Pakistan is one of 10 countries with the highest number of undernourished mothers, and children with high rates of fetal under-nutrition and low birth weight. [1] Many children do not meet their developmental potential by the age of 5. [2] This exposure to early adversity has serious repercussions for subsequent growth, cognitive development, school readiness and educational achievement and could potentially impact on economic growth and development.

The goal of the project is to demonstrate the relationship, if any, between nutrition interventions in pregnancy and infancy with intermediate and long term outcomes in representative at-risk populations.

This project will follow three cohorts of children who received nutrition interventions in the first 1000 days of life. In the first cohort, maternal micronutrient supplementation was administered. The second cohort received micronutrient supplementation as newborns. The third cohort received complementary feeding strategies to support micronutrient status and child growth. Now 4-9 years later, the children enrolled in these three interventions will be followed up and assessed on growth, developmental outcomes, and school performance. This is the first such cohort tracing exercise in Pakistan in relation to the continuum of maternal, infant and young child interventions and will offer a unique insight into the effects of early life interventions and exposures.

• Better weight gain and lower diarrhea morbidity in the first six months of life for newborns who received micronutrient supplementation.
• Increase in birth weight among infants whose mothers received multiple micronutrients over those whose mothers received iron folic acid supplements.
• 1,819 assessments conducted with children across three interventions groups.

Funders

• Grand Challenges Canada

Key Drivers

1. Multidisciplinary study team

Multidisciplinary study team with expertise in nutrition, field epidemiology and child development

2. Strong infrastructure

Strong infrastructure in the Aga Khan university including a nutrition laboratory and field site research offices with trained personnel

3. High re-enrollment capacity

Facilitated by the fact that households are well characterized and Geographical Information System (GIS)- mapped; additionally, populations are relatively stable and team has ongoing demographic surveillance in these sites.

Challenges

• Logistics and quality-control challenges of blood collection in field settings is a challenge.
• Buy-in from the community members and health department for these interventions.
• Recruitment of sufficient numbers of participants from original cohorts.
• Sociopolitical situation at one field site led to delays.

The present study will follow 3 cohorts of children previously involved in rigorous randomized control trials. The long term effects on human capital following intervention in the first 1000 days of life will be assessed at several time points in early childhood (preschool and school age) in the available cohorts.

 Three study teams consisting of a trained physician, child development specialist and community health worker are undertaking nutrition assessments (anthropometry) and standard health assessments by clinical examination. Appropriate household-level information, socioeconomic indicators and information on key health and nutrition practices is being obtained from the parents through home visits by the study teams. Formal information on school performance is obtained from the school system’s regular records. Laboratory assessments will be conducted, including phlebotomy for blood sampling, urine collections for iodine status, BIA and indirect calorimetry. A quality control and quality assurance system will be in place for all data collection procedures.

Outcome measures assessed in the child include: morbidity, injuries and health (e.g. infection and hospitalization history), physical growth, body mass index and metabolic rate, nutrition and micronutrient status and development. Measures assess for the household include food security, physical environment and care-giving environment (i.e. learning and language stimulation). Maternal emotional well-being and reasoning ability are also assessed.

Re-enrollment rates were 58% of original participants across the 3 original studies, for a total of approximately 1818 children overall. This project expects to demonstrate the relationship, if any, between nutrition interventions in pregnancy and early infancy with intermediate and long-term cognitive outcomes in children in at-risk populations. Assessments as outlined above are currently underway.

1. Khan Y, Bhutta ZA. (2010) Nutritional deficiencies in the developing world: current status and opportunities for intervention. Pediatr Clin North Am. 2010;57(6):1409-41.
2. Grantham-McGregor S., et al. (2007) Developmental potential in the first 5 years for children in developing countries. Lancet 2007, 369(9555):60-70.
3. Bhutta ZA, et al. (2009) A comparative evaluation of multiple micronutrient and iron-folic acid supplementation during pregnancy in Pakistan: impact on pregnancy outcomes. Food and Nutrition Bulletin. 30(4 Suppl):S496-505.