ABSTRACT Background Eggs are a rich source of nutrients important for brain development, including choline, riboflavin, vitamins B-6 and B-12, folate, zinc, protein, and DHA. Objective Our objective was to evaluate the effect of the consumption of 1 egg per day over a 6-mo period on child development. Methods In the Mazira Project randomized controlled trial, 660 children aged 6–9 mo were randomly allocated into an intervention or control group. Eggs were provided to intervention households during twice-weekly home visits for 6 mo. Control households were visited at the same frequency. At enrollment, blinded assessors administered the Malawi Developmental Assessment Tool (MDAT), and 2 eye-tracking tasks using a Tobii-Pro X2–60 eye tracker: a visual paired comparison memory task and an Infant Orienting with Attention task. At endline, 6-mo later, blinded assessors administered the MDAT and eye-tracking tasks plus an additional elicited imitation memory task. Results At endline, intervention and control groups did not significantly differ in any developmental score, with the exception that a smaller percentage of children were delayed in fine motor development in the intervention group (10.6%) compared with the control group (16.5%; prevalence ratio: 0.59, 95% CI: 0.38–0.91). Among 10 prespecified effect modifiers for the 8 primary developmental outcomes, we found 7 significant interactions demonstrating a consistent pattern that children who were less vulnerable, for example, those with higher household wealth and maternal education, showed positive effects of the intervention. Given multiple hypothesis testing, some findings may have been due to chance. Conclusion The provision of 1 egg per day had no overall effect on child development in this population of children, however, some benefits may be seen among children in less vulnerable circumstances. This trial was registered at clinicaltrials.gov as NCT03385252.

Background Eggs are a rich source of choline, an essential nutrient important for child growth and development. In a randomized trial of one egg/day among young children in Ecuador, an egg intervention led to significant improvements in growth, which was partially mediated by increased plasma choline concentration. A similar trial in Malawi (clinicaltrials.gov: NCT03385252) found little improvement in child growth or development. Objective We aimed to evaluate the effect of one egg/day for 6 months on plasma choline concentrations among Malawian children enrolled in a randomized trial. Methods Infants age 6-9 months in rural Malawi were randomized to receive one egg/day (n = 331) or serve as a nonintervention control (n = 329) for 6 months. Anthropometric, developmental, and dietary data were collected at baseline and 6 month follow up, along with a blood draw. Plasma choline, betaine, dimethylglycine, trimethylamine N-oxide (TMAO), and docosahexaenoic acid were measured at both time points using UPLC-MS/MS (n = 200 per group). Linear regression analysis was used to determine the difference in plasma choline and related metabolites between groups after 6 months of intervention. Results Plasma choline, betaine, dimethylglycine, and docosahexaenoic acid concentrations did not differ between groups at 6 month follow up. Plasma TMAO was significantly (26% [95% CI: 7%, 48%]) higher in the egg intervention group in a fully adjusted model. Conclusions Provision of one egg/day for 6 months did not result in increases in plasma choline or related metabolites, except TMAO. This may partially explain the lack of effect on growth and development. Additional interventions are needed to improve choline status, growth, and development in this population.

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Choline and DHA are nutrients that, when provided during the first 1000 days from conception to age 2 years, may have beneficial effects on child neurodevelopment as well as related health factors, including birth outcomes and child growth, morbidity, and inflammation. Because these nutrients are found mainly in animal-source foods, they may be lacking in the diets of pregnant and lactating women and young children in low- and middle-income countries, potentially putting children at risk for suboptimal development and health. Prior reviews of these nutrients have mainly focused on studies from high-income countries. Here, a narrative review is presented of studies describing the pre- and postnatal roles of choline, docosahexaenoic acid, and a combination of the 2 nutrients on child neurodevelopment, birth outcomes, growth, morbidity, and inflammation in low- and middle-income countries. More studies are needed to understand the specific, long-term effects of perinatal choline and docosahexaenoic acid intake in various contexts.

