Issues in the timing of integrated early interventions: contributions from nutrition, neuroscience, and psychological research

Neurodevelopmental performance among pre-schoolers treated for severe anaemia at Lira Regional Referral Hospital, Uganda

BACKGROUND

Severe anaemia is a common clinical problem among young children in sub-Saharan Africa. However, the effect of severe anaemia on neurodevelopment of these children is not well described. Therefore, we assessed the neurodevelopmental performance of preschool children diagnosed with severe anaemia in Northern Uganda.

METHODS

We conducted a prospective cohort study among children < 5 years of age 14 days post discharge after an episode of severe anaemia (Hb < 5.0 g/dl; n = 171; mean Hb = 3.9g/dl) at Lira Regional Referral Hospital, Uganda. Neurodevelopmental outcomes (cognitive, language and motor) were assessed using Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III). Age-adjusted z-scores for each domain were calculated using scores from healthy community control children (n = 88) recruited from the same environment for each age category. Multiple linear regression was used to compare z-scores in the cognitive, language and motor scales between the two groups after adjusting for weight-for-age z-score, socioeconomic status, mother's education, and father's employment on all the scales.

RESULTS

The prevalence of neurodevelopmental impairment was 2.3% (95% CI: 0.8-6.1) for cognition, 1.7% (95%: 0.6-5.3) for language and 3.5% (95% CI: 1.6-7.6) for motor scales and 4.6% (95% CI: 2.3-9.1) for deficits in ≥1 area of neurodevelopment. Significant differences were observed between the two groups with the SA group performing worse on cognition [adjusted mean score, (Standard error, SE), P-value] [-0.20, (0.01) vs. 0.00, (0.01), P = 0.02]; language [-0.25, (0.01) vs. 0.00, (0.01), P< 0.001]; and motor [-0.17, (0.01) vs. 0.00, (0.01), P = 0.05] scales.

CONCLUSION

In children < 5 years of age, severe anaemia was associated with neurocognitive (cognition, language and motor) deficits in the immediate period post treatment. Further research is needed to identify risk factors and determine the long-term effects of poor neurodevelopment in young children with severe anaemia.

All Children Thrive: Integration of Nutrition and Early Childhood Development

Building on the successes of child survival, we review the evidence needed to ensure both that children who survive also thrive and that recommendations promote equity, with no child left behind. To illustrate the critical roles played by nutrition and child development, we revise the Conceptual Framework for the Causes of Malnutrition and Death and the Nurturing Care Framework to create the Conceptual Framework of All Children Surviving and Thriving. The revised framework highlights the goals of child growth and development, supported by health, nutrition, learning, responsive caregiving, and security and safety. We review the challenges posed by undernutrition, stunting, micronutrient deficiencies, overweight, and children not reaching their developmental potential. Although integrated nutrition-childhood development interventions have shown promising effects, most have not been implemented at scale. Implementation science that investigates how and why integrated interventions work in real life, along with the acceptability, feasibility, cost, coverage, and sustainability of the interventions, is needed to ensure equity for all children thriving.

Effects of Maternal Fish Oil and/or 5-Methyl-Tetrahydrofolate Supplementation during Pregnancy on Offspring Brain Resting-State at 10 Years Old: A Follow-Up Study from the NUHEAL Randomized Controlled Trial

Recent studies have shown that maternal supplementation with folate and long-chain polyunsaturated fatty acids (LC-PUFAs) during pregnancy may affect children's brain development. We aimed at examining the potential long-term effect of maternal supplementation with fish oil (FO) and/or 5-methyl-tetrahydrofolate (5-MTHF) on the brain functionality of offspring at the age of 9.5-10 years. The current study was conducted as a follow-up of the Spanish participants belonging to the Nutraceuticals for a Healthier Life (NUHEAL) project; 57 children were divided into groups according to mother's supplementation and assessed through functional magnetic resonance imaging (fMRI) scanning and neurodevelopment testing. Independent component analysis and double regression methods were implemented to investigate plausible associations. Children born to mothers supplemented with FO (FO and FO + 5-MTHF groups, n = 33) showed weaker functional connectivity in the default mode (DM) (angular gyrus), the sensorimotor (SM) (motor and somatosensory cortices) and the fronto-parietal (FP) (angular gyrus) networks compared to the No-FO group (placebo and 5-MTHF groups, n = 24) (PFWE < 0.05). Furthermore, no differences were found regarding the neuropsychological tests, except for a trend of better results in an object recall (memory) test. Considering the No-FO group, the aforementioned networks were associated negatively with attention and speed-processing functions. Mother's FO supplementation during pregnancy seems to be able to shape resting-state network functioning in their children at school age and appears to produce long-term effects on children´s cognitive processing.

Supporting family engagement with child and adolescent mental health services: A scoping review

A key challenge facing the mental health field is connecting children and families to services when symptoms first appear. Multiple barriers inhibit timely access to treatment, and interventions to resolve barriers to care are not common among health and social care organisations. To address this research-to-practice gap this study undertook a scoping review of the empirical literature aimed at identifying key factors in the social ecology of families which influence family engagement with child and adolescent mental health services, then identifying and describing models of intervention designed to help facilitate access to care. Forty studies published between 1 January 2000 and 28 February 2019 were reviewed. Key factors associated with child and adolescent mental health service engagement included family attitudes towards mental illness and help seeking, the flexibility and availability of needed services, community attitudes and stigma surrounding mental illness and mental health treatment, and the degree of coordination and integration across systems of health and social care. Models of intervention to facilitate engagement with mental health services included family outreach, telephone and digital health strategies, and integrated care approaches. Empirical support is strongest for family outreach and integrated care, although telephone and digital health strategies are underexplored with children and families and a potentially promising avenue for future research. To support family engagement with child and adolescent mental health services health and social care organisations should be prepared to identify barriers in their local practice settings and integrate efficacious engagement approaches into their continuum of available services.

Gender Dysphoria: A Review Investigating the Relationship Between Genetic Influences and Brain Development

Gender dysphoria (GD) is a facet of modern human biology which is believed to be derived from the sexual differentiation of the brain. GD “involves a conflict between a person’s physical or assigned gender and the gender with which he/she/they identify”, as defined in the DSM-5. Individuals report feeling uncomfortable and faced with prejudice from those around them, affecting their mental health. Elucidating the relationship between genetic influences on gonadal and brain development could give an insight into understanding this clinical condition. To explore this issue, a review of the literature database was carried out. Evidence suggests that abnormal biological processes, including mutations in certain genes, can lead to abnormal gonadal development, causing some fetuses to present with indifferent gonads and to be reassigned at birth to the default female sex. This disparity in genetic influences relates to an increased likelihood of a diagnosis of GD. An investigation into complete androgen insensitivity syndrome, involving androgen receptor (AR) gene mutation, suggests that such individuals also experience GD. It is known that the brains of males and females are different. Evidence further suggests that brain anatomy and neuronal signaling pathways are more closely aligned with a person’s perceived gender identity. Individuals who present with discordant gonadal and brain developments experience psychological challenges that may contribute to a state of unease or generalized dissatisfaction with their biological sex. These point to a possible biological and genetic underpinning of GD as stemming from a discordance between gonadal and brain development. However, not enough evidence has associated these differences with GD. Further research is required to elucidate the true mechanisms and possible inheritance pattern of GD for a better education and greater understanding by clinicians and the general public on perceptions regarding GD.

Effects of food supplementation on cognitive function, cerebral blood flow, and nutritional status in young children at risk of undernutrition: randomized controlled trial

OBJECTIVE

To assess the effects of food supplementation on improving working memory and additional measures including cerebral blood flow in children at risk of undernutrition.

