Early childhood stunting and later fine motor abilities

Growth, physical, and cognitive function in children who are born HIV-free: School-age follow-up of a cluster-randomised trial in rural Zimbabwe

BACKGROUND

Globally, over 16 million children were exposed to HIV during pregnancy but remain HIV-free at birth and throughout childhood by 2022. Children born HIV-free (CBHF) have higher morbidity and mortality and poorer neurodevelopment in early life compared to children who are HIV-unexposed (CHU), but long-term outcomes remain uncertain. We characterised school-age growth, cognitive and physical function in CBHF and CHU previously enrolled in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial in rural Zimbabwe.

METHODS AND FINDINGS

The SHINE trial enrolled pregnant women between 2012 and 2015 across 2 rural Zimbabwean districts. Co-primary outcomes were height-for-age Z-score and haemoglobin at age 18 months (clinicaltrials.gov NCT01824940). Children were re-enrolled if they were aged 7 years, resident in Shurugwi district, and had known pregnancy HIV-exposure status. From 5,280 pregnant women originally enrolled, 376 CBHF and 2016 CHU reached the trial endpoint at 18 months in Shurugwi; of these, 264 CBHF and 990 CHU were evaluated at age 7 years using the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox. Cognitive function was evaluated using the Kaufman Assessment Battery for Children (KABC-II), with additional tools measuring executive function, literacy, numeracy, fine motor skills, and socioemotional function. Physical function was assessed using standing broad jump and handgrip for strength, and the shuttle-run test for cardiovascular fitness. Growth was assessed by anthropometry. Body composition was assessed by bioimpedance analysis and skinfold thicknesses. A caregiver questionnaire measured demographics, socioeconomic status, nurturing, child discipline, food, and water insecurity. We prespecified the primary comparisons and used generalised estimating equations with an exchangeable working correlation structure to account for clustering. Adjusted models used covariates from the trial (study arm, study nurse, exact child age, sex, calendar month measured, and ambient temperature). They also included covariates derived from directed acyclic graphs, with separate models adjusted for contemporary variables (socioeconomic status, household food insecurity, religion, social support, gender norms, caregiver depression, age, caregiver education, adversity score, and number of children's books) and early-life variables (length-for-age-Z-score) at 18 months, birthweight, maternal baseline depression, household diet, maternal schooling and haemoglobin, socioeconomic status, facility birth, and gender norms. We applied a Bonferroni correction for the 27 comparisons (0.05/27) with threshold of p < 0.00185 as significant. We found strong evidence that cognitive function was lower in CBHF compared to CHU across multiple domains. The KABC-II mental processing index was 45.2 (standard deviation (SD) 10.5) in CBHF and 48.3 (11.3) in CHU (mean difference 3.3 points [95% confidence interval (95% CI) 2.0, 4.5]; p < 0.001). The school achievement test score was 39.0 (SD 26.0) in CBHF and 45.7 (27.8) in CHU (mean difference 7.3 points [95% CI 3.6, 10.9]; p < 0.001); differences remained significant in adjusted analyses. Executive function was reduced but not significantly in adjusted analyses. We found no consistent evidence of differences in growth or physical function outcomes. The main limitation of our study was the restriction to one of two previous study districts, with possible survivor and selection bias.

CONCLUSIONS

In this study, we found that CBHF had reductions in cognitive function compared to CHU at 7 years of age across multiple domains. Further research is needed to define the biological and psychosocial mechanisms underlying these differences to inform future interventions that help CBHF thrive across the life-course.

TRIAL REGISTRATION

ClinicalTrials.gov The SHINE follow-up study was registered with the Pan-African Clinical Trials Registry (PACTR202201828512110). The original SHINE trial was registered at NCT https://clinicaltrials.gov/study/NCT01824940.

