Factors associated with dietary diversity and length‐for‐age z‐score in rural Ethiopian children aged 6–23 months: A novel approach to the analysis of baseline data from the Sustainable Undernutrition Reduction in Ethiopia evaluation

Infants and young children need diets high in nutrient density and diversity to meet the requirements of rapid growth and development. Our aim was to evaluate sociodemographic, agricultural diversity, and women's empowerment factors associated with child dietary diversity and length‐for‐age z‐score (LAZ) in children 6–23 months using data collected as part of the Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study baseline survey in May–June 2016. We here present a novel analysis using directed acyclic graphs (DAGs) to represent our assumptions about the causal influences between the factors of interest and the outcomes. The causal diagrams enabled the identification of variables to be included in multivariable analysis to estimate the total effects of factors of interest using ordinal logistic/linear regression models. We found that child dietary diversity was positively associated with LAZ with children consuming 4 or more food groups having on average an LAZ score 0.42 (95% CI [0.08, 0.77]) higher than those consuming no complementary foods. Household production of fruits and vegetables was associated with both increased child dietary diversity (adjusted OR 1.16; 95% CI [1.09, 1.24]) and LAZ (adjusted mean difference 0.05; 95% CI [0.005, 0.10]). Other factors positively associated with child dietary diversity included age in months, socio‐economic status, maternal education, women's empowerment and dietary diversity, paternal childcare support, household food security, fruit and vegetable cultivation, and land ownership. LAZ was positively associated with age, socio‐economic status, maternal education, fruit and vegetable production, and land ownership.     

Women's dietary diversity in rural Bangladesh: Pathways through women's empowerment

The relationship between women's empowerment and women's nutrition is understudied. We aimed to elucidate this relationship by quantifying possible pathways between empowerment and dietary diversity among women in rural Bangladesh. In 2015, we conducted a cross‐sectional survey of 2,599 married women ages 15–40 (median: 25) living in 96 settlements of Habiganj District, Bangladesh, as a baseline for the Food and Agricultural Approaches to Reducing Malnutrition trial. We collected data on women's empowerment (highest completed grade of schooling and agency), dietary diversity, and demographic factors, including household wealth. We used exploratory factor analysis and confirmatory factor analysis on random split‐half samples, followed by structural equation modelling, to test pathways from schooling, through domains of women's agency, to dietary diversity. Factor analysis revealed 3 latent domains of women's agency: social solidarity, decision‐making, and voice with husband. In the adjusted mediation model, having any postprimary schooling was positively associated with voice with husband (β₄₁ = .051, p = .010), which was positively associated with dietary diversity (β₅₄ = .39, p = .002). Schooling also had a direct positive association with women's dietary diversity (β₅₁ = .22, p < .001). Neither women's social solidarity nor decision‐making mediated the relationship between schooling and dietary diversity. The link between schooling and dietary diversity was direct and indirect, through women's voice with husband but not through women's social solidarity or decision‐making. In this population, women with postprimary schooling seem to be better able to negotiate improved diets for themselves.     

Dissimilarities across age groups in the associations between complementary feeding practices and child growth: Evidence from rural Togo

Adequate complementary feeding (CF) practices are essential for achieving optimal growth but challenging to measure comprehensively. This paper describes CF practices in 2,034 children aged 6–23 months and investigates their relationships with length‐for‐age z‐score (LAZ) and stunting, using cross‐sectional data collected from May to July 2014 in rural Northern Togo. The World Health Organization infant and young child feeding indicators were computed, along with ancillary indicators on feeding style and timing of introduction of complementary foods. The associations between those indicators and children's LAZ and stunting were assessed using linear and logistic regressions after stratification by age group and adjustment for children, maternal, and household characteristics. CF practices were suboptimal, and their associations with child's growth varied across indicators and age groups. In children aged 6–11 months, reaching the minimum dietary diversity and the minimum acceptable diet was associated with higher LAZ (p < .05). In 18‐ to 23‐month‐old children, only the consumption of iron‐rich food was associated with both LAZ (p = .02) and stunting (p = .05). The late introduction of family foods was associated with higher odds of being stunted and lower LAZ in children aged 12–17 months (p < .001). The untimely introduction of porridge was associated with higher odds of stunting in children aged 9–23 months (p < .05). Unexpectedly, helping the child to eat was negatively associated with linear growth in all age groups. These findings nurture the ongoing process of review of the World Health Organization infant and young child feeding indicators showing that, in their current version, they hardly capture the links between CF and child's growth at different ages.     

