Review Article

Nutrition (Micronutrients) in Child Growth and Development: A

Systematic Review on Current Evidence, Recommendations and
Opportunities for Further Research
Mohammad Yawar Yakoob, MD, MS, DS,* Clifford W. Lo, MD, PhD†

ABSTRACT: Objective: An important aspect of malnutrition is deficiency of different micronutrients during

pregnancy or early childhood. We systematically reviewed the role of nutrition in child growth (weight or
height gain) and development. Methods: A comprehensive literature search was done on PubMed/Cochrane
Library browsing through 38,795 abstracts until December 31, 2016 to select systematic reviews/meta-
analyses and individual randomized controlled trials (RCTs) of micronutrient supplementation. Results:
Micronutrients studied included iron, iodine, folate, zinc, calcium, magnesium, selenium, vitamin D, vitamin
A, vitamin B complex, and multiple micronutrients. We summarize evidence with details and results of RCTs,
highlight strengths/weaknesses, and critically interpret findings. Effects of breastfeeding-promotion, food-
supplementation (complementary and school feeding), conditional-cash-transfers, and integrated nutrition/
psychosocial interventions are discussed. Conclusion: Based on this evidence we make policy and pro-
grammatic recommendations for supplementation to mothers and children at high-risk of deficiency.
(J Dev Behav Pediatr 38:665–679, 2017) Index terms: micronutrient supplementation, pregnancy, child growth and development.

T he future of human societies depends on children

being able to achieve their optimal growth and de-
velopment. The Lancet Series on Child Development
identified 4 risk factors in resource-poor countries where
the need for intervention is urgent in terms of improving
child development, 3 of which were nutrition-related:
stunting, iodine deficiency, and iron deficiency anemia.
These, along with other undernutrition factors, are com-
mon during pregnancy and early childhood in resource-
poor countries. It is important to address nutrition-related
risks to support optimal development in early childhood
with implications throughout life.1,2
Inadequate maternal and early child nutrition may limit
the development of important aspects of the brain’s ar-
chitecture. The brain is vulnerable to nutritional influen-
ces from the preconception period as well as the earliest
stages of pregnancy from the time the neural plate is
formed leading to a neural tube, a process that is complete
from 21 to 28 days after conception.3 The brain also
grows very rapidly in the last trimester of pregnancy and
From the *Department of Epidemiology, Harvard T. H. Chan School of Public
Health, Boston, MA; †Department of Nutrition, Children’s Hospital Boston,
Boston, MA.
Received June 2016; accepted June 2017.
Disclosure: The authors declare no conflict of interest.
Supplemental digital content is available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of this
article on the journal’s Web site (www.jdbp.org).
Address for reprints: Mohammad Yawar Yakoob, MD, MS, DS, Department of
Nutrition, Harvard T. H. Chan School of Public Health, 677 Huntington Avenue,
Boston, MA 02115; e-mail: myyakoob@mail.harvard.edu.
Copyright Ó 2017 Wolters Kluwer Health, Inc. All rights reserved.
first 2 years of life. This requires a diet that provides suf-
ficient nutrients for normal, healthy growth.3 Maternal
undernutrition can lead to low birth weight (LBW), pre-
term births, and small-for-gestational age babies.4 Preterm
and LBW infants are at increased risk of major impair-
ments, as well as below-average cognitive abilities and
greater behavioral problems at school age, even in the
absence of obvious neurological deficits.5 Therefore,
interventions can be targeted at the periconceptional
phase and during pregnancy.
The development of the brain occurs at an earlier
stage than the rest of the body. This can be illustrated by
the fact that a newborn’s brain is about 10% of the body
weight, whereas in the adult, it is only 2%. By the age of
1 year, the child will be about 15% of the final body
weight but the brain will be already about 70% of that of
a young adult. By 2 years of age, the brain will be about
77% of its final weight, whereas the body is about 20% of
the adult level.6 After birth, the key window of oppor-
tunity for interventions is during the first 24 months of
life, since the brain development is in an important
phase during this period. This is the period of peak in-
cidence of growth faltering, micronutrient deficiencies,
and infectious illnesses in resource-poor countries.7 After
this period, the effects of malnutrition on stunting may
be irreversible, and some of the functional deficits may
become permanent.8 Exclusive breastfeeding is recom-
mended for the first 6 months of life, after which com-
plementary foods should be introduced. Therefore,
interventions like breastfeeding-promotion and comple-
mentary feeding strategies (provision of complementary
foods with or without nutrition education is discussed

Vol. 38, No. 8, October 2017 www.jdbp.org | 665

Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
later in this article) that are effective at reducing mal-
nutrition during this vulnerable period should be a high
priority. Early childhood stunting caused by malnutrition
is associated with adverse developmental outcomes, es-
pecially, deficits in cognition and school achievement
from early childhood to late adolescence.9–11
Malnutrition, especially, micronutrient deficiencies,
can also occur in resource-rich countries. Subtle dif-
ferences in diet composition can lead to micronutrient
deficiencies. Micronutrient deficiencies may also in-
teract with the gut microbiome and alter the immune
response of the intestine. For example, iron deficiency
can deplete lactobacilli that convert lactose and other
sugars to lactic acid and may result in diarrhea, or zinc
deficiency can decrease richness and species diversity,
decrease Gram-negative facultative anaerobes and lac-
tobacilli, and affect the immune system.12,13
It is also now widely recognized that nutritional
well-being is not only related to dietary adequacy and
quality, but also to the process of feeding and parenting
psychosocial determinants. These include areas like cog-
nitive stimulation, caregiver sensitivity and responsiveness
to the child, and caregiver affect (emotional warmth or
rejection of the child). It is known that responsive feeding
might have a role in ameliorating child undernutrition
because positive caregiver verbalizations during feeding
can increase child acceptance of food.14 Similarly, par-
enting styles and feeding practices can influence a child’s
body mass index (BMI), for example, indulgent or pro-
tective parenting was associated with higher BMI and
authoritative parenting with a healthy BMI.15 Besides,
studies by Galler et al. and Lozoff et al. have shown that
compromised nutritional status during the first year of
life is associated with neurocognitive impairments per-
sisting into adulthood despite complete catch-up physical
growth at adolescence.16–18
This review, therefore, includes the efficacy and ef-
fectiveness of nutrition-only–related interventions along
with integrated nutrition-psychosocial interventions af-
fecting child growth (weight or height gain) and de-
velopment. We conclude with considerations for policy
and program planners for large-scale implementation.