The interlink between chrono-nutrition and stunting: current insights and future perspectives

Stunting is the one factor that is responsible for the irretrievable damage to children's mental and physical health. Stunting imitates chronic undernutrition throughout the most extreme critical stages of growth and development of a child in their early life, and due to that stunted child does not completely develop and are too short for their age. Stunting is mainly linked with brain underdevelopment, along with lifelong damaging consequences, comprising weakened mental and learning capacity, deprived performance in school during childhood, and enhanced risks of nutrition linked to chronic long-lasting ailments, such as diabetes, hypertension, diabesity, and obesity in the future. In this review, the authors mainly summarize the latest studies related to chronic nutrition and how it is related to stunting. Optimal nutrition, particularly during pregnancy and the first 24 months of a child's life, is crucial in preventing stunting. Circadian rhythms play a significant role in maternal and fetal health, affecting outcomes such as premature birth and stunting. Maintaining a balanced diet, avoiding late-night carbohydrate-heavy meals during pregnancy, and promoting breastfeeding align with the body's biological clock, which can benefit newborns in various ways. Providing dedicated spaces for breastfeeding in public places is important to support infant health.

Characterising school-age health and function in rural Zimbabwe using the SAHARAN toolbox

INTRODUCTION

We developed the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox to address the shortage of school-age assessment tools that combine growth, physical and cognitive function. Here we present i) development, acceptability and feasibility of the SAHARAN toolbox; ii) characteristics of a pilot cohort; and iii) associations between the domains measured in the cohort.

METHODS

Growth was measured with anthropometry, knee-heel length and skinfold thicknesses. Bioimpedance analysis measured lean mass index and phase angle. Cognition was assessed using the mental processing index, derived from the Kaufman Assessment Battery for Children version 2, a fine motor finger-tapping task, and School Achievement Test (SAT). Physical function combined grip strength, broad jump and the 20m shuttle-run test to produce a total physical score. A caregiver questionnaire was performed in parallel.

RESULTS

The SAHARAN toolbox was feasible to implement in rural Zimbabwe, and highly acceptable to children and caregivers following some minor modifications. Eighty children with mean (SD) age 7.6 (0.2) years had mean height-for-age (HAZ) and weight-for-age Z-scores (WAZ) of -0.63 (0.81) and -0.55 (0.85), respectively. Lean mass index and total skinfold thicknesses were related to WAZ and BMI Z-score, but not to HAZ. Total physical score was associated with unit rises in HAZ (1.29, 95% CI 0.75, 1.82, p<0.001), and lean mass index (0.50, 95% CI 0.16, 0.83, p = 0.004), but not skinfold thicknesses. The SAT was associated with unit increases in the mental processing index and child socioemotional score. The caregiver questionnaire identified high levels of adversity and food insecurity.

CONCLUSIONS

The SAHARAN toolbox provided a feasible and acceptable holistic assessment of child growth and function in mid-childhood. We found clear associations between growth, height-adjusted lean mass and physical function, but not cognitive function. The SAHARAN toolbox could be deployed to characterise school-age growth, development and function elsewhere in sub-Saharan Africa.

Comparison of Cognitive Function in Children with Stunting and Children with Undernutrition with Normal Stature

Background. Stunting is the impaired growth and development that children experience from poor nutrition, repeated infection, and inadequate psychosocial stimulation. Children are defined as stunted if their height-for-age is more than two standard deviations below the WHO Child Growth Standards median. According to the Indonesia Basic National Health Survey 2013, Indonesia’s stunting prevalence reached 37.2%. Various studies have shown that impaired cognitive development is found in children with stunting and undernutrition. This study aims to determine cognitive development in stunted and undernutrition with normal stature children using the Bayley Scale of Infant Development III (Bayley-III). Methods. A cross-sectional study on 51 children aged one month to 3 years who fulfilled the inclusion criteria and who visited the outpatient clinic of Dr. Cipto Mangunkusumo National General Hospital from June 2017 to January 2018 was performed. Cognitive development was assessed using the Bayley Scale of Infant Development, Third Edition (Bayley-III). Results. 26 children with stunting and 25 children with undernutrition with normal stature participated in this study. There was a statistically nonsignificant trend toward lower median score percentiles in the stunted group compared to that in the undernourished with normal stature group in the motor (median (range) 1 (0.1–75) vs. 4 (0–79); $p=0.183$ ), cognitive (12.5 (0.1–75) vs. 16 (0.1–99.9); $p=0.550$ ), and adaptive behavior (7 (0.1–75) vs. 12 (0.1–58); $p=0.657$ ) domains. Conclusions. There is a trend toward lower cognitive, motor, and adaptive behavior abilities in stunted children compared to undernourished children with normal stature which needs further study. In addition, children with undernutrition have below-average abilities across all domains even before stunting has occurred.