Choline is an essential micronutrient that may influence growth and development; however, few studies have examined postnatal choline status and children's growth and development in low-and middle-income countries. The aim of this observational analysis was to examine associations of plasma choline with growth and development among Malawian children aged 6-15 months enrolled in an egg intervention trial. Plasma choline and related metabolites (betaine, dimethylglycine and trimethylamine N-oxide) were measured at baseline and 6-month follow-up, along with anthropometric (length, weight, head circumference) and developmental assessments (the Malawi Developmental Assessment Tool [MDAT], the Infant Orienting with Attention task [IOWA], a visual paired comparison [VPC] task and an elicited imitation [EI] task).In cross-sectional covariate-adjusted models, each 1 SD higher plasma choline was associated with lower length-for-age z-score (−0.09 SD [95% confidence interval, CI −0.17 to −0.01]), slower IOWA response time (8.84 ms [1.66-16.03]) and faster processing speed on the VPC task (−203.5 ms [−366.2 to −40.7]). In predictive models, baseline plasma choline was negatively associated with MDAT fine motor z-score at 6-month follow-up (−0.13 SD [−0.22 to −0.04]). There were no other significant associations of plasma choline with child measures. Similarly, associations of choline metabolites with growth and development were null except higher trimethylamine N-oxide was associated with slower information processing on the VPC task and higher memory scores on the EI task.In this cohort of children with low dietary choline intake, we conclude that there were no strong or consistent associations between plasma choline and growth and development.

Objectives Choline is an essential nutrient which may be important for child growth and development; however, data on intake among children in low and middle income countries are scarce. We aimed to describe choline intake among Malawian children age 6–9 and 12–15 months enrolled in an egg intervention trial. Methods The Mazira Project was a randomized controlled trial of the effect of daily egg consumption on growth and development in Malawian children. Children 6–9 months old were randomized to the intervention group, which received one egg/day for 6 months, or to the control group, which did not receive eggs. Data on children's complementary food intake were collected by 24-hour recall interview with the primary caregiver at baseline (6–9 months of age; n = 659) and at endline (12–15 months of age; n = 595). Choline from complementary foods was calculated based on local recipe and food composition tables. Breastmilk intake was approximated as the child's estimated energy requirement minus energy from complementary foods, and then multiplied by an assumed choline concentration. Total choline intake was compared to the Adequate Intake (AI) level. Contribution to choline intake by food source was calculated at each time point. Since eggs are high in choline, analysis was stratified by group at endline. Results The median (IQR) total choline intake at 6–9 months was 98.2 (77.7–120.6) mg. Breastmilk was the top contributor (80% of total choline), followed by maize (10%). At 12–15 months, median (IQR) choline intake in the egg group was 126.2 (91.9–166.2) mg and the main contributors were breastmilk (40%), eggs (29%) and maize (10%). Choline intake in the control group was lower, at 94.3 (63.3–118.1) mg, and was mainly from breastmilk (53%) and maize (15%). Median intake was below the AI at both ages; however, at 12–15 months, median intake was 65% of the AI in the egg group and only 47% in the control group. Conclusions Choline intake is low among the Malawian children in this sample, potentially putting them at risk for poor development. The egg intervention increased choline intake, specifically from eggs, but the median intake in this group was still below the AI. Funding Sources The Bill and Melinda Gates Foundation, Egg Nutrition Center.

Objectives Choline has been positively associated with child growth and development, but few studies have been in areas of high stunting and low choline intake. This secondary analysis examines the association of plasma choline with growth/development in Malawian children enrolled in a randomized trial of 1 egg/day versus nonintervention control. Methods Venous blood, anthropometric, and developmental measures were collected at enrollment (at age 6–9 mos) and at endline 6 mos later. Plasma choline, betaine, dimethylglycine, and trimethylamine N-oxide were measured using untargeted metabolomics among 400 children. Length, weight, and head circumference were converted to z-scores using WHO Growth Standards. Developmental measures included fine and gross motor, personal social, and language skills (measured and normed using the Malawi Developmental Assessment Tool), memory (elicited imitation [endline only] and visual paired comparison tasks), and attention (Infant Orienting with Attention [IOWA] task). Generalized linear models, adjusted for covariates including group assignment, were used to examine the association of plasma choline with growth/developmental outcomes. Results In cross-sectional models including both time points (baseline, endline) and adjusting for repeated measures, a 1 SD-unit increase in plasma choline was negatively associated with length-for-age z-score (–0.11 SD [95% CI: –0.20, –0.02]) and positively associated with IOWA reaction time (8.8 ms [1.7, 16.0]), meaning slower shifts in attention with higher plasma choline. In predictive models, higher baseline plasma choline predicted lower endline fine motor z-scores (–0.13 SD [–0.22, –0.04]). There were no associations of plasma choline with weight-for-age, head-circumference-for-age, weight-for-length, or the other developmental outcomes. Analysis of other biomarkers revealed few significant associations with growth/development. Conclusions Plasma choline was not strongly associated with growth or development in this sample of Malawian children. The few significant associations suggested poorer growth/development with higher plasma choline. Further research in various contexts is needed. Funding Sources Bill and Melinda Gates Foundation; Egg Nutrition Center.

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