Suaahara in Nepal: An at‐scale,multi‐sectoral nutrition program influences knowledge and practices while enhancing equity

The burden of undernutrition in South Asia is greater than anywhere else. Policies and programmatic efforts increasingly address health and non‐health determinants of undernutrition. In Nepal, one large‐scale integrated nutrition program, Suaahara, aimed to reduce undernutrition among women and children in the 1,000‐day period, while simultaneously addressing inequities. In this study, we use household‐level process evaluation data (N = 480) to assess levels of exposure to program inputs and levels of knowledge and practices related to health, nutrition, and water, sanitation, and hygiene (WASH). We also assess Suaahara's effect on the differences between disadvantaged (DAG) and non‐disadvantaged households in exposure, knowledge, and practice indicators. All regression models were adjusted for potential confounders at the child‐, maternal‐, and household levels, as well as clustering. We found a higher prevalence of almost all exposure and knowledge indicators and some practice indicators in Suaahara areas versus comparison areas. A higher proportion of DAG households in Suaahara areas reported exposure, were knowledgeable, and practiced optimal behaviors related to nearly all maternal and child health, nutrition, and WASH indicators than DAG households in non‐Suaahara areas and sometimes even than non‐DAG households in Suaahara areas. Moreover, differences in some of these indicators between DAG and non‐DAG households were significantly smaller in Suaahara areas than in comparison areas. These results indicate that large‐scale integrated interventions can influence nutrition‐related knowledge and practices, while simultaneously reducing inequities.     

The association of early linear growth and haemoglobin concentration with later cognitive,motor, and social–emotional development at preschool age in Ghana

It is important to identify the periods during childhood when exposure to environmental risk factors results in long‐term neurodevelopmental deficits. Stunting and anaemia may be sensitive indicators of exposure to such risks. In a prospective cohort enrolled before birth, we investigated the association of developmental scores at 4–6 years with (a) birth length and linear growth during three postnatal periods and (2) haemoglobin (Hb) concentration at three time points. Children were participants in a follow‐up study of a randomized controlled trial of nutritional supplementation in Ghana. At 4–6 years, cognitive, motor, and social–emotional developments were assessed using standard tests adapted for this population. We estimated the associations of length‐for‐age z‐score (LAZ) at birth and postnatal linear growth (n = 710) and Hb (n = 617) with developmental scores in regression models, using multistage least squares analysis to calculate uncorrelated residuals for postnatal growth. Cognitive development at 4–6 years was significantly associated with LAZ at birth (β = 0.12, 95% CI = 0.05, 0.19), ΔLAZ from 6 to 18 months (β = 0.16, 95% CI = 0.04, 0.28), and Hb at 18 months (β = 0.13, 95% CI = 0.06, 0.20), but not with ΔLAZ during 0–6 months, ΔLAZ from 18 months to 4–6 years, Hb at 6 months, or Hb at 4–6 years. No evidence of associations with motor or social–emotional development were found. These results suggest that in similar contexts, the earlier periods prior to birth and up to 18 months are more sensitive to risk factors for long‐term cognitive development associated with LAZ and Hb compared with later childhood. This may inform the optimal timing of interventions targeting improved cognitive development.     

