Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial.

BACKGROUND: Stimulation and nutrition delivered through health programmes at a large scale could potentially benefit more than 200 million young children worldwide who are not meeting their developmental potential. We investigated the feasibility and effectiveness of the integration of interventions to enhance child development and growth outcomes in the Lady Health Worker (LHW) programme in Sindh, Pakistan. METHODS: We implemented a community-based cluster-randomised effectiveness trial through the LHW programme in rural Sindh, Pakistan, with a 2 × 2 factorial design. We randomly allocated 80 clusters (LHW catchments) of children to receive routine health and nutrition services (controls; n=368), nutrition education and multiple micronutrient powders (enhanced nutrition; n=364), responsive stimulation (responsive stimulation; n=383), or a combination of both enriched interventions (n=374). The allocation ratio was 1:20 (ie, 20 clusters per intervention group). The data collection team were masked to the allocated intervention. All children born in the study area between April, 2009, and March, 2010, were eligible for enrolment if they were up to 2·5 months old without signs of severe impairments. Interventions were delivered by LHWs to families with children up to 24 months of age in routine monthly group sessions and home visits. The primary endpoints were child development at 12 and 24 months of age (assessed with the Bayley Scales of Infant and Toddler Development, Third Edition) and growth at 24 months of age. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT007159636. FINDINGS: 1489 mother-infant dyads were enrolled into the study, of whom 1411 (93%) were followed up until the children were 24 months old. Children who received responsive stimulation had significantly higher development scores on the cognitive, language, and motor scales at 12 and 24 months of age, and on the social-emotional scale at 12 months of age, than did those who did not receive the intervention. Children who received enhanced nutrition had significantly higher development scores on the cognitive, language, and social-emotional scales at 12 months of age than those who did not receive this intervention, but at 24 months of age only the language scores remained significantly higher. We did not record any additive benefits when responsive stimulation was combined with nutrition interventions. Responsive stimulation effect sizes (Cohen's d) were 0·6 for cognition, 0·7 for language, and 0·5 for motor development at 24 months of age; these effect sizes were slightly smaller for the combined intervention group and were low to moderate for the enhanced nutrition intervention alone. Children exposed to enhanced nutrition had significantly better height-for-age Z scores at 6 months (p<0·0001) and 18 months (p=0·02) than did children not exposed to enhanced nutrition. Longitudinal analysis showed a small benefit to linear growth from enrolment to 24 months (p=0·026) in the children who received the enhanced nutrition intervention. INTERPRETATION: The responsive stimulation intervention can be delivered effectively by LHWs and positively affects development outcomes. The absence of a major effect of the enhanced nutrition intervention on growth shows the need for further analysis of mediating variables (eg, household food security status) that will help to optimise future nutrition implementation design. FUNDING: UNICEF.

Capacity building in the health sector to improve care for child nutrition and development.

The effectiveness of interventions promoting healthy child growth and development depends upon the capacity of the health system to deliver a high-quality intervention. However, few health workers are trained in providing integrated early child-development services. Building capacity entails not only training the frontline worker, but also mobilizing knowledge and support to promote early child development across the health system. In this paper, we present the paradigm shift required to build effective partnerships between health workers and families in order to support children's health, growth, and development, the practical skills frontline health workers require to promote optimal caregiving, and the need for knowledge mobilization across multiple institutional levels to support frontline health workers. We present case studies illustrating challenges and success stories around capacity development. There is a need to galvanize increased commitment and resources to building capacity in health systems to deliver early child-development services.

Annual Research Review: Improved nutrition--pathway to resilience.

BACKGROUND: Early child nutritional deficiencies are prevalent in low- and middle-countries with consequences linked not only to poor survival and growth, but also to poor development outcomes. Children in disadvantaged communities face multiple risks for nutritional deficiencies, yet some children may be less susceptible or may recover more quickly from malnutrition. A greater understanding is needed about factors which moderate the effects of nutrition-related risks and foster resilience to protect against or ameliorate poor development outcomes. METHODS: A literature review was undertaken from August to December 2011 and updated in August 2012. Key word searches using terms Nutrition, Malnutrition, Child Development, Responsive Care, Stimulation, Low and Middle Income Countries and Resilience were undertaken using PubMed and Psychinfo. RESULTS: Dietary adequacy is critical for growth and development, but current evidence indicates that nutrition supplementation alone is insufficient to foster resilience to protect against, mitigate, and recover from nutritional threats and to promote healthy development. The combination of nutrition interventions with stimulation and responsive care is necessary. Combined nutrition and psychosocial stimulation approaches can potentially work effectively together to promote protective factors and mitigate risks for poor cognitive, motor, social, and affective functioning helping children to adapt in times of adversity. However, there are gaps in our existing knowledge to combine nutrition and psychosocial stimulation interventions effectively and promote these interventions at scale. CONCLUSIONS: Research needs to address barriers at the level of family, community, programme, and policy which have prevented thus far the uptake of combined nutrition and psychosocial intervention strategies. Further investigations are needed on how to provide support to caregivers, enabling them to implement appropriate care for feeding and stimulation. Finally, the effect of combined interventions on pathways of care and protective mediators that foster resilience need to be better understood to determine focus areas for content of combined intervention curricula which help families in high-risk settings.