New evidence of the positive effects of cognitive stimulation and nutrition interventions for under-2s

Written by: Fiona Burtt, 24 June 2014

An article published last week in international medical journal, The Lancet,[1] showcases new evidence of the encouraging effects of ECD interventions for young children, demonstrating that:

  1. A responsive stimulation and/or enhanced nutrition intervention works for children up to two years old; and
  2. A responsive stimulation intervention that positively affects development outcomes can be delivered effectively by community health workers.

In a large, UNICEF-funded randomised control trial carried out in rural Pakistan, child development, growth and health outcomes were achieved by adding on an integrated cognitive stimulation/ nutrition intervention for 0-2s to a lay community health worker programme. More than 1,400 mother/child pairs were enrolled when infants born between April 2009 and March 2010 were aged 2-5 months. They were divided into four groups. One group received nutrition education and multiple micronutrient powders; one received a responsive stimulation intervention; a third received a combination of both enriched interventions; and the control group received only routine health and nutrition services. Interventions were delivered to families with children up to 24 months old in routine monthly group sessions and home visits, and the children’s development was tested at regular points up to 24 months.

The aim of the study was to test whether, when compared with either a responsive stimulation or an enhanced care for nutrition intervention delivered alone, a combined approach would have independent or additive effects on child development, growth and morbidity outcomes at 24 months.

The researchers from Aga Khan University report that children who received responsive stimulation had significantly higher development scores on the cognitive, language and motor scales[2] at 12 and 24 months of age, and on the social-emotional scale at 12 months of age, than those who did not receive the intervention. For children who received enhanced nutrition, only the language scores remained significantly higher at 24 months, even though they had significantly higher development scores on the cognitive, language, and social-emotional scales at 12 months of age than those who had not received enhanced nutrition. This intervention resulted, however, in the most improved growth (height-for-age). The prevalence of diarrhoeal disease and acute respiratory illness decreased over time as a result of exposure to both responsive stimulation and enhanced nutrition, compared with non-exposure.

Despite the positive outcomes of all three interventions, no additional benefits were recorded from the combined intervention.

The intervention outcomes echo the results of a University of West Indies trial undertaken in Jamaica in the late 1980s,[3] which also employed a combination of stimulation and nutritional supplementation, delivered through home visits by community health workers. A major difference in the two studies is that the Jamaican subjects were stunted children (aged 9-24 months), while the Pakistani infants were identified as being ‘without signs of severe impairments’. A rare subject of longitudinal research to assess the long-term benefits of ECD interventions, the Jamaican study showed that initial cognitive benefits of nutritional supplementation had faded by early primary school and that combining stimulation and nutrition had no discernible effect. Those undernourished children who received stimulation (alone or combined), however, still demonstrated positive effects by late adolescence.

Further follow-up of the Pakistani children over time will be required to determine the long-lasting effects of this ECD intervention. The immediate results are sufficiently promising to be noted by programme developers and policy-makers throughout low-middle income countries, including South Africa.


[1]Yousafzai, A.K., Rasheed, M.A., Rizvi, A., Armstrong, R. and Bhutta, Z.A. 2014. Effect of integrated responsive stimulation and nutrition interventions in the Lady Health Worker programme in Pakistan on child development, growth, and health outcomes: a cluster-randomised factorial effectiveness trial. The Lancet online, 17 June 2014.

[2] Using the Bayley Scales of Infant and Toddler Development, Third Edition.

[3]Walker S.P., Chang, S.M., Powell, C.A., Grantham-McGregor, S.M. 2005. Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study. The Lancet, 366 (19 November 2005).

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