Mother's dietary diversity and association with stunting among children <2 years old in a low socio‐economic environment: A case–control study in an urban care setting in Dhaka,Bangladesh

Mothers are often responsible for preparing nutritious foods in their households. However, the quality of mother's diets is often neglected, which may affect both mother's and child's nutrition. Because no single food contains all necessary nutrients, diversity in dietary sources is needed to ensure a quality diet. We aimed to study the association between mother's dietary diversity and stunting in children <2 years attending Dhaka Hospital of icddr,b, a diarrhoeal disease hospital in Dhaka, Bangladesh. A case–control study (n = 296) was conducted from November 2016 to February 2017. Data were collected from mothers of stunted children <2 years (length‐for‐age z score [LAZ] < ?2) as “cases” and nonstunted (LAZ ≥ ?1) children <2 years as “controls.” Mothers were asked to recall consumption of 10 defined food groups 24 hr prior to the interview as per Guidelines for Minimum Dietary Diversity for Women. Among the mothers of cases, 58% consumed <5 food groups during the last 24 hr, compared with 45% in control mothers (P = 0.03). Children whose mothers consumed <5 food groups were 1.7 times more likely to be stunted than children whose mothers consumed ≥5 food groups (P = 0.04). Intake of food groups such as pulses, dairy, eggs, and vitamin A rich fruit was higher in control mothers. Proportion of mother's illiteracy, short stature, monthly family income <BDT 11,480, absence of bank account, and poor sanitation was also found to be higher in stunted group. Further study particularly intervention or longitudinal study to see the causality of mother's dietary diversity with child stunting is recommended.     

Early childhood development and stunting: Findings from the MAL‐ED birth cohort study in Bangladesh

Information on the association between stunting and child development is limited from low‐income settings including Bangladesh where 36% of children under‐ 5 are stunted. This study aimed to explore differences in early childhood development (ECD) between stunted (length‐for‐age z‐score [LAZ] < ?2) and nonstunted (LAZ ≥ ?2) children in Bangladesh. Children (n = 265) aged 6–24 months who participated in the MAL‐ED birth cohort study were evaluated by trained psychologists at 6, 15, and 24 months of age using the Bayley Scales of Infant and Toddler Development‐III; child length and weight were measured using standard procedures. ECD scores (z‐scores derived from cognitive, motor, language and socio‐emotional skills) were compared between stunted, underweight (weight‐for‐age z‐score < ?2), and wasted (weight‐for‐length z‐score < ?2) children, controlling for child age and sex and maternal age, education, body mass index (BMI), and depressive symptoms. Stunted children had significantly lower ECD scores than their nonstunted peers on cognitive (P = .049), motor (P < .001), language (P < .001) and social–emotional (P = .038) scales where boys had significantly lower fine motor skills compared with girls (P = .027). Mother's schooling and BMI were significant predictors of ECD. Similar to stunting, underweight children had developmental deficits in all domains (cognitive: P = .001; fine motor: P = .039, and P < .001 for both gross motor and total motor; expressive communication: P = .032; total language: P = .013; social–emotional development: P = .017). Wasted children had poor motor skills (P = .006 for the fine motor; P < .001 for both gross motor and total motor development) compared with the nonwasted peers. Early childhood stunting and underweight were associated with poor developmental outcomes in Bangladesh.     

Associations between social support,psychological well‐being,decision making,empowerment, infant and young child feeding,and nutritional status in Ugandan children ages 0 to 24 months

