Characteristics and effects of integrated nutrition and stimulation interventions to improve the nutritional status and development of children under 5 years of age : a systematic review and meta-analysis

Introduction Around 250million children in low-income and middle-income countries are at risk of not fulfilling their developmental potential. There is a need to update syntheses investigating the effects of combined nutrition and stimulation interventions on children’s growth and development and identify intervention characteristics associated with positive effects. Methods We did a systematic review to: (1) understand the effects of integrated nutrition and stimulation interventions versus (i) usual care and (ii) standalone nutrition or stimulation interventions, on the growth and development of children under five; (2) explore intervention characteristics (delivery strategies, behaviour change techniques, intensity and personnel) associated with positive effects. We searched eight databases for studies published from inception to 16 November 2020. Eligible studies were randomised and non-randomised controlled trials of integrated nutrition and stimulation interventions examining growth and developmental outcomes. We performed meta-analyses for length-for-age/height-forage, weight-for-age and weight-for-length/weight-for-height Z scores and cognitive, motor and language development scores, and subgroup analyses by intervention characteristics.We conducted random-effects metaregression to assess potential subgroup differences in outcomes by intervention characteristics. Results Twenty trials were included in the meta-analysis. Pooled effect sizes showed significant benefits of integrated interventions on developmental outcomes compared with usual care and standalone nutrition interventions (Ҏ >75%) but not on growth outcomes. Moreover, integrated interventions have non-significant effects on developmental outcomes compared with standalone stimulation interventions. Integrated interventions showed greater effects on cognitive (p=0.039) and language (p=0.040) outcomes for undernourished children compared with adequately nourished children. The effects of integrated interventions on developmental outcomes did not differ by intervention characteristics. Conclusion Integrated interventions have greater benefits for children’s development than usual care or standalone nutrition interventions, especially in settings with high levels of undernutrition. Future studies should use standardised reporting of implementation processes to identify intervention characteristics linked to positive effects

Feeding, caregiving practices, and developmental delay among children under five in lowland Nepal: a community-based cross-sectional survey

Background: Nurturing care, including adequate nutrition, responsive caregiving and early learning, is critical to early childhood development. In Nepal, national surveys highlight inequity in feeding and caregiving practices for young children. Our objective was to describe infant and young child feeding (IYCF) and cognitive and socio-emotional caregiving practices among caregivers of children under five in Dhanusha district, Nepal, and to explore socio-demographic and economic factors associated with these practices. Methods: We did a cross-sectional analysis of a subset of data from the MIRA Dhanusha cluster randomised controlled trial, including mother-child dyads (N = 1360), sampled when children were median age 46 days and a follow-up survey of the same mother-child dyads (N = 1352) when children were median age 38 months. We used World Health Organization IYCF indicators and questions from the Multiple Indicator Cluster Survey-4 tool to obtain information on IYCF and cognitive and socio-emotional caregiving practices. Using multivariable logistic regression models, potential explanatory household, parental and child-level variables were tested to determine their independent associations with IYCF and caregiving indicators. Results: The prevalence of feeding indicators varied. IYCF indicators, including ever breastfed (99%), exclusive breastfeeding (24-hour recall) (89%), and vegetable/fruit consumption (69%) were common. Problem areas were early initiation of breastfeeding (16%), colostrum feeding (67%), no pre-lacteal feeding (53%), timely introduction of complementary feeding (56%), minimum dietary diversity (49%) and animal-source food consumption (23%). Amongst caregiving indicators, access to 3+ children’s books (7%), early stimulation and responsive caregiving (11%), and participation in early childhood education (27%) were of particular concern, while 64% had access to 2+ toys and 71% received adequate care. According to the Early Child Development Index score, only 38% of children were developmentally on track. Younger children from poor households, whose mothers were young, had not received antenatal visits and delivered at home were at higher risk of poor IYCF and caregiving practices. Conclusions: Suboptimal caregiving practices, inappropriate early breastfeeding practices, delayed introduction of complementary foods, inadequate dietary diversity and low animal-source food consumption are challenges in lowland Nepal. We call for urgent integrated nutrition and caregiving interventions, especially as interventions for child development are lacking in Nepal

Multiple Interferon Stimulated Genes Synergize with the Zinc Finger Antiviral Protein to Mediate Anti-Alphavirus Activity

The zinc finger antiviral protein (ZAP) is a host factor that mediates inhibition of viruses in the Filoviridae, Retroviridae and Togaviridae families. We previously demonstrated that ZAP blocks replication of Sindbis virus (SINV), the prototype Alphavirus in the Togaviridae family at an early step prior to translation of the incoming genome and that synergy between ZAP and one or more interferon stimulated genes (ISGs) resulted in maximal inhibitory activity. The present study aimed to identify those ISGs that synergize with ZAP to mediate Alphavirus inhibition. Using a library of lentiviruses individually expressing more than 350 ISGs, we screened for inhibitory activity in interferon defective cells with or without ZAP overexpression. Confirmatory tests of the 23 ISGs demonstrating the largest infection reduction in combination with ZAP revealed that 16 were synergistic. Confirmatory tests of all potentially synergistic ISGs revealed 15 additional ISGs with a statistically significant synergistic effect in combination with ZAP. These 31 ISGs are candidates for further mechanistic studies. The number and diversity of the identified ZAP-synergistic ISGs lead us to speculate that ZAP may play an important role in priming the cell for optimal ISG function

Multiple interferon stimulated genes synergize with the zinc finger antiviral protein to mediate anti-alphavirus activity.