METHODOLOGY
We did a comprehensive literature search on PubMed
(MEDLINE) and the Cochrane Clinical Trials using the
following search strategy:
(“Micronutrients” [Mesh] OR nutrition OR micro-
nutrient* OR “multiple micronutrient*” OR zinc OR
iodine OR calcium OR magnesium OR “vitamin D”
OR “vitamin A” OR iron OR “folic acid” OR “vitamin B”
OR breastfeeding OR food OR “cash transfer*”) AND
(growth OR development) AND (infan* OR child OR
children).
The last date of search was January 31, 2010. A total of
36,000 abstracts were screened and evaluated. The
search for recent systematic reviews and meta-analyses
was updated in December 2016 up to December 31,
666 Nutrition in Child Growth and Development
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2016, and involved screening a further approximate
2795 abstracts. The approximate search terms used
were, for example, (iron) AND (growth OR de-
velopment) AND (infan* OR child OR children); (“vita-
min a”) AND (growth OR development) AND (infan* OR
child OR children) AND suppl*; (breastfeeding) AND
(growth OR development) AND (infan* OR child OR
children) AND (promotion OR support); (food OR
feeding) AND (growth OR development) AND (infan*
OR child OR children) AND (complementary OR pre-
school OR preschool OR school); and (“conditional cash
transfer*”) AND (growth OR development) AND (infan*
OR child OR children).
Studies that reported outcomes on growth (weight
and height gain) and/or development were selected and
were from both resource-rich and resource-poor coun-
tries. The priority was to obtain systematic reviews and
the most recent randomized controlled trials on the
topic. In the absence of such evidence, observational
studies were also selected. We have made separate
sections of supplementation during pregnancy and
during childhood and within each section described the
outcomes of growth first and then development. We
excluded studies of food fortification and where
micronutrients were part of the diet and not given as
supplements.
RESULTS
Role of Micronutrients
The main micronutrients considered in this review in-
clude iron, iodine, folic acid, zinc, vitamin A and vitamin
D. Deficiency may occur for more than 1 nutrient;
therefore, the role of multiple micronutrients (MMNs) is
also covered in this article (Supplemental Digital Content
1, http://links.lww.com/JDBP/A143). Other miscellaneous
micronutrients are also discussed in brief like calcium,
magnesium, selenium and vitamin B complex.
Iron Supplementation
Globally, anemia affects 47.4% of preschool children
and 25.4% of school age children,3 most of which is due
to iron deficiency. Iron deficiency anemia is, therefore,
one of the most prevalent yet neglected nutritional
deficiencies in the world. The influence of iron de-
ficiency in children has been reviewed in several studies
leading to very similar conclusions. It has been seen that
it leads to poorer developmental outcomes in infancy
and childhood, especially, motor, cognitive, social-
emotional and neurophysiologic development in the
short term and in the long term.19–24 The effects of early
iron deficiency include decreased myelination, changes
in dopamine metabolism in the striatum, and alterations
in the energy metabolism of the hippocampus, an area of
the brain important for memory.25 New findings also
point to the need for more attention to the de-
velopmental effects of prenatal iron deficiency. The most
common etiology of reduced iron supply to the fetus is
maternal iron deficiency, and fetal and neonatal iron
Journal of Developmental & Behavioral Pediatrics
deficiency adversely affects developing brain-behavior
systems.23
Iron Supplementation in Pregnancy
A recent systematic review by Chmielewska et al.26
that studied prenatal iron supplementation during preg-
nancy showed no effect of iron supplementation on the
mental development or the behavioral status of their
children. Individual studies found from our literature
search reported similar findings. In a randomized study
by Frith et al.27 from Bangladesh, mothers from 14 weeks
of gestation to 12 weeks postpartum were assigned into
3 groups: 30 mg Fe 1 400 mg folic acid, 60 mg Fe 1 400
mg folic acid, and MMNs. Compared with 30 mg Fe, 60
mg Fe decreased the quality of maternal-infant feeding
interaction by approximately 10%. This could be because
of a higher dose of iron inhibiting zinc absorption lead-
ing to decreased plasma zinc concentrations, gastroin-
testinal side effects, and increased maternal morbidity
because of reduced immunity or higher bacterial viru-
lence. MMNs compared with 30 mg of iron did not im-
prove interaction but reduced early postpartum distress.
This may be related to the effect of micronutrients on
significant neurotransmitters. A randomized controlled
trial from Australia28 by Zhou et al. on prenatal 20 mg/
d iron supplementation from 20 weeks of gestation to
delivery compared with placebo group found no differ-
ence in the mean composite IQ score or any of its sub-
scales or in the proportion of children with IQ 1 or 2 SD
below the mean at 4 years of age after multiple con-
founder adjustments such as sex, birth order, gestational
age, maternal age, maternal education, paternal educa-
tion, home environment, and breastfeeding. Another
Chinese study by Li et al. on prenatal iron and folic acid
supplementation (60 mg iron and 400 mg/d folic acid)
compared with folic acid alone showed no effect on the
Bayley mental development index and Bayley psycho-
motor development index (PDI) of children at 3, 6, and
12 months of age.29,30
Iron Supplementation in Infancy/Children
Petry et al.,30 Ramakrishnan et al.,31,32 US Preventive
Services Task Force,33 Baumgartner et al.,34 Pasricha
et al.,35,36 Vucic et al.37 and Sachdev et al.38 did meta-
analyses/systematic reviews of randomized controlled
intervention trials of the impact of iron supplementation
on child growth and showed that iron had no significant
effect on child growth. There was no significant effect of
iron therapy on any of the anthropometric variables
studied: weight-for-age, weight-for-height, height-for-age,
mid-upper arm circumference, skinfold thickness, and
head circumference.30,38 Overall, effect sizes were 0.09
[95% confidence interval (CI), 20.07 to 0.24] for height
and 0.13 (95% CI, 20.05 to 0.30) for weight.31 Iron
therapy, however, did significantly improve hemoglobin
levels in these reviews.30,31 Also, another 2006 review39
showed that with iron supplementation, weight gains
were adversely affected in iron-replete children and the
effects on height were inconclusive. Many studies, in-
cluding randomized trials, have been published after
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these reviews and the findings for iron-replete children
have been conflicting. Gahagan et al.40 retrospectively
examined short- and long-term growth in iron-sufficient
(IS) infants from a randomized trial of iron supplemen-
tation among breastfed, low- to middle-income Chilean
infants. Growth trajectories between iron supplemented
and usual nutrition groups did not differ during or after
supplementation indicating no adverse effect of iron in IS
infants. Similarly, in Bangladesh, iron was found to have
no impact on the rate of length or weight gain for infants
aged 6 to 12 months or when stratified by baseline he-
moglobin concentration.41 However, Lind et al. from
secondary analysis of 6-month old Indonesian infants
participating in a randomized trial showed that weight-
for-age Z score (WAZ) from 6 to 12 months and mean
WAZ at 12 months were significantly lower in the iron-
replete iron-supplemented group compared with
iron-replete non–iron-supplemented infants.42 In another
recent randomized trial43 on breastfed infants enrolled at
1 month and supplemented from 4 months, medicinal
iron was associated with a small but significant reduction
in length gain and a trend toward reduced weight gain at
the end of supplementation at 9 months. However,
provision of medicinal iron or iron-fortified cereal did
improve the iron status in this study.