Maternal capabilities—qualities of mothers that enable them to leverage skills and resources into child health—hold potential influence over mother's adoption of child caring practices, including infant and young child feeding. We developed a survey (n = 195) that assessed the associations of 4 dimensions of maternal capabilities (social support, psychological health, decision making, and empowerment) with mothers' infant and young child feeding practices and children's nutritional status in Uganda. Maternal responses were converted to categorical subscales and an overall index. Scale reliability coefficients were moderate to strong (α range = 0.49 to 0.80). Mothers with higher social support scores were more likely to feed children according to the minimum meal frequency (odds ratio [OR] [95% confidence interval (CI)] = 1.38 [1.10, 1.73]), dietary diversity (OR [95% CI] = 1.56 [1.15, 2.11]), iron rich foods, (OR [95% CI] = 1.47 [1.14, 1.89]), and minimally acceptable diet (OR [95% CI] = 1.55 [1.10, 2.21]) indicators. Empowerment was associated with a greater likelihood of feeding a minimally diverse and acceptable diet. The maternal capabilities index was significantly associated with feeding the minimum number of times per day (OR [95% CI] = 1.29 [1.03, 1.63]), dietary diversity (OR [95% CI] = 1.44 [1.06, 1.94]), and minimally acceptable diet (OR [95% CI] = 1.43 [1.01, 2.01]). Mothers with higher psychological satisfaction were more likely to have a stunted child (OR [95% CI] = 1.31 [1.06, 1.63]). No other associations between the capabilities scales and child growth were significant. Strengthening social support for mothers and expanding overall maternal capabilities hold potential for addressing important underlying determinants of child feeding in the Ugandan context.     

Changes in growth,anaemia, and iron deficiency among children aged 6–23 months in two districts in Nepal that were part of the post‐pilot scale‐up of an integrated infant and young child feeding and micronutrient powder intervention

There is limited research on integrated infant and young child feeding (IYCF) and micronutrient powders (MNPs) programmes operating at scale, despite widespread implementation. This study uses cross‐sectional baseline (n = 2,542) and endline (n = 2,578) surveys representative of children 6–23 months in two districts in Nepal that were part of a post‐pilot scale‐up of a IYCF–MNP programme. Multivariable log‐binomial regression models were used to estimate prevalence ratios (PRs) for stunting (length‐for‐age z‐score <?2), wasting (weight‐for‐length z‐score <?2), underweight (weight‐for‐age z‐score <?2), anaemia (altitude‐adjusted haemoglobin <110 μg/L), moderate or severe anaemia (altitude‐adjusted haemoglobin <100 g/L), iron deficiency (inflammation‐adjusted ferritin <12 μg/L), and iron deficiency anaemia (iron deficiency + anaemia [IDA]) at endline versus baseline and also to compare children in the endline survey based on frequency of mothers' interactions with female community health volunteers (FCHVs; >1× per month or monthly vs. <1× per month) and MNP coverage (1 or ≥2 distributions vs. none among children 12–23 months). Endline children were significantly less likely to be stunted than baseline children in both districts (multivariable‐adjusted PR [95% CI]: 0.77 [0.69, 0.85], P < 0.001 and 0.82 [0.75, 0.91], P < 0.001 in Kapilvastu and Achham, respectively); however, only Achham had significantly lower prevalences of underweight, moderate/severe anaemia, iron deficiency, and IDA at endline. At endline, 53.5% and 71.4% of children had tried MNP in Kapilvastu and Achham districts, respectively, consuming an average of 24 sachets from the last distribution. Frequent maternal–FCHV interactions were associated with a reduced risk of stunting and underweight at endline, whereas repeat MNP coverage was associated with reduced risk of anaemia and IDA. Future research using experimental designs should verify the potential of integrated IYCF–MNP programmes to improve children's nutritional status.     

Women's bargaining power and child feeding in Nepal: Linkages through nutrition information

Women's intra‐household bargaining power is an important determinant of child nutritional status, but there is limited evidence on how it relates to infant and young child feeding (IYCF) practices. We conducted a cross‐sectional analysis using 2012 baseline data from the impact evaluation of Suaahara, a multisectoral programme in Nepal, focusing on households with children 0–23 months (n = 1787). We examined if women's bargaining power was related to exposure to IYCF information and if exposure to IYCF information was in turn associated with improved IYCF practices: early initiation of breastfeeding, exclusive breastfeeding, minimum meal frequency and dietary diversity. Bargaining power consisted of four domains: (i) ownership and control of assets; (ii) social participation; (iii) workload; and (iv) household decision‐making control and were primarily measured using additive scales. We used generalized structural equation modelling to examine if exposure to IYCF information mediated the relationship between the bargaining domains and the four IYCF practices, separately. Social participation was positively associated with exposure to IYCF information (β = 0.266, P < .001), which in turn was related to early initiation (β = 0.241, P = .001). We obtained similar results for the relationship between social participation and dietary diversity. Decision‐making control was directly associated with exclusive breastfeeding (β = 0.350, P = .036). No domains were associated with minimum meal frequency. Different domains of women's bargaining power may relate to exposure to nutrition information and IYCF behaviours. Understanding specific domains of bargaining power is critical to developing interventions that can effectively address gender‐related issues that underlie child nutrition outcomes.     

