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Interventions and public health nutrition

Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomised trial



Psychosocial stimulation (PS) and food supplementation (FS) improve development of malnourished children. This study evaluates the effects of a community-based approach of PS and FS on growth and development of severely malnourished children.


Severely underweight hospitalised children aged 6–24 months (n=507) were randomly allocated on discharge to five groups: (i) PS, (ii) FS, (iii) PS+FS, (iv) clinic-control and (v) hospital-control. PS included play sessions and parental counselling on child development. This was done at each fortnightly follow-up visit, that is, every second week, for 6 months at community clinics. FS included distribution of cereal-based food packets (150–300 kcal/day) for 3 months. All groups received medical care, micronutrient supplementation, health-education and growth monitoring. Children's development was assessed using revised version of Bayley Scales of Infant Development at baseline and after 3 and 6 months of intervention. Anthropometry was measured using standard procedure.


Comparing groups with any stimulation with those with no stimulation there was a significant effect of stimulation on children's mental development index (group*session interaction P=0.037, effect size=0.37 s.d.) and weight-for-age Z-score (group*session interaction P=0.02, effect size=0.26 s.d.). Poor levels of development and nutritional status were sustained, however, due to their initial very severe malnutrition. There was no effect on motor development and linear growth.


Children receiving any stimulation showed a significant benefit to mental development and growth in weight. More intensive intervention with longer duration is needed to correct their poor developmental levels and nutritional status.

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  • Ahmed T, Begum B, Badiuzzaman, Ali M, Fuchs G (2001). Management of severe malnutrition and diarrhea. Indian J Pediatr 68, 45–51.

    Article  CAS  Google Scholar 

  • Ashworth A (2006). Efficacy and effectiveness of community-based treatment of severe malnutrition. Food Nutr Bull 27 (3 Suppl), S24–S48.

    Article  Google Scholar 

  • Bayley N (1993). The Bayley Scales of Infant Development-II. Psychological corporation: San Antonio, Texas USA.

    Google Scholar 

  • Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S (2003). Mothers of undernourished Jamaican children have poorer psychosocial functioning and this is associated with stimulation provided in the home. Eur J Clin Nutr 57, 786–792.

    Article  CAS  Google Scholar 

  • Baker-Henningham H, Powell C, Walker S, Grantham-McGregor S (2005). The effect of early stimulation on maternal depression: a cluster randomised controlled trial. Arch Dis Child 90, 1230–1234.

    Article  CAS  Google Scholar 

  • Black MM, Baqui AH, Zaman K, El Arifeen S, Black RE (2009). Maternal depressive symptoms and infant growth in rural Bangladesh. Am J Clin Nutr (3), 951S–957S.

    Article  Google Scholar 

  • Black MM, Baqui AH, Zaman K, McNary SW, Le K, Arifeen SE et al. (2007). Depressive symptoms among rural Bangladeshi mothers: implications for infant development. J Child Psychol Psychiatry 48, 764–772.

    Article  Google Scholar 

  • Black MM, Sazawal S, Black RE, Khosla S, Kumar J, Menon V (2004). Cognitive and motor development among small-for-gestational-age infants: impact of zinc supplementation, birth weight, and caregiving practices. Pediatrics 113, 1297–1305.

    Article  Google Scholar 

  • Chang SM, Walker SP, Grantham-McGregor SM, Powell CA (2002). Early childhood stunting and later behaviour and school achievement. J Child Psychol Psychiatry 43, 775–783.

    Article  CAS  Google Scholar 

  • Dewey KG, Begum K (2011). Long-term consequences of stunting in early life. Matern Child Nutr 7, 5–18.

    Article  Google Scholar 

  • Freeman HE, Klein RE, Kagan J, Yarbrough C (1977). Relations between nutrition and cognition in rural Guatemala. Am J Public Health 67, 233–239.

