Early Child Development and Nutrition in Guatemala

Professor, Department of Pediatrics, University of Maryland School of Medicine

Over 200 million children under the age of 5 years in low and middle-income countries do not reach their developmental potential, largely due to lack of adequate nutrients and lack of psychosocial stimulation. Stunting (length-for-age < -2 z-scores) is an indication of chronic undernutrition. Guatemala has the high rates of stunting in the Western Hemisphere (over 40%). This trial examines the effect of providing a micronutrient powder manufactured in Guatemala vs. placebo and an early learning environment vs. no early learning environment on the growth, health, and development of young children in Guatemala.

Study Overview

• Status: Completed
• Conditions: Undernutrition
• Intervention / Treatment: Dietary supplement: Micronutrients; Behavioral: Responsive feeding; Dietary supplement: Placebo

Detailed Description

The plan is to implement a clustered randomized placebo controlled trial with an infant phase (6-12 months of age) and a preschool phase (36-48 months of age). For the infant phase, the investigators will use ProPAN (Process for the Promotion of Child Feeding) in the development of the evaluation and intervention, with modifications as necessary for the Guatemalan context. ProPAN is a tool developed and distributed by the Pan American Health Organization to develop, implement, and evaluate interventions and programs to improve infant and young child diet and feeding. ProPAN includes four modules:

Module 1: Assessment Module 2: Testing Recipes and Recommendations Module 3: Intervention Module 4: Monitoring and Evaluation

For the preschool phase, the investigators will use an evidence-based school readiness intervention (Little By Little) that has been shown to be effective with Hispanic preschoolers. The intervention will be implemented through the Association for the Prevention and Study of HIV/AIDS who will train and supervise the community health workers. By working directly with a local non-profit organization, the project will be well positioned to inform strategies to scale up the intervention on a community wide basis, if beneficial effects are shown.

The project examines the effects of an integrated intervention that includes both micronutrient powder added to food and responsive feeding for infants or school readiness for preschoolers. The primary aim is to examine how an integrated micronutrients + responsive feeding/school readiness intervention changes the development (primary outcome), growth and micronutrient status (secondary outcomes) of young children. The investigators will focus on infants (6-12 months) when the risk for micronutrient deficiencies is high, as they transition from breast feeding to complementary feeding and the family diet. The investigators will focus on preschoolers (36-48 months) to examine if micronutrients + a school readiness intervention can improve children's school readiness skills. The design includes neighborhood clusters randomized into four groups: 1) micronutrients plus responsive feeding/school readiness 2) micronutrients only, 3) placebo plus responsive feeding/school readiness, and 4) placebo only.

The investigators will test the following hypotheses:

1. Children in the two micronutrients groups have better change from baseline in development (primary outcome), growth and micronutrient status (secondary oitcomes), than children in the two placebo groups.
2. Mothers and children in the two responsive feeding/school readiness groups have better change from baseline measures of child development than those in the two control groups.
3. The impact of the responsive feeding/school readiness intervention is greater in the micronutrient groups than in the placebo groups. Children in the micronutrients plus responsive feeding/school readiness group have better change from baseline in development than children in any of the other three groups.

• Study Type: Interventional
• Enrollment (Actual): 1730
• Phase: Not Applicable

Contacts and Locations

Study Locations

• Guatemala
  • Retalhuleu, Guatemala
    • APEVIHS (Association for the Prevention and Study of HIV/AIDS)

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 6 months to 4 years (Child)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Child speaks Spanish.
• Child is age 6-12 months or age 36-48 months.
• Child must be undernourished (length and height for age < -1 z-score).
• Child does not have any obvious health or developmental problems that would interfere with growth, nutrition, or development.
• Child will remain in the area for the subsequent year.
• Parent or legal guardian of the child is age 18 years or older.
• Parent or legal guardian speaks and understands Spanish.
• Parent or legal guardian lives with child in study community.

Exclusion Criteria:

• Child is not age 6-12 months or 36-48 months.
• Child has severe stunting (length and height for age < -3 z-scores).
• Child has identified conditions that could interfere with their development and growth.
• Child is severely anemic (hemoglobin < 7).