Women's empowerment and child nutritional status in South Asia: a synthesis of the literature

Women's disempowerment is hypothesised to contribute to high rates of undernutrition among South Asian children. However, evidence for this relationship has not been systematically reviewed. This review of empirical studies aims to: (1) synthesise the evidence linking women's empowerment and child nutritional status in South Asia and (2) suggest directions for future research. We systematically searched Global Health, Embase (classic and Ovid), MEDLINE, Campbell Collaboration, Popline, Eldis, Web of Science, EconLit and Scopus. We generated 1661 studies for abstract and title screening. We full‐text screened 44 of these, plus 10 additional studies the authors were aware of. Only 12 studies fulfilled our inclusion criteria. We included English materials published between 1990 and 2012 that examined the relationship(s) of at least one women's empowerment domain and nutritional status among South Asian children. Data were extracted and synthesised within three domains of empowerment: control of resources and autonomy, workload and time, and social support. The results showed women's empowerment to be generally associated with child anthropometry, but the findings are mixed. Inter‐study differences in population characteristics, settings or methods/conceptualisations of women's empowerment, and the specific domains studied, likely contributed to these inconsistencies. This review also highlights that different women's empowerment domains may relate differently to child nutritional status. Future research should aim to harmonise definitions of women's empowerment, which key domains it should include, and how it is measured. Rigorous evaluation work is also needed to establish which policies and programmes facilitate women's empowerment and in turn, foster child nutritional well‐being.     

Agro‐ecological zone and farm diversity are factors associated with haemoglobin and anaemia among rural school‐aged children and adolescents in Ghana

Understanding contextual risk factors for haemoglobin (Hb) status and anaemia of rural school‐aged children (SAC) and adolescents is critical in developing appropriate interventions to prevent anaemia. We analysed secondary data from the baseline of an impact evaluation of the Ghana School Feeding Programme to determine the severity of anaemia and contextual factors associated with anaemia and Hb status among rural SAC (6–9 years; n = 323) and adolescents (10–17 years; n = 319) in Ghana. We used regression models with variable selection based on backward elimination in our analyses. The mean Hb was 113.8 ± 13.1 g/L, and the overall prevalence of anaemia was 52.3%, being 55.1% and 49.5% among SAC and adolescents, respectively. We identified child's age (β = 2.21, P < 0.001); farm diversity score (β = 0.59, P = 0.036); and agro‐ecological zone (P trend <0.001) as the main predictors of Hb of SAC. Household asset index (P trend = 0.042) and agro‐ecological zone (P trend <0.001) were predictors of Hb in adolescents. Agro‐ecological zone and age were predictors of anaemia, but the effect of age was only significant for girls and not boys (prevalence odds ratio [POR] = 1.35, 95% CI [1.04, 1.76] vs. POR = 1.14, 95% CI [0.88, 1.46]). SAC in households with maize stock were less likely to be anaemic (POR = 0.55, 95% CI [0.32, 0.97]). Household dietary diversity score (β = 0.59, P = 0.033) was associated with Hb status for the full sample only. Anaemia is a severe public health problem among SAC and adolescents in rural Ghana irrespective of sex. Farm diversity score, availability of maize stock in the household, household asset index, and agro‐ecological zone were the main predictors of Hb and anaemia among the rural SAC and adolescents.     

