Effect of a Center-Based Early Childhood Care and Education Program on Child Nutritional Status: A Secondary Analysis of a Stepped-Wedge Cluster Randomized Controlled Trial in Rural Sindh, Pakistan

Abstract

BackgroundHigh-quality early childhood care and education (ECCE) programs can positively impact children’s development. However, as an unintended consequence, ECCE attendance may also affect children’s nutritional status. ObjectiveWe evaluated the effect of a center-based ECCE intervention on child nutritional outcomes in rural Pakistan. MethodsThis study utilized data from a stepped-wedge cluster randomized controlled trial of a center-based ECCE program that trained female youth to run high-quality preschools for children aged 3.5–5.5 y (Youth Leaders for Early Childhood Assuring Children are Prepared for School (LEAPS) program) in rural Sindh, Pakistan. The program did not include any school meals. A total of 99 village clusters were randomized to receive the LEAPS intervention in 3 steps, and repeated cross-sectional surveys were conducted to assess the impact on children (age: 4.5–5.5 y) at 4- time points. ITT analyses with multilevel mixed-effect models were used to estimate the effect of the intervention on child anthropometric outcomes. ResultsThe analysis included 3858 children with anthropometric data from 4 cross-sectional survey rounds. The LEAPS intervention was found to have a positive effect on child height-for-age z score (mean difference: 0.13 z-scores; 95% confidence interval [CI]: 0.02, 0.24). However, there was a negative effect on weight-based anthropometric indicators, −0.29 weight-for-height z score (WHZ) (95% CI: −0.42, −0.15), −0.13 BMI z score (BMIZ) (95% CI: −0.23, −0.03), and −0.16 mid-upper arm circumference-for-age z score MUACZ (95% CI: −0.25, −0.05). An exploratory analysis suggested that the magnitude of the negative effect of LEAPS on WHZ, BMIZ, and weight-for-age z score (WAZ) was greater in the survey round during the COVID-19 lockdown. DiscussionThe LEAPS intervention positively affected child linear growth but had negative effects on multiple weight-based anthropometric measures. ECCE programs in low- and middle-income country settings should evaluate the integration of nutrition-specific interventions (eg school lunch, counseling on healthy diets) and infection control strategies to promote children's healthy growth and development. Clinical Trial Registryclinicaltrials.gov, NCT03764436, https://clinicaltrials.gov/ct2/show/NCT03764436