DESIGN

Randomized controlled trial.

SETTING

10 villages in Guinea-Bissau.

PARTICIPANTS

1059 children aged 15 months to 7 years; children younger than 4 were the primary population.

INTERVENTIONS

Supervised isocaloric servings (≈1300 kJ, five mornings each week, 23 weeks) of a new food supplement (NEWSUP, high in plant polyphenols and omega 3 fatty acids, within a wide variety and high fortification of micronutrients, and a high protein content), or a fortified blended food (FBF) used in nutrition programs, or a control meal (traditional rice breakfast).

MAIN OUTCOME MEASUREMENTS

The primary outcome was working memory, a core executive function predicting long term academic achievement. Additional outcomes were hemoglobin concentration, growth, body composition, and index of cerebral blood flow (CBFi). In addition to an intention-to-treat analysis, a predefined per protocol analysis was conducted in children who consumed at least 75% of the supplement (820/925, 89%). The primary outcome was assessed by a multivariable Poisson model; other outcomes were assessed by multivariable linear mixed models.

RESULTS

Among children younger than 4, randomization to NEWSUP increased working memory compared with the control meal (rate ratio 1.20, 95% confidence interval 1.02 to 1.41, P=0.03), with a larger effect in the per protocol population (1.25, 1.06 to 1.47, P=0.009). NEWSUP also increased hemoglobin concentration among children with anemia (adjusted mean difference 0.65 g/dL, 95% confidence interval 0.23 to 1.07, P=0.003) compared with the control meal, decreased body mass index z score gain (-0.23, -0.43 to -0.02, P=0.03), and increased lean tissue accretion (2.98 cm2, 0.04 to 5.92, P=0.046) with less fat (-5.82 cm2, -11.28 to -0.36, P=0.04) compared with FBF. Additionally, NEWSUP increased CBFi compared with the control meal and FBF in both age groups combined (1.14 mm2/s×10-8, 0.10 to 2.23, P=0.04 for both comparisons). Among children aged 4 and older, NEWSUP had no significant effect on working memory or anemia, but increased lean tissue compared with FBF (4.31 cm2, 0.34 to 8.28, P=0.03).

CONCLUSIONS

Childhood undernutrition is associated with long term impairment in cognition. Contrary to current understanding, supplementary feeding for 23 weeks could improve executive function, brain health, and nutritional status in vulnerable young children living in low income countries. Further research is needed to optimize nutritional prescriptions for regenerative improvements in cognitive function, and to test effectiveness in other vulnerable groups.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03017209.

The Role of Iron in Brain Development: A Systematic Review

One-third of children falter in cognitive development by pre-school age. Iron plays an important role in many neurodevelopmental processes, and animal studies suggest that iron sufficiency in pregnancy and infancy is particularly important for neurodevelopment. However, it is not clear whether iron deficiency directly impacts developmental outcomes, and, if so, whether impact differs by timing of exposure or developmental domain. We searched four databases for studies on iron deficiency or iron supplementation in pregnancy, or at 0-6 months, 6-24 months, or 2-4 years of age. All studies included neurodevelopmental assessments in infants or children up to 4 years old. We then qualitatively synthesized the literature. There was no clear relationship between iron status and developmental outcomes across any of the time windows or domains included. We identified a large quantity of low-quality studies, significant heterogeneity in study design and a lack of research focused on pregnancy and early infancy. In summary, despite good mechanistic evidence for the role of iron in brain development, evidence for the impact of iron deficiency or iron supplementation on early development is inconsistent. Further high-quality research is needed, particularly within pregnancy and early infancy, which has previously been neglected.

The Effects of Early-Life Iron Deficiency on Brain Energy Metabolism

Iron deficiency (ID) is one of the most prevalent nutritional deficiencies in the world. Iron deficiency in the late fetal and newborn period causes abnormal cognitive performance and emotional regulation, which can persist into adulthood despite iron repletion. Potential mechanisms contributing to these impairments include deficits in brain energy metabolism, neurotransmission, and myelination. Here, we comprehensively review the existing data that demonstrate diminished brain energetic capacity as a mechanistic driver of impaired neurobehavioral development due to early-life (fetal-neonatal) ID. We further discuss a novel hypothesis that permanent metabolic reprogramming, which occurs during the period of ID, leads to chronically impaired neuronal energetics and mitochondrial capacity in adulthood, thus limiting adult neuroplasticity and neurobehavioral function. We conclude that early-life ID impairs energy metabolism in a brain region- and age-dependent manner, with particularly strong evidence for hippocampal neurons. Additional studies, focusing on other brain regions and cell types, are needed.

Starting strong: Dietary, behavioral, and environmental factors that promote "strength" from conception to age 2 years

Beginning with conception and continuing through childhood and adolescence, the word "strength" connotes the totality of optimal early bone and tissue growth; neural wiring of the brain; and acquisition of fine motor, gross motor, language, and socioemotional skills. The robustness of each of these attributes depend on 3 critical epigenetic (external) factors: the quality of nutrition; positive adult nurturing; and experiences acquired within a stimulating, safe environment that affords free exploration. This review highlights the relationship between the epigenetic factors in the period of conception to age 2 years and a child's future health, cognitive capacity, and social aptitude, which collectively comprise their "strength". This paper was presented as part of the 2018 Strength Summit conference entitled, The Role of Strength in Optimal Health and Well-being. Novelty Strength in infants signifies the totality of optimal early growth and neural wiring of the brain. Strength at this life stage also includes the acquisition of motor, language, and socioemotional skills. Three epigenetic factors are critical during birth to 24 months: nutrition, nurturing, and free exploration.

A More Comprehensive Approach to the Neuroprotective Potential of Long-Chain Polyunsaturated Fatty Acids in Preterm Infants Is Needed-Should We Consider Maternal Diet and the n-6:n-3 Fatty Acid Ratio?

There is growing evidence that long-chain polyunsaturated fatty acids (LCPUFAs) are of importance for normal brain development. Adequate supply of LCPUFAs may be particularly important for preterm infants, because the third trimester is an important period of brain growth and accumulation of arachidonic acid (n-6 LCPUFA) and docosahexaenoic acid (n-3 LCPUFA). Fatty acids from the n-6 and n-3 series, particularly, have important functions in the brain as well as in the immune system, and their absolute and relative intakes may alter both the risk of impaired neurodevelopment and response to injury. This narrative review focuses on the potential importance of the n-6:n-3 fatty acid ratio in preterm brain development. Randomized trials of post-natal LCPUFA supplementation in preterm infants are presented. Pre-clinical evidence, results from observational studies in preterm infants as well as studies in term infants and evidence related to maternal diet during pregnancy, focusing on the n-6:n-3 fatty acid ratio, are also summarized. Two randomized trials in preterm infants have compared different ratios of arachidonic acid and docosahexaenoic acid intakes. Most of the other studies in preterm infants have compared formula supplemented with arachidonic acid and docosahexaenoic acid to un-supplemented formula. No trial has had a comprehensive approach to differences in total intake of both n-6 and n-3 fatty acids during a longer period of neurodevelopment. The results from preclinical and clinical studies indicate that intake of LCPUFAs during pregnancy and post-natal development is of importance for neurodevelopment and neuroprotection in preterm infants, but the interplay between fatty acids and their metabolites is complex. The best clinical approach to LCPUFA supplementation and n-6 to n-3 fatty acid ratio is still far from evident, and requires in-depth future studies that investigate specific fatty acid supplementation in the context of other fatty acids in the diet.

