Cognitive development among children in a low-income setting: Cost-effectiveness analysis of a maternal nutrition education intervention in rural Uganda.

Inadequate nutrition and insufficient stimulation in early childhood can lead to long-term deficits in cognitive and social development. Evidence for policy and decision-making regarding the cost of delivering nutrition education is lacking in low and middle-income countries (LMIC). In rural Uganda, we conducted a cluster-randomized controlled trial (RCT) examining the effect of a maternal nutrition education intervention on developmental outcomes among children aged 6-8 months. This intervention led to significantly improved cognitive scores when the children reached the age of 20-24 months. When considering the potential for this intervention's future implementation, the desired effects should be weighed against the increased costs. This study therefore aimed to assess the cost-effectiveness of this education intervention compared with current practice. Health outcome data were based on the RCT. Cost data were initially identified by reviewing publications from the RCT, while more detailed information was obtained by interviewing researchers involved in processing the intervention. This study considered a healthcare provider perspective for an 18-months' time horizon. The control group was considered as the current practice for the future large-scale implementation of this intervention. A cost-effectiveness analysis was performed, including calculations of incremental cost-effectiveness ratios (ICERs). In addition, uncertainty in the results was characterized using one-way and probabilistic sensitivity analyses. The ICER for the education intervention compared with current practice was USD ($) 16.50 per cognitive composite score gained, with an incremental cost of $265.79 and an incremental cognitive composite score of 16.11. The sensitivity analyses indicated the robustness of these results. The ICER was sensitive to changes in cognitive composite score and the cost of personnel. The education intervention can be considered cost-effective compared with the current practice. The outcome of this study, including the cost analysis, health outcome, cost-effectiveness, and sensitivity analysis, can be useful to inform policymakers and stakeholders about effective resource allocation processes in Uganda and possibly other LMIC.

Long-Term Effects of a Randomized Maternal Education Trial in Rural Uganda: Implications for Child Oral Health.

The aim was to examine oral health among 5-6-year-old children whose mothers participated in a 6 months' cluster-randomized education trial in rural Uganda starting when their children were 6-8 months old. The education focused on nutrition, oral hygiene, and child stimulation. In the current follow-up study, 357/511 (70%) children from the original trial were available for data collection (200 in the intervention and 157 in the control group). Molar caries was assessed on intraoral photographs. Children and/or caregivers answered a WHO health questionnaire for collection of oral data. Dental practices were compared between the intervention and control group using multilevel mixed effect logistic regression accounting for clustering. The children in the intervention group had less caries compared with the control group: 41% versus 60% (odds ratio [OR] 0.46; 95% confidence intervals [CI] 0.24-0.86, P = 0.02). The use of toothbrush to clean teeth was more frequent in the intervention than in the control group: 66% versus 38% (OR 3.39; 95% CI 1.54-7.45, P = 0.003), as was high teeth-cleaning frequency: 74% versus 62% (OR 1.72; 95% CI 1.09-2.69, P = 0.02). Self-reported problems such as toothache (10% versus 19%), difficulty biting (12% versus 24%) and chewing food (8.5% versus 18%) were significantly less frequent among children in the intervention compared with the control group. No significant differences were found in dietary habits. Our data shows that an educational intervention adjusted to a low-resource setting, provided in infancy, resulted in improved oral hygiene and reduced development of dental caries among children aged 5-6 years.

Child saliva microbiota and caries: a randomized controlled maternal education trial in rural Uganda.

