Integrating Nutrition and Child Development
Interventions Among Infants in Rural India:
Lessons from the Field
Maureen Black, Ph.D.
Madhaven Nair, Ph.D.
Sylvia Fernandez Rao, Ph.D. Nagalla Balakrishna, Ph.D.
Kristen Hurley, Ph.D.
Seshikiran Boindala, MD
Shahnaz Vazir, Ph.D.
Radha Krishna, MD
Kim Harding, MPH
Greg Rheinhart, Ph.D.
Nick Tilton, MPH
Objectives
• To evaluate if an intervention of multiple
micronutrients (MMN) and early stimulation (play &
communication) enhances child development
• To facilitate scaling up by using village level workers
and Anganwadi Centers
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Background
Theory
Design
Management
Implementation and status
2007 Lancet Series on Child
Development
• More than 200 million children under age 5 years in
low- and middle-income countries do not reach their
developmental potential
• Major risks for poor child development
– Chronic undernutrition
– Nutritional deficiencies (iron, iodine)
– Lack of stimulating opportunities
• Evidence on effective early interventions
% of disadvantaged children by country
2011 Lancet Series on Child
Development
• Inequality in early childhood: risk and protective
factors for early child development.
– Reviews new evidence on:
• causes of developmental inequality
• effective interventions to promote child development
• Strategies for reducing inequalities and improving
developmental outcomes.
– Priorities for early childhood policies and programs to
reduce inequalities
– Estimates the cost of not investing in early childhood
programs
Worldwide timing of growth faltering
from 54 countries
1000 days
Victora et al. Pediatrics 2010;125:e473-e480
Stunting in children
<5years
X-sectional associations
between stunting &
poor cognition or school
achievement
Cognitive or schooling deficits associated with
moderate stunting <3yrs in 6 longitudinal studies
0.5
Philippines
0.1
-0.3
-0.7
deviation scores
-1.1
-1.5
S Africa
Indonesia
Brazil
Peru
Jamaica
The developing brain
• The brain develops through dynamic interactions
of genetic, biological, and psychosocial
influences and child behavior
• Exposure to biological and psychosocial risks
(toxic stress) leads to deficits in brain structure
and function, and pervasive impairments in
educational outcome, mental and physical
health, and overall well-being
• Disparities increase with early, multiple, and
cumulative risks
Iron Deficiency
• Most prevalent single nutrient deficiency in the
world
– ~35%
– Leading cause of anemia
– Associated with deficits in motor, cognitive &
socioemotional behavior
– May affect brain functions
• Myelination
• Dopamine
• Norepinephrine metabolism
1000 days
Iron:
0.27 mg/day
0–6 months
11 mg/day
6-12 months
7 mg/day
1-3 years
Thompson & Nelson, 2000
Psychosocial risks
• Lack of learning opportunities and poor
quality caregiver-child interaction – major risk
for poor development
• Brain architecture develops in the context of
relationships
• Protective influences that promote child
development
– responsive caregiver-child interaction
– opportunities for young children to play and learn
Nutrition and health are necessary,
but not sufficient for early child
development
Substantial gains in children’s development
require:
•Improvements in parenting, stimulation and
early education
•Reductions in stressful experiences through
psychosocial support for children and families
affected by societal violence
Development of inequality
1000 days
Social-Ecological Theory
Distal threats and
opportunities reach
the child through
proximal
interactions
between child &
family
Bronfenbrenner & Ceci, 1994
Poverty
Lack of
Stimulation
Motor
Dev
Parent-Child
Interaction
Low quality diet
Cognitive
Dev
SocioEmotional
Dev
Child Iron
Deficiency
Intervene
Outcome
Mediators
Project Grow Smart (India)
• Home Infant Phase (6-12 months: 1 year RCT)
MMN
Sachets
Play &
Commun
Vit Sachets
(Placebo)
Play &
Commun
MMN
Sachets
Vit Sachets
(Placebo)
• Preschool Phase (3-5 years: 1 year RCT)
– Anganwadi Centers (AWC): preschoolers
• MMN or Placebo – food provided at AWC
• Collaborators
• National Institute of Nutrition (Hyderabad), Univ of Maryland,
Micronutrient Initiative, Mathile Institute
Formative Phase
• Ensure culturally and developmentally appropriate
material, messages, and methods
• Focus groups
• Consultation with village workers and leaders
• Mothers wanted children to be smart – thus the title
“Grow Smart”
Assessed Acceptability of MMN
When mixed with 50g
(1 fist) of soft and
smashed rice with
pulse or milk, MMN
formulation
acceptable:
Color
Smell
Texture
Taste
Assessed Feasibility of
Play/Communication Intervention
Feasibility of play and
communication
intervention assessed to
be high, based on pilot
testing and consultation
with other agencies
Formal Approvals
• Approvals obtained from:
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National Institute of Nutrition, India
Institutional Review Board, University of Maryland
Health Ministry Screening Committee, India
India Council of Medical Research
Department of Women and Child Development, India
Local village leaders
Local Anganwadi Centers
Conclusion
• An intervention trial using local village level workers
(VLW) to promote nutritional status and child
development through MMN and a
play/communication intervention delivered in the
home for infants and AWC for preschoolers is:
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needed
acceptable
feasible
approved
Intervention Strategy
• Infancy Phase
– Home Visits
• Nutrition Intervention (MMN messages) – Universal
• Play and Communication Intervention – Randomized
• Distribution of MMN/Placebo sachets (blinded)
• Preschool Phase
– Anganwadi Center
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Government-sponsored childcare centers, food
Nutrition Intervention (MMN messages) – Universal
Distribution of MMN/Placebo food (blinded)
Quality determined by ECERS – Early Childhood Environmental
Rating Scale, Modified
MMN Fortification
MMN
6-12 months
12-24 months
Preschool
Iron
8 mg
10 mg
13 mg
Zinc
5 mg
5 mg
5 mg
Folic acid
20 mg
20 mg
20 mg
Vitamin A
200 ug
200 ug
150 ug
Vitamin C
20 mg
20 mg
20 mg
Vitamin B12
0.5 ug
0.5 ug
0.5 ug
Vitamin B2
0.5 ug
0.5 ug
0.5 ug
Play and Communication Intervention
• Infant Phase (Flip Charts)
– Trial informed by:
• Social-Ecological Theory (Bronfenbrenner & Ceci, 1994)
• Care for Development (WHO, 2001)
• Pakistan Early Development Study (Yousafzai, 2010)
• Preschool Phase
– No trial
– Early Childhood Environmental Rating Scale, Modified
(ECERS)
VISIT 7
Play peek- a- boo with your child
VISIT 7 (age 9-11)
NEW MESSAGE: Play peek- a- boo with your child (SHOW PICTURE)
EXPLANATION: [CHILD] will love to play games with you. Remember [CHILD] is always learning. Things
that seem simple to you will be amusing as well as rewarding to the child. Play games like peek-a-boo
and clapping hands with your child. He will enjoy it immensely and will learn to play with others as
well.