We identified a few reviews on the relationship be-
tween iron and developmental outcomes. The results
were mixed. Reviews34,36,39,44,45 of oral, preventive ,and
therapeutic iron supplementation in children showed
reductions or improvement in cognitive and motor de-
velopment deficits, and improvement in memory and
learning in iron-deficient or anemic children, particu-
larly, with longer-duration, lower-dose regimens. The
review by Low et al. reported improvement in global
cognitive scores, IQ, attention, and concentration.44
Similarly, a recent review by Lam and Lawlis46 was based
on 2 trials, of which 1 reported improvement in in-
telligence and attention after iron supplementation,47
whereas the other reported higher increase in IQ score
in weekly versus daily supplementation but no differ-
ence between weekly and placebo.48 Another review,
based on 5 RCTs, suggested a possible moderate im-
provement in PDI score that was most evident at 12
months of age with no effect on mental development or
behavior of children.26 Another systematic review by
Sachdev et al.49 comprising 15 randomized studies on
2827 children showed that after supplementation the
combined mental development score standardized mean
difference (SMD) (random model) was 0.30 (95% CI,
0.15–0.46; p , .001). Baseline anemia and iron de-
ficiency anemia were responsible for heterogeneity. For
IQ scores (4 trials on children $ 8 years of age), the
combined SMD was 0.41 (95% CI, 0.20–0.62, p , .001).
There was no effect of iron on motor development
score. In contrast, other recent reviews concluded that
iron supplementation in children under 2 years of age
did not have an effect on Bayley MDI (MD 1.65, 95% CI
20.63 to 3.94; 6 studies, n 5 1093) and PDI (1.05, 21.36
Copyright Ó 2017 Wolters Kluwer Health, Inc. All rights reserved. 667
to 3.46; 6 studies, n 5 1086).30,35,50 A review by Guo
et al. reported no difference in global cognitive perfor-
mance in primary school children after iron supple-
mentation51 and similarly, US Preventive Services Task
Force review found mostly nonsignificant results for
developmental test scores after 3 to 12 months of follow-
up.33 A Cochrane review52,53 on iron therapy in children
less than 3 years of age with iron deficiency anemia in-
cluded 5 trials and studied measures of psychomotor
development within 30 days of commencement of
therapy. The combined difference in pretreatment to
posttreatment change in Bayley PDI between iron and
placebo groups and in Bayley MDI was also non-
significant, but the days elapsed since the start of treat-
ment were few.
Iodine Supplementation
Iodine is a clear example of a nutrient that, if deficient
during a critical period of brain development, has long-
term adverse consequences.3 Iodine deficiency is the
single most important cause of preventable brain damage
and mental retardation. It is required for the production
of thyroid hormones that are essential for brain de-
velopment, and the fetus, newborn, and young child are
particularly vulnerable to iodine deficiency. Severe io-
dine deficiency during gestation results in fetal brain
damage that is irreversible by mid-gestation, commonly
leading to cretinism and impaired cognitive function in
children.54 Mild-to-moderate maternal hypothyroxinemia
may also result in suboptimal neurodevelopment.55 Even
mild-to-moderate deficiency in children has been asso-
ciated with lower IQs and more disruptive behavior.56–58
Iodine Supplementation During Pregnancy
Multiple systematic reviews and meta-analyses have
studied maternal iodine supplementation.55,59–65 The
findings from the trials have also been mixed. In 1 trial
from Peru, there was no difference between iodine and
placebo groups in gross development of newborns, but
in subgroup observational analysis, iodine-supplemented
mothers had infants with higher IQ scores (85.6 6 13.9
compared with 74.4 6 14.8, p 5 .002) and lower psy-
chological age retardation (15.5 6 11.6% compared with
26.6 6 14.1%, p , .01).66–68 In the trial from Papua New
Guinea, incidence proportion of cretinism in iodine-
supplemented villages was 2% versus 6% in placebo
group (relative risk 5 0.27, 0.12–0.60, p 5 .002) up to
a follow-up period of 15 years after intervention.69–72
RCTs on pregnant women with mild thyroid dysfunction
found no effect on children’s IQ status or cognitive
functioning through 3 or 5 years with levothyroxine
treatment versus none started before 18 weeks of ges-
tation.73,74 Similarly, another recent randomized in-
tervention study75 comprising 3 groups (iodized salt in
cooking and at the table, 200 mg of potassium iodide
(KI)/d, 300 mg/d of KI) evaluated maternal iodine sup-
plementation in 131 pregnant women during the first
trimester and found no effect on children’s neurological
development nor effect modification by treatment
668 Nutrition in Child Growth and Development
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groups. Five other quasi-experimental or observational
studies were found. A nonrandomized intervention
study76 compared psychological development of infants
aged 3 to 18 months for 300 mg/d of KI (n 5 133) during
the first trimester of pregnancy versus no iodine sup-
plements (n 5 61). This study found that children of
iodine-supplemented mothers had a more favorable
psychometric assessment than those of the unexposed
group. They had higher scores on the PDI (p 5 .02) and
the Behavior Rating Scale. However, this study was not
controlled for different confounding factors but is the
best evidence available. Another recent intervention
study77 of pregnant women with mild hypothyroxinemia
reported delayed neurodevelopmental outcomes among
children of nonsupplemented mothers. The mean de-
velopmental quotient of children of mothers with thy-
roxine levels above the 20th percentile at the beginning
of gestation (4–6 weeks) was 101.8 6 9.7 versus 87.5 6
8.9 in nonsupplemented mothers. The timing of the start
of intervention was potentially important; supplementa-
tion starting at 12 to 14 weeks of gestation was associ-
ated with worse scores than supplementation starting at
4 to 6 weeks. In a small pilot study in France (n 5 44) of
prenatal 150 mg/d of iodine supplementation from , 10
weeks of gestation to 3 months postpartum, scores in
Bayley Scales of Infant Development were not different
in exposed at 24 months compared with unexposed
group.78 However, 2 other studies79,80 from Spain
reported that women with self-reported iodine intake of
150 mg/d compared with ,100 mg/d had infants with
lower PDI (PDI , 85, OR 5 1.8, 1.0–3.3). The compar-
ison range of iodine intake was narrower in these studies
with potential for misclassification in reporting intakes.
