Child development infant intervention and importance

Nervous system

1. Integrating Nutrition and Child Development 
Interventions Among Infants in Rural India: 
Lessons from the Field 
Maureen Black, Ph.D.
Sylvia Fernandez Rao, Ph.D.
Kristen Hurley, Ph.D.
Shahnaz Vazir, Ph.D.
Kim Harding, MPH
Nick Tilton, MPH
Madhavan Nair K, Ph.D.
Nagalla Balakrishna, Ph.D.
Sesikeran Boindala, MD
Radha Krishna, MD
Ravinder Punjal, PhD
Greg Reinhart, Ph.D.

2. Objectives
•Theoretical basis of nutrition-child development
integration
•Developmental basis for responsive feeding
•Child development beyond feeding
•Nutrition-child development interventions
•Next steps

3. 2007 & 2011
LancetSeries on Child Development
•Over 200 million children < age 5 y in low & middle
income countries do not reach developmental potenti al
–Nutrition: Chronic undernutrition, micronutrient de ficiencies
–Lack of stimulating opportunities
–Extended to social & environmental risks
•Efficacy of early interventions
–Priorities for early childhood policies and program s to reduce
inequalities
–Estimates the cost of not investing in child dev pr ograms
–Need for policies/procedures to scale up.

4. % of disadvantaged children by country

5. Integration of Nutrition & Child
Development
•The 36 countries at greatest risk for poor child
development are also at greatest risk for
undernutrition.
•Integrated intervention may be economical and
feasible.

6. Worldwide timing of growth faltering
from 54 countries
Victora et al. Pediatrics 2010;125:e473-e480
1000 days

7. Thompson & Nelson, 2000
Iron: 0.27 mg/day 11 mg/day 7 m g/day
0–6 months 6-12 months 1-3 years
1000 days
h2

8. Slide 7 h2 
5 mg/d for 6-12 mo nad 9 mg/d for 1-3 years.  hp, 6/25/2012

9. Social-Ecological Theory of Child
Development
Distal threats and
opportunities reach
the child through
proximal
interactions
between child &
family
Bronfenbrenner & Ceci, 1994
h12

10. Slide 8 h12 
Do we need to have this religious settings ? hp, 6/25/2012

11. Stunting in children
<5years

12. Functional Isolation Hypothesis
•Caregivers adjust their expectations and
opportunities to the perceived competence of
offspring
–Short offspring perceived to be weak or less compet ent
than tall offspring
–Expectations to short offspring reduced
–Opportunities for short offspring limited
•Short offspring lag behind taller offspring in task s of
competence
Levitsky DA, Barnes RH. Nutritional and environmental in teractions in the
behavioral development of the rat. Science.1972;176(4030):68-71.
,

13. Low quality diet
Lack of
Stimulation
Child MN
Deficient/
Stunted
Parent-Child
Interaction
Motor
Dev
Cognitive
Dev
Socio-
Emotional
Dev
Poverty
h13
h14

14. Slide 11 h13 
SES and poverty link can be included hp, 6/25/2012
h14 
Poverty alleviation stategies of govt hp, 6/25/2012

15. Low quality diet
Lack of
Stimulation
Child MN
Deficient/
Stunted
Parent-Child
Interaction
Motor
Dev
Cognitive
Dev
Socio-
Emotional
Dev
Poverty
Intervene Outcome
Mediators
h15
h16

16. Slide 12 h15 
SES and poverty link can be included hp, 6/25/2012
h16 
Poverty alleviation stategies of govt hp, 6/25/2012

17. Nutrition and health are necessary, but
not sufficient for child development Substantial gains in children’s development also re quire:
•Opportunities for responsive parenting, stimulation
and early education
•Relatively stress-free experiences (no violence, fo od
insecurity)
•Psychosocial support for children and families
Black et al., 2008

18. Maternal
Depression
Uninvolved/
Inconsistent
Caregiving
Poor
growth
Poverty
Intervene Outcome
Mediators
h10
h11

19. Slide 14 h10 
SES and poverty link can be included hp, 6/25/2012
h11 
Poverty alleviation stategies of govt hp, 6/25/2012

20. Maternal Depression
•Meta-analysis
•17 studies; 13,923 mother-child pairs; 11 countries
•Children of depressed mothers at increased risk:
underweight(OR: 1.5; 95% CI: 1.2–1.8)
stunted (OR: 1.4; 95% CI: 1.2–1.7)
•PAR: if infant population were unexposed to
depression, 23%-29% decline in underweight/stunting
Surkan, Kennedy, Hurley, Black. Bull WHO, 2011