Undernutrition is a public health challenge in sub-Saharan countries, including Uganda. In a previous randomized controlled trial (RCT) with a nutrition, hygiene and stimulation education intervention among mothers of 6 months' old children, we found less caries in the intervention group when the children were 36 months of age. We now examined the effects of (i) the intervention on the microbiota, (ii) microbiota on caries, and (iii) the intervention and microbiota on caries. The original RCT comprised 511 mother/child pairs whereas in the current study we had access to data from 344/511 (67%) children aged 36 months. The saliva microbiota was determined using 16S rRNA gene sequencing. Carious lesions (a proxy for dental health) were identified using close-up intra-oral photographs of the upper front teeth. Statistical models were used to determine host-microbiota associations. The intervention had a significant effect on the microbiota, e.g. an increase in Streptococcus abundance and decreases in Alloprevotella and Tannerella. Significant associations between the microbiota and dental caries were identified: Positive associations of Capnocytophaga and Tannerella suggest that these taxa may be deleterious to dental health while negative associations of Granulicatella, Fusobacterium, and Abiotrophia suggest taxa potentially beneficial or benign contributors to dental health. Based on taxonomic profiles, the effects of the intervention and microbiota on dental health may be independent of one another. Educational interventions with emphasis on nutrition and oral hygiene may provide a feasible strategy to decrease progression of childhood caries in low-resource settings.

Model Selection Reveals the Butyrate-Producing Gut Bacterium Coprococcus eutactus as Predictor for Language Development in 3-Year-Old Rural Ugandan Children.

INTRODUCTION: The metabolic activity of the gut microbiota plays a pivotal role in the gut-brain axis through the effects of bacterial metabolites on brain function and development. In this study we investigated the association of gut microbiota composition with language development of 3-year-old rural Ugandan children. METHODS: We studied the language ability in 139 children of 36 months in our controlled maternal education intervention trial to stimulate children's growth and development. The dataset includes 1170 potential predictors, including anthropometric and cognitive parameters at 24 months, 542 composition parameters of the children's gut microbiota at 24 months and 621 of these parameters at 36 months. We applied a novel computationally efficient version of the all-subsets regression methodology and identified predictors of language ability of 36-months-old children scored according to the Bayley Scales of Infant and Toddler Development (BSID-III). RESULTS: The best three-term model, selected from more than 266 million models, includes the predictors Coprococcus eutactus at 24 months of age, Bifidobacterium at 36 months of age, and language development at 24 months. The top 20 four-term models, selected from more than 77 billion models, consistently include C. eutactus abundance at 24 months, while 14 of these models include the other two predictors as well. Mann-Whitney U tests suggest that the abundance of gut bacteria in language non-impaired children (n = 78) differs from that in language impaired children (n = 61). While anaerobic butyrate-producers, including C. eutactus, Faecalibacterium prausnitzii, Holdemanella biformis, Roseburia hominis are less abundant, facultative anaerobic bacteria, including Granulicatella elegans, Escherichia/Shigella and Campylobacter coli, are more abundant in language impaired children. The overall predominance of oxygen tolerant species in the gut microbiota was slightly higher in the language impaired group than in the non-impaired group (P = 0.09). CONCLUSION: Application of the all-subsets regression methodology to microbiota data established a correlation between the relative abundance of the anaerobic butyrate-producing gut bacterium C. eutactus and language development in Ugandan children. We propose that the gut redox potential and the overall bacterial butyrate-producing capacity in the gut are important factors for language development.

Nutrition, Hygiene and Stimulation Education for Impoverished Mothers in Rural Uganda: Effect on Maternal Depression Symptoms and Their Associations to Child Development Outcomes.

Optimal nutrition improves child development, and impaired development is associated with maternal depression symptoms, in particular in low resource settings. In this follow-up of an open cluster-randomized education trial, we examined its effects among mothers in rural Uganda on their depression symptoms and the association of these symptoms to child development. The education comprised complementary feeding, stimulation, and hygiene. We assessed 77 intervention mothers and 78 controls using Beck Depression Inventory-II (BDI-II) and Center for Epidemiologic Studies Depression Scale (CES-D) scores. Child development was assessed with Bayley Scales of Infant and Toddler Development-III (BSID-III) composite scores for cognitive, language and motor development. Compared to controls, the intervention reduced depression symptoms' scores with mean (95% CI) differences: -8.26 (-11.49 to -1.13, p = 0.0001) and -6.54; (-8.69 to -2.99, p = 0.004) for BDI II at 20-24 and 36 months, respectively. Similar results were obtained with CES-D. There was a negative association of BDI-II scores and BSID-III cognitive and language scores at 20-24 (p = 0.01 and 0.008, respectively) and 36 months (p = 0.017 and 0.001, respectively). CES-D associations with BSID-III cognitive and language scores showed similar trends. BSID-III motor scores were associated with depression scores at 36 months for both BDI-II and CES-D (p = 0.043 and 0.028, respectively). In conclusion, the group education was associated with reduced maternal depression scores. Moreover, the depression scores were inversely associated with child cognitive and language development outcomes.