Meta-analysis comprising some of these non-RCTs plus
additional ones found that iodine supplementation be-
fore or early in pregnancy compared with control had an
average effect size of 0.51 (8 non-RCTs) for mental de-
velopment score that was smaller (d 5 0.17) for late
pregnancy supplementation (4 non-RCTs).64
Iodine Supplementation in Children
Childhood iodine supplementation has been
covered in multiple systematic reviews and meta-
analyses.59–61,64,81 The Cochrane review81 on iodine
supplementation in children under 18 years of age in
iodine deficiency areas included a total of 26 studies.
Different forms of iodine supplementation were used in
these studies, including iodized salt, iodized oil (oral
form), intramuscular oil, iodized water, etc. Body weight
was given as an outcome in 4 studies82–85: weight in-
creased by 5.2% (after 4 months) to 27.5% (after 22
months) in the intervention groups (oral-iodized oil) and
3.4% to 13.2% (both after 10 months) in the control
groups. In 3 of these 4 trials, increases were slightly
greater in the intervention group than in the control, but
were nonsignificant. Increase in height was also given in
4 studies.82–84,86 It was 2.7% (after 10 months) to 7%
(after 22 months) in the intervention (oral-iodized oil)
group and 2.3% (after 10 months) to 7.9% (after 22
Journal of Developmental & Behavioral Pediatrics
months) in the control group. Moreover, 3 prospective
double-blind supplementation intervention versus
placebo studies87,88 were conducted on 7- to 10-year-old
severely iodine-deficient Moroccan children (n 5 71;
10-month study of iodized salt), moderately deficient 10-
to 12-year-old Albanian children (n 5 310; 6-month
study; 400 mg iodine as oral iodized oil), and mildly
deficient 5- to 14-year-old South African children (n 5
188; 6-month study; 2 doses of 200 mg iodine as oral-
iodized oil). At follow-up, supplementation did not have
a significant effect on somatic growth among South
African children but increased WAZ and height-for-age Z
scores (HAZ) in Moroccan and Albanian children.
Shrestha84 showed significant improvement in hand
grip between intervention and control groups (32 vs
23.3% after 10 months). The difference in sitting/stand-
ing ability was also significant. The same study reported
significant differences in ball-throwing abilities with no
differences in pegboard and balancing tests after 4
months. Huda 200185 evaluated 12 different cognitive
and motor function tests without any significant differ-
ences between the 2 groups. IQ was measured in 1 study
by Bautista et al.82 There were no significant differences
in increase in IQ, improvement in school grades, or in
perceptual-motor development between intervention
and control groups. Improvement in cognitive perfor-
mance was also nonsignificant between the 2 groups as
measured by Untoro et al.89 However, children who
were more iodine-deficient exhibited greater increase in
cognitive performance than those who were more io-
dine replete.
A randomized, double-blind placebo-controlled trial90 of
iodine supplementation was conducted in Dunedin, New
Zealand, among 184 children aged 10 to 13 years who
were mildly iodine-deficient. Children were randomly
assigned a daily tablet of 150 mg iodine or placebo for 28
weeks. Iodine supplementation significantly improved
scores for 2 of the 4 cognitive subsets (picture concepts
[p 5 .023] and matrix reasoning [p 5 .040]) but not for
letter-number sequencing (p 5 .480) or symbol search
(p 5 .608). The overall cognitive score of the iodine-
supplemented group was 0.19 SDs higher than that of
the placebo group (p 5 .011). After 28 weeks of supple-
mentation, iodine status improved in intervention group,
whereas the placebo group remained iodine-deficient.
Another randomized double-blind trial of iodine supple-
mentation in iodine-deficient 10- to 12-year-old children in
Albania91 showed that compared with placebo, iodine
treatment significantly improved performance on 4 of 7
tests: rapid target marking, symbol search, rapid object
naming, and Raven’s Colored Progressive Matrices
(p , .0001). Meta-analysis based on these 2 studies59
showed a significant improvement in global cognitive
scores (adjusted SMD 5 0.27, 0.10–0.44, p 5 .002) and in
perceptual reasoning (0.55, 0.05–1.04, p 5 .03) with sig-
nificant between-study heterogeneity for the latter out-
come (I2 5 90%, p 5 .001). There was no benefit for the
domains of processing speed index and working memory.
Vol. 38, No. 8, October 2017
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Zinc Supplementation
Zinc is involved in the activity of over 200 enzymes, in
particular, those associated with synthesis of DNA and
RNA. An estimated 17.3% of the world population has
inadequate zinc intakes.92 Although zinc plays essential
developmental roles both before and after birth, its role
in the brain is poorly understood. In animal studies, it has
been shown that zinc deficiency during gestation and
lactation results in irreversible cognitive impairment.3
Zinc deficiency in infants may also compromise behav-
iors necessary for cognitive functioning including activ-
ity and attention.93
Zinc Supplementation During Pregnancy
The Cochrane review on zinc supplementation during
pregnancy by Ota et al.94 has reported birth outcomes and
growth outcomes. Based on a meta-analysis of 14 RCTs
involving 5643 women, zinc supplementation during
pregnancy was found to have no significant difference in
low birth weight (LBW) (relative risk 5 0.93; 95% CI,
0.78–1.12), head circumference (7 RCTs), or mid-upper
arm circumference (3 RCTs). Infant WAZ score was sim-
ilar at 6 months in the 2 groups based on 2 RCTs,95,96 but
by 13 months, no-zinc group showed significantly higher
scores based on 1 RCT.95 Weight-for-height was also not
different between the 2 groups at 6 months. In a recent
trial of antenatal micronutrient supplementation,97 the
mean height of school age children in rural Nepal of
mothers in the iron 1 folic acid 1 zinc group was 113.93
(65.79) cm, compared with 113.33 (65.32) cm in iron 1
folic acid group (nonsignificant). The mean weight was
also 18.12 (62.36) kg in the intervention versus 18.05
(62.32) kg in the iron 1 folic acid group. Another ma-
ternal supplementation study in Peru showed no effect on
linear growth, but it was associated with greater weight
gain through age 1 year of infancy (p , .001).98
A meta-analysis by Warthon-Medina et al.99 showed no
effects of maternal zinc supplementation on the child’s
cognitive domains of intelligence, executive function, and
motor skills. In the Cochrane review on maternal zinc
supplementation,100 2 trials101,102 measured child de-
velopment outcomes. Hamadani et al.101 found that among
168 Bangladeshi infants studied at 13 months, the zinc
group had significantly worse mental development, PDI
scores, emotional tone, and cooperation compared with
no-zinc group, with infant approach, activity, and vocali-
zation showing no differences. The other RCT102 that fol-
lowed 355 infants of African-American mothers at 5 years
of age found no significant differences for differential
abilities, visual or auditory sequential memory scores, Knox
cube, gross motor scale, and grooved pegboard scores.