Nutritional Status and Symptoms in Preschool Children With Autism Spectrum Disorder: A Two-Center Comparative Study in Chongqing and Hainan Province, China

Objective: The study aimed to compare the nutritional status and symptoms of preschool children with autism spectrum disorder (ASD) from two regions of China, and to analyze the association between nutritional status and symptoms of ASD. Methods: In this cross-sectional study, 738 ASD children and 302 typically developing children (TD) were recruited from Chongqing and Hainan of China. Symptoms of ASD children were evaluated with the Autism Behavior Checklist (ABC), Social Responsiveness Scale (SRS), and Childhood Autism Rating Scale (CARS). Neurodevelopment of ASD children was assessed with the Gesell Developmental Scale (GDS). Nutritional status was evaluated by anthropometric measures, biochemical detection of micronutrients, and providing questionnaire and food frequency questionnaire (FFQ) to caregivers. Results: Comparing ASD children with local TD children, ASD children consumed fewer whole grains, milk and dairy products, beans and soy products, vegetables, and fruits than local TD children in both regions. The serum concentrations of folate, vitamin B12 (VB12), and vitamin D (VD) were consistently lower in ASD children in both regions. Comparing the ASD children between the two regions, the ASD children in Chongqing had significantly higher mean scores of CARS, SRS, and ABC than those in Hainan. The ASD children in Chongqing consumed fewer whole grains, seafood, and fruits than those in Hainan. The serum concentrations of ferritin, vitamin A (VA), VB12, and VD were reduced in the ASD children of Chongqing than those in Hainan, and the ASD children in Chongqing had higher deficiency rates of zinc, ferritin, VA, and VD than those in Hainan. The serum levels of VA, VD, and folate showed a negative association with symptom scores of ASD children. VD and zinc levels had a positive association with the GDS scores of ASD children. Conclusions: ASD children exhibit a higher risk of nutrient deficiencies than neurotypical children, and there are regional differences in the nutritional status of ASD children. Micronutrients VA, VD, folate, and zinc levels were correlated with symptoms and development of ASD children. Therefore, it is essential to provide detailed nutrition evaluation and individualized nutrition interventions for ASD children from different backgrounds.

Significant Effects of Maternal Diet During Pregnancy on the Murine Fetal Brain Transcriptome and Offspring Behavior

BACKGROUND

Maternal over- and undernutrition in pregnancy plays a critical role in fetal brain development and function. The effects of different maternal diet compositions on intrauterine programing of the fetal brain is a lesser-explored area. The goal of this study was to investigate the impact of two chowmaternal diets on fetal brain gene expression signatures, fetal/neonatal growth, and neonatal and adult behavior in a mouse model.

METHODS

Throughout pregnancy and lactation, female C57Bl/6J mice were fed one of two standard, commercially available chow diets (pellet versus powder). The powdered chow diet was relatively deficient in micronutrients and enriched for carbohydrates and n-3 long-chain polyunsaturated fatty acids compared to the pelleted chow. RNA was extracted from embryonic day 15.5 forebrains and hybridized to whole genome expression microarrays (N = 5/maternal diet group). Functional analyses of significantly differentially expressed fetal brain genes were performed using Ingenuity Pathways Analysis and Gene Set Enrichment Analysis. Neonatal behavior was assessed using a validated scale (N = 62 pellet-exposed and 31 powder-exposed). Hippocampal learning, locomotor behavior, and motor coordination were assessed in a subset of adults using fear conditioning, open field testing, and Rotarod tests (N = 16 pellet-exposed, 14 powder-exposed).

RESULTS

Comparing powdered to pelleted chow diets, neither maternal weight trajectory in pregnancy nor embryo size differed. Maternal powdered chow diet was associated with 1647 differentially expressed fetal brain genes. Functional analyses identified significant upregulation of canonical pathways and upstream regulators involved in cell cycle regulation, synaptic plasticity, and sensory nervous system development in the fetal brain, and significant downregulation of pathways related to cell and embryo death. Pathways related to DNA damage response, brain immune response, amino acid and fatty acid transport, and dopaminergic signaling were significantly dysregulated. Powdered chow-exposed neonates were significantly longer but not heavier than pelleted chow-exposed counterparts. On neonatal behavioral testing, powdered chow-exposed neonates achieved coordination- and strength-related milestones significantly earlier, but sensory maturation reflexes significantly later. On adult behavioral testing, powdered chow-exposed offspring exhibited hyperactivity and hippocampal learning deficits.

CONCLUSION

In wild-type offspring, two diets that differed primarily with respect to micronutrient composition had significant effects on the fetal brain transcriptome, neonatal and adult behavior. These effects did not appear to be mediated by alterations in gross maternal nutritional status nor fetal/neonatal weight. Maternal dietary content is an important variable to consider for investigators evaluating fetal brain development and offspring behavior.

Early life factors, gray matter brain volume and academic performance in overweight/obese children: The ActiveBrains project

Early life factors may influence brain and academic outcomes later in life, especially during childhood. Here we investigate the associations of early life factors (i.e., birth weight, birth length, and breastfeeding) with gray matter volume, adjusted for body mass index and cardiorespiratory fitness, and ii) we test whether early-life factor-related differences in gray matter volume are associated with academic performance in overweight/obese children. 96 children with overweight/obesity aged 8-11 years participated. Birth weight, birth length and gestational age were collected from birth records, and breastfeeding practices were asked to parents. T1-weighted images were acquired with a 3.0 T Magnetom Tim Trio system. Academic performance was assessed with the Bateria III Woodcock-Muñoz Tests of Achievement. Whole-brain voxel-wise multiple regressions were used to test the associations of each early life factor with gray matter volume. Higher birth weight and birth length were associated with greater gray matter volume in 9 brain regions including the middle frontal gyrus, rectal gyrus, thalamus, putamen, middle temporal gyrus, lingual gyrus, middle occipital gyrus, calcarine cortex and cerebellum bilaterally (β ranging from 0.361 to 0.539, t ranging from 3.46 to 5.62 and cluster size from 82 to 4478 voxels; p < 0.001); and greater duration of any breastfeeding was associated with greater gray matter volume in 3 regions including the bilateral inferior frontal gyrus and rolandic operculum (β ranging from 0.359 to 0.408, t ranging from 4.01 to 4.32 and cluster size from 64 to 171 voxels; p < 0.001). No associations were found for duration of exclusive breastfeeding. Additionally, none of the gray matter regions that were associated with the early life factors were associated with academic performance (all p > 0.05). Our results demonstrate that birth weight, birth length, and breastfeeding are predictive of gray matter volume of numerous brain structures that are involved in higher order cognition and emotion regulation, but how these results relate to measures of academic achievement remain a matter of speculation.

Intellectual Performance and Educational Attainment of Mexican Adolescents in Poverty

The objective of this study was to determine factors that can predict the intellectual performance and educational attainment of adolescents living in poverty. Data of Mexican adolescents from rural and urban areas (N = 1,093, 55.8% male, 61% urban) and their mothers were analyzed. The data came from a probabilistic sample with national representativeness of beneficiary households of the governmental program to fight poverty Oportunidades. Mothers and children were surveyed separately at home using questionnaires. Results from structural equations modeling revealed that higher intellectual performance was determined by older age, higher maternal intellectual performance and education, more adequate parenting practices, fewer siblings, and less insecure neighborhoods. Higher educational attainment was predicted by older age, higher intellectual performance, and more psychological resources. Data explained 25% of the variance of intellectual performance, and 39% of the variance of educational attainment. Results are discussed regarding the possibility of enhancing intellectual performance and education.