Nutrition‐sensitive agricultural interventions and gender dynamics: A qualitative study in Nepal

Undernutrition and low women's status persist as major development obstacles in South Asia and specifically, Nepal. Multi‐sectoral approaches, including nutrition‐sensitive agriculture, are potential avenues for further reductions in undernutrition. Although evidence is growing, many questions remain regarding how gender mediates the translation of agricultural production activities into nutritional benefit. In this study, we examined how gender influences the pathway from agricultural production to improved income and control of income, with a focus on five domains of empowerment: decision‐making power, freedom of mobility, social support, workload and time, and self‐efficacy. For this, we conducted a qualitative retrospective assessment (N = 10 FGDs) among 73 beneficiary women of a nutrition‐sensitive agriculture programme implemented from 2008 to 2012 in two districts of Nepal—Baitadi and Kailali. We found that women reported increased decision‐making power, new knowledge and skills, increased recognition by their family members of their new knowledge and contributions, and self‐efficacy as farmers and sellers, whereas workload and time were the most consistent constraints noted. We also found that each empowerment domain operated differently at different stages of the pathway, sometimes representing barriers and at other times, opportunities and that the interconnectedness of the domains made them difficult to disentangle in practice. Finally, there were major contextual differences for some domains (e.g., freedom of mobility) between the two districts. Future policies and programmes need to include in‐depth formative research to ensure that interventions address context‐specific gender and social norms to maximise programmatic opportunities to achieve desired results.     

Supplementation during pregnancy with small‐quantity lipid‐based nutrient supplements or multiple micronutrients,compared with iron and folic acid,increases women's urinary iodine concentration in semiurban Ghana: A randomized controlled trial

There is little information on whether prenatal multiple micronutrient (MMN) supplements containing iodine affect women's iodine status. In the International Lipid‐based Nutrient Supplements DYAD‐Ghana trial, we aimed to assess women's urinary iodine concentration (UIC, μg/L) during pregnancy, as one of the planned secondary outcomes. Women (n = 1,320) <20 weeks of gestation were randomized to consume 60 mg iron and 400 μg folic acid per day (iron and folic acid [IFA]); 18 vitamins and minerals including 250 μg iodine per day (MMN); or 20 g/day of small‐quantity lipid‐based nutrient supplements (LNS) with the same and additional 4 vitamins and minerals as the MMN (LNS). In a subsample (n = 295), we tested differences in groups' geometric mean UICs at 36 weeks of gestation controlling for baseline UIC and compared the geometric means (approximately median UICs) with the World Health Organization (WHO) cut‐offs: median UIC <150, 150–249, and ≥500 reflecting low, adequate, and excessive iodine intakes, respectively. At baseline, overall median UIC was 137. At 36 weeks of gestation, controlling for baseline UIC, geometric mean (95% confidence interval) UICs of the MMN (161 [133, 184]) and LNS (158 [132, 185]) groups did not differ; both values were significantly greater (overall p = .004) than that of the IFA group (116 [101, 135]). The median UICs of the MMN and LNS groups were within the WHO “adequate” range, whereas that of the IFA group was below the WHO adequate range. In this setting, supplementation during pregnancy with small‐quantity LNS or MMN providing iodine at the WHO‐recommended dose, compared with IFA, increases the likelihood of adequate iodine status.     

Caregiver–infant's feeding behaviours are associated with energy intake of 9‐11 month‐old infants in rural Ethiopia

