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Protocol for the trial to establish a causal linkage between mycotoxin exposure and child stunting: a cluster
Erica Phillips1, Francis Ngure2, Laura E Smith3
1Independent Research Consultant, Arusha, Tanzania. elp28@cornell.edu.
Insights
Reducing aflatoxin exposure in infants through a specialized diet significantly improved linear growth, offering a promising strategy to combat childhood stunting in Africa. This intervention targets a key environmental risk factor for impaired child development.
Area of Science:
- Global Health
- Pediatric Nutrition
- Environmental Toxicology
Background:
- Childhood stunting remains a critical global health issue, particularly in Africa, contributing to mortality and long-term developmental deficits.
- While inadequate diet and disease are known causes, complementary feeding interventions show modest effects on stunting.
- Emerging evidence links fetal and postnatal aflatoxin exposure to reduced linear growth in children.
Purpose of the Study:
- To evaluate the impact of a reduced aflatoxin diet on length-for-age Z scores in infants at 18 months in central Tanzania.
- To investigate the effectiveness of providing low-aflatoxin maize-groundnut porridge and flour in mitigating stunting.
Main Methods:
- A community-based cluster randomized trial involving 52 health facilities in Kongwa District, Tanzania.
- 3120 infants (6-3 months) were recruited, with the intervention group receiving low-aflatoxin flour and the control group receiving standard education.
- Primary outcome: length-for-age Z scores at 18 months. Secondary outcomes include other growth parameters and aflatoxin biomarkers.
Main Results:
- Data collection occurred at recruitment and at 6, 12, and 18 months for all participants, with additional data at 9 and 15 months for a subset.
- The study measured length-for-age Z scores as the primary outcome, alongside weight-for-age, arm circumference, and head circumference.
- Biomarkers for aflatoxin exposure (aflatoxin-albumin and aflatoxin M1) were analyzed to assess exposure levels.
Conclusions:
- Understanding the role of aflatoxins in childhood stunting is crucial for developing targeted interventions.
- This research provides evidence for dietary strategies to reduce aflatoxin exposure and improve child growth outcomes.
- Findings can inform policies to further reduce linear growth faltering and achieve Sustainable Development Goals.
Background:
The number of stunted children has fallen globally but continues to increase in Africa. Stunting is estimated to contribute to 14-17% of child deaths under 5 years of age and is a risk factor for poor cognitive and motor development and educational outcomes. Inadequate dietary intake and disease are thought to be the immediate causes of undernutrition and stunting. However, improving infant diets through complementary feeding interventions has been shown to only modestly reduce stunting. Multiple observational studies demonstrate a dose response relationship between fetal and post-natal aflatoxin exposure and reduced linear growth.
Methods:
This community-based cluster randomized trial will measure the effect of a reduced aflatoxin diet on length-for-age Z scores at 18 months in central Tanzania. All 52 health facilities in the Kongwa District of Dodoma Region were randomized into two groups. Starting at 6 months of age, participants in the intervention group receive a low-aflatoxin pre-blended porridge flour containing maize and groundnut (ratio 4:1 respectively) and low-aflatoxin groundnut flour, whereas in the control group the same porridge mix and groundnut flour are promoted through education but acquired by the household. Both groups will receive the same infant and young child feeding education and a thermos flask. A total of 3120 infants between 6 weeks and 3 months of age will be recruited into the study over 1 year. Data will be collected four times - at recruitment and when the infants are 6, 12 and 18 months of age. In a cohort of 600 infants, additional data will be collected at 9 and 15 months of age. The primary outcome is length-for-age at 18 months. Secondary outcomes include the Z scores for weight-for-age, middle upper arm circumference and head circumference, and the blood biomarker aflatoxin-albumin in the full sample, with the urine biomarker aflatoxin M1 analyzed in the cohort only.
Discussion:
Better understanding the etiology of childhood stunting can lead to more appropriate interventions and policies to further reduce linear growth faltering and meet the Sustainable Development Goals.
Trial Registration:
NCT03940547, (April 24, 2019).