The Associations Between Infant Development and Parenting Stress in Infants with Congenital Heart Disease at Six and Twelve Months of Age

PURPOSE

Developmental delays are among the major morbidities of children with complex congenital heart disease. Parents of infants with complex congenital heart disease experience increased parenting stress levels, which can interfere with parenting processes during infancy. The current study examined associations between infant development and parenting stress in infants with complex congenital heart disease at six and twelve months of age.

DESIGN AND METHODS

A secondary analysis of data examined cross-sectional associations between infant's mental and psychomotor development and parenting stress, using general linear regression modeling (N = 75). Data were obtained from a larger prospective cohort study.

RESULTS

Mental development was negatively associated with the Parent Domain at six months, and with the Parent Domain and Total Stress at twelve months. Psychomotor development was not significantly associated with parenting stress at six and twelve months.

CONCLUSIONS

Parenting stress in parents of infant with complex congenital heart disease may be among the factors shaping the parent-child relationship during the first year of life, which plays an important role in infant development. A potential bidirectional relationship between parenting stress and infant development may fit a transactional model representing the phenomena.

PRACTICE IMPLICATIONS

Family interventions aiming to reshape illness perceptions may promote parental adaptive coping and productive parenting practices in populations at risk.

Association of solid fuel use with risk of stunting in children living in China

Stunting adversely affects physical and mental outcomes of children. It has not been examined whether household air pollution from solid fuel combustion is a risk factor for stunting in children. In a total of 41,439 children aged 6-17 across China, height was measured using a unified protocol. Multivariable linear regression models and logistic regression models were used to assess the associations of solid fuel use for cooking/heating with stunting in children. Adjusted for covariates, cooking/heating with solid fuel was significantly associated with a lower z-score for height for age and sex (β = -0.21 [-0.32 to -0.09] and -0.17 [-0.31 to -0.03], respectively) and an increased risk of stunting with an estimated ORs of 1.34 [1.07~1.68] and 1.37 [1.02~1.83], respectively. The risk of stunting associated with solid fuel use was statistically significant in high-age children. And the effect was greater on girls than on boys, though the difference was not statistically significant. Our study suggested that Chinese children living in households using solid fuel had a significantly higher risk of stunting than those living in households using cleaner fuel.

The relationship of undernutrition/psychosocial factors and developmental outcomes of children in extreme poverty in Ethiopia

BACKGROUND

Extreme poverty is severe deprivation of basic needs and services. Children living in extreme poverty may lack adequate parental care and face increased developmental and health risks. However, there is a paucity of literature on the combined influences of undernutrition and psychosocial factors (such as limited play materials, playground, playtime, interactions of children with their peers and mother-child interaction) on children's developmental outcomes. The main objective of this study was, therefore, to ascertain the association of developmental outcomes and psychosocial factors after controlling nutritional indices.

METHODS

A community-based cross-sectional study design was used to compare the developmental outcomes of extremely poor children (N = 819: 420 girls and 399 boys) younger than 5 years versus age-matched reference children (N = 819: 414 girls and 405 boys) in South-West Ethiopia. Using Denver II-Jimma, development in personal-social, language, fine and gross motor skills were assessed, and social-emotional skills were evaluated using the Ages and Stages Questionnaires: Social-Emotional (ASQ: SE). Nutritional status was derived from the anthropometric method. Independent samples t-test was used to detect mean differences in developmental outcomes between extremely poor and reference children. Multiple linear regression analysis was employed to identify nutritional and psychosocial factors associated with the developmental scores of children in extreme poverty.

RESULTS

Children in extreme poverty performed worse in all the developmental domains than the reference children. Among the 819 extremely poor children, 325 (39.7%) were stunted, 135 (16.5%) were underweight and 27 (3.3%) were wasted. The results also disclosed that stunting and underweightness were negatively associated with all the developmental skills. After taking into account the effects of stunting and being underweight on the developmental scores, it was observed that limited play activities, limited child-to-child interactions and mother-child relationships were negatively related mainly to gross motor and language performances of children in extreme poverty.

