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Meta-Analysis
. 2015 Mar 5;2015(3):CD009924.
doi: 10.1002/14651858.CD009924.pub2.

Food supplementation for improving the physical and psychosocial health of socio-economically disadvantaged children aged three months to five years

Affiliations
Meta-Analysis

Food supplementation for improving the physical and psychosocial health of socio-economically disadvantaged children aged three months to five years

Elizabeth Kristjansson et al. Cochrane Database Syst Rev. .

Abstract

Background: Undernutrition contributes to five million deaths of children under five each year. Furthermore, throughout the life cycle, undernutrition contributes to increased risk of infection, poor cognitive functioning, chronic disease, and mortality. It is thus important for decision-makers to have evidence about the effectiveness of nutrition interventions for young children.

Objectives: Primary objective1. To assess the effectiveness of supplementary feeding interventions, alone or with co-intervention, for improving the physical and psychosocial health of disadvantaged children aged three months to five years.Secondary objectives1. To assess the potential of such programmes to reduce socio-economic inequalities in undernutrition.2. To evaluate implementation and to understand how this may impact on outcomes.3. To determine whether there are any adverse effects of supplementary feeding.

Search methods: We searched CENTRAL, Ovid MEDLINE, PsycINFO, and seven other databases for all available years up to January 2014. We also searched ClinicalTrials.gov and several sources of grey literature. In addition, we searched the reference lists of relevant articles and reviews, and asked experts in the area about ongoing and unpublished trials.

Selection criteria: Randomised controlled trials (RCTs), cluster-RCTs, controlled clinical trials (CCTs), controlled before-and-after studies (CBAs), and interrupted time series (ITS) that provided supplementary food (with or without co-intervention) to children aged three months to five years, from all countries. Adjunctive treatments, such as nutrition education, were allowed. Controls had to be untreated.

Data collection and analysis: Two or more review authors independently reviewed searches, selected studies for inclusion or exclusion, extracted data, and assessed risk of bias. We conducted meta-analyses for continuous data using the mean difference (MD) or the standardised mean difference (SMD) with a 95% confidence interval (CI), correcting for clustering if necessary. We analysed studies from low- and middle-income countries and from high-income countries separately, and RCTs separately from CBAs. We conducted a process evaluation to understand which factors impact on effectiveness.

Main results: We included 32 studies (21 RCTs and 11 CBAs); 26 of these (16 RCTs and 10 CBAs) were in meta-analyses. More than 50% of the RCTs were judged to have low risk of bias for random selection and incomplete outcome assessment. We judged most RCTS to be unclear for allocation concealment, blinding of outcome assessment, and selective outcome reporting. Because children and parents knew that they were given food, we judged blinding of participants and personnel to be at high risk for all studies.Growth. Supplementary feeding had positive effects on growth in low- and middle-income countries. Meta-analysis of the RCTs showed that supplemented children gained an average of 0.12 kg more than controls over six months (95% confidence interval (CI) 0.05 to 0.18, 9 trials, 1057 participants, moderate quality evidence). In the CBAs, the effect was similar; 0.24 kg over a year (95% CI 0.09 to 0.39, 1784 participants, very low quality evidence). In high-income countries, one RCT found no difference in weight, but in a CBA with 116 Aboriginal children in Australia, the effect on weight was 0.95 kg (95% CI 0.58 to 1.33). For height, meta-analysis of nine RCTs revealed that supplemented children grew an average of 0.27 cm more over six months than those who were not supplemented (95% CI 0.07 to 0.48, 1463 participants, moderate quality evidence). Meta-analysis of seven CBAs showed no evidence of an effect (mean difference (MD) 0.52 cm, 95% CI -0.07 to 1.10, 7 trials, 1782 participants, very low quality evidence). Meta-analyses of the RCTs demonstrated benefits for weight-for-age z-scores (WAZ) (MD 0.15, 95% CI 0.05 to 0.24, 8 trials, 1565 participants, moderate quality evidence), and height-for-age z-scores (HAZ) (MD 0.15, 95% CI 0.06 to 0.24, 9 trials, 4638 participants, moderate quality evidence), but not for weight-for-height z-scores MD 0.10 (95% CI -0.02 to 0.22, 7 trials, 4176 participants, moderate quality evidence). Meta-analyses of the CBAs showed no effects on WAZ, HAZ, or WHZ (very low quality evidence). We found moderate positive effects for haemoglobin (SMD 0.49, 95% CI 0.07 to 0.91, 5 trials, 300 participants) in a meta-analysis of the RCTs.Psychosocial outcomes. Eight RCTs in low- and middle-income countries assessed psychosocial outcomes. Our meta-analysis of two studies showed moderate positive effects of feeding on psychomotor development (SMD 0.41, 95% CI 0.10 to 0.72, 178 participants). The evidence of effects on cognitive development was sparse and mixed.We found evidence of substantial leakage. When feeding was given at home, children benefited from only 36% of the energy in the supplement. However, when the supplementary food was given in day cares or feeding centres, there was less leakage; children took in 85% of the energy provided in the supplement. Supplementary food was generally more effective for younger children (less than two years of age) and for those who were poorer/ less well-nourished. Results for sex were equivocal. Our results also suggested that feeding programmes which were given in day-care/feeding centres and those which provided a moderate-to-high proportion of the recommended daily intake (% RDI) for energy were more effective.