ACTIVITY:
•Using your hands or the pallu of your sari to cover and uncover your face. Tell [CHILD] ‘Here I am’
when your face is uncovered. Vary where you reappear (to the left, right, top, bottom).
•Place [CHILD] in front of a mirror. Put a piece of cloth between her face and the mirror and then
remove it. Repeat the action, so the child appears and disappears, while saying “Where is [CHILD]?”.
DEMONSTRATE AND PRACTICE ACTIVITIES (PRAISE, PROBLEM SOLVE, ENCOURAGE)
CHECKING QUESTIONS:
•What games are you familiar with? When do you play them? How does your child react?
•When can you and your family play these types of games with your child?
MOTIVATION: Your child will enjoy interactive games. She will laugh and develop a sense of presence
and absence, as she anticipates where you will appear. These activities will help her learn to focus and
she will feel good about playing them with you and good about herself. The games will help her
attention span so she can focus on learning.
Nutrition Intervention
• Flip Charts
• Informed by:
– Indo-US Study (Vazir, 2012)
Give dark green or orange vegetables
and fruits daily
Reminder
VISIT 10
REINFORCE MESSAGE: Give dark green or orange vegetables and fruits daily or as often as
possible (SHOW PICTURE)
FLIP CHART ACTIVITY (SHOW PICTURE): Ask mother to point to dark green or orange
vegetables and fruits that her family commonly eats.
CHECKING QUESTIONS:
•What vegetables have you been giving to [INFANT]?
•What fruits have you been giving to [INFANT]?
•How have you been preparing them for [INFANT]? (If yes PRAISE; if not, ENCOURAGE the
mother to prepare vegetables and fruits for her baby)
MOTIVATION:
•[INFANT] will like food with fruits and vegetables in them and will stay healthier and
become smarter
REMINDERS:
•Before preparing food and feeding [INFANT], wash your hands with soap and water.
Washing gets rid of germs that can make [INFANT] sick. At this age, children like to pick up
food and feed themselves/ or put their fingers in their mouth. Wash their hands to avoid
germs.
Evaluations
• Child
o Anthropometry
o Iron, zinc status
o Cognitive, motor, socialemotional development
o Inhibitory control
• Mother-child
o Video-taped play
observation
o HOME Inventory
• Mother
o Feeding practices
o Child’s dietary intake
o Maternal depressive
symptoms & parenting stress
o Maternal iron status
o Demographics
(education, marital status,
assets, etc.)
Management
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Ethical procedures
Operations manual
Tracking system
Supervisory structure
Criteria for reliability (intervention and evaluation)
Regularly scheduled training/feedback/re-training
Systematic data entry, cleaning, back-up
Transparency
Management
Structure
Investigators
Project Coordinator
Data Entry/Cleaning
Evaluation Team
Lead Psychologist
Psychologists
Data
Management/Analysis
Intervention Team
Lead Interventionist
Medical Team
Physician
Village Level Worker
Supervisors
Phelobotomists
Village Level Workers
Anthropometrists
Management Processes
• Investigators
– Weekly/biweekly conference calls with agenda & minutes
– Shared electronic communication: Drop Box
• Includes all protocols, consent forms, background articles,
evaluation material, intervention material, correspondence
• Dated and available to entire team of investigators
– Periodic face-to-face visits, scheduled with specific goals
• India Team
– Tracking system to handle schedules
– Field visits 4 days/week. Meetings/office/updated
shedules on Friday
– Timely feedback
Monitoring and Evaluation
• Infant Phase
– VLW workers record quality of intervention contact
– Checklist/observation of VLW workers by VLW Supervisors
• Motivational Interviewing techniques
• Demonstration and modeling
• Conversational and listening to mother (not reading)
– Checklist/observation of VLW Supervisors by Lead
Interventionist
• Preschool Phase
– AWC teacher records attendance and amount of food
eaten
– Checklist/observation of AWC teacher by VLW Supervisors
Status
• Infant Phase
– Completed enrollment & baseline evaluation
– Intervention ongoing
• Preschool Phase
– Completed training
– Pilot testing ongoing
– Enrollment & baseline about to begin
• Timeline
– Infant phase: through ~ June 2013
– Preschool phase: through ~ September 2013