Child development, growth and microbiota: follow-up of a randomized education trial in Uganda.

BACKGROUND: Undernutrition impairs child development outcomes and growth. In this follow-up study of an open cluster-randomized intervention trial we examined the effects of an education package delivered to mothers in rural Uganda on their children's development, growth and gut microbiota at 36 months of age. METHODS: The parental trial included 511 mother-child pairs recruited when the children were 6-8 months. In that trial, a nutrition, stimulation and hygiene education was delivered to mothers in the intervention group while the control group received routine health care. A follow-up sample of 155 pairs (intervention n = 77, control n = 78) were re-enrolled when the children were 24 months. Developmental outcomes were assessed with the Bayley Scales of Infant and Toddler Development (BSID-III) composite scores for cognitive (primary endpoint), language and motor development. Development outcomes were also evaluated using the Ages and Stages Questionnaire (ASQ) and the Mullen Scales of Early Learning (MSEL). Other outcomes included growth and gut microbiota composition. RESULTS: The demographic characteristics were not different (P > 0.05) between the intervention and control groups and similar to those of the parental study. The intervention group had higher BSID-III scores than controls, with mean difference 10.13 (95% confidence interval (CI): 3.31-17.05, P = 0.002); 7.59 (1.62-13.66, P = 0.01); 9.00 (2.92-15.40, P = 0.005), for cognitive, language and motor composite scores, respectively. An improvement in the intervention compared to the control group was obtained for both the ASQ and the MSEL scores. The mean difference in height-for-age z-score was higher in the intervention compared to the control group: 0.50 (0.25-0.75, P = 0.0001). Gut microbiota composition did not differ significantly between the two study groups. CONCLUSIONS: The maternal education intervention had positive effects on child development and growth at three years, but did not alter gut microbiota composition. This intervention may be applicable in other low-resource settings. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT02098031.

Effects of nutrition and hygiene education on oral health and growth among toddlers in rural Uganda: follow-up of a cluster-randomised controlled trial.

OBJECTIVE: To examine the effect of a nutrition and hygiene education intervention on oral health behaviour and whether early onset of caries was related to child growth in rural Uganda. METHODS: Follow-up study of a cluster-randomised controlled trial conducted between October 2013 and January 2015. Data were available from 399 mother/child pairs (203 in the intervention and 198 in the control group) of the original trial (78%) when the children were 36 months old. Oral health behaviour was evaluated using questionnaires. Photographs of the maxillary anterior teeth were examined for unmistakably carious lesions, and 115 water samples from the study area were analysed for fluoride concentration. RESULTS: The frequency of cleaning of the child's teeth at 36 months was about twice as high in the intervention as in the control group (84.3% vs. 46.6%; P = 0.0001). Cavitated carious lesions occurred more frequently in the control than the intervention group (27.8% vs. 18.2%; P = 0.04). Extraction of 'false teeth' (ebiino), a painful and crude traditional operation, was profoundly reduced in the intervention group (8.9% vs. 24.7%; P = 0.001). There was no evidence of association between the occurrence of caries and child growth. CONCLUSIONS: The education intervention improved oral hygiene practices and reduced the development and progression of caries and extraction of ebiino. Early childhood caries was not clearly associated with child growth.

Nutrition, hygiene, and stimulation education to improve growth, cognitive, language, and motor development among infants in Uganda: A cluster-randomized trial.