21. Disparities in Child Development
Begin Prenatally or Early in Life
•Poverty
•Undernutrition
•Stress
•Environmental toxins and threats
•Infections/Illnesses (environmental enteropathies)
•Parental illnesses (including maternal depressive
symptoms)
•Lack of opportunities
–Stimulation
–Responsive relationships
–Protection from harm

22. Development of disparities

23. Development of disparities

24. Child Development
•Stable, caring relationships form the basis for sec ure and
healthy child development
•Children:
–active partnersin their own development
–long-termdevelopmentmore important than short-term
compliance

25. Parental Responsivity is:
•Prompt
•Developmentally appropriate
•Enriching
Parent Responsivity is not:
•Giving children whatever
they want.
•Letting children be in
charge.

26. Feeding
•Reciprocity between caregiver & child
•Both view reactions –modeling
•Lack of reciprocity Reciprocity

27. Child opens
mouth &
accepts
Mother
offers another
bite
Child
looks away,
mouth
shut
Mother
offers a bite
of food
…………………
...
Time…………
RESPONSIVE FEEDING BEHAVIORS
Promote Healthy Eating & Growth
Patterns
Ummm,
maybe she is
telling me
she wants to
feed herself.

28. Child opens
mouth &
accepts
Mother
offers another
bite
Child
looks away,
mouth
shut
Child
picks up food
& eats
Mother
waits, smiles,
finger food
Mother
offers a bite
of food
…………………
...
Time…………
Promote Healthy Eating & Growth
Patterns
RESPONSIVE FEEDING BEHAVIORS

29. Child opens
mouth &
accepts
Mother
offers another
bite
Child
looks away,
mouth
shut
Mother
offers a bite
of food
…………………
...
Time…………
NON-RESPONSIVE FEEDING BEHAVIORS
Hinder Healthy Eating & Growth
Patterns
Oh no, he
needs to
eat.

30. Child opens
mouth &
accepts
Mother
offers another
bite
Child
looks away,
mouth
shut
Child
Cries & spits
out food
Mother
holds child &
force feeds
Mother
offers a bite
of food
…………………
...
Time…………
Hinder Healthy Eating & Growth
Patterns
NON-RESPONSIVE FEEDING BEHAVIORS

31. What Is Unresponsive Feeding?
•Excessive parental control
–Forceful–Eat! Eat!
–Restrictive–No dessert for you! 
•Lack of parental control
•Indulgent –Eat whatever you want
–Uninvolved –Eat alone

32. Why Parents Use Unresponsive Feeding
–Concerns
•child’s size: 
•child’s eating behavior: 
•child’s temperament: 
•child’s health
•child’s competence: 
•Food availability, waste, spillage, time
–Opportunity for intervention

33. How to Incorporate Child Development
Principles into Feeding

34. 0-6 Months
What Child 
Can Do 
What Parent 
Can Do
What Child Is 
Learning 
• Suck/swallow
• Cry when hungry
• Stop eating when full
• Smile
• Breastfeed exclusively
• Respond to child’s 
signals
• Provide consistent 
feeding
• Vesibular-proprioceptive 
soothing
• Auditory, visual, and 
tactile stimulation 
• Low stress
• Protect from harm (lack 
of food)
• To establish regulatory 
patterns 
• To signal hunger and 
satiety 
• Caregivers respond to 
signals
• To recognize people and 
environmental experiences 
• That eating feels good

35. 6-12 Months
What Child 
Can Do 
What Parent 
Can Do
What Child Is 
Learning 
• Sit up
• Self-feed with fingers
• Chew and swallow 
increasingly complex 
textures 
• Ensure child is well-
supported & positioned to 
use her hands
• Establish family 
mealtimes & routines
• Start with semi-solid 
food . Move to thicker & 
lumpier, then soft pieces
• Offer safe finger foods
• Use two spoons so child 
learns to self-feed
• Turn off TV/radio, 
reduce distractions. Use 
mealtimes to share about 
daily activities.
• To self feed
• To decide how much to 
eat
• To experience tastes and 
textures and decide 
favorites
• To focus on eating 
during mealtimes
• That eating and 
mealtimes are fun and feel 
good 

