Feeding interventions for infants and young children: What works and why

1. Feeding interventions for infants and young children: What works and why Elizabeth Kristjanssonfor the Review team

2. Overview • Background and objectives • Methods • Findings on child outcomes • Who benefited most from feeding? • Process analysis: what factors were important? • Conclusions

3. The issue • Under-nutrition is the single biggest cause of the global burden of disease • Every hour, 300 children under 5 die because of undernutrition • Almost half a billion children are at risk of permanent damage over the next 15 years. • Affects growth, current and future health • Undernutrition lowers cognitive performance and learning in school • Yet, it is too often ignored in the development literature

4. One response: Feeding programs • For infants and young children • Given in day-care, preschool, feeding centres or delivered to home

5. Objectives • Primary objective: • To assess effectiveness of interventions that provide energy, nutrientsand micronutrients through food or drink to improve the physical and psychosocial health of disadvantaged children aged three months to five years. • Secondary objectives • To assess the potential for reducing socioeconomic inequalities in under-nutrition and its consequences. • To evaluate the process of implementation and to understand how this may impact on outcomes.

6. Feeding programmes to improve physical and psychosocial health of children aged 6 months to 5 years Context: Political systems, Economic development, Food insecurity. Setting: Preschool, Daycare, Community. Feeding programmes Programme (intervention & implementation issues/process issues) Unfortified and fortified meals Fortified foods (optional) Nutrition education (optional) Child factors (Baseline nutritional status, child preferences, individual food security etc.) Implementation and process (nutritional adequacy, acceptability, supervision, place to eat, time to eat, distance to feeding centre, etc. ) Underlying/immediate causes Substitution (harm) Child dietary intake (harm or benefit) Intermediate outcomes Household(HH) factors (family SES, HH size, Intra-HH food distribution etc.) Child physical health (e.g. anthropometric measures, plasma nutrient levels, reduced infections, etc.) Child psychosocial health Outcomes Child development (e.g. growth, cognitive outcomes)

7. Methods • Types of studies   • Randomised controlled trials, • Cluster randomised control trials, • Clinical control trials • Control before and after studies (Cohort) • Interrupted time series (None found)

8. Our Search • Strategy developed by librarian scientist in collaboration with CLPG librarian • Searched up to February 2013. • Also searched • Reference lists of all included studies, reviews • Websites of relevant NGOs

9. Methods/Analysis • Two people independently reviewed search, decided on inclusion/exclusion, extracted data, rated ROB • Examined change in outcome over study period, corrected for clustering • Process/implementation evaluation, including level of supervision, energy given, net increase in energy intake • Sub-group analysis by these factors • Realist review

10. Results • 29517 articles  290 potentially useful  45 studies potentially relevant  30 studies met inclusion criteria; 15 were excluded. 24 in meta-analyses. • Characteristics of Included Studies • 27 from LMIC, 3 from HIC (1 Aboriginal children) • 19 RCTs , 9 CBAs • Cluster • 16 allocated by cluster. Only a few corrected for clustering; we did the rest

11. Characteristics of included studies • Participants • Children ‘s ages ranged from 3 to 60 months • Both genders; • Low SES: from urban slums, poor rural areas, little running water, parents low education • Study size ranged from 30 to 3166

12. The interventions • Lower income countries (N = 27) • 9 in Day-cares or feeding centres • 18 Take-home or Home Delivered Rations • Provision of energy, with nutrients/micronutrients • Some gave local food (veg, legumes), others gave milk or cereal with milk, others RUTF • Energy content ranged from 8% to 105% of RDA

13. Effectiveness: Growth • Weight • RCTs: (8 studies) n.s. • CBAs (7 studies)0.25 kg more per year for exp. (95% C.I. 0.11 to 0.39). • Height • RCTs: (8) 0.25 kg more than those who were not supplemented (95% C.I. 0.11 to 0.39) • CBAs (7) n.s.

