Developmental outcomes of an individualised complementary feeding intervention for stunted children: a substudy from a larger randomised controlled trial in Guatemala

Assessment of aflatoxin exposure, growth faltering and the gut microbiome among children in rural Guatemala: protocol for an observational prospective cohort and bioreactor simulations

INTRODUCTION

Aflatoxin B1 (AFB1) is a carcinogen produced by Aspergillus flavus and Aspergillus parasiticus which grow on maize. Given the high prevalence of child stunting (ie, impaired growth) and other nutritional disorders in low-income and middle-income countries, where maize is consumed, the role of aflatoxin exposure may be significant. Observational reports have demonstrated associations between aflatoxin exposure and impaired child growth; however, most have been cross-sectional and have not assessed seasonal variations in aflatoxin, food preparation and dynamic changes in growth. Biological mechanistic data on how aflatoxin may exert an impact on child growth is missing. This study incorporates a prospective cohort of children from rural Guatemala to assess (1) temporal associations between aflatoxin exposure and child growth and (2) possible mediation of the gut microbiome among aflatoxin exposure, inflammation and child growth.

METHODS AND ANALYSIS

We will prospectively evaluate aflatoxin exposure and height-for-age difference trajectories for 18 months in a cohort of 185 children aged 6-9 months at enrolment. We will assess aflatoxin exposure levels and biomarkers of gut and systemic inflammation. We will examine the faecal microbiome of each child and identify key species and metabolic pathways for differing AFB1 exposure levels and child growth trajectories. In parallel, we will use bioreactors, inoculated with faeces, to investigate the response of the gut microbiome to varying levels of AFB1 exposure. We will monitor key microbial metabolites and AFB1 biotransformation products to study nutrient metabolism and the impact of the gut microbiome on aflatoxin detoxification/metabolism. Finally, we will use path analysis to summarise the effect of aflatoxin exposure and the gut microbiome on child growth.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Arizona State University Institutional Review Board (IRB; STUDY00016799) and Wuqu' Kawoq/Maya Health Alliance IRB (WK-2022-003). Findings will be disseminated in scientific presentations and peer-reviewed publications.

Hybrid type 1 effectiveness/implementation trial of the international Guide for Monitoring Child Development: protocol for a cluster-randomised controlled trial

INTRODUCTION

More than 40% of children under 5 years of age in low-income and middle-income countries are at risk of not reaching their developmental potential. The international Guide for Monitoring Child Development (GMCD) early intervention package is a comprehensive programme to address developmental difficulties using an individualised intervention plan for young children and their families. We will conduct a hybrid type 1 effectiveness-implementation evaluation of the GMCD intervention in rural India and Guatemala.

METHODS AND ANALYSIS

Using a cluster-randomised design, 624 children aged 0-24 months in 52 clusters (26 in India, 26 in Guatemala) will be assigned to usual care or the GMCD intervention plus usual care delivered by frontline workers for 12 months. After 12 months, the usual care arm will cross over to the intervention, which will continue for 12 additional months (24 total). The intervention will be delivered using a digital mobile device interface. Effectiveness will be assessed for developmental functioning (Bayley Scales of Infant Development, 3rd edition) and nurturing care (Home Observation for Measurement of the Environment Scale) outcomes. Implementation will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. Explanatory qualitative analysis guided by the Consolidated Framework for Implementation Research will explore determinants between clusters with high versus low implementation effectiveness.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Boards of Brigham and Women's Hospital, Mahatma Gandhi Institute of Medical Sciences and Maya Health Alliance; and by the Indian Council of Medical Research/Health Ministry Screening Committee. Key study findings will be published in international open-access journals.

TRIAL REGISTRATION NUMBER

NCT04665297, CTRI/2020/12/029748.

PROTOCOL VERSION

1.0 (12 November 2020).

Education of family members to support weaning to solids and nutrition in later infancy in term-born infants

BACKGROUND

Education of family members about infant weaning practices could affect nutrition, growth, and development of children in different settings across the world.

OBJECTIVES

To compare effects of family nutrition educational interventions for infant weaning with conventional management on growth and neurodevelopment in childhood.

