A Combined Dietary and Cognitive Intervention in 3⁻5-Year-Old Children in Indonesia: A Randomized Controlled Trial

Improved Neurodevelopmental Outcomes at 5.5 Years of Age in Children Who Received Bovine Milk Fat Globule Membrane and Lactoferrin in Infant Formula Through 12 Months: A Randomized Controlled Trial

OBJECTIVE

To evaluate the neurodevelopmental outcomes at 5.5 years of age in children who were previously randomized to cow milk-based infant formula (control) or similar formula (milk fat globule membrane + lactoferrin) with added sources of bovine milk fat globule membrane and bovine lactoferrin through 12 months of age.

DESIGN

Children who completed study feeding were invited to participate in follow-up assessments: cognitive development across multiple domains (primary outcome; Wechsler Preschool & Primary Scale of Intelligence, 4th Edition), inhibitory control/rule learning (Stroop Task), flexibility/rule learning (Dimensional Change Card Sort), and behavior/emotion (Child Behavior Checklist).

RESULTS

Of 292 eligible participants (control: 148, milk fat globule membrane + lactoferrin: 144), 116 enrolled and completed assessments (control: 59, milk fat globule membrane + LF: 57). There were no group demographic differences except family income (milk fat globule membrane + lactoferrin significantly higher). Wechsler Preschool & Primary Scale of Intelligence, 4th Edition composite scores (mean ± standard error) for Visual Spatial (100.6 ± 1.7 vs 95.3 ± 1.7; P = .027), Processing Speed (107.1 ± 1.4 vs 100.0 ± 1.4; P < .001), and Full-Scale IQ (98.7 ± 1.4 vs 93.5 ± 1.5; P = .012) were significantly higher for milk fat globule membrane + lactoferrin versus control, even after controlling for demographic/socioeconomic factors. Stroop Task scores were significantly higher in milk fat globule membrane + lactoferrin versus control (P < .001). Higher Dimensional Change Card Sort scores (P = .013) in the border phase (most complex/challenging) were detected, and more children passed the border phase (32% vs 12%; P = .039) for milk fat globule membrane versus control. No group differences in Child Behavior Checklist score were detected.

CONCLUSIONS

Children who received infant formula to 12 months of age with added bovine milk fat globule membrane and bovine lactoferrin versus standard formula demonstrated improved cognitive outcomes in multiple domains at 5.5 years of age, including measures of intelligence and executive function.

TRIAL REGISTRATION

Clinicaltrials.gov: https://clinicaltrials.gov/ct2/show/NCT04442477.

Diet and Acanthosis Nigricans over a Two-Year Period in Children of the Pacific Region

BACKGROUND

The impact that dietary carbohydrates have on children developing type 2 diabetes remains controversial. Furthermore, there are limited pediatric longitudinal studies on changes in body mass index (BMI) and diet related to the development of acanthosis nigricans (AN), a risk factor associated with type 2 diabetes.

METHODS

Two 24 h dietary records were collected for 558 children, 2-8 years of age, at baseline and at a 2-year follow-up. Data on age, sex, BMI, and the presence of AN were also collected at each time point from the Children's Healthy Living Program. Logistic regression was used to determine factors associated with the presence of AN at follow-up. Multinominal regression was used to determine factors associated with changes in AN status. Linear regression was used to measure the associations between changes in dietary intake and in the Burke Score for AN.

RESULTS

AN was present in 28 children at baseline and 34 children at follow-up. Adjusting for the presence of AN at baseline, age, sex, study group, baseline BMI, change in BMI z-score, time between assessments, and baseline intake, an increase from baseline for each teaspoon of sugar and serving of carbohydrate-rich food increased the risk for having AN at follow-up by 9% and 8%, respectively (p ≤ 0.05). An increased intake of added sugar (teaspoons) increased the risk of developing AN by 13% (p ≤ 0.01) and an increase in servings of foods rich in starch increased the risk of developing AN by 12% (p ≤ 0.01) compared to children who never had AN. Increasing the intake of fruit was also associated with decreased Burke Scores using multiple regression. However, the intake of energy and macronutrients were not associated with AN.

CONCLUSIONS

Added sugar and foods rich in starch were independently associated with the occurrence of AN, suggesting the type of carbohydrates consumed is a factor in AN occurrence.

The Effects of Nutritional Interventions on the Cognitive Development of Preschool-Age Children: A Systematic Review

The developing human brain requires all essential nutrients to form and to maintain its structure. Infant and child cognitive development is dependent on adequate nutrition. Children who do not receive sufficient nutrition are at high risk of exhibiting impaired cognitive skills. This systematic review aimed to examine the effects of nutritional interventions on cognitive outcomes of preschool-age children. PubMed, PsycInfo, Academic Search Complete, and Cochrane Library electronic databases were searched to identify Randomized Controlled Trials (RCTs) published after the year 2000. Studies assessing the effects of food-based, single, and multiple micronutrient interventions on the cognition of nourished and undernourished children aged 2-6 years were deemed eligible. A total of 12 trials were identified. Eight out of the twelve studies found significant positive effects on cognitive outcomes. Iron and multiple-micronutrients supplementation yield improvements in the cognitive abilities of undernourished preschool-age children. Increased fish consumption was found to have a beneficial effect in the cognitive outcomes of nourished children. On the other hand, B-vitamin, iodized salt, and guava powder interventions failed to display significant results. Findings of this review highlight the importance of adequate nutrition during preschool years, and the crucial role sufficient nutrition plays in cognitive development.