Motor Evoked Potentials as Potential Biomarkers of Early Atypical Corticospinal Tract Development in Infants with Perinatal Stroke

Diagnosis of cerebral palsy (CP) after perinatal stroke is often delayed beyond infancy, a period of rapid neuromotor development with heightened potential for rehabilitation. This study sought to assess whether the presence or absence of motor evoked potentials (MEPs) elicited by transcranial magnetic stimulation (TMS) could be an early biomarker of atypical development within the first year of life. In 10 infants with perinatal stroke, motor outcome was assessed with a standardized movement assessment. Single-pulse TMS was utilized to assess presence of MEPs. Younger infants (3-6 months CA, n = 5, 4/5 (80%)) were more likely to present with an MEP from the more-affected hemisphere (MAH) compared to older infants (7-12 months CA, n = 5, 0/5, (0%)) (p = 0.048). Atypical movement was demonstrated in the majority of infants with an absent MEP from the MAH (5/6, 83%) compared to those with a present MEP (1/4, 25%) (p = 0.191). We found that age influences the ability to elicit an MEP from the MAH, and motor outcome may be related to MAH MEP absence. Assessment of MEPs in conjunction with current practice of neuroimaging and motor assessments could promote early detection and intervention in infants at risk of CP.

Dietary intake of n-3 and n-6 polyunsaturated fatty acids in Korean toddlers 12-24 months of age with comparison to the dietary recommendations

BACKGROUND/OBJECTIVES

Adequate dietary fatty acid intake is important for toddlers between 12-24 months of age, as this is a period of dietary transition in conjunction with rapid growth and development; however, actual fatty acid intake during this period seldom has been explored. This study was conducted to assess the intake status of n-3 and n-6 polyunsaturated fatty acids by toddlers during the 12-24-month period using 2010-2015 Korea National Health and Nutrition Examination Survey data.

SUBJECTS/METHODS

Twenty-four-hour dietary recall data of 12-24-month-old toddlers (n = 544) was used to estimate the intakes of α-linolenic acid (ALA; 18:3n-3), eicosapentaenoic acid (EPA; 20:5n-3), docosahexaenoic acid (DHA; 22:6n-3), linoleic acid (LA; 18:2n-6), and arachidonic acid (AA; 20:4n-6), as well as the major dietary sources of each. The results were compared with the expected intake for exclusively breastfed infants in the first 6 months of life and available dietary recommendations.

RESULTS

Mean daily intakes of ALA, EPA, DHA, LA, and AA were 529.9, 22.4, 37.0, 3907.6, and 20.0 mg/day, respectively. Dietary intakes of these fatty acids fell below the expected intake for 0-5-month-old exclusively breastfed infants. In particular, DHA and AA intakes were 4 to 5 times lower. The dietary assessment indicated that the mean intake of essential fatty acids ALA and LA was below the European and the FAO/WHO dietary recommendations, particularly for DHA, which was approximately 30% and 14-16% lower, respectively. The key sources of the essential fatty acids, DHA, and AA were soy (28.2%), fish (97.3%), and animals (53.7%), respectively.

CONCLUSIONS

Considering the prevailing view of DHA and AA requirements on early brain development, there remains considerable room for improvement in their intakes in the diets of Korean toddlers. Further studies are warranted to explore how increasing dietary intakes of DHA and AA could benefit brain development during infancy and early childhood.

A systematic literature review of the relation between iron status/anemia in pregnancy and offspring neurodevelopment

BACKGROUND

The fetal brain starts developing early and animal studies have suggested that iron plays several roles for the development, but results from epidemiological studies investigating associations between gestational iron and offspring neurodevelopment are inconsistent.

OBJECTIVE

To systematically examine results from observational studies and RCTs on gestational iron and offspring neurodevelopment, with focus on the importance of four domains: iron status indicators, exposure timing, neurodevelopmental outcomes, and offspring age.

METHODS

PRISMA guidelines were followed. Embase, PsychInfo, Scopus, and The Cochrane library were searched in September 2017 and February 2018. Overall, 3307 articles were identified and 108 retrieved for full-text assessment. Pre-specified eligibility criteria were used to select studies and 27 articles were included;19 observational and 8 RCTs.

RESULTS

Iron status in pregnancy was associated with offspring behavior, cognition, and academic achievement. The direction of associations with behavioral outcomes were unclear and the conclusions related to cognition and academic achievement were based on few studies, only. Little evidence was found for associations with motor development. Observed associations were shown to persist beyond infancy into adolescence, and results depended on iron status indicator type but not on the timing of exposure.

CONCLUSION

We conclude that there is some evidence that low pregnancy iron, possibly particularly in the 3rd trimester, may be associated with adverse offspring neurodevelopment. As most previous research used Hemoglobin, inferring results to iron deficiency should be done with caution. No conclusions could be reached regarding associations beyond early childhood, and supplementation with iron during pregnancy did not seem to influence offspring neurodevelopment.

Body composition and cognition in preschool-age children with congenital gastrointestinal anomalies

BACKGROUND

Children with congenital gastrointestinal anomalies (CGIAs) experience multiple stressors while hospitalized in neonatal intensive care units during an essential time of growth and development. Early stress and inadequate nutrition are linked to altered growth patterns and later neurodevelopmental delays. In other at-risk populations, improved fat-free mass (FFM) accretion is associated with improved cognitive outcomes.

OBJECTIVE

To determine if body composition is associated with cognitive function in preschool-age children with CGIAs.

STUDY DESIGN

An observational study examined body composition and cognition in 34 preschool-age children with CGIAs. Anthropometric measurements and body composition testing via air displacement plethysmography were obtained. Measurements were compared with a reference group of healthy, term-born children. Cognition was measured with the NIH Toolbox Early Childhood Cognition Battery. Linear regression was used to test the association of body composition with cognitive function.

RESULTS

Compared with the reference group, children with CGIAs had similar anthropometric measurements (weight, height, and body mass index z-scores) and body composition at preschool-age. Processing speed scores were lower than standardized means (p = 0.001). Increased FFM was associated with higher receptive vocabulary scores (p = 0.001), cognitive flexibility scores (p = 0.005), and general cognitive function scores (p = 0.05).

CONCLUSIONS

At preschool-age, children with CGIAs have similar growth and body composition to their peers. In children with CGIAs, higher FFM was associated with higher cognitive scores. Closer tracking of body composition and interventions aimed at increasing FFM may improve long-term outcomes in this population.

Prenatal Exposure to Environmental Tobacco Smoke and Early Development of Children in Rural Guizhou Province, China

BACKGROUND

There is a substantial body of evidence supporting the association between maternal active smoking during pregnancy and child development, but the association between prenatal exposure to environmental tobacco smoke (ETS) and early child development has not been well documented. This cross-sectional study examines the association between prenatal exposure to ETS and the development of children in their first two years of life.

METHODS

We interviewed the primary caregivers of 446 children under two years old in rural Guizhou Province, China. Based on self-reported assessments about whether the mother was exposed to ETS during pregnancy, we divided the children into the ETS-exposed group or the non-exposed group. Sociodemographic information was collected through a questionnaire. The cognitive, language, motor, and socioemotional abilities of children were assessed using the Bayley Scales of Infant Development III (BSID-III). A multivariate linear regression model adjusting for confounding variables was used to estimate the association of interest.