Another review by Hess and King103 reports data from
a study in Peru104 where some improvements in infant
neurobehavioral development (novelty preference) was
observed in zinc-supplemented group at 6 months of age.
Zinc Supplementation in Children
The impact of zinc supplementation in prepubertal
and under-5 children on growth has been the subject of
Copyright Ó 2017 Wolters Kluwer Health, Inc. All rights reserved. 669
many reviews30,32,105–111 and multiple other studies. In
a 2009 review on preventive zinc supplementation by
Brown et al.,105 it was shown that there was a signifi-
cantly greater change in height among prepubertal chil-
dren who received zinc supplements, with an overall
effect size of 0.170 (95% CI, 0.075–0.264), p 5 .001
based on 37 controlled trials (47 data sets). There was no
correlation between mean initial HAZ and effect size in
this analysis, unlike the results of a previous review106
where a positive response to zinc was only seen among
studies that enrolled children with initial mean
HAZ , 21.5 z. The reason could be exclusion of studies
of hospitalized, severely malnourished children from the
2009 review. Similarly, zinc had a significant positive
overall impact on change in weight from 35 trials
(45 data sets): mean effect size of 0.119 (95% CI, 0.048–
0.190), p 5 .002. The effect on change in weight-
for-height Z score (WHZ), although small, was also
marginally significant.105 Meanwhile, the review by
Ramakrishnan et al.32 showed that overall weighted
mean effect for change in height was small and not sig-
nificant with zinc supplementation (0.07; 95% CI, 20.03
to 0.17). Similar was the result for weight gain (0.09; 95%
CI, 20.11 to 0.25). The difference between Brown et al.
and Ramakrishnan et al. analyses is the inclusion/exclu-
sion criteria used. Ramakrishnan et al. included only
studies with children younger than 5 years compared
with prepubertal children in the review by Brown et al.
Brown et al. excluded studies of zinc fortification and
those studies where SD for change in length was not
given in the paper, whereas Ramakrishnan et al. included
them. Several studies have been published after these
reviews. Another meta-analysis by Petry et al. showed
that zinc supplementation had no effect on childhood
wasting, stunting, and underweight in children.30 A re-
cent randomized, double-blind trial112 in New Delhi, In-
dia, published after these reviews on 2482 children aged
6 to 30 months showed that after 4 months of supple-
mentation, there were no differences between in-
tervention (zinc) and placebo groups with respect to
weight and length gains, and with respect to length-for-
age Z scores, WAZ, and weight-for-length Z scores. An-
other community-based randomized study of zinc in
preschool children in Iran with retarded linear growth
showed significantly increased weight gain in children
compared with placebo, but no effect on mid-upper arm
circumference increment. A highly significant impact
was seen in boys’ height increment at the end of the
follow-up period.113 This trial, however, had a small total
sample size of 85. Data from another 4 randomized,
double-blind trials in 4 different countries114 show that
zinc supplementation in infants aged 4 to 6 months had
no effect on increments in height or weight during the 6-
month supplementation period, nor on mean HAZ, WAZ,
or WHZ scores. However, in logistic regression analysis,
infants receiving zinc were less likely to be stunted than
infants not getting zinc (OR 5 0.80; 95% CI, 0.64–1.0, p 5
.049). Another interesting finding in this analysis was that
670 Nutrition in Child Growth and Development
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
anemia at baseline modified the effect of zinc on HAZ and
WAZ scores. Anemic infants supplemented for 6 months
had significantly higher HAZ (0.17) and WAZ (0.14)
scores, with no effect on growth in infants not anemic at
baseline. Among Bangladeshi infants, Fischer Walker et al.
showed that there was no effect of zinc on the rate of
length or weight gain for infants aged 6 to 12 months or
even when stratified by baseline hemoglobin (Hb)
concentration.41
The combined effects of zinc supplementation in
children on the final MDI and PDI using the Bayley
scores have been reported in the reviews by Brown
et al.,105 Nissensohn et al.115 and Gogia et al.116 Most
studies in the Brown et al. review did not present intra-
individual changes in developmental scores during the
course of the intervention that allowed only final values
to be compared. There was no impact of preventive zinc
on final MDI (effect size 5 0.021, 95% CI: 20.133 to
0.175, p 5 .76) or on final PDI (effect size: 0.025, 95% CI:
20.149 to 0.198, p 5 .75). We also identified a few other
studies besides those included in this review. Heinig
et al.117 in a double-blind, randomized, placebo-
controlled trial showed that gross motor development
was not significantly different in zinc-supplemented
infants aged 4 to 10 months compared with placebo
group based on mean Alberta Infant Motor Scale (AIMS)
scores. However, in another meta-analysis by Warthon-
Medina et al.,99 zinc supplementation during childhood
had positive impacts on executive function and motor
skills and no effect on intelligence but was limited by
a few data sets.
Folic Acid Supplementation
Folic acid is involved in nucleotide synthesis, DNA
integrity, and transcription that explains its importance
for brain development.118 It has an established role
periconceptionally in decreasing the incidence of neural
tube defects. Although the data are very limited, there
are suggestions that an adequate supply of folate is also
important for growth and development at later stages
because Gross et al.119 found that infants born to moth-
ers with severe folate deficiency during pregnancy
showed abnormal or delayed development. Other stud-
ies, however, have not found associations between folate
status in the second half of pregnancy and neuro-
psychological development of children at age 5. This
may be because of their classification of low-folate status
based on biochemical measures rather than megaloblas-
tic anemia.120
Folate Use in Pregnancy
In a meta-analysis review, folic acid supplementation
during pregnancy had no impact on pregnancy out-
comes such as preterm birth; however, improvements
were seen in mean birth weight (mean difference
[MD] 5 135.75 g, 95% CI, 47.85–223.68).121 Multiple
reviews have studied maternal folate supplementation or
intake and effects on cognition and neuro-
development.26,122–124 A systematic review on folic acid
Journal of Developmental & Behavioral Pediatrics
supplementation/intake122 during pregnancy on neuro-
developmental and autism outcomes found 22 studies (2
RCTs, 18 cohorts, and 2 case-control studies) of which
15 showed a beneficial effect, 6 showed no association,
whereas 1 showed a harmful effect. A large retrospective
study125 based on 1988 National Maternal Infant Health
Survey and the 1991 follow-up supplement in the United
States studied the effect of prenatal folic acid use on early
child development. Folate use was associated with sig-
nificant reduced odds for moderate risk on gross motor
scale (OR 5 0.5), but was also associated with marginally
significant increased odds for moderate risk on the
personal-social scale (OR 5 1.8). A population-based
cohort study—The Generation R Study—prospectively
assessed maternal folic acid supplement use during the
first trimester by questionnaire.126 Child outcomes were
assessed at 18 months of age in 4214 toddlers. Results
showed that children of mothers who did not use folic
acid supplements in the first trimester had a higher risk of
total behavioral problems (OR 5 1.44; 95% CI, 1.12–1.86).