Design Factors for Food Supplementation and Nutrition Education Interventions That Limit Conclusions about Effectiveness for Wasting Prevention: A Scoping Review of Peer-Reviewed Literature

We conducted a scoping review to characterize the evidence base for the effectiveness of food supplementation (FS), nutrition education (NE), or FS/NE interventions to prevent wasting among children aged 6 to 59 mo. We aimed to identify gaps in peer-reviewed literature and to develop recommendations for strengthening study designs. We identified 56 unique studies (FS = 21, NE = 19, FS/NE = 16) for which we assessed intervention design factors, implementation context, evaluation methods, and wasting impact. Compared with studies focused on stunting, fewer wasting-focused studies reported weight-for-height z score (WHZ). Midupper arm circumference (MUAC) was more commonly reported in wasting-focused studies (71.4%) than those focused on stunting (36.8%) or wasting and stunting (30.4%). FS studies measured anthropometry (mean, 95% CI) more frequently at every 11.3 (7.8, 14.8) wk than NE interventions at 36.3 (8.8, 62.1) wk (P = 0.036), but not FS/NE interventions at 25.8 (5.6, 49.1) wk (P = 0.138). NE interventions tended to be of longer duration than FS or FS/NE interventions. Only 6 studies followed and measured children after the intervention period ended. Across all studies, 45% reported a significant effect on wasting; these included FS, NE, and FS/NE interventions. The lack of comparability across studies limits conclusions about the effectiveness of specific types of interventions. To build a more unified evidence base for wasting prevention we recommend that future studies 1) report on a consistent set of metrics, including MUAC; 2) attempt to measure change in wasting incidence using more frequent measures; 3) measure wasting prevalence among the general population; 4) follow children postintervention to assess relapse; 5) measure food insecurity and diet quality; and 6) use harmonized protocols across multiple settings. Such efforts to improve study comparability will strengthen the evidence base, may help unite divergent professional communities, and ultimately accelerate progress toward eliminating child undernutrition.

Characteristics and effects of integrated nutrition and stimulation interventions to improve the nutritional status and development of children under 5 years of age: a systematic review and meta-analysis

Introduction

Around 250 million children in low-income and middle-income countries are at risk of not fulfilling their developmental potential. There is a need to update syntheses investigating the effects of combined nutrition and stimulation interventions on children’s growth and development and identify intervention characteristics associated with positive effects.

Methods

We did a systematic review to: (1) understand the effects of integrated nutrition and stimulation interventions versus (i) usual care and (ii) standalone nutrition or stimulation interventions, on the growth and development of children under five; (2) explore intervention characteristics (delivery strategies, behaviour change techniques, intensity and personnel) associated with positive effects. We searched eight databases for studies published from inception to 16 November 2020. Eligible studies were randomised and non-randomised controlled trials of integrated nutrition and stimulation interventions examining growth and developmental outcomes. We performed meta-analyses for length-for-age/height-for-age, weight-for-age and weight-for-length/weight-for-height Z scores and cognitive, motor and language development scores, and subgroup analyses by intervention characteristics. We conducted random-effects metaregression to assess potential subgroup differences in outcomes by intervention characteristics.

Results

Twenty trials were included in the meta-analysis. Pooled effect sizes showed significant benefits of integrated interventions on developmental outcomes compared with usual care and standalone nutrition interventions (I² >75%) but not on growth outcomes. Moreover, integrated interventions have non-significant effects on developmental outcomes compared with standalone stimulation interventions. Integrated interventions showed greater effects on cognitive (p=0.039) and language (p=0.040) outcomes for undernourished children compared with adequately nourished children. The effects of integrated interventions on developmental outcomes did not differ by intervention characteristics.

Conclusion

Integrated interventions have greater benefits for children’s development than usual care or standalone nutrition interventions, especially in settings with high levels of undernutrition. Future studies should use standardised reporting of implementation processes to identify intervention characteristics linked to positive effects.

Sociodemographic, nutritional, and environmental factors are associated with cognitive performance among Orang Asli children in Malaysia

Children aged 2 to 6 years are in a crucial period of growth development, during which it is important for them to attain specific cognition related to concentration and attention so that they can perform well in school later in life. Various factors influence children’s cognition during this crucial period. However, to date, only a limited number of studies have examined the cognitive performance of underprivileged children living in poverty, particularly indigenous children (also known as Orang Asli children in Malaysia). Therefore, this cross-sectional study aimed to determine the associations between sociodemographic factors, nutritional factors (body composition and hemoglobin), and environmental factors (home environment and parasitic infections) with cognitive performance among Orang Asli children in Negeri Sembilan, Malaysia. The participants were 269 children (51% boys, 49% girls) aged 2 to 6 years (M = 4.0, SD = 1.2 years) and their mothers, from 14 Orang Asli villages. Face-to-face interviews were conducted with the mothers, and the children’s cognitive performance, operationalized as working memory index (WMI), processing speed index (PSI), and cognitive proficiency index (CPI), was assessed using the Wechsler Preschool and Primary Scale of Intelligence, Fourth Edition (WPPSI-IV). The children’s weight and height were measured, and their blood and stool samples were collected to assess hemoglobin level and parasitic infections, respectively. Multiple linear regression analysis showed that the father’s years of education (β = 0.262–0.342, p < 0.05), availability of learning materials at home (β = 0.263–0.425, p < 0.05), and responsiveness of the parent to the child (β = 0.192–0.331, p < 0.05) were consistently associated with all three cognitive indices (WMI, PSI, and CPI). A holistic approach involving parents, communities, and government agencies should be established to improve the cognitive performance of these underprivileged children.