The zinc finger antiviral protein (ZAP) is a host factor that mediates inhibition of viruses in the Filoviridae, Retroviridae and Togaviridae families. We previously demonstrated that ZAP blocks replication of Sindbis virus (SINV), the prototype Alphavirus in the Togaviridae family at an early step prior to translation of the incoming genome and that synergy between ZAP and one or more interferon stimulated genes (ISGs) resulted in maximal inhibitory activity. The present study aimed to identify those ISGs that synergize with ZAP to mediate Alphavirus inhibition. Using a library of lentiviruses individually expressing more than 350 ISGs, we screened for inhibitory activity in interferon defective cells with or without ZAP overexpression. Confirmatory tests of the 23 ISGs demonstrating the largest infection reduction in combination with ZAP revealed that 16 were synergistic. Confirmatory tests of all potentially synergistic ISGs revealed 15 additional ISGs with a statistically significant synergistic effect in combination with ZAP. These 31 ISGs are candidates for further mechanistic studies. The number and diversity of the identified ZAP-synergistic ISGs lead us to speculate that ZAP may play an important role in priming the cell for optimal ISG function

Anti-SINV activity of a library of 383 ISGs in control and ZAP-expressing cells.

<p>BHK/HA-Zeo (Control) cells or BHK/NZAP-Zeo cells expressing the amino terminal domain of rat ZAP (ZAP cells) were transduced with lentiviruses co-expressing individual ISGs and the red fluorescent protein TagRFP. After 2 d, the cells were challenged with SINV expressing GFP (moi = 5). After 8 h, the cells were harvested and analyzed by flow cytometry to determine the percentage of infected cells (GFP+) within the transduced (RFP+) population. Red symbols indicate cells expressing the control protein, Fluc, while black open circles indicate cells expressing the individual ISGs. For each cell type, the line in the scatter plot indicates the mean value for the percentage of infected cells. Gene symbols are shown for ISGs resulting in infection rates below an arbitrary cutoff of 85% (dashed line).</p

Confirmatory testing of the top ISG hits synergizing with ZAP.

<p>Triplicate wells of BHK/HA-Zeo cells (Control cells, gray bars) or BHK/NZAP-Zeo cells expressing the amino terminal domain of rat ZAP (ZAP cells, blue bars) were transduced with lentiviruses co-expressing the indicated ISGs and the red fluorescent protein TagRFP. After 2 d, the cells were challenged with SINV expressing GFP (moi = 5). After 8 h, the cells were harvested and analyzed by flow cytometry to determine the percentage of infected cells (GFP+) within the transduced (RFP+) population. Mean values are plotted; error bars indicate the standard deviation. Dashed lines indicate the percentage of infection determined in control cells expressing Fluc (gray) or ZAP cells expressing Fluc (blue). For FLJ39739 transduction of ZAP cells, there was only one replicate for analysis. Asterisks indicate mean values statistically different than values obtained in Fluc-expressing cells for the corresponding cell type (unpaired <i>t</i> test, *, P<0.05; **, P<0.01; ***, P<0.001).</p

Validation of synergy between ZAP and the top three ISGs in a knockdown system.

<p>A) Triplicate wells of Huh-7 cells were transfected with irrelevant siRNA, ZAP-specific siRNA, ISG-specific siRNA that targets IRF2, RIG-I or IL28RA, or siRNAs that target both ZAP and an ISG. ISG-specific siRNA was added to cells again on the second day after seeding. Forty-eight h after initial siRNA transfection, cells were infected with Toto1101/Luc (moi = 5). Viral replication was determined by firefly luciferase activity 4 h after infection. Huh-7 cells that were not transfected with siRNA were included as a negative control. Means and standard deviations of triplicate samples are shown. Asterisks indicate mean values statistically different between two siRNA treatments (unpaired t test, *, P<0.05; **, P<0.01; ***, P<0.001). B) Forty-eight h after initial siRNA transfection, total RNA was extracted from the cells and used to generate cDNA. RNA levels of IRF2, RIG-I, IL28RA and RPS11 were measured by real-time PCR. The ISG mRNA levels were normalized with that of RPS11, and the ISG mRNA levels in irrelevant siRNA-transfected cells were set as 1. Data are means +/− SD of one experiment in triplicate.</p

Reduction in the percentage of infected cells by ZAP.

<p>For each ISG the reduction in the percentage of infected cells due to ZAP co-expression was calculated by subtracting the percentage of infected cells in the ZAP cells from the percentage infected in the control cells. After sorting, the differences were plotted versus an arbitrary ISG number. The difference seen between the control and ZAP cells in the absence of ISG expression (Fluc) is shown by the red symbol. Gene symbols are shown for the 23 ISGs with the greatest difference in infection percentage (≥18) due to ZAP expression.</p