RESULTS

About 60% of mothers experienced ETS exposure during pregnancy. Cognitive and language scores were lower among children in the ETS-exposed group. When adjusting for characteristics of the child, the mother, the household, and village fixed effects, prenatal exposure to ETS was associated with lower cognition scores (-3.41; 95% confidence interval (CI): -6.39 to -0.42; p = 0.03) and language scores (-3.01; 95% CI: -5.39 to -0.09; p = 0.04). Frequency of prenatal exposure to ETS was also negatively associated with language development (-0.48; 95% CI: -0.87 to -0.09; p = 0.02) before children reached two years old.

CONCLUSIONS

Prenatal exposure to ETS is negatively associated with the cognitive and language development of rural young children within their first two years of life. The government should take action to raise public awareness about the negative effects of tobacco use, with an emphasis on the protection of pregnant women and their children, in order to carry through comprehensive smoke-free laws in rural areas, while also increasing tobacco taxation.

Early life nutrition

Nutritionally, the first 1,000 days of an infant's life - from conception to two years - has been identified as a highly influential period, during which lasting health can be achieved. Significant evidence links patterns of infant feeding to both short and long-term health outcomes, many of which can be prevented through nutritional modifications. Recommended globally, breastfeeding is recognised as the gold standard of infant nutrition; providing key nutrients to achieve optimal health, growth and development, and conferring immunologic protective effects against disease. Nevertheless, infant formulas are often the sole source of nutrition for many infants during the first stage of life. Producers of infant formula strive to supply high quality, healthy, safe alternatives to breast milk with a comparable balance of nutrients to human milk imitating its composition and functional performance measures. The concept of 'nutritional programming', and the theory that exposure to specific conditions, can predispose an individual's health status in later life has become an accepted dictum, and has sparked important nutritional research prospects. This review explores the impact of early life nutrition, specifically, how different feeding methods affect health outcomes.

The Earlier the Better? Individual Participant Data and Traditional Meta-analysis of Age Effects of Parenting Interventions

Strong arguments have been made for early intervention for child problems, stating that early is more effective than later, as the brain is more malleable, and costs are lower. However, there is scant evidence from trials to support this hypothesis, which we therefore tested in two well-powered, state-of-the-art meta-analyses with complementary strengths: (a) Individual participant data (IPD) meta-analysis of European trials of Incredible Years parenting intervention (k = 13, n = 1696; age = 2-11); (b) Larger, trial-level robust variance estimation meta-analysis of a wider range of parenting programs (k = 156, n = 13,378, M_age  = 2-10) for reducing disruptive behavior. Both analyses found no evidence that intervention earlier in childhood was more effective; programs targeted at a narrower age range were no more effective than general ones.

Nutritional influences on brain development

There is increasing evidence from preclinical and human studies that nutrition in the late foetal and early neonatal period has a significant impact on neurodevelopment across the lifespan. Certain nutrients have particularly large effects in this time period, and their deficits cause greater long-term risk. The mechanisms by which nutrients influence early brain growth and the sensitive periods for when certain nutrients should be provided are being elucidated. Assessments of nutritional status that index brain growth and predict long-term development are important to assess the efficacy of early life nutritional therapies.

CONCLUSION

Optimizing nutrition during foetal and early postnatal life is a golden opportunity to impact neurodevelopment and brain function across the lifespan.

Atypical fetal development: Fetal alcohol syndrome, nutritional deprivation, teratogens, and risk for neurodevelopmental disorders and psychopathology

Accumulating evidence indicates that the fetal environment plays an important role in brain development and sets the brain on a trajectory across the life span. An abnormal fetal environment results when factors that should be present during a critical period of development are absent or when factors that should not be in the developing brain are present. While these factors may acutely disrupt brain function, the real cost to society resides in the long-term effects, which include important mental health issues. We review the effects of three factors, fetal alcohol exposure, teratogen exposure, and nutrient deficiencies, on the developing brain and the consequent risk for developmental psychopathology. Each is reviewed with respect to the evidence found in epidemiological and clinical studies in humans as well as preclinical molecular and cellular studies that explicate mechanisms of action.

Pathways of Association from Stress to Obesity in Early Childhood

OBJECTIVE

The objective of this study is to critically review the literature on early life stress in relation to obesity in humans, including the multiple biological and behavioral mechanisms through which early life stress exposure (birth to the age of 5 years) may associate with obesity risk during childhood.

METHODS

A review of the literature was conducted to identify studies on associations between early childhood stress and risk for obesity and the mechanisms of association. Multiple databases (PubMed, PsycInfo, Google Scholar) were used in the search as well as a "snowball" search strategy. All study designs were included.

RESULTS

Early life stress and adverse childhood experiences are associated with obesity and overweight in adults. Evidence is less consistent in children. Studies vary in the nature of the stress examined (e.g., chronic vs. acute), sample characteristics, and study designs. Longitudinal studies are needed, as the effects of early life stress exposure may not emerge until later in the life-span. Early life stress exposure is associated with biological and behavioral pathways that may increase risk for childhood obesity.

CONCLUSIONS

There is evidence that early life stress is associated with multiple biological and behavioral pathways in children that may increase risk for later obesity. Little work has detailed the interconnections among these mechanisms across development or identified potential moderators of the association. Mapping the mechanisms connecting early life stress exposure to obesity risk in young children longitudinally should be a priority for obesity researchers. Recommendations for developmentally sensitive approaches to research that can inform obesity prevention strategies are presented.

Could Autism Be Associated With Nutritional Status in the Palestinian population? The Outcomes of the Palestinian Micronutrient Survey

BACKGROUND

Autism spectrum disorder is a neurodevelopmental disorder. It is believed that the cause of autism is multifactorial, where genetic predispositions interact with environmental factors. In this context, micronutrients play a crucial role.

OBJECTIVE

To present evidence on current micronutrient status in Palestine and highlight its possible role in increasing problems of neurodevelopment disorders in general and autism in particular.

METHOD

Analytical review of results.

RESULTS AND CONCLUSIONS

The Palestinian Micronutrient Survey was conducted to assess micronutrient status in most vulnerable groups and also micronutrient deficiencies. The data from Palestinian population showed severe anaemia due to iron, Zn, B12, and folic acid deficiencies. One in every 3 Palestinian pregnant women is anaemic. Moreover, 78.2% and 87.1% of lactating mothers from the West Bank and Gaza Strip are Zn deficient. For children from 6 to 59 months old, 1 in every 4 boys and 1 in every 5 girls are considered anaemic. Similar trend was found with respect to vitamins E, D, A, and folic acid. We reviewed the literature that linked micronutrient deficiencies to neurodevelopmental disorders and expected the number of neurodevelopmental disorder cases, including autism, to increase.

Associations between feeding practices and growth and neurodevelopmental outcomes at 36 months among children living in low- and low-middle income countries who participated in the BRAIN-HIT trial

BACKGROUND

Feeding practices over the first several years of a child's life can critically influence development. The purpose of this study was to examine associations between feeding practices and growth and neurodevelopmental outcomes at 36 months of age among children from low- and low-middle-income countries (LMIC).

METHODS

We conducted a secondary analysis using data collected from children in India, Pakistan, and Zambia who were enrolled in a randomized controlled trial of a home-based early development intervention program called Brain Research to Ameliorate Impaired Neurodevelopment Home-based Intervention Trial. Qualitative dietary data collected at 36 months was used to assess the modified Minimum Acceptable Diet (mMAD), a measure based on a core indicator developed by the World Health Organization to measure whether young children receive the minimum number of meals recommended and adequate diversity of major food groups in their diet. Regression models were used to assess cross-sectional associations between diet and growth indices, including Z-scores for height-for-age (HAZ), weight-for-age (WAZ), weight-for-height (WHZ), head circumference (HCZ), and Bayley Scales of Infant Development II mental and psychomotor developmental measures at 36 months of age.