Folic acid supplement use also significantly protected
from both internalizing and externalizing problems, even
when adjusted for maternal characteristics.126
Folate Use in Infancy/Childhood
A study by Olney et al.127 showed that combined iron
and folic acid supplementation with or without zinc
from 5 to 7 months of age in children was associated
with earlier initiation of walking by approximately 1
month than in children without iron/folate (p 5 .020).
Supplementation with MMNs and long-chain poly-
unsaturated fatty acids is discussed in the online Sup-
plemental Material (Supplemental Digital Content 1,
http://links.lww.com/JDBP/A143).
Supplementation with Other Individual
Micronutrients i.e. Vitamin A and Vitamin D
A meta-analysis by Ramakrishnan et al.32 on vitamin A
supplementation on child growth in children under 5 years
of age was based on 17 studies with 19 data sets. The
overall weighted mean effect size for change in height was
small and not significant (0.08; 95% CI, 20.18 to 0.34). The
weighted mean effect size for weight gain was 20.03; 95%
CI, 20.23 to 0.18. Semba et al.128 reported the effect of
expanded national vitamin A program among preschool
children in India. The prevalence of stunting, severe
stunting, underweight, and severe underweight was higher
among children who did not receive vitamin A compared
with those who received it (p , .0001).
Vitamin D is another vitamin that is thought to play an
important role in brain development and functioning and
its deficiency may affect growth and development po-
tential of infants and children. Meta-analyses of vitamin D
supplementation during pregnancy report significantly
greater birth weight and birth length in neonates by
107.6 and 0.3 cm, respectively,129 and reduction in risk
of LBW.130 A Cochrane review on vitamin D supple-
mentation in pregnancy131 reported infant weight at 12
months of age based on 1 study.132 The weight was
Vol. 38, No. 8, October 2017
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
significantly greater in the infants of supplemented
mothers compared with nonsupplemented group (MD:
0.41; 95% CI, 0.18–0.64).
Breastfeeding Promotion Activities
Human breast milk contains 3 to 5% fat, 0.8 to 0.9%
protein, 6.9 to 7.2% carbohydrates, and 0.2% mineral
constituents that include sodium, potassium, calcium,
magnesium, phosphorus, and chloride.133 Proteins in
breast milk also include immunoglobulin A, lysozyme,
and albumin related to child’s immune function. There
are numerous observational studies linking breast milk
to higher scores on cognitive tests and in motor and
mental development, especially, in LBW or preterm
infants134–136 because of breast milk being rich in long-
chain polyunsaturated fatty acids (LCPUFAs). Studies
have supported the hypothesis that breast milk promotes
brain development, particularly white matter growth.137
Exclusive breastfeeding for the first 6 months is of prime
importance as it reduces the incidence of infections,138
but evidence on its effect on child’s growth is conflict-
ing. Some studies report better growth with formula
milk, whereas others report that breast milk is sufficient
for adequate growth during the first 6 months of life.139
Some studies have also reported higher weight gains
with exclusive breastfeeding in early days of life that
then transforms in favor of formula milk by 6 to 7 months
of life.138,140 Breast milk also contains adiponectin,
a protein that is associated with lower obesity,141 along
with other hormones and growth factors, namely ghre-
lin, resistin, and obestatin that are involved in food intake
regulation and energy balance.142 It may also, therefore,
have a role in reducing obesity. The World Health Or-
ganization currently recommends exclusive breastfeed-
ing up to 6 months of age after which complementary
foods should be introduced and breastfeeding then
continued up to 2 years of age.143
Multiple reviews on the effect of breastfeeding pro-
motion activities on child growth exist.144,145 Based on
16 to 17 data sets between 2006 and 2014, breastfeeding
promotion had no impact on weight or height z-scores
but had a modest, significant reduction in body mass
index (BMI) or WHZ scores in studies from resource-
poor countries. However, Kramer et al.146 from their
large PROBIT trial included in this meta-analysis reported
no significant effects of breastfeeding promotion in-
tervention on height, BMI, waist or hip circumference,
triceps, or subscapular skinfold thickness. The authors
present the latest evidence of the effect of prolonged and
exclusive breastfeeding on child’s cognitive ability at 6.5
years of age.147 The intervention was based on the Baby-
Friendly Hospital Initiative, which was developed by the
WHO and UNICEF, whereas the control maternity hos-
pitals and polyclinics continued the practices and poli-
cies in effect at the time of randomization. A total of
17,046 healthy breastfeeding infants were enrolled, of
whom 13,889 (81.5%) were followed-up at age 6.5 years.
The experimental group had higher means on all of the
Copyright Ó 2017 Wolters Kluwer Health, Inc. All rights reserved. 671
Wechsler Abbreviated Scales of Intelligence measures,
with cluster-adjusted mean difference of 17.5 (10.8 to
114.3) for verbal IQ that was statistically significant.
Other means for performance IQ and full scale IQ were
higher in the intervention group as well, but non-
significant. Teachers’ academic ratings were significantly
higher in the experimental group for both reading and
writing. The same authors in another article148 report no
significant treatment effects on either the mother or the
teacher, Strengths and Difficulties Questionnaire ratings
of total difficulties, emotional symptoms, conduct prob-
lems, hyperactivity, peer problems, or prosocial behav-
ior or on the supplemental behavioral questions.
Complementary/Preschool Feeding
To sustain optimal growth and development of infants
and children is important for their future and also for
development of societies in which they live.149 Common
factors causing malnutrition in infancy include in-
appropriate feeding practices such as lack of exclusive
breastfeeding and premature introduction of weaning
foods. Later on during childhood, inadequate diets in
quantity and quality are important causes.150 Studies have
linked household food insecurity with risk of stunting and
underweight in preschool children,151 and also with
negative effects on development and learning poten-
tial.152,153 Similarly, household food security has been as-
sociated with greater growth among children.154
Complementary/supplementary feeding interventions are
usually targeted to children aged 6 to 24 months because
this is the period of peak incidence of growth faltering,
micronutrient deficiencies, and infectious illnesses.7 The
preschool years (i.e., 1–5 years of age) is also a time of
rapid and dramatic postnatal brain development (i.e.,
neural plasticity), and of fundamental acquisition of cog-
nitive development (i.e., working memory, attention, and
inhibitory control). A food-based, comprehensive ap-
proach may be more effective and sustainable than pro-
grams targeting individual nutrient deficiencies.