Authors' conclusions: Feeding programmes for young children in low- and middle-income countries can work, but good implementation is key.

PubMed Disclaimer

Conflict of interest statement

Elizabeth Kristjansson ‐ none known. Damian K Francis ‐ none known. Selma Liberato ‐ none known. Maria Benkhalti Jandu ‐ none known. Vivian Welch ‐ none known. Malek Batal ‐ none known. Trish Greenhalgh ‐ none known. Tamara Rader ‐ none known. Eamonn Noonan ‐ none known. Beverley Shea ‐ none known. Laura Janzen ‐ none known. George A Wells ‐ none known. Mark Petticrew ‐none known.

Figures

1
1
Types of feeding programs in the preschool review
2
2
Conceptual model for feeding interventions to improve physical and psychosocial health of children aged two months to five years Footnotes SES ‐ socio‐economic status HH ‐ household
3
3
Study flow diagram
4
4
Risk of bias summary for RCTs: review authors' judgements about each risk of bias item for each included study
5
5
Forest plot of comparison: 11 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT. Outcome: 11.9 Single food intervention vs multifaceted intervention: height gain in cm
1.1
1.1. Analysis
Comparison 1 Low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 1 Weight gain.
1.2
1.2. Analysis
Comparison 1 Low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 2 Height gain.
1.3
1.3. Analysis
Comparison 1 Low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 3 Weight‐for‐age z‐scores (WAZ).
1.4
1.4. Analysis
Comparison 1 Low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 4 Height‐for‐age z‐scores (HAZ).
1.5
1.5. Analysis
Comparison 1 Low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 5 Weight‐for‐height z‐scores (WHZ).
2.1
2.1. Analysis
Comparison 2 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 1 Weight gain.
2.2
2.2. Analysis
Comparison 2 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 2 WAZ scores.
2.3
2.3. Analysis
Comparison 2 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 3 HAZ scores.
2.4
2.4. Analysis
Comparison 2 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control ‐ growth. RCT, Outcome 4 WHZ scores.
3.1
3.1. Analysis
Comparison 3 Low‐ and middle‐income countries: feeding vs control. CBA, Outcome 1 Weight gain (kg).
3.2
3.2. Analysis
Comparison 3 Low‐ and middle‐income countries: feeding vs control. CBA, Outcome 2 Height gain (cm).
3.3
3.3. Analysis
Comparison 3 Low‐ and middle‐income countries: feeding vs control. CBA, Outcome 3 WAZ scores.
3.4
3.4. Analysis
Comparison 3 Low‐ and middle‐income countries: feeding vs control. CBA, Outcome 4 HAZ scores.
3.5
3.5. Analysis
Comparison 3 Low‐ and middle‐income countries: feeding vs control. CBA, Outcome 5 WHZ scores.
4.1
4.1. Analysis
Comparison 4 High‐income countries: feeding vs control. RCT, Outcome 1 Weight gain.
4.2
4.2. Analysis
Comparison 4 High‐income countries: feeding vs control. RCT, Outcome 2 Height gain.
4.3
4.3. Analysis
Comparison 4 High‐income countries: feeding vs control. RCT, Outcome 3 WAZ scores.
4.4
4.4. Analysis
Comparison 4 High‐income countries: feeding vs control. RCT, Outcome 4 HAZ scores.
4.5
4.5. Analysis
Comparison 4 High‐income countries: feeding vs control. RCT, Outcome 5 WHZ scores.
5.1
5.1. Analysis
Comparison 5 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control. CBA, Outcome 1 Weight gain (kg).
5.2
5.2. Analysis
Comparison 5 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control. CBA, Outcome 2 Height gain (cm).
5.3
5.3. Analysis
Comparison 5 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control. CBA, Outcome 3 WAZ scores.
5.4
5.4. Analysis
Comparison 5 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control. CBA, Outcome 4 HAZ scores.
5.5
5.5. Analysis
Comparison 5 Sensitivity analysis ICC 0.10: low‐ and middle‐income countries: feeding vs control. CBA, Outcome 5 WHZ scores.
6.1
6.1. Analysis
Comparison 6 Low‐ and middle‐income countries: feeding vs control ‐ psychosocial development. RCT, Outcome 1 Psychomotor development.
6.2
6.2. Analysis
Comparison 6 Low‐ and middle‐income countries: feeding vs control ‐ psychosocial development. RCT, Outcome 2 Cognitive development: test battery.