SEARCH METHODS

We used the standard strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5), MEDLINE via PubMed (1966 to 26 June 2018), Embase (1980 to 26 June 2018), and the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1982 to 26 June 2018). We searched clinical trials databases, conference proceedings, and references of retrieved articles. We ran an updated search from 1 January 2018 to 12 December 2019 in the following databases: CENTRAL via CRS Web, MEDLINE via Ovid, and CINAHL via EBSCOhost.

SELECTION CRITERIA

We included randomised controlled trials that examined effects of nutrition education for weaning practices delivered to families of infants born at term compared to conventional management (standard care in the population) up to one year of age.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified eligible trial reports from the literature search and performed data extraction and quality assessments for each included trial. We synthesised effect estimates using risk ratios (RRs), risk differences (RDs), and mean differences (MDs), with 95% confidence intervals (CIs). We used the GRADE approach to assess the certainty of evidence.

MAIN RESULTS

We included 21 trials, recruiting 14,241 infants. Five of the trials were conducted in high-income countries and the remaining 16 were conducted in middle- and low-income countries. Meta-analysis showed that nutrition education targeted at improving weaning-related feeding practices probably increases both weight-for-age z scores (WAZ) (MD 0.15 standard deviations, 95% CI 0.07 to 0.22; 6 studies; 2551 infants; I² = 32%; moderate-certainty evidence) and height-for-age z scores (0.12 standard deviations, 95% CI 0.05 to 0.19; 7 studies; 3620 infants; I² = 49%; moderate-certainty evidence) by 12 months of age. Meta-analysis of outcomes at 18 months of age was heterogeneous and inconsistent in the magnitude of effects of nutrition education on WAZ and weight-for-height z score across studies. One trial that assessed effects of nutrition education on growth at six years reported an uncertain effect on change in height and body mass index z score. Two studies investigated effects of nutrition education on neurodevelopment at 12 to 24 months of age with conflicting results. No trials assessed effects of nutrition education on long-term neurodevelopmental outcomes.

AUTHORS' CONCLUSIONS

Nutrition education for families of infants may reduce the risk of undernutrition in term-born infants (evidence of low to moderate certainty due to limitations in study design and substantial heterogeneity of included studies). Modest effects on growth during infancy may not be of clinical significance. However, it is unclear whether these small improvements in growth parameters in the first two years of life affect long-term childhood growth and development. Further studies are needed to resolve this question.

Advancing child nutrition science in the scaling up nutrition era: a systematic scoping review of stunting research in Guatemala

INTRODUCTION

Ever since the 1960s, Guatemala has been a principle site for global academic research on child growth and nutrition. Nevertheless, Guatemala still has one of the highest rates of child stunting in the world. Since 2012, Guatemala has had a comprehensive national policy on stunting, calling for a renewed investment in innovative, multilevel nutrition interventions and implementation science. Our objective was to perform a systematic search and scoping review of the literature on stunting in Guatemala to identify gaps in research and opportunities for responding to this unique policy opportunity.

METHODS

We conducted a systematic search and scoping review on stunting in Guatemala, searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were of any design or format, published in English and Spanish from 2000 to 2018. Articles were thematically grouped by those published before (2000-2011) and after (2012-2018) the new national policy initiatives.

RESULTS

We identified a total of 1934 articles through database searches. After full-text review, 104 were included in the synthesis. The volume of published articles on stunting increased from a mean of 3.2 to 9.4 articles/year before and after 2012. There was a shift toward articles generating new data on priority populations, including rural indigenous Maya populations (34% vs 61%, χ² test, p=0.01). However, the proportion of studies conducting implementation evaluations or testing new interventions was low and did not change significantly (34% vs 18%, χ² test, p=0.07). Among 17 identified intervention studies, only 4 tested multilevel interventions, and there were no published interventions incorporating nutrition-sensitive interventions.

CONCLUSIONS

A systematic search and scoping review of the literature on child stunting in Guatemala identified critical opportunities for new research in multilevel interventions, nutrition-sensitive interventions and implementation science.