Diet and Care Mediate the Effects of Parenting and Nutrition Interventions on Childhood Infections

The effect of community-based multi-input interventions that promote health, nutrition, and development on childhood infections, and the pathways that explain these effects remain unclear. We conducted a secondary analysis of a factorial-designed clustered randomized controlled trial (N = 1489) conducted in rural Pakistan to estimate the effects of responsive stimulation and enhanced nutrition (responsive feeding and multiple micronutrient powders (MNPs)) interventions on diarrhoea, fever, and acute respiratory infection (ARI) among children under 2 years using Poisson regression models. We used a counterfactual framework and weighting-based approach to conduct mediation analyses through diet and care-related factors. The responsive stimulation intervention reduced diarrhoea between 12 and 24 months of age (rate ratio (RR): 0.87; 95% CI: 0.77, 0.97), fever from 6 to 24 months (RR: 0.80; 95% CI: 0.73, 0.88), and ARI from 6 to 24 months (RR: 0.91; 95% CI: 0.83, 0.99). In contrast, enhanced nutrition increased rates of fever from 6 to 24 months (RR: 1.34; 95% CI: 1.22, 1.48). Reductions in maternal depressive symptoms partially mediated the positive effects of responsive stimulation on diarrhoea, fever, and ARI between 6 and 24 months (54.7%, 15.6%, and 49.1% mediated, respectively) and also provided positive indirect effects for the enhanced nutrition intervention on these outcomes. Improvements in meal frequency contributed to reductions in child diarrhoea for both interventions. Responsive stimulation and enhanced nutrition had contrasting effects on childhood infections, but both interventions improved diet and care-related mediators that contributed positive indirect effects. The provision of iron-containing MNPs may explain the overall negative effect of the enhanced nutrition package on fever. Trial Registration: Clinicaltrials.gov identifier: NCT007159636.