RESULTS

Of 371 children, 174 (47%) consumed the mMAD, with significantly higher mean adjusted WHZ than those who did not meet mMAD (0.20 vs - 0.08, p = 0.05). Egg consumption was found to be significantly associated with a decreased risk of wasting [adjusted RR (95% CI): 0.37 (0.15, 0.89), p = 0.03]. HCZ at 36 months did not differ significantly for children who did and did not receive the mMAD.

CONCLUSION

Meeting the mMAD was associated with better weight-for-height outcomes at 36 months in children in these three LMIC, highlighting the importance of adequate food quantity and quality.

TRIAL REGISTRATION

registered on March 20, 2008.

Of Microbes and Minds: A Narrative Review on the Second Brain Aging

In recent years, an extensive body of literature focused on the gut-brain axis and the possible role played by the gut microbiota in modulating brain morphology and function from birth to old age. Gut microbiota has been proposed as a relevant player during the early phases of neurodevelopment, with possible long-standing effects in later life. The reduction in gut microbiota diversity has also become one of the hallmarks of aging, and disturbances in its composition are associated with several (age-related) neurological conditions, including depression, Alzheimer's disease, and Parkinson's disease. Several pathways have been evoked for gut microbiota-brain communication, including neural connections (vagus nerve), circulating mediators derived by host-bacteria cometabolism, as well as the influence exerted by gut microbiota on host gut function, metabolism, and immune system. Although the most provoking data emerged from animal studies and despite the huge debate around the possible epiphenomenal nature of those findings, the gut microbiota-brain axis still remains a fascinating target to be exploited to attenuate some of the most burdensome consequences of aging.

Advocacy for Improving Nutrition in the First 1000 Days to Support Childhood Development and Adult Health

Maternal prenatal nutrition and the child's nutrition in the first 2 years of life (1000 days) are crucial factors in a child's neurodevelopment and lifelong mental health. Child and adult health risks, including obesity, hypertension, and diabetes, may be programmed by nutritional status during this period. Calories are essential for growth of both fetus and child but are not sufficient for normal brain development. Although all nutrients are necessary for brain growth, key nutrients that support neurodevelopment include protein; zinc; iron; choline; folate; iodine; vitamins A, D, B₆, and B₁₂; and long-chain polyunsaturated fatty acids. Failure to provide key nutrients during this critical period of brain development may result in lifelong deficits in brain function despite subsequent nutrient repletion. Understanding the complex interplay of micro- and macronutrients and neurodevelopment is key to moving beyond simply recommending a "good diet" to optimizing nutrient delivery for the developing child. Leaders in pediatric health and policy makers must be aware of this research given its implications for public policy at the federal and state level. Pediatricians should refer to existing services for nutrition support for pregnant and breastfeeding women, infants, and toddlers. Finally, all providers caring for children can advocate for healthy diets for mothers, infants, and young children in the first 1000 days. Prioritizing public policies that ensure the provision of adequate nutrients and healthy eating during this crucial time would ensure that all children have an early foundation for optimal neurodevelopment, a key factor in long-term health.

Iron Nutriture of the Fetus, Neonate, Infant, and Child

Iron is a key nutrient and is essential for the developing fetus, neonate, infant, and child. Iron requirements are high during early stages of life because it is critically important for the production of new red blood cells and muscle cells as well as brain development. Neonates, infants, and children obtain iron from dietary sources including breast milk (lactoferrin) and heme- and non-heme-containing foods. Iron deficiency (ID) is the most common micronutrient deficiency in children and pregnant women worldwide. ID and iron deficiency anemia (IDA) can affect growth and energy levels as well as motor and cognitive performance in the developing child. The fetus is completely dependent on maternal iron crossing through the placenta and, although it is generally well protected against deficiency at birth, ID in mothers can increase the risk of ID and IDA in their children as early as 4 months. This review will discuss the uses of iron, iron requirements, and the sources of iron from conception through childhood. In addition, it will describe the prevalence and clinical manifestations of ID and IDA in children and discuss recommendations for iron supplementation of children and pregnant women.

Iron assessment to protect the developing brain

Iron deficiency (ID) before the age of 3 y can lead to long-term neurological deficits despite prompt diagnosis of ID anemia (IDA) by screening of hemoglobin concentrations followed by iron treatment. Furthermore, pre- or nonanemic ID alters neurobehavioral function and is 3 times more common than IDA in toddlers. Given the global prevalence of ID and the enormous societal cost of developmental disabilities across the life span, better methods are needed to detect the risk of inadequate concentrations of iron for brain development (i.e., brain tissue ID) before dysfunction occurs and to monitor its amelioration after diagnosis and treatment. The current screening and treatment strategy for IDA fails to achieve this goal for 3 reasons. First, anemia is the final state in iron depletion. Thus, the developing brain is already iron deficient when IDA is diagnosed owing to the prioritization of available iron to red blood cells over all other tissues during negative iron balance in development. Second, brain ID, independently of IDA, is responsible for long-term neurological deficits. Thus, starting iron treatment after the onset of IDA is less effective than prevention. Multiple studies in humans and animal models show that post hoc treatment strategies do not reliably prevent ID-induced neurological deficits. Third, most currently used indexes of ID are population statistical cutoffs for either hematologic or iron status but are not bioindicators of brain ID and brain dysfunction in children. Furthermore, their relation to brain iron status is not known. To protect the developing brain, there is a need to generate serum measures that index brain dysfunction in the preanemic stage of ID, assess the ability of standard iron indicators to detect ID-induced brain dysfunction, and evaluate the efficacy of early iron treatment in preventing ID-induced brain dysfunction.

Shaping long-term primate development: Telomere length trajectory as an indicator of early maternal maltreatment and predictor of future physiologic regulation

The molecular, neurobiological, and physical health impacts of child maltreatment are well established, yet mechanistic pathways remain inadequately defined. Telomere length (TL) decline is an emerging molecular indicator of stress exposure with definitive links to negative health outcomes in maltreated individuals. The multiple confounders endemic to human maltreatment research impede the identification of causal pathways. This study leverages a unique randomized, cross-foster, study design in a naturalistic translational nonhuman primate model of infant maltreatment. At birth, newborn macaques were randomly assigned to either a maltreating or a competent control mother, balancing for sex, biological mother parenting history, and social rank. Offspring TL was measured longitudinally across the first 6 months of life (infancy) from peripheral blood. Hair cortisol accumulation was also determined at 6, 12, and 18 months of age. TL decline was greater in animals randomized to maltreatment, but also interacted with biological mother group. Shorter TL at 6 months was associated with higher mean cortisol levels through 18 months (juvenile period) when controlling for relevant covariates. These results suggest that even under the equivalent social, nutritional, and environmental conditions feasible in naturalistic translational nonhuman primate models, early adverse caregiving results in lasting molecular scars that foreshadow elevated health risk and physiologic dysregulation.

