A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency

Abstract

Background Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools. Objectives This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity. Methods We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social–emotional), anthropometry, and morbidity to preschoolers (aged 29–49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale–Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools. Results At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social–emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity. Conclusions Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers’ expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers’ development. This trial was registered at clinicaltrials.gov as NCT01660958.

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

“…Table 2 summarizes the characteristics of RCTs contained in this review. In summary, 50% of trials were conducted in developed countries [55][56][57][58][59][60] and 50% in low and middleincome countries (LMICs) [61][62][63][64][65][66]. Four experimental studies were conducted in rural areas with low socioeconomic status [61,62,64,66], and six studies in urban areas with high socioeconomic status [55][56][57][58][59][60].…”

“…Four experimental studies were conducted in rural areas with low socioeconomic status [61,62,64,66], and six studies in urban areas with high socioeconomic status [55][56][57][58][59][60]. The earliest trial was completed in 2004 [58] and the latest in 2020 [65]. The shortest intervention was implemented for two months [58], and the longest trial lasted ten months [61].…”

“…Six studies had an overall low risk of bias [55,56,59,60,65,66] and six had a moderate risk of bias [57,58,[61][62][63][64] as indicated in Table 3. Five studies did not record methods of handling withdrawal [57,58,[61][62][63] and two studies [57,64] reported moderate differences between study groups at baseline.…”

Comparing costs and cost‐efficiency of platforms for micronutrient powder (MNP) delivery to children in rural Uganda

“…[11][12][13] Efficacy trials in LMICs have shown that MNP can deliver sufficient iron to reduce anemia and the prevalence of iron deficiency in young children 14 and may also increase cognitive performance. 15 While MNP is efficacious when compliance is ensured, adherence to MNP protocols among beneficiaries varies widely. 16 MNP has been promoted as a low-cost and effective intervention, 12 reportedly costing $3.60 per child per year, 17 with a cost-effectiveness ratio as high as 37:1 (calculated as the present value of the gain in earnings for each dollar spent on the intervention).…”

“…11 , 12 , 13 Efficacy trials in LMICs have shown that MNP can deliver sufficient iron to reduce anemia and the prevalence of iron deficiency in young children 14 and may also increase cognitive performance. 15 While MNP is efficacious when compliance is ensured, adherence to MNP protocols among beneficiaries varies widely. 16 …”