CONCLUSION

Undernutrition and psychosocial factors were negatively related to the developmental outcomes, independently, of children living in extreme poverty. Intervention, for these children, should integrate home-based play-assisted developmental stimulation and nutritional rehabilitation.

Factors associated With the development of motor proficiency in school children of Kolkata: A cross-sectional study to assess the role of chronic nutritional and socio-economic status

BACKGROUND

Development of coordinated movements is determined among others by individual growth and environmental factors, but the dynamic relationship between motor proficiency and potential contributing factors such as chronic nutritional status and socio-economic status (SES) is not known in school children of Kolkata.

AIM

To characterize the motor proficiency in school children of Kolkata and to investigate association of chronic nutritional and SES on motor proficiency.

METHODS

Motor proficiency in 843 school children of Kolkata aged 5-12 years was assessed by the Bruininks-Oseretsky Test of Motor-Proficiency-Second Edition-Short Form (BOT-2 SF). Chronic nutritional status was determined from height-for-age Z-scores (HAZ) using WHO reference and SES was measured using the updated Kuppuswamy's scale.

RESULTS

Children's motor proficiency was poor compared with the reference values. Children classified as severely undernourished and children of lower SES were found to be "below average" and "well-below average" in motor proficiency categories compared with normal nourished groups and children of upper SES. Children's BOT-2 SF standardized scores decreased incrementally with the severity of chronic undernutrition and lower grades of SES.

CONCLUSION

Chronic undernutrition and lower SES are associated with poorer motor proficiency in children. Understanding the complex interrelationships that shape childen's motor skills can help inform the development of health promotion programs and tailored interventions to help children reach their full potential. © 2016 Wiley Periodicals, Inc. Dev Psychobiol 58:734-744, 2016.

A quarter century of the Pacific Basin Consortium: looking back to move forward

The Pacific Basin Consortium (PBC) was formed 25 years ago to address significant public health challenges to vulnerable populations imposed by environmental threats in the region, including areas surrounding the rim of and in the Pacific Ocean. Originally focused on toxic waste pollution, the PBC has broadened its efforts over the years, embracing a health focus and more of a balance between engineering and public health. This move was informed by the PBC's close relationship with the National Institutes of Health (NIH) National Institute of Environmental Health Sciences (NIEHS) Superfund Hazardous Substances Basic Research and Training Program (Superfund Research Program, or SRP), which played a dynamic role in the PBC from its early days. In addition, a sub-focus on children's environmental health emerged, which helped set the agenda for children's environmental health research in the region. Progress has also been made in reducing harm from some threats, particularly via extensive interventions to remediate arsenic in drinking water in Bangladesh, western Thailand, and Vietnam. However, many of the environmental health problems in the Pacific Basin region persist, including air pollution, inadequate safe drinking water, undernutrition, and a growing electronic waste problem. In the Pacific Basin and elsewhere, people with the lowest incomes often live in areas with the worst pollution. Although it is difficult to implement, dynamic strategic networking efforts are vital to understanding and correcting the inequities that persist in global environmental health. The PBC can help accomplish this by continuing and expanding its work to foster and enhance collaborations and communications between environmental health and engineering investigators and to integrate investigator-initiated research. As the PBC looks forward, there is also a need to exert increased effort to establish and maintain partnerships, to develop community-based primary-care and health services for vulnerable populations, as well as to connect with researchers in the eastern side of the Pacific basin and those in smaller island states.

Linear growth and child development in low- and middle-income countries: a meta-analysis

BACKGROUND AND OBJECTIVE

The initial years of life are critical for physical growth and broader cognitive, motor, and socioemotional development, but the magnitude of the link between these processes remains unclear. Our objective was to produce quantitative estimates of the cross-sectional and prospective association of height-for-age z score (HAZ) with child development.