36. 12-24 Months
What Child 
Can Do 
What Parent 
Can Do
What Child Is 
Learning 
• Self-feed many 
different foods
• Begin to use baby-
safe utensils 
• Offer 3-4 healthy 
choices/meal
• Offer 2-3 healthy 
snacks/day
• Offer foods that can 
be picked up, chewed 
and swallowed easily
• Offer child-size 
utensils and provide 
help when needed.
• To try new foods
• To do things for herself
• To ask for help
• To trust that parent will 
help her when she needs 
help 

37. 12-24 Months
What Child 
Can Do 
What Parent 
Can Do
What Child Is 
Learning 
• Use actions & words 
to communicate 
thoughts & feelings, 
including hunger and 
satiety
• Make meals a time to 
connect with your child
• Point to & name foods 
or objects on the table
• Talk about things 
beyond food, such as 
daily activities 
• New words
• That she can effectively 
communicate
• That parent will listen and 
respect her
• That her feelings matter

38. Evidence
•Associations between poor growth and unresponsive
feeding practices
–Unresponsive feeding poor growth
–Poor growth unresponsive feeding
•Does responsive feeding promote healthy growth?
–Emerging evidence is suggestive
–Need for clarity in definition of responsive feedin g
Bentley, Wasser, Creed-Kanashiro, 2011

39. Integration of Nutrition and Child
Development Extends Beyond Feeding
•Developmental skills
–Motor, language, cognitive, emotional
•Opportunities for learning and exploration
•Supportive interactions
•Predictable routine
•Protection from stress and potential harm

40. Integrated Nutrition/Child Development
Interventions
•At least 17 interventions, published or ongoing
–Home-based (age 0-3)
–Center-based (age 3-5)
•Identified issues
–Overall Responsibility/Accountability
–Timing and Duration
–Training and Supervision
–Demonstration/Coaching > Didactic/Telling
–Monitoring and Evaluation: Process & Outcome

41. Nutrition and Child Development
•Multiple Micronutrient Fortification
•Early Play and Communication

42. •Home Infant Phase (6-12 months: 1 year RCT)
•Preschool Phase (3-4 years: 1 year RCT)
oAnganwadi Centers (AWC): preschoolers
•MMN or Placebo –food provided at AWC
Project Grow Smart (India) MMN
Sachets
Play &
Commun
MMN
Sachets
Vit Sachets
(Placebo)
Play &
Commun
Vit Sachets
(Placebo)

43. Initial Nutritional Status

44. Baseline Anemia

45. Formal Approvals
•Approvals obtained from:
–National Institute of Nutrition, Institutional Ethi cs
Committee
–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
h17

46. Slide 40 h17 
Registerd as clinical trial hp, 6/25/2012

47. Formative Phase
•Ensure culturally and developmentally appropriate
material, messages, and methods
•Consultation with village workers and leaders
•Mothers wanted children to be smart –thus the title
“Grow Smart”
•Adapt intervention and evaluation materials

48. 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

49. 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 µg 20 µg 20 µg
Vitamin A 200 µg 200µg 150µg
Vitamin C 20 mg 20 mg 20 mg
Vitamin B12 0.5 µg 0.5µg 0.5µg
Vitamin B2 0.5 mg 0.5mg 0.5 mg
Placebo 6-12 months 12-24 months Preschool Vitamin B2 0.5 mg 0.5 mg 0.5 mg

50. Assessed Acceptability of
Fortification
When mixed with 50g
(1 fist) of soft and smashed
rice with pulse or milk,
formulation was acceptable:
Color
Smell
Texture
Taste

51. Summary of Formative
•An intervention trial using local village level wor kers
(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:
•needed
•acceptable
•feasible
•approved

52. Intervention Strategy
•Infancy Phase
–Home Visits
•Nutrition –Universal
•Play and Communication (Randomized)
•Distribution of sachets (Randomized)
•Flip Charts
–Nutrition, informed by:
•Indo-US Study (Vazir, 2012)
–Play & Communication, informed by:
•Social-Ecological Theory (Bronfenbrenner & Ceci, 19 94)
•Care for Development (WHO, 2001)
•Pakistan Early Development Study (Yousafzai, 2010)