A systematic review by Imdad et al. showed significant
positive effects/gains of complementary feeding with or
without nutrition counseling and nutrition counseling
alone on weight (weighted mean difference 5 0.34 SD,
0.11–0.56; 0.30 SD, 0.05–0.54) and height (0.26 SD, 0.08–
0.43; 0.21 SD, 0.01–0.41).155 Similar positive findings have
been shown for food supplementation in socioeconomi-
cally disadvantaged children aged 3 months to 5 years in
another review156 and in other reviews in children under
2 years of age157,158 in resource-poor countries. However,
in a review published earlier, Dewey and Adu-Afarwuah7
on complementary feeding interventions found that pro-
vision of complementary foods (often fortified) had
a positive, but nonsignificant, impact on weight and linear
growth. In this review, 4 efficacy trials provided data on
behavioral development. The provision of a fat-based
fortified food product or micronutrients alone improved
gross motor development in Ghana,159 but had no signif-
icant impact in South Africa160 or India.161 School feeding
672 Nutrition in Child Growth and Development
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
programs and conditional cash transfers are discussed in
the online Supplemental Material (Supplemental Digital
Content 1, http://links.lww.com/JDBP/A143).
Integrated Nutrition and Psychosocial
Interventions
Malnutrition can have a major influence on a child’s
behavioral development; for example, iron-deficient
children are irritable and tired, and protein deficiency
can lead to lethargy and unhappiness among children
that can reduce their interaction with parents or sib-
lings.162,163 Research has shown that in combined nu-
trition and psychosocial interventions, the psychosocial
support provided by increased stimulation can have
greater effects on psychological functioning than on
physical growth, whereas nutrition supplementation
would improve both growth and development. The
combination of stimulation and supplement inter-
ventions appears to have a greater effect on cognitive
development than either one alone.164 Similar results
have been shown by large-scale programs including
Integrated Child Development Services (ICDS) Project
in India165 and Head Start in the United States166 and
Chile.167 Other programs include PANDAI (Child De-
velopment and Mother’s Care) Project in Indonesia,
PRONOEI in Peru, Hogares Comunitarios de Bienestar
(Homes of Well-Being) in Columbia, Programa de Ali-
mentacao de Pre-escolar (PROAPE) in Brazil and In-
tegrated Programme for Child and Family Development
(IFBECD), and Family Development Programme (FCP)
in Thailand. The aim of ICDS in India165 was to improve
nutritional and health status of children under age 6.
This program combined supplementary feeding for
children with health and nutrition education. The pro-
gram had an impact on physical growth of children as
evidenced by lower levels of undernutrition in ICDS
areas. Children who attended the program regularly also
scored higher on cognitive tests than nonparticipants.
The Head Start program in the United States166 was
started to provide comprehensive child development
services for low-income children and their families. It
enrolled children aged 3 to 5 years. Snacks and pre-
school education were provided, along with health
care services. No impact was seen on height-for-age,
but positive effects were noted on the Peabody
Picture Vocabulary Test (PPVT). Effects persisted into
and translated into improved school attainment for
white and Hispanic children but not African-American
children.
Nutrition Plus Responsive Care/Responsive Feeding
Aboud et al.168 using a cluster randomized field trial in
Bangladesh evaluated a 6-session educational program of
responsive complementary feeding that emphasized
child self-feeding and maternal responsiveness. A total of
108 mothers and their 8- to 20-month-old children
attended the sessions, whereas 95 mothers and children
served as controls and received sessions on foods to feed
Journal of Developmental & Behavioral Pediatrics
without any intervention of responsive complementary
feeding. At follow-up, the percent of self-fed mouthfuls
and the number of responsive verbalizations were sig-
nificantly higher in the intervention group compared
with controls. Mouthfuls of food eaten by children and
weight were equivalent in the 2 groups.
Nutrition Plus Stimulation
Gardner et al. assessed the effects of zinc supple-
mentation and psychosocial stimulation given together
or separately on the psychomotor development of un-
dernourished Jamaican children.169 Zinc was given as 10
mg elemental zinc daily for 6 months, whereas the psy-
chosocial stimulation program focused on improving
maternal-child interactions. There were 4 groups in this
study: zinc and stimulation, zinc alone, stimulation alone,
and a control group. Developmental quotient and all
subscale scores declined in all the 4 groups after 6
months of the study period probably because the chil-
dren were from poor, disadvantaged backgrounds where
other micronutrient deficiencies may coexist. In multi-
level model, children who received both zinc and stim-
ulation had the highest developmental quotients after
the intervention. There was no main effect of zinc sup-
plementation alone, although stimulation alone also had
a significant effect on development quotient. There was
also a significant interaction between zinc and stimula-
tion on the hand and eye subscale that indicated that
children having both treatments had the highest scores.
Zinc alone, however, also benefited the hand and eye
subscale. Stimulation alone had significant main effects
on hearing and speech and performance. Neither in-
tervention benefited locomotor development.
Another recent study by the same group170–173 ran-
domly assigned 129 stunted children aged 9 to 24 months
to 4 groups: control, nutrition supplemented (milk-based
formula), stimulated, or both treatments in poor Kingston
(Jamaica) neighborhoods. A fifth group of nonstunted
children matched for baseline characteristics was also
studied. After 2 years, supplementation and stimulation
had independent benefits on the children’s development
and the effects were additive. The group receiving both
treatments caught up to the nonstunted children. Four
years after the end of the 2-year intervention, a battery of
cognitive function, school achievement, and fine motor
tests were performed. The perceptual-motor factor
showed a significant benefit from stimulation, and sup-
plementation benefitted only those children whose
mothers had higher verbal IQs. However, each in-
tervention group had higher scores than the stunted
control subjects on more tests than would be expected by
chance (supplemented and both groups on 14 of 15 tests,
p 5 .002; stimulated group in 13 of 15 tests, p 5 .01).