METHODS

Observational studies conducted in low- and middle-income countries (LMICs) presenting data on the relationship of linear growth with any measure of child development among children <12 years of age were identified from a systematic search of PubMed, Embase, and PsycINFO. Two reviewers then extracted these data by using a standardized form.

RESULTS

A total of 68 published studies conducted in 29 LMICs were included in the final database. The pooled adjusted standardized mean difference in cross-sectional cognitive ability per unit increase in HAZ for children ≤ 2 years old was +0.24 (95% confidence interval [CI], 0.14-0.33; I(2) = 53%) and +0.09 for children > 2 years old (95% CI, 0.05-0.12; I(2) = 78%). Prospectively, each unit increase in HAZ for children ≤ 2 years old was associated with a +0.22-SD increase in cognition at 5 to 11 years after multivariate adjustment (95% CI, 0.17-0.27; I(2) = 0%). HAZ was also significantly associated with earlier walking age and better motor scores (P < .05).

CONCLUSIONS

Observational evidence suggests a robust positive association between linear growth during the first 2 years of life with cognitive and motor development. Effective interventions that reduce linear growth restriction may improve developmental outcomes; however, integration with environmental, educational, and stimulation interventions may produce larger positive effects.

Regulation of early human growth: impact on long-term health

Growth and development are central characteristics of childhood. Deviations from normal growth can indicate serious health challenges. The adverse impact of early growth faltering and malnutrition on later health has long been known. In contrast, the impact of rapid early weight and body fat gain on programming of later disease risk have only recently received increased attention. Numerous observational studies related diet in early childhood and rapid early growth to the risk of later obesity and associated disorders. Causality was confirmed in a large, double-blind randomised trial testing the 'Early Protein Hypothesis'. In this trial we found that attenuation of protein supply in infancy normalized early growth and markedly reduced obesity prevalence in early school age. These results indicate the need to describe and analyse growth patterns and their regulation through diet in more detail and to characterize the underlying metabolic and epigenetic mechanisms, given the potential major relevance for public health and policy. Better understanding of growth patterns and their regulation could have major benefits for the promotion of public health, consumer-orientated nutrition recommendations, and the development of improved food products for specific target populations.

Neurocognitive function in HIV-positive children in a developing country

OBJECTIVES

We aimed to characterize neurological outcomes and determine the prevalence of HIV encephalopathy in a cohort of HIV-infected children in Jamaica.

METHODS

Data for 287 HIV-infected children presenting between 2002 and 2008 were reviewed and neurological outcomes characterized. A nested case-control study was conducted between July and September 2009 used 15 randomly selected encephalopathic HIV-infected children aged 7-10 years and 15 matched controls (non-encephalopathic HIV-infected). Their neurocognitive functions were evaluated using clinical assessment and standardized tests for intelligence, short term memory (visuo-spatial and auditory), selective attention, and fine motor and coordination functions. Outcomes were compared using Fisher's exact test and the Mann-Whitney U-test.

RESULTS

Sixty-seven (23.3%) children were encephalopathic. The median age at diagnosis of HIV encephalopathy was 1.6 years (interquartile range (IQR) 1.1-3.4 years). Predominant abnormalities were delayed milestones (59, 88.1%), hyperreflexia (59, 86.5%), spasticity (50, 74.6%), microcephaly (42, 61.7%), and quadriparesis (21, 31.3%). The median age of tested children was 8.7 years (IQR 7.6-10.8 years) in the encephalopathic group and 9 years (IQR 7.4-10.7 years) in the non-encephalopathic group. Encephalopathic children performed worse in all domains of neurocognitive function (p<0.05).

CONCLUSIONS

A high prevalence of HIV encephalopathy was noted, and significant neurocognitive dysfunction identified in encephalopathic children. Optimized management through the early identification of neurological impairment and implementation of appropriate interventions is recommended to improve quality of life.

Association of impaired linear growth and worse neurodevelopmental outcome in infants with single ventricle physiology: a report from the pediatric heart network infant single ventricle trial

OBJECTIVES

To describe neurodevelopmental outcomes in infants with single ventricle (SV) physiology and determine factors associated with worse outcomes.