53. Reminder
Give dark green or orange vegetables
and fruits daily

54. REINFORCE MESSAGE:
FLIP CHART ACTIVITY (SHOW PICTURE):
CHECKING QUESTIONS:
MOTIVATION:
REMINDERS:

55. Play peek-a-boowith your child

56. (age 9-11 mos)
NEW MESSAGE: Play peek-a-boowith your child (SHOW
PICTURE)
EXPLANATION:
ACTIVITY:
DEMONSTRATE, PRACTICE, COACH ACTIVITIES (PRAISE,
PROBLEM SOLVE, ENCOURAGE)
CHECKING QUESTIONS:
MOTIVATION:

57. Evaluation Design
•Outcome
oCognitive, motor, social-emotional development
oMullen Scales of Early Learning (direct assessment –5 areas)
oInfant/Toddler Social Emotional Assessment (caregiv er report)
oInhibitory control
oA not B, Card sorting (direct assessment)
•Mediators
oMMN Status
oIron, zinc, C-reactive protein, Hb (blood draw)
oParent-Child Interaction
oVideo-taped observation (Emotional Availability Sca les)
oHOME Inventory (observation)

58. Management
•Ethical procedures
•Operations manual
•Tracking system
•Supervisory structure
•Criteria for reliability (intervention and evaluati on)
•Regularly scheduled training/feedback/re-training
•Systematic data entry, cleaning, back-up
•Transparency

59. Investigators Investigators
Project Coordinator Project Coordinator
Evaluation Team
Lead Psychologist
Evaluation Team
Lead Psychologist
Data
Management/Analysis
Data
Management/Analysis
Intervention Team
Lead Interventionist
Intervention Team
Lead Interventionist
Medical Team
Physician
Medical Team
Physician
Data Entry/Cleaning Data Entry/Cleaning
Village Level Worker
Supervisors
Village Level Worker
Supervisors
Village Level Workers Village Level Workers
Phelobotomists Phelobotomists
Anthropometrists Anthropometrists
Psychologists Psychologists
Management
Structure

60. Management Processes
•Investigators
–Weekly/biweekly conference calls with agenda & minu tes
–Shared electronic communication: Drop Box
•Includes all protocols, consent forms, background a rticles,
evaluation material, intervention material, corresp ondence
•Dated and available to entire team of investigators
–Periodic face-to-face visits, scheduled with specif ic goals
•India Team
–Tracking system to handle schedules
–Field visits 4 days/week. Meetings/office/updated
shedules on Friday
–Timely feedback

61. Monitoring and Evaluation
•Infant Phase
–VLW workers record quality of intervention contact
–Checklist/observation of VLW workers by VLW Superv isors
•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 Supervi sors

62. Design and Analysis
•Baseline
•Follow-Up: mid-line (6 mos) and end-line (12 mos)
•Intent to treat
•Multivariate, cluster randomized
•Path analysis to examine effects of MMN and
play/communication on child development and
mediating effects of MMN status and parent-child
interaction

63. Procedure
•Village recruitment and agreement
–Site for evaluations
–Nomination of VLW Supervisors and VLWs
•Training of VLW Supervisors and VLWs
•Enumeration of village households–location of 6-12
month old children
•Enrollment
•Baseline
oBlood draw, anthropometry, development, caregiver
questionnaires
•Randomize and initiate intervention

64. Follow-Up
•6 month post-baseline
–Repeat baseline
•12 month post-baseline
–Repeat baseline
•Share findings and debriefing
–Families
–VLWs and VLW supervisors
–AWC and village leaders

65. Future Directions: Integration of Nutrition
& Child Development
•Prenatal
–Maternal nutritional adequacy
–Reduce maternal stress & depression
•Postnatal
–Exclusive breastfeeding
–Maternal responsivity and support
•Infancy and Toddlerhood
–Dietary adequacy, including micronutrients
–Responsive feeding
–Play and communication
–Protection from stress & environmental threats

66. Future Directions: Integration of Nutrition
& Child Development
•Preschool/School Age
–Dietary adequacy, including micronutrients
–Availability of high quality center-based programs
–Protection from stress & environmental threats
•Policy
–Based on implementation science: moving science to
practice

67. Implications for Success
(begin with effective interventions)
Be clear about
outcomes
(organizational
and
programmatic)
Build
partnerships
with
stakeholders &
policymakers
Adapt
programs
without losing
effectiveness
Monitor
implementation
fidelity and
effectiveness
Plan for
sustainability
from the
beginning
Fixsen & Blase, 2009

68. Thank You!!