    Article  CAS  Google Scholar 

  • Gandhi M, Ashorn P, Maleta K, Teivaanmäki T, Duan X, Cheung YB (2011). Height gain during early childhood is an important predictor of schooling and mathematics ability outcomes. Acta Paediatr 100, 1113–1118.

    Article  Google Scholar 

  • Grantham-McGregor SM (1995). A review of studies of the effect of severe malnutrition on mental development. J Nutr 125 (8 Suppl), 2233S–2238S.

    Article  CAS  Google Scholar 

  • Grantham-McGregor SM (2007). Early child development in developing countries. Lancet 369, 824.

    Article  Google Scholar 

  • Grantham-McGregor SM, Powell CA, Walker SP, Himes JH (1991). Nutritional supplementation, psychosocial stimulation and mental development of stunted children: the Jamaican Study. Lancet 338, 1–5.

    Article  CAS  Google Scholar 

  • Hamadani JD, Fuchs G, Osendarp S, Khatun F, Huda SN, Grantham-McGregor SM (2001). Randomized controlled trial of the effect of zinc supplementation on the mental development of Bangladeshi infants. Am J Clin Nutr 74, 381–386.

    Article  CAS  Google Scholar 

  • Hamadani JD, Huda SN, Khatun F, Grantham-McGregor SM (2006). Psychosocial stimulation improves the development of undernourished children in rural Bangladesh. J Nutr 136, 2645–2652.

    Article  CAS  Google Scholar 

  • Hossain MI, Nahar B, Hamadani JD, Ahmed T, Brown KH (2011). Effects of community-based follow-up care in managing severely underweight children. J Pediatr Gastroenterol Nutr 53, 310–319.

    Article  Google Scholar 

  • IPHN (2008). National Guidelines for the Management of Severely Malnourished Children in Bangladesh. Institute of Public Health Nutrition: Dhaka.

  • Karim R, Desplats G, Schaetzel T, Herforth A, Ahmed F, Salamatullah Q et al. (2005). Seeking optimal means to address micronutrient deficiencies in food supplements: a case study from the Bangladesh Integrated Nutrition Project. J Health Popul Nutr 23, 369–376.

    PubMed  Google Scholar 

  • Nahar B, Hamadani JD, Ahmed T, Tofail F, Rahman A, Huda SN et al. (2009). Effects of psychosocial stimulation on growth and development of severely malnourished children in a nutrition unit in Bangladesh. Eur J Clin Nutr 63, 725–731.

    Article  CAS  Google Scholar 

  • Powell C, Baker-Henningham H, Walker S, Gernay J, Grantham-McGregor S (2004). Feasibility of integrating early stimulation into primary care for undernourished Jamaican children: cluster randomised controlled trial. BMJ 329, 89.

    Article  Google Scholar 

  • Radloff LS (1977). The CES-D Scale: a self-report depression scale for research in the general population. Appl Psychol Meas 3, 385–401.

    Article  Google Scholar 

  • Sadler K, Myatt M, Feleke T, Collins S (2007). A comparison of the programme coverage of two therapeutic feeding interventions implemented in neighbouring districts of Malawi. Public Health Nutr 10, 907–913.

    Article  Google Scholar 

  • Sadler K, Puett C, Mothabbir G, Myatt M (2011). Community Case Management of Severe Acute Malnutrition in Southern Bangladesh. Feinstein International Centre Publication: USA.

    Google Scholar 

  • Super CM, Herrera MG, Mora JO (1990). Long-term effects of food supplementation and psychosocial intervention on the physical growth of Colombian infants at risk of malnutrition. Child Dev 61, 29–49.

    Article  CAS  Google Scholar 

  • Tofail F, Kabir I, Hamadani JD, Chowdhury F, Yesmin S, Mehreen F et al. (2008). Effects of prenatal food and micronutrient supplementation on infant development: a randomized trial from the Maternal and Infant Nutrition Interventions, Matlab (MINIMat) study. Am J Clin Nutr 87, 704–711.

    Article  CAS  Google Scholar 

  • UNICEF (2010). The State of the World's Children 2010: Child Rights. UNICEF publications: New York.