Perbedaan Asupan Energi, Protein, Zink, dan Perkembangan pada Balita Stunting dan non Stunting

 Background: Stunting is a nutritional problem caused by inadequate nutrition intake for  a long time and/or recurrent infectious diseases. The impacts of stunting are increase mortality,  morbidity,  health costs, decrease cognitive development, motor, and language development.There are nutrients that important to linear growth as energy, protein, and zinc. Objectives: The purpose of this study was to analyze the differences of intake of the energy, protein, Zinc, development in stunting and non-stunting toddler. Methods: The research was a cross sectional study with quantitative approach. The sample size was 64 toddler in Manyar Sabrangan Sub-district, Surabaya, 32 toddler each stunting and non-stunting were taken by simple random sampling. The data were collected by measuring height, structure questionnaire, food recall 2x24 hours, questionnaire for screening development (KPSP). The data were analyzed using Chi Square Test. Results: Non-stunting toddlers have an adequate intake of energy, protein, zinc respectively 71,9%, 93,7%, 71,9%, meanwhile appropriate development was 75%. Stunting toddlers have an inadequate intake of energy, zinc respectively 68,7%, 65,6% and adequate intake of protein was 68,7%, meanwhile deviance development was 62,5%. The results of this study showed that the comparison of differences between stunting and non-stunting toddler were significant (≤0,05) in energy, protein, Zinc, and development. Conclusion: Non-stunting toddler have a higher intake of the energy, protein, Zinc, and development rather than stunting toddler. Mother of toddler should to increase intake of energy, protein, Zinc to prevent stunting and achieve appropriate development.ABSTRAK Latar belakang: Stunting adalah permasalahan gizi yang disebabkan oleh asupan zat gizi yang kurang dalam waktu lama dan/atau penyakit infeksi yang berulang. Terdapat beberapa zat gizi yang berperan dalam pertumbuhan linier. Salah satu zat gizi tersebut adalah energi, protein, dan zink. Dampak stunting dapat meningkatkan mortalitas, morbiditas, biaya kesehatan, menurunkan perkembangan kognitif, motorik, dan bahasa.Tujuan: Tujuan dari penelitian ini adalah untuk menganalisis perbedaan asupan energi, protein, Zink, dan perkembangan pada balita stunting dan non stunting.Metode: Penelian ini menggunakan studi cross sectional dengan pendekatan kuantitatif. Sampel terdiri dari 64 balita yang di Kelurahan Manyar Sabrangan Surabaya, balita stunting dan non-stunting masing-masing berjumlah 32. Pengumpulan data menggunakan pengukuran tinggi badan, food recall 2x24 jam, kuesioner pra skrining perkembangan (KPSP) ,dan kuesioner. Data dianalisis menggunakan chi square Tets.Hasil: Balita non-stunting mempunyai asupan energi, protein, zink adekuat yaitu 71,9%, 93,7%, dan 71,9% serta perkembangan sesuai yaitu 75%. Balita stunting mempunyai asupan energi, zink inadekuat yaitu 68,7%, 65,6% dan protein adekuat yaitu 68,7% serta perkembangan menyimpang yaitu 62,5%. Hasil dari penelitian menunjukkan perbandingan balita stunting dan non stunting adalah ada perbedaan signifikan (p≤0,05) pada energi, protein, Zink, dan perkembangan.Kesimpulan: Balita non-stunting mempunyai asupan energi, protein, Fe, Zink yang tinggi dan stimulasi psikososial serta perkembangan yang baik daripada balita stunting. Ibu balita harus meningkatkan asupan energi, protein, Zink agar dapat mencegah terjadinya stunting dan dapat mencapai perkembangan yang sesuai.

Effects of lipid-based nutrient supplements v. micronutrient powders on nutritional and developmental outcomes among Peruvian infants

OBJECTIVE

To determine the effects of lipid-based nutrient supplements (LNS) on children's Hb, linear growth and development, compared with supplementation with micronutrient powder (MNP).

DESIGN

The study was a two-arm parallel-group randomized controlled trial, where participants received either LNS or MNP for daily consumption during 6 months. Supplements were delivered by staff at government-run health centres. Hb, anthropometric, motor development, language development and problem-solving indicators were measured by trained research assistants when children were 12 months of age.

SETTING

The study was conducted in five rural districts in the Province of Ambo in the Department of Huánuco, Peru.

SUBJECTS

We enrolled 6-month-old children (n 422) at nineteen health centres.

RESULTS

Children who received LNS had a higher mean Hb concentration and lower odds of anaemia than those who received MNP. No significant differences in height-for-age, weight-for-height or weight-for-age Z-score, or stunting and underweight prevalence, were observed. Provision of LNS was associated with a higher pre-verbal language (gestures) score, but such effect lost significance after adjustment for covariates. Children in the LNS group had higher problem-solving task scores and increased odds of achieving this cognitive task than children in the MNP group. No significant differences were observed on receptive language or gross motor development.

CONCLUSIONS

LNS between 6 and 12 months of age increased Hb concentration, reduced anaemia and improved cognitive development in children, but showed no effects on anthropometric indicators, motor or language development.

Understanding Brain Reorganization in Infants With Perinatal Stroke Through Neuroexcitability and Neuroimaging

PURPOSE

The primary aim of this proposed study is to evaluate brain reorganization patterns in infants with perinatal stroke between 3 and 5 months of age using transcranial magnetic stimulation and magnetic resonance imaging, with the addition of the General Movements Assessment. A secondary aim is to demonstrate feasibility and safety of infant-appropriate brain assessment protocols.

METHODS

Ten infants with perinatal stroke will be enrolled. In this exploratory study, infants will first receive magnetic resonance imaging scanning during natural sleep to examine their corticospinal tract integrity. Infants will then receive transcranial magnetic stimulation to assess their corticomotor excitability. A General Movements Assessment video of at least 5 minutes will also be recorded.

DISCUSSION

Study results will enhance our understanding of brain reorganization in infants with perinatal stroke. We expect these results will also guide the development of early interventions designed to mitigate maladaptive neuroplastic changes and improve long-term motor outcomes.

Neurodevelopment: The Impact of Nutrition and Inflammation During Preconception and Pregnancy in Low-Resource Settings

The rapid pace of fetal development by far exceeds any other stage of the life span, and thus, environmental influences can profoundly alter the developmental course. Stress during the prenatal period, including malnutrition and inflammation, impact maternal and fetal neurodevelopment with long-term consequences for physical and mental health of both the mother and her child. One primary consequence of maternal malnutrition, inflammation, and other sources of prenatal stress is a poor birth outcome, such as prematurity or growth restriction. These phenotypes are often used as indications of prenatal adversity. In fact, the original evidence supporting the fetal programming hypothesis came from studies documenting an association between birth phenotype and the development of subsequent physical and mental health problems. Fetal growth restriction in both term and preterm infants is associated with neonatal morbidities and a wide variety of behavioral and psychological diagnoses in childhood and adolescence, including attention-deficit/hyperactivity disorder, anxiety, depression, internalizing and thought problems, poor social skills, and autism spectrum disorder. Improving maternal-child health requires interventions that begin before pregnancy and continue throughout gestation and into the postpartum period. Such interventions might include supporting pregnancy intention, maternal nutrition, health/medical care, mental health, and providing social support. This article discusses the impact of maternal nutrition and inflammation during preconception and pregnancy among women living in low-resource settings, with an emphasis on key knowledge gaps that need to be addressed to guide program and policy decisions at local, regional and global levels.

Neurodevelopment: The Impact of Nutrition and Inflammation During Early to Middle Childhood in Low-Resource Settings

The early to middle childhood years are a critical period for child neurodevelopment. Nutritional deficiencies, infection, and inflammation are major contributors to impaired child neurodevelopment in these years, particularly in low-resource settings. This review identifies global research priorities relating to nutrition, infection, and inflammation in early to middle childhood neurodevelopment. The research priority areas identified include: (1) assessment of how nutrition, infection, or inflammation in the preconception, prenatal, and infancy periods (or interventions in these periods) affect function in early to middle childhood; (2) assessment of whether effects of nutritional interventions vary by poverty or inflammation; (3) determination of the feasibility of preschool- and school-based integrated nutritional interventions; (4) improved assessment of the epidemiology of infection- and inflammation-related neurodevelopmental impairment (NDI); (5) identification of mechanisms through which infection causes NDI; (6) identification of noninfectious causes of inflammation-related NDI and interventions for causes already identified (eg, environmental factors); and (7) studies on the effects of interactions between nutritional, infectious, and inflammatory factors on neurodevelopment in early to middle childhood. Areas of emerging importance that require additional study include the effects of maternal Zika virus infection, childhood environmental enteropathy, and alterations in the child's microbiome on neurodevelopment in early to middle childhood. Research in these key areas will be critical to the development of interventions to optimize the neurodevelopmental potential of children worldwide in the early to middle childhood years.