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Treatment
• Allocation: Randomized
• Interventional Model: Factorial Assignment
• Masking: Quadruple

Number of Arms

4

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Experimental: Micronutrients No responsive feeding; Micronutrient powder and no responsive feeding	Dietary supplement: Micronutrients; Nutrient Quantity Nutrient Quantity Zinc 9 mg Copper 0.3 mg Iron 12.5 mg Vitamin D3 5 mg Folic Acid 160 mcg Vitamin E 5 mg Iodine 90 mcg Calcium 200 mg Vitamin A 250 mg Phosphorus 150 mg Vitamin C 40 mg Magnesium 40 mg Vitamin B12 0.9 mcg Selenium 17 mcg Thiamine 0.5 mg Manganese 0.17 mg Niacin 0.5 mg Biotin 8 mg Riboflavin 6 mg Vitamin B5 1.8 mg Vitamin B6 0.5 mg
Placebo Comparator: Placebo and Responsive Feeding; Placebo (vitamin B2) and Responsive Feeding	Behavioral: Responsive feeding; Strategy Mother ensures that feeding area is set up with infant and mother able to see one another. Mother mirrors the infant's facial expressions to attract the infant's attention. Mother interprets infant's behavior with a positive voice, "Oh, you like the spinach." Mother extends infant's behavior by saying, "Oh the cereal is all gone" and doing a consistent hand signal Mother models eating, makes positive comments in a nurturing tone. Mother offers finger food or use of utensil; Dietary supplement: Placebo; Riboflavin Vitamin B2
Experimental: Micronutrients and Responsive caregiving; Micronutrients and Responsive feeding intervention	Dietary supplement: Micronutrients; Nutrient Quantity Nutrient Quantity Zinc 9 mg Copper 0.3 mg Iron 12.5 mg Vitamin D3 5 mg Folic Acid 160 mcg Vitamin E 5 mg Iodine 90 mcg Calcium 200 mg Vitamin A 250 mg Phosphorus 150 mg Vitamin C 40 mg Magnesium 40 mg Vitamin B12 0.9 mcg Selenium 17 mcg Thiamine 0.5 mg Manganese 0.17 mg Niacin 0.5 mg Biotin 8 mg Riboflavin 6 mg Vitamin B5 1.8 mg Vitamin B6 0.5 mg; Behavioral: Responsive feeding; Strategy Mother ensures that feeding area is set up with infant and mother able to see one another. Mother mirrors the infant's facial expressions to attract the infant's attention. Mother interprets infant's behavior with a positive voice, "Oh, you like the spinach." Mother extends infant's behavior by saying, "Oh the cereal is all gone" and doing a consistent hand signal Mother models eating, makes positive comments in a nurturing tone. Mother offers finger food or use of utensil
Placebo Comparator: Placebo and No responsive caregiving	Dietary supplement: Placebo; Riboflavin Vitamin B2

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in cognitive, motor, social-emotional development from baseline to 12 months	Cognitive and social-emotional assessments	Baseline, 12 months

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Change in Growth from baseline to 12 months	Weight, length/height	Baseline, 12 months
Change in micronutrient status from baseline to 12 months	Blood draw	Baseline, 12 months

Collaborators and Investigators

• Sponsor: University of Maryland, Baltimore
• Collaborators: Association for the Study and Prevention of HIV/AIDS
• Investigators: Principal Investigator: Maureen M Black, Ph.D., Uniersity of Maryland, Baltimore

Publications and helpful links

General Publications

• Unable to connect to PubMed to validate , last attempt on November 19, 2014 at 3:47 PM EST

Study record dates

Study Major Dates

• Study Start (Actual): February 16, 2015
• Primary Completion (Actual): December 8, 2015
• Study Completion (Actual): December 8, 2015

Study Registration Dates

• First Submitted: October 31, 2014
• First Submitted That Met QC Criteria: November 24, 2014
• First Posted (Estimate): November 27, 2014

Study Record Updates

• Last Update Posted (Actual): August 16, 2019
• Last Update Submitted That Met QC Criteria: August 14, 2019
• Last Verified: August 1, 2019

More Information

Terms related to this study

• Keywords: Micronutrient intervention; Responsive feeding intervention; School readiness intervention
• Additional Relevant MeSH Terms: Nutrition Disorders; Malnutrition; Physiological Effects of Drugs; Micronutrients; Trace Elements
• Other Study ID Numbers: HP-00061322