Peer-reviewed article

Comparison of Layered "Nutrition-Plus" vs "Nutrition" Alone Interventions for Improving Growth in Children Under 5 in Low- and Middle-Income Countries: A Systematic Review.

Shakya E, Yang Z, Dou N, Na M · 30 Oct 2025

Abstract

Context The persistence of child undernutrition in low- and middle-income countries (LMICs) highlights the need for more effective evidence-based multisectoral interventions. Objective To examine whether combining direct nutritional interventions with indirect multisectoral interventions ("nutrition-plus") is more effective in improving growth outcomes in children under 5 than direct nutritional interventions ("nutrition") alone. Data sources A systematic search of PubMed, PsycINFO, and Web of Science from inception until July 17, 2024, identified 4377 unique articles. Data extraction We included 8 randomized controlled trials with a "nutrition-plus" group and a corresponding "nutrition" comparison, and examined at least 1 of the following outcomes: stunting, wasting, height-for-age z score (HAZ), and weight-for-height z score (WHZ) among children under 5 years. Data analysis Standardized mean differences and unadjusted odds ratios were calculated for continuous and dichotomous outcomes, respectively, and results were synthesized narratively. The 14-item National Heart, Lung, and Blood Institute Quality Assessment of Controlled Intervention Studies tool assessed the risk of bias. Conclusion Three types of "nutrition-plus" interventions were identified: "nutrition plus cash transfer" (n = 3), "nutrition plus water, sanitation, and hygiene (WASH)" (n = 3), and "nutrition plus psychosocial stimulation" (n = 2). The additional impact of "nutrition-plus" interventions, compared with "nutrition" alone, was nonsignificant in most studies, particularly in those with comprehensive "nutrition" interventions. Only 2 studies reported a positive additive effect of "nutrition plus cash" on HAZ but inconsistent effects on WHZ. One study found a significant positive impact of "nutrition plus psychosocial stimulation" on WHZ among stunted children. Given the limited evidence, we cannot conclude that "nutrition-plus" strategies are more effective than "nutrition" alone strategies. The need for additional research to evaluate the effectiveness of multifactorial "nutrition-plus" strategies to optimize programs aimed at improving infant and child growth in LMICs is evident. Systematic review registration PROSPERO registration no. CRD42022359012.