Inappropriate complementary feeding, both in quantity and quality, is a major determinant of undernutrition. However, little is known about how infant–caregiver's feeding behaviours affect infants' energy intake. Therefore, the objective of this study was to characterize infant–caregiver feeding behaviours and investigate their association with infants' energy intake. The study involved 106 mother–child pairs recruited from seven randomly selected kebeles of Mecha district, West Gojam, Ethiopia. The feeding styles were assessed through observations of 1‐day, in‐home, feeding episodes that were videotaped and coded into self‐feeding, responsive, active, distracting, and social feeding behaviours. Infants' haemoglobin and anthropometric measurements were taken. The association between feeding behaviour scores and energy intake per meal was investigated. The mean food intake of the infants was very low (11.4 ± 7.0 g/kg body weight per meal) compared to the minimum theoretical gastric capacity (30 g/kg body weight per meal). Infants' haemoglobin concentration was negatively associated with energy intake (ρ = 0.178, p = .03). Infants' responsive and active positive feeding styles were positively associated with energy intakes (ρ = 0.258 and 0.432, p = .004 and p < .001, respectively) as well as caregivers' responsive positive feeding styles (ρ = 0.237, p = .007). Both haemoglobin concentrations and feeding styles were associated with infant's energy intake. Anaemia prevention and control measures should be reinforced. Current nutrition education programmes should give emphasis on ways to effectively incorporate culturally adapted responsive feeding messages in this and similar settings.     

Adaptation of a mental development assessment tool for the evaluation of the long‐term effect of a successful nutrition intervention in Ghana

This study adapted a cognitive assessment tool to be used in evaluating nutrition interventions in developing countries and assessed its reliability and validity in Ghana. The tool was used to evaluate the long‐term effect of the Enhancing Child Nutrition through Animal Source Food Management (ENAM) project. The former ENAM participants' children were contacted (now 13 to 15 years old). The items in the Wechsler Abbreviated Scale of Intelligence‐II were adapted, pretested, refined, and pretested again. Cross‐sectional data collection was conducted with former ENAM participants (60 interventions and 51 comparison families) in one of ENAM's three sites (the Guinea Savanna zone). Data on participants' socio‐economic status and food insecurity were collected, along with their children's intellectual functioning, dietary intake, school attainment, anthropometry, and symptoms of depression. Alpha coefficient of the verbal subscale improved between the first and second pretest (from .34 to .80). After controlling for age, the intelligence scores of the children were associated with their grade (r = .35, p = .001) and academic performance (r = .26 to .33, p < .05). The verbal scale was associated with their anthropometry (r = .24 to .27, p < .05). The intervention children still recorded a better dietary diversity score than controls (6.8 vs 5.8, p = .0001); however, significance was lost after adjusting for confounders. There were no significant group differences in growth or intellectual functioning. The adapted Wechsler Abbreviated Scale of Intelligence‐II tool performed well in evaluating adolescent intellectual functioning in rural Ghana, and there were no long‐term effects of ENAM intervention on child growth and development.     

An integrated infant and young child feeding and small‐quantity lipid‐based nutrient supplementation programme in the Democratic Republic of Congo is associated with improvements in breastfeeding and handwashing behaviours but not dietary diversity

Integrating small‐quantity lipid‐based nutrient supplements (SQ‐LNS) into infant and young child feeding (IYCF) programmes can increase consumption of essential nutrients among children in vulnerable populations; however, few studies have assessed the impact of integrated IYCF–SQ‐LNS programmes on IYCF practices. A 2‐year, enhanced IYCF intervention targeting pregnant women and infants (0–12 months) was implemented in a health zone in the Democratic Republic of Congo (DRC). The enhanced IYCF intervention included community‐ and facility‐based counselling for mothers on handwashing, SQ‐LNS, and IYCF practices, plus monthly SQ‐LNS distributions for children 6–12 months; a control zone received the national IYCF programme (facility‐based IYCF counselling with no SQ‐LNS distributions). Cross‐sectional preintervention and postintervention surveys (n = 650 and 638 in intervention and control areas at baseline; n = 654 and 653 in each area at endline, respectively) were conducted in mothers of children 6–18 months representative of both zones. Difference in differences (DiD) analyses used mixed linear regression models. There were significantly greater increases in the proportion of mothers in the intervention (vs. control) zone who reported: initiating breastfeeding within 1 hr of birth (Adj. DiD [95% CI]: +56.4% [49.3, 63.4], P < 0.001), waiting until 6 months to introduce water (+66.9% [60.6, 73.2], P < 0.001) and complementary foods (+56.4% [49.3, 63.4], P < 0.001), feeding the minimum meal frequency the previous day (+9.2% [2.7, 15.7], P = 0.005); feeding the child in a separate bowl (+9.7% [2.2, 17.2], P = 0.01); awareness of anaemia (+16.9% [10.4, 23.3], P < 0.001); owning soap (+14.9% [8.3, 21.5], P < 0.001); and washing hands after defecating and before cooking and feeding the child the previous day (+10.5% [5.8, 15.2], +12.5% [9.3, 15.6] and +15.0% [11.2, 18.8], respectively, P < 0.001 for all). The enhanced IYCF intervention in the DRC was associated with an improvement in several important IYCF practices but was not associated with a change in dietary diversity (minimum dietary diversity and minimum acceptable diet remained below 10% in both zones without significant differences between zones). The provision of fortified complementary foods, such as SQ‐LNS, may be an important source of micronutrients and macronutrients for young children in areas with high rates of poverty and limited access to diverse foods. Future research should verify the potential of integrated IYCF–SQ‐LNS to improve IYCF practices, and ultimately children's nutritional status.     