STUDY DESIGN

Neurodevelopmental outcomes for infants with SV enrolled in a multicenter drug trial were assessed at 14 months of age using the Bayley Scales of Infant Development-II. Multivariable regression analysis was used to identify factors associated with worse outcomes.

RESULTS

Neurodevelopmental testing was performed at 14 ± 1 months in 170/185 subjects in the trial. Hypoplastic left heart syndrome was present in 59% and 75% had undergone the Norwood operation. Mean Psychomotor Developmental Index (PDI) and mental developmental index (MDI) were 80 ± 18 and 96 ± 14, respectively, (normal 100 ± 15, P < .001 for each). Group-based trajectory analysis provided a 2-group model ("high" and "low") for height z-score trajectory and brain type natriuretic peptide (BNP) trajectory. The predicted PDI scores were 15 points higher in the "high" height z-score trajectory compared with the "low" cluster (P < .001). A higher number of serious adverse events during the trial was associated with lower PDI scores (P = .02). The predicted MDI scores were 13-17 points lower in "low height trajectory-high BNP trajectory" group compared with the other 3 groups (P < .001). MDI scores were also lower in subjects who required extracorporeal membrane oxygenation during the neonatal hospitalization (P = .01) or supplemental oxygen at discharge (P = .01).

CONCLUSIONS

Neurodevelopmental outcome at 14 months of age is impaired in infants with SV physiology. Low height trajectory and high BNP trajectory were associated with worse neurodevelopmental outcomes. Efforts to improve nutritional status alone may not improve neurodevelopmental outcomes.

Determinants of variability in motor performance in middle childhood: a cross-sectional study of balance and motor co-ordination skills

BACKGROUND

Physical activity is a key component of exploration and development. Poor motor proficiency, by limiting participation in physical and social activities, can therefore contribute to poor psychological and social development. The current study examined the correlates of motor performance in a setting where no locally validated measures of motor skills previously existed. The development of an appropriate assessment schedule is important to avoid the potential misclassification of children's motor performance.

METHODS

A cross-sectional study was conducted among a predominantly rural population. Boys (N = 148) and girls (N = 160) aged between 8 and 11 years were randomly selected from five schools within Kilifi District in Kenya. Four tests of static and dynamic balance and four tests of motor coordination and manual dexterity were developed through a 4-step systematic adaptation procedure. Independent samples t-tests, correlational, univariate and regression analyses were applied to examine associations between background variables and motor scores.

RESULTS

The battery of tests demonstrated acceptable reliability and validity. Variability in motor performance was significantly associated with a number of background characteristics measured at the child, (gender, nutritional status and school exposure) household (household resources) and neighbourhood levels (area of residence). The strongest effect sizes were related to nutritional status and school exposure.

CONCLUSIONS

The current study provides preliminary evidence of motor performance from a typically developing rural population within an age range that has not been previously studied. As well as being culturally appropriate, the developed tests were reliable, valid and sensitive to biological and environmental correlates. Further, the use of composite scores seems to strengthen the magnitude of differences seen among groups.

Child development at 5 years of age predicted mathematics ability and schooling outcomes in Malawian adolescents

AIM

This study aimed to examine the association between child development at 5 years of age and mathematics ability and schooling outcomes at 12 years of age in Malawian children.

METHODS

A prospective cohort study looking at 609 rural Malawian children. Outcome measures were percentage of correctly answered mathematics questions, highest school grade completed and number of times repeating school grades at 12 years of age. A child development summary score obtained at 5 years of age was the main exposure variable. Regression analyses were used to estimate the association and adjust for confounders. Sensitivity analysis was performed by handling losses to follow-up with multiple imputation (MI) method.

RESULTS

The summary score was positively associated with percentage of correctly answered mathematics questions (p = 0.057; p = 0.031 MI) and with highest school grade completed (p = 0.096; p = 0.070 MI), and negatively associated with number of times repeating school grades (p = 0.834; p = 0.339 MI). Fine motor score at 5 years was independently associated with the mathematic score (p = 0.032; p = 0.011 MI). The association between child development and mathematics ability did not depend on school attendance.

CONCLUSION

Child development at 5 years of age showed signs of positive association with mathematics ability and possibly with highest school grade completed at 12 years of age.