Prenatal and preschool micronutrient supplementation and behavioral outcomes in school-aged children in Nepal-a cohort study

Document Type

Journal Article

Publication Date

10-13-2025

Journal

The American journal of clinical nutrition

DOI

10.1016/j.ajcnut.2025.10.006

Keywords

child behavior; nutrition; prenatal; preschool; supplementation

Abstract

BACKGROUND: A few studies examined behavioral difficulties among children in low-income countries or the influence of early life nutrition interventions. OBJECTIVES: We examined the effect of micronutrient supplementation done as part of 2 randomized trials during pregnancy or in early preschool age on behavioral outcomes among school-aged children in rural Nepal. METHODS: Children between 7 and 9 y of age were enrolled in a cohort follow-up study in which the Conners Rating Scale-Revised was administered to their parents and teachers. These children were offspring of participants in a cluster-randomized trial during pregnancy receiving daily iron-folic acid, iron-folic acid + zinc, or multiple micronutrients, compared with a control (all groups received vitamin A). These children between 12 and 35 mo of age also received daily placebo, iron-folic acid, zinc alone, or iron-folic acid + zinc in a separate randomized trial. Factor analysis identified 2 attention-deficit hyperactivity disorder-related behaviors for parent scores (hyperactivity/oppositional and inattention) and 2 for teacher scores (hyperactivity and inattention). Using mixed-effects linear regression analysis, we analyzed the effect of early life supplementation on behavioral domains in school children (n = 1255). RESULTS: Exposure to prenatal iron-folic acid resulted in lower oppositionality/hyperactivity and inattention scores in children assessed via parental ratings in both unadjusted and adjusted analyses. Iron-folic acid with zinc reversed the positive effect seen with iron-folic acid. Multiple micronutrient supplementation resulted in a lower oppositionality and/or hyperactivity score, using parent and teacher ratings in the adjusted analysis. All 3 supplement groups in the preschool trial reduced child inattention when assessed by parents. Based on teacher ratings, groups that had received iron-folic acid alone or with zinc during preschool had reduced scores of hyperactivity in both unadjusted and adjusted analyses. CONCLUSIONS: Our study shows potential benefit of early life exposure to micronutrient supplementation for child-related behavior outcomes in a South Asian setting where inadequate diets and nutrition deficiencies exist.

Department

Global Health

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