14. Effectiveness: Growth • WAZ • RCTS (6): MD = 0.17 95% C.I. = 0.02 to 0.31) • CBA (4): n. s. • HAZ • RCTs (7): (MD = 0.18, 95% C.I. = (0.08 to 0.28). • CBAS (4) n.s. • WHZ • RCT (5) and CBA (3): n.s.

15. Effectiveness: psychosocial outcomes • Psychomotor Dev. • 4 of 5 studies in LMIC sig. more high energy activity, walked earlier, higher scores on DQ. • E.g. (SMD = 0.62, 95% C.I. = 0.23 to 1.02) • Mental Development. • 2 out of 3 studies in LMIC showed effectiveness for mental and cognitive development. Moderate ES • MacKay (supp+ stim).SMD = 1.69, 95% C.I. 1.29 to 2.10)

16. Long Term Development • Long-term Development • Some evidence for improved intelligence, one study only if mothers had higher PPVT scores

17. Who does preschool feeding work best for? • Children who are lower income/ have poorer nutritional status. • Generally, grew more relative to controls than those with better nutritional status • Three-way interaction: age, nutritional status and feeding • But in one study, children in lower SES neighbourhoods did worse; poor environmental conditions

18. Who does preschool feeding work best for? • Children who are younger • Feeding more effective for younger children for growth, cognition. BUT still effective for older children, especially for cognition • Possibly, for girls • Gender equity important consideration in LMIC; in some countries, male household heads and boys fed preferentially • Evidence on sex differences in effectiveness sparse

19. Why lower than expected effectiveness?

20. Impacts on Effectiveness • Leakage/ Substitution in Family • Dietary recall data. Children only benefit from part of supplement • Home delivered. Children only take in 1/3 of energy of supplement (e.g. 200 of 600 calories) • If 600 calories given, and usual diet is 1000, only goes up to 1200 • Parents often redistribute supplement within family • Day-care: 2/3 of energy given (e.g. 400 of 600 calories) • Child may get less at home if parents know that he/she got fed in day-care • Child may be unable to consume all of supplement • Esp. if supplement is high-volume • Breakdown in supply chain (e.g Brazil)

21. Impacts on Effectiveness • Energy given in supplement • Subgroup analysis showed mixed findings, but tended towards greater growth with more energy • Level of supervision: Strict (day-care or feeding centre or daily visits to home), moderate, little or none • Subgroup analysis. Generally, more effectiveness with strict or moderate monitoring • Multiple intervention • Many children live and go to school in persistently unfavourable environments

22. Impacts on Effectiveness • Multiple interventions • In RCTS, subgroup analysis showed more effectiveness for growth with multiple interventions (supp. + stim, supp +cond. Cash) • More effectiveness for cognition if supp. + stim. • Many children live and go to school in persistently unfavourable environments

23. Suggestions for practice • Before implementing programs, work with communities, parents to develop programs and decide on supplements • Ensure that communities are well-organized

24. Suggestions for practice • Target most undernourished children • Areas with a high proportion of malnutrition • Give high (at least 40 – 60%) of percent RDA for energy • Foods should be palatable and energy dense, fortified • Close supervision; ideally in feeding centre or day-care

25. Suggestions for practice • Provide extra rations for family to reduce sharing • Build family capacity. Work with caregivers/ teachers to teach and encourage feeding and stimulation of child • Consider sustainability. Create economic opportunities through feeding. • Monitor, evaluate, adapt on a continuous basis

26. Research needs • More studies on child psychosocial development in response to feeding • Key outcome • Study effectiveness for older children • How to reduce attrition

27. A final note • 'Nutrition is a desperately neglected aspect of maternal, newborn, and child health' (p 179, Horton 2008).

28. Funding and support • 3ie • Global Development Network Thank you!

29. Review team Elizabeth Kristjansson Damian Francis Selma Liberato Maria Benkhalti-Jandu Vivian Welch Beverley Shea MalekBatal Trish Greenhalgh Laura Janzen Mark Petticrew Eamonn Noonan Tamara Radar George Wells

30. Funding and support • 3ie • Global Development Network Thank you!