Home fortification during the first 1000 d improves child development in Bangladesh: a cluster-randomized effectiveness trial

Background: Nutrition during the first 1000 d is critical for brain development.Objective: We evaluated the effects on child development of home fortification with lipid-based nutrient supplements (LNSs) for mothers and/or children or micronutrient powder (MNP) for children.Design: We conducted a cluster-randomized effectiveness trial with 4 arms: 1) LNSs during pregnancy and the first 6 mo postpartum and LNSs for the offspring from 6 to 24 mo (LNS-LNS), 2) iron and folic acid (IFA) during pregnancy and the first 3 mo postpartum and LNSs for the children from 6 to 24 mo (IFA-LNS), 3) IFA (as above) and MNP for the offspring from 6 to 24 mo (IFA-MNP), and 4) IFA (as above) and no child supplement (IFA-Control). Women were enrolled at ≤20 wk of gestation; children were assessed at 12 (n = 3331), 18 (n = 3364), and 24 (n = 3379) mo.Results: Compared with the IFA-Control group, motor development scores were higher in the LNS-LNS (P = 0.016) and IFA-LNS groups (P = 0.006) at 18 mo and in the IFA-MNP group (P = 0.048) at 24 mo. Receptive language scores were higher for the LNS-LNS group (P = 0.028) at 18 mo and for all 3 groups at 24 mo (P = 0.008 for LNS-LNS, P = 0.022 for IFA-LNS, and P = 0.009 for IFA-MNP compared with IFA-Control). Expressive language scores did not differ at 18 mo (P = 0.236) but were higher in the LNS-LNS (P = 0.035) and IFA-MNP (P = 0.002) groups than in the IFA-Control group at 24 mo. Groups did not differ in personal-social scores at 18 (P = 0.233) or 24 (P = 0.146) mo or in executive function score at 24 mo (P = 0.467).Conclusion: Prenatal LNSs, postnatal LNSs, or both, or postnatal MNP had a positive effect on motor and language development in Bangladeshi children. This trial was registered at clinicaltrials.gov as NCT01715038.

Retrospectively self-reported age of childhood abuse onset in a United States nationally representative sample

Background

Child abuse is common and several studies have linked it to health outcomes throughout the lifecourse. Recent information about timing of abuse reported retrospectively is underrepresented in the literature, despite its importance to informing target populations for primary prevention of child abuse and studying effects of child abuse. This study uses data from Wave IV (2008–2009) of The National Longitudinal Study of Adolescent Health to Adult Health (N = 14,776) to describe distributions of retrospectively self-reported age of onset of childhood emotional, physical, and sexual abuse perpetrated by parents/adult caregivers and sexual abuse perpetrated by other individuals. Information on childhood abuse history was collected when participants were between 24 and 32 years old.

Findings

Parental/adult caregiver perpetrated abuse frequently started in early childhood, particularly sexual abuse. Non-parental/adult caregiver sexual abuse motivated by physical force also started early in boys (median age = 7.21 years (95% CI: 5.92, 9.05)). Earlier onset of some types of abuse was associated with male sex, not being raised by both biological parents, and low childhood household income.

Conclusions

Future studies should further examine timing of childhood abuse onset and include diverse measures of abuse, including those derived from longitudinal studies and validated reports. If these results are replicated, they suggest that abuse, particularly sexual abuse perpetrated by parents/adult caregivers, often starts in early childhood, and preventive interventions should be designed to protect younger children.

Does household access to improved water and sanitation in infancy and childhood predict better vocabulary test performance in Ethiopian, Indian, Peruvian and Vietnamese cohort studies?

OBJECTIVE

Test associations between household water and sanitation (W&S) and children's concurrent and subsequent Peabody Picture Vocabulary Test (PPVT) scores.

DESIGN

Prospective cohort study.

SETTING

Ethiopia, India, Peru, Vietnam.

PARTICIPANTS

7269 children.

PRIMARY OUTCOME MEASURES

PPVT scores at 5 and 8 years. Key exposure variables were related to W&S, and collected at 1, 5 and 8 years, including 'improved' water (eg, piped, public tap or standpipe) and 'improved' toilets (eg, collection, storage, treatment and recycling of human excreta).

RESULTS

Access to improved water at 1 year was associated with higher language scores at 5 years (3/4 unadjusted associations) and 8 years (4/4 unadjusted associations). Ethiopian children with access to improved water at 1 year had test scores that were 0.26 SD (95% CI 0.17 to 0.36) higher at 5 years than children without access. Access to improved water at 5 years was associated with higher concurrent PPVT scores (in 3/4 unadjusted associations), but not later scores (in 1/4 unadjusted associations). 5-year-old Peruvian children with access to improved water had better concurrent performance on the PPVT (0.44 SD, 95% CI 0.30 to 0.59) than children without access to improved water. Toilet access at 1 year was also associated with better PPVT scores at 5 years (3/4 unadjusted associations) and sometimes associated with test results at 8 years (2/4 unadjusted associations). Toilet access at 5 years was associated with concurrent PPVT scores (3/4 unadjusted associations). More than half of all associations in unadjusted models (water and toilets) persisted in adjusted models, particularly for toilets in India, Peru and Vietnam.

CONCLUSIONS

Access to 'improved' water and toilets had independent associations with children's PPVT scores that often persisted with adjustment for covariates. Our findings suggest that effects of W&S may go beyond subacute and acute infections and physical growth to include children's language performance, a critical component of cognitive development.

Early childhood development coming of age: science through the life course

Early childhood development programmes vary in coordination and quality, with inadequate and inequitable access, especially for children younger than 3 years. New estimates, based on proxy measures of stunting and poverty, indicate that 250 million children (43%) younger than 5 years in low-income and middle-income countries are at risk of not reaching their developmental potential. There is therefore an urgent need to increase multisectoral coverage of quality programming that incorporates health, nutrition, security and safety, responsive caregiving, and early learning. Equitable early childhood policies and programmes are crucial for meeting Sustainable Development Goals, and for children to develop the intellectual skills, creativity, and wellbeing required to become healthy and productive adults. In this paper, the first in a three part Series on early childhood development, we examine recent scientific progress and global commitments to early childhood development. Research, programmes, and policies have advanced substantially since 2000, with new neuroscientific evidence linking early adversity and nurturing care with brain development and function throughout the life course.

Converging on child mental health - toward shared global action for child development

We are a group of researchers and clinicians with collective experience in child survival, nutrition, cognitive and social development, and treatment of common mental conditions. We join together to welcome an expanded definition of child development to guide global approaches to child health and overall social development. We call for resolve to integrate maternal and child mental health with child health, nutrition, and development services and policies, and see this as fundamental to the health and sustainable development of societies. We suggest specific steps toward achieving this objective, with associated global organizational and resource commitments. In particular, we call for a Global Planning Summit to establish a much needed Global Alliance for Child Development and Mental Health in all Policies.