  • Waber DP, Vuori-Christiansen L, Ortiz N, Clement JR, Christiansen NE, Mora JO et al. (1981). Nutritional supplementation, maternal education, and cognitive development of infants at risk of malnutrition. Am J Clin Nutr 34, 807–813.

    Article  CAS  Google Scholar 

  • Walker SP, Chang SM, Powell CA, Grantham-McGregor SM (2004). Psychosocial intervention improves the development of term low-birth-weight infants. J Nutr 134, 1417–1423.

    Article  CAS  Google Scholar 

  • Walker SP, Chang SM, Powell CA, Grantham-McGregor SM (2005). Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. Lancet 366, 1804–1807.

    Article  Google Scholar 

  • Walker SP, Chang SM, Powell CA, Simonoff E, Grantham-McGregor SM (2006). Effects of psychosocial stimulation and dietary supplementation in early childhood on psychosocial functioning in late adolescence: follow-up of randomised controlled trial. BMJ 333, 472.

    Article  Google Scholar 

  • Walker SP, Chang SM, Powell CA, Simonoff E, Grantham-McGregor SM (2007). Early childhood stunting is associated with poor psychological functioning in late adolescence and effects are reduced by psychosocial stimulation. J Nutr 137, 2464–2469.

    Article  CAS  Google Scholar 

  • Walker SP, Chang SM, Vera-Hernández M, Grantham-McGregor S (2011). Early childhood stimulation benefits adult competence and reduces violent behavior. Pediatrics 127, 849–857.

    Article  Google Scholar 

  • Walker SP, Chang SM, Younger N, Grantham-McGregor SM (2010). The effect of psychosocial stimulation on cognition and behaviour at 6 years in a cohort of term, low-birthweight Jamaican children. Dev Med Child Neurol 52, 148–154.

    Article  Google Scholar 

  • WHO, WFP, UNSCN, UNICEF (2007). Community-based management of severe acute malnutrition: a Joint Statement by the World Health Organization, the World Food Programme, the United Nations System Standing Committee on Nutrition and the United Nations Children's Fund.

  • World Health Organization (1995). Physical Status: the Use and Interpretation of Anthropometry Report of a WHO Expert Committee. World Health Organization: Geneva. Technical report series, no 854.

  • World Health Organization (1999). Management of Severe Malnutrition: A Manual for Physicians and Other Senior Health Workers. World Health Organization: Geneva.

  • World Health Organization (2006). WHO Child Growth Standards: Length/Height-for-Age, Weight-for-Age, Weight-for-Length, Weight-for-Height and Body Mass Index-for-Age: Methods and Development. World Health Organization: Geneva.

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The study was funded by Sida/SAREC, Sweden and supported by ICDDR,B and its donors, which provide unrestricted support to the Centre for its operations and research. Current donors providing unrestricted support include: the Australian Agency for International Development (AusAID), Government of the People's Republic of Bangladesh, Canadian International Development Agency (CIDA), Embassy of the Kingdom of the Netherlands (EKN), Swedish International Development Cooperation Agency (Sida), Swiss Agency for Development and Cooperation (SDC) and Department for International Development (DFID), UK. We sincerely appreciate these donors for their support and commitment to the Centre's research efforts. The study was also supported by the International Maternal and Child Health (IMCH), Department of Women's and Children's Health, Uppsala University, Sweden. We sincerely appreciate the secretarial assistance of IMCH staffs. We gratefully acknowledge the study participants, their parents and family members and all the staff of research team.

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Correspondence to B Nahar.

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Nahar, B., Hossain, M., Hamadani, J. et al. Effects of a community-based approach of food and psychosocial stimulation on growth and development of severely malnourished children in Bangladesh: a randomised trial. Eur J Clin Nutr 66, 701–709 (2012).

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  • malnutrition
  • community-based intervention
  • psychosocial stimulation
  • food supplementation
  • Bangladesh
  • children

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