The impact of caregiver post‐traumatic stress and depressive symptoms on pediatric transplant outcomes

PTSS as well as symptoms of depression have been reported in children who experience a serious medical adversity as well as their caretakers. The adverse effects of PTSS, when experienced by the patients, on medical outcomes have been clearly documented. However, the impact of those symptoms, if any, when experienced by the caretakers on child outcomes has not been investigated prospectively. We evaluated whether caregiver PTSS and depression symptoms predict adherence to medications and medical outcomes in a prospective multisite study. Four hundred children participated in MALT. Caretaker PTSS were assessed by the IES and depressive symptoms by CES‐D. During 2 years of follow‐up, the MLVI was used to determine adherence. Centrally read, biopsy‐confirmed organ rejection was the primary medical outcome. IES scores were not associated with either adherence or rejection outcomes. In contrast, there were significant correlations between CES‐D (depression) scores and lower adherence, r = .13, P < .001, and a trend toward higher scores on the CES‐D among those whose children had experienced rejection, 12.4 (SD = 10.9) versus 9.1 (SD = 8.6), P = .077. Caregivers' PTSS were not a risk factor for poor child outcomes in this cohort, whereas depression symptoms were associated with non‐adherence and possibly increased rates of rejection. Further study can validate if caregivers' depression as opposed to PTSS confers greater risk and should be a focus during the clinical care of medically ill children.     

Determinants of growth in HIV‐exposed and HIV‐uninfected infants in the Kabeho Study

HIV‐exposed and HIV‐uninfected (HEU) infants may be at increased risk of poor health and growth outcomes. We characterized infant growth trajectories in a cohort of HEU infants to identify factors associated with healthy growth. HIV‐positive women participating in prevention of mother‐to‐child HIV transmission programmes in Kigali, Rwanda, were followed until their infants were 2 years old. Infant anthropometrics were regularly collected. Latent class analysis was used to categorize infant growth trajectories. Multiple logistic regression was used to estimate the odds of infants belonging to each growth trajectory class. On average, this population of HEU infants had moderate linear growth faltering, but only modest faltering in weight, resulting in mean weight‐for‐length z‐score (WLZ) above the World Health Organization (WHO) median. Mean WLZ was 0.53, and mean length‐for‐age z‐score (LAZ) was ?1.14 over the first 2 years of life. We identified four unique WLZ trajectories and seven trajectories in LAZ. Low neonatal weight‐for‐age and a high rate of illness increased the likelihood that infants were in the lightest WLZ class. Shorter mothers were more likely to have infants with linear growth faltering. Female infants who were older at the end of exclusive breastfeeding were more likely to be in the second tallest LAZ class. In conclusion, the current WHO recommendations of Option B+ and extended breastfeeding may induce higher WLZ and lower LAZ early in infancy. However, there is considerable heterogeneity in growth patterns that is obscured by simply analysing average growth trends, necessitating the analysis of growth in subpopulations.