There was no longer an additive effect of combined
treatments at this 4-year follow-up. The third study we
found174 looked at the addition of psychosocial stimula-
tion to the nutrition interventions (food packets) for
malnutrition in undernourished Bangladeshi children aged
Vol. 38, No. 8, October 2017
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
6 to 24 months. The undernourished intervened children
(intervention for 12 months) showed significantly greater
improvements in their MDI (4.6 6 2.0; p , .01), response
to examiner (p 5 .001), and cooperation (p 5 .005)
compared with undernourished controls. Change in PDI
(3.5 6 2.2; p 5 .06), emotional tone (p 5 .03), maternal
knowledge about rearing (p , .001), and vocalization
(p 5 .04) also approached significance between the 2
groups. Two other efficacy studies on this topic found
from the WHO document164 include 1 from Bogota,
Colombia, and the other from Cali, Colombia. In the
Bogota study on undernourished children, there was
no added benefit of the combined supplementation-
stimulation interventions on psychological development,
but it had a greater effect on physical growth than sup-
plementation alone.175 The study from Cali showed that
combined supplementation and stimulation had the
greatest effects on psychological development, whereas
supplementation alone (before initiating the preschool)
had no effect on psychological development.176
DISCUSSION/CONCLUSIONS
This review has great implications for the promotion
of child growth and development, especially in
resource-poor countries. There are some clear messages
emanating from this review. It highlights the role of
micronutrients and other nutrition interventions like
breastfeeding and complementary feeding. Iron folate is
routinely used during pregnancy in resource-poor
countries and its role in preventing and treating ane-
mia is well established, preventing numerous compli-
cations in the mother and newborn. Folate during
pregnancy is also well known for preventing neural
tube defects and should be given periconceptionally as
well. Almost no studies have assessed the impact of iron
and/or folate during pregnancy on short- and long-term
development of children, possibly because of its proven
beneficial role in anemia and further randomized con-
trolled trials (RCTs) being unethical. There is a debate
currently on replacing iron folate with multiple micro-
nutrients (MMNs) during pregnancy in resource-poor
countries. A major concern is increase in birth weight
in the setting of limited cesarean facilities that may lead
to increased mortality later in pregnancy i.e., during
labor. Besides this, other procedures such as symphy-
siotomies during delivery can be debilitating and
subsequent impaired maternal health can affect
child development balancing out the benefits of
a well-nourished child. More evidence for MMNs sup-
plementation is needed in remote or rural areas of
resource-poor countries before a recommendation for
universal use can be made. Iodine should be given to all
mothers in iodine-deficient areas, mostly through the
fortification of salt. Routine use of zinc during
pregnancy is not recommended because of null results
on newborn or other growth or developmental out-
comes. There are no separate data evaluating zinc
Copyright Ó 2017 Wolters Kluwer Health, Inc. All rights reserved. 673
supplementation in zinc-deficient mothers. Studies are
needed, particularly in resource-poor countries.
Iron should be supplemented to all iron-deficient
children, and mass supplementation is not recom-
mended because it does not appear to have utility for
improving growth or developmental outcomes in iron-
replete children. However, iodine should be provided to
all children in iodine-deficient areas. Data on the impact
of preventive zinc on growth are conflicting. Before
large-scale recommendation for routine preventive sup-
plementation is made, its impact on other outcomes
such as mortality and morbidity, specifically because of
infections, needs to be studied. More RCTs are needed to
assess the impact of zinc on growth, especially height,
among children who are anemic or are stunted. The role
of vitamin A supplementation in children in preventing
all-cause and infection-specific mortality have been well
demonstrated in recent reviews.177 It should be part of
large-scale programs for children at risk despite con-
flicting results on growth. It is hypothesized that by re-
ducing incidence of infections like diarrhea and measles,
it should have a positive effect on growth and de-
velopment as well. There is only 1 study evaluating the
use of folic acid for child development outcomes and
there is no substantial evidence to recommend it rou-
tinely with iron in iron-deficient children.
All children should be exclusively breastfed up to the
first 6 months of life based on its protective effect on
infections and also optimal growth, despite some studies
on growth being conflicting. It is important that weaning
foods be started in the right quantity and quality to have
positive impacts on child growth and development, with
breast milk continued up to 2 years of age. More data are
needed on the impact of complementary feeding inter-
ventions on early child development. Provision of com-
plementary foods also had a positive impact on growth.
With maternal education for complementary feeding, also
there was an additional increase in weight and height.
Studies from Africa and South Asia generally showed
positive results for growth, whereas those in other regions
were more variable. This could be explained by higher
food insecurity rates in Africa and South Asia. Other
interventions such as managing poverty and improving
sanitation and health care need to be coupled with com-
plementary feeding interventions to have a more sub-
stantial impact on child growth and development. The
key challenge would, however, be to introduce high-
quality programs that incorporate these interventions that
are sustainable when delivered on a large scale.
It should be noted here that research has shown that
nutrition interventions combined with psychosocial
interventions such as parent psychosocial stimulation,
parenting programs, caregiver responsiveness, etc. can
have an additive or even synergistic effects on child de-
velopment. In combined nutrition and psychosocial
interventions, the psychosocial support provided by in-
creased stimulation can have greater effects on psycho-
logical functioning than on physical growth, whereas
674 Nutrition in Child Growth and Development
Copyright Ó 2017 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
nutrition supplementation would improve both growth
and development. Studies have shown that combination
of stimulation and supplement interventions appears to
have a greater effect on cognitive development than ei-
ther one alone.164 Similar results have been shown by
large-scale programs in different countries including In-
tegrated Child Development Services (ICDS) Project in
India165 and Head Start in the United States.166 Therefore,
nutrition and psychosocial interventions should be com-
bined to achieve optimal benefits in large-scale programs.
The need of the hour is to translate these recom-
mendations into large-scale, community-based public
health programs and increase their coverage, especially
for the most impoverished pregnant women and chil-
dren in resource-poor countries. Other research oppor-
tunities also exist. More evidence is needed for MMNs
supplements compared with iron folate, particularly in
regions that do not have appropriate health care delivery
facilities. Zinc and vitamin D supplementation in preg-
nancy may be important for women deficient in these
nutrients but current evidence does not show any con-
vincing benefits for child growth and development. Al-
though we recommend vitamin A supplementation for
children at risk in resource-poor countries, its effects on
growth are conflicting. Furthermore, there are no studies
of vitamin A supplementation evaluating developmental
outcomes. Observational studies could be done to ob-
serve effects on these outcomes because according to
new evidence,177 further RCTs of vitamin A supple-
mentation would be unethical in children. Zinc supple-
mentation in children also has a potential role to play,
particularly in preventing stunting, but more evidence is
needed before it can be recommended routinely. Its role,
however, in preventing infections like diarrhea and
pneumonia in children is strong.178
In conclusion, micronutrient supplementation plays
a significant role in child growth and development either
during pregnancy or early childhood. In making policy
recommendations or guidelines, it is important to rec-
ognize that micronutrients also provide benefits beyond
those of growth and development. This can potentially
include reduction in incidence of infections and mortal-
ity such as for zinc and vitamin A supplementation in
children. This review has highlighted current evidence
and further areas of research opportunities related to
micronutrient deficiencies, and supplementation efforts
to overcome these deficiencies.
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