Stunting is associated with impaired cognitive and motor function. The effect of an education intervention including nutrition, stimulation, sanitation, and hygiene on child growth and cognitive/language/motor development, delivered to impoverished mothers in Uganda, was assessed. In a community-based, open cluster-randomized trial, 511 mother/children dyads aged 6-8 months were enrolled to an intervention (n = 263) or control (n = 248) group. The primary outcome was change in length-for-age z-score at age 20-24 months. Secondary outcomes included anthropometry and scores on the 2 developmental scales: Bayley Scales of Infant and Toddler Development-III and the Ages and Stages Questionnaire. There was no evidence of a difference in mean length-for-age z-score at 20-24 months between the 2 study groups: 0.10, 95% CI [-0.17, 0.36], p = .49. The intervention group had higher mean composite development scores than the controls on Bayley Scales of Infant and Toddler Development-III, the mean difference being 15.6, 95% CI [10.9, 20.2], p = .0001; 9.9, 95% CI [6.4, 13.2], p = .0001; and 14.6, 95% CI [10.9, 18.2], p = .0001, for cognitive, language, and motor composite scores, respectively. The mean difference in scores from the Ages and Stages Questionnaire were 7.0, 95% CI [2.9, 11.3], p = .001; 5.9, 95% CI [1.2, 10.3], p = .01; 4.2, 95% CI [1.7, 6.7], p = .001; 8.9, 95% CI [5.3, 12.3], p = .0001; and 4.4, 95% CI [0.0, 8.8], p = .05, for communication, gross motor, fine motor, problem solving, and personal-social development, respectively. The intervention education delivered to mothers promoted early development domains in cognitive, language, and motor development but not linear growth of small children in impoverished rural communities in Uganda. Our study showed that child development may be improved with a relatively low cost intervention strategy. This trial was registered at ClinicalTrials.gov as NCT02098031.

Nutritional and developmental status among 6- to 8-month-old children in southwestern Uganda: a cross-sectional study.

BACKGROUND: Undernutrition continues to pose challenges to Uganda's children, but there is limited knowledge on its association with physical and intellectual development. OBJECTIVE: In this cross-sectional study, we assessed the nutritional status and milestone development of 6- to 8-month-old children and associated factors in two districts of southwestern Uganda. DESIGN: Five hundred and twelve households with mother-infant (6-8 months) pairs were randomly sampled. Data about background variables (e.g. household characteristics, poverty likelihood, and child dietary diversity scores (CDDS)) were collected using questionnaires. Bayley Scales of Infant and Toddler Development (BSID III) and Ages and Stages questionnaires (ASQ) were used to collect data on child development. Anthropometric measures were used to determine z-scores for weight-for-age (WAZ), length-for-age (LAZ), weight-for-length (WLZ), head circumference (HCZ), and mid-upper arm circumference. Chi-square tests, correlation coefficients, and linear regression analyses were used to relate background variables, nutritional status indicators, and infant development. RESULTS: The prevalence of underweight, stunting, and wasting was 12.1, 24.6, and 4.7%, respectively. Household head education, gender, sanitation, household size, maternal age and education, birth order, poverty likelihood, and CDDS were associated (p<0.05) with WAZ, LAZ, and WLZ. Regression analysis showed that gender, sanitation, CDDS, and likelihood to be below the poverty line were predictors (p<0.05) of undernutrition. BSID III indicated development delay of 1.3% in cognitive and language, and 1.6% in motor development. The ASQ indicated delayed development of 24, 9.1, 25.2, 12.2, and 15.1% in communication, fine motor, gross motor, problem solving, and personal social ability, respectively. All nutritional status indicators except HCZ were positively and significantly associated with development domains. WAZ was the main predictor for all development domains. CONCLUSION: Undernutrition among infants living in impoverished rural Uganda was associated with household sanitation, poverty, and low dietary diversity. Development domains were positively and significantly associated with nutritional status. Nutritional interventions might add value to improvement of child growth and development.