6.3
6.3. Analysis
Comparison 6 Low‐ and middle‐income countries: feeding vs control ‐ psychosocial development. RCT, Outcome 3 Cognitive development: Bayley's Mental Development Index (BMDI).
7.1
7.1. Analysis
Comparison 7 High‐income countries. CBA, Outcome 1 Weight.
7.2
7.2. Analysis
Comparison 7 High‐income countries. CBA, Outcome 2 Height.
8.1
8.1. Analysis
Comparison 8 Low‐ and middle‐income countries: feeding vs control ‐ biochemical markers. RCT, Outcome 1 Change in haemoglobin (g/L).
9.1
9.1. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 1 Subgroup analysis: weight by sex.
9.2
9.2. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 2 Subgroup analysis: height by sex.
9.3
9.3. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 3 Nutritional adequacy. Low vs moderate vs high: weight gain in kg.
9.4
9.4. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 4 Nutritional adequacy. Low vs moderate vs high: height gain in cm.
9.5
9.5. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 5 Day‐care/feeding centre vs take‐home ration: weight gain in kg.
9.6
9.6. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 6 Day‐care/feeding centre vs take‐home ration: height gain in cm.
9.7
9.7. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 7 Strict supervision of feeding vs moderate supervision vs low supervison: weight gain in kg.
9.8
9.8. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 8 Strict supervision of feeding vs moderate supervision vs low supervison: height gain in cm.
9.9
9.9. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 9 Single food intervention vs multifaceted intervention: weight gain in kg.
9.10
9.10. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 10 Single food intervention vs multifaceted intervention: height gain in cm.
9.11
9.11. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 11 Sensitivity analysis: day care: weight.
9.12
9.12. Analysis
Comparison 9 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. CBA, Outcome 12 Sensitivity analysis: daycare: height.
10.1
10.1. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 1 Baseline WAZ lower than median vs higher than median: weight gain in kg.
10.2
10.2. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 2 Baseline WAZ lower than median vs higher than median: height gain in cm.
10.3
10.3. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 3 Nutritional adequacy. Low vs moderate vs high: weight gain in kg.
10.4
10.4. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 4 Nutritional adequacy. Low vs moderate vs high: height gain in cm.
10.5
10.5. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 5 Day‐care/feeding centre vs take‐home ration: weight gain in kg.
10.6
10.6. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 6 Strict supervision of feeding vs moderate supervision vs low supervison: weight gain in kg.
10.7
10.7. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 7 Strict supervision of feeding vs moderate supervision vs low supervison: height gain in cm.
10.8
10.8. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 8 Single food intervention vs multifaceted intervention: weight gain in kg.
10.9
10.9. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 9 Single food intervention vs multifaceted intervention: height gain in cm.
10.10
10.10. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 10 Single food intervention vs multifaceted intervention: psychomotor development.
10.11
10.11. Analysis
Comparison 10 Low‐ and middle‐income countries: subgroup analysis ‐ feeding vs control. RCT, Outcome 11 Exploratory analysis of well‐implemented studies (Bhandari, Grantham‐MacGregor, Kuuisiaplo).

Update of

References

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Baertl 1970 {published data only}
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Hicks 1982 {published data only}
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References to other published versions of this review

Kristjansson 2012
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