses during the intervention period, as well as one or more years after the interventions ended. These studies are particularly relevant when considering the long-term effects of early childhood undernutrition and the policy implications for human resource development. The studies that will be reviewed were conducted in Mexico; Guatemala; Cali, Colombia; Bogota, Colombia; and Jamaica

Nutritional supplementation, psychosocial stimulation, and growth of stunted children: the Jamaican study

The benefits of nutritional supplementation, with or without psychosocial stimulation, on the growth of stunted children were evaluated. Children aged 9-24 mo with lengths < -2 SD of the National Center of Health Statistics references (n = 129) were randomly assigned to four groups: control, nutritional supplementation, stimulation, and both interventions. A fifth group with lengths > -1 SD was also enrolled. Length, weight, head and arm circumferences, and triceps and subscapular skinfold thicknesses were measured on enrollment and 6 and 12 mo later. Multiple-regression analysis was used to determine the effects of the interventions in which age, sex, initial status, initial dietary intake, and several socioeconomic variables were controlled for. Stimulation had no effect on growth and there was no interaction between the interventions. After 12 mo supplemented children had significantly increased length, weight, and head circumference (all P < 0.01). The effects of supplementation were not cumulative but occurred in the first 6 mo.(AU)

Development of severly malnourished children who receive psychosocial stimulation: six-year follow-up

The development of 16 children who were hospitalized for severe malnutrition and participated in a home-visiting program of psychosocial stimulation was compared with that of two other groups who were also hospitalized but received standard medical care only: severely malnourished group (n = 18) and an adequately nourished one (n = 20). All groups were assessed regularly on the Griffiths Mental Development Scales and the Stanford-Binet test. Both groups of malnourished children were markedly behind the adequately nourished group on admission to the hospital and the group that received no intervention showed little sign of catching up. The intervention group caught up to the adequately nourished group in 2 years. This report covers the third year of home-visiting and the 3 years following its cessation. The intervention group showed a decline in three of the five Griffiths subscales. However, they retained a marked advantage over the nonintervention group of malnourished children on the Stanford-Binet test until the end of follow-up, showing no further decline in the last year. For height, both malnourished groups failed to catch up to the adequately nourished group. It was concluded that a relatively simple intervention can benefit the development of severely malnourished children. (AU)

A longitudinal study of the mental development of severly malnourished Jamaican children - abstract

A longitudinal study of the mental development of seventeen children admitted to hospital with severe protein energy malnutrition (PEM) was commenced in 1975. They were compared with fourteen adequately nourished children hospitalized for other reasons. Throughout the three years after leaving hospital all children had regular developmental assessments on the Griffiths Mental Development Scales, and anthropomentric measurements. When they left hospital the developmental level (DQ) of the malnourished group was markedly behind that of the comparisons. During the following three years the deficit was reduced, but the malnourished group remained significantly behind. (Malnourished mean = 86.1, SD = 11.8: comparison mean = 99.7, SD = 8.2, p<01). The malnourished group was significantly behind the comparisons in each subscale of the Griffiths test. Since leaving hospital the malnourished children had reduced their deficit in "performance" and "hand and eye' subscales but not in "locomotor" or "hearing and speech" subscales. All children were given the School Achievement Test (SAT) and Peabody Picture Vocabulary Test (PPVT) between one and six months after their 36-month test. These tests have been modified for Jamaica and are used to assess children's progress in Basic School. In both tests the malnourished children were behind the well nourished. (PPVT mean: comparison = 27.5, SD = 10.9, malnourished = 19.7, SD = 9.4; p<0.5 SAT mean: comparison = 34.3, SD = 19.0, malnourished = 26.8, SD = 10.6, p<.05). The malnourished children caught up to the comparison in percentage expected weight for age, but remained significantly more stunted, with smaller head circumferences and lighter. It was concluded that Jamaican children who suffer from severe PEM in early childhood have a persistent lag in mental development and retarded physical growth for several years. It is apparent that more comprehensive care is required to ensure full rehabilitation (AU)

Early childhood supplementation and cognitive development, during and after intervention

Studies of the effects of supplementation during childhood have been reviewed previously and a meta-analysis of the concurrent effects on development was recently conducted. This review looks at five studies in Latin America and the Caribbean, in which the effects of supplementation have been assesses during the intervention period, as well as one or more years after the interventions ended. These studies are particularly relevant when considering the long-term effects of early childhood undernutrition and the policy implications for human resource development. The studies that will be reviewed were conducted in Mexico; Guatemala; Cali, Colombia; Bogota, Colombia; and Jamaica (AU)