Early child health in Lahore, Pakistan: XII. Milestones

Delivering integrated child development care in Pakistan: protocol for a clustered randomised trial

Background

Early childhood developmental delay is associated with significant disadvantage in adult life. In Pakistan, high prevalence of developmental delay is associated with poverty, under-nutrition, and maternal depression.

Aim

To assess the effectiveness of an early child development counselling intervention delivered at private GP clinics, in poor urban communities.

Design & setting

A clustered randomised trial in Pakistan.

Method

The intervention was developed following a period of formative research, and in consultation with local experts. A total of 2112 mother–child pairs will be recruited at 32 clinics, from within the locality (cluster); 16 clinics per arm. A primary care counselling intervention (promoting child development, nutrition, and maternal mental health) will be delivered at 6 weeks, 3, 6, and 9 months of the child’s age. Monitoring, assessment, and treatment will also be performed at quarterly visits in intervention clinics. Primary outcome is the developmental delay at 12 months (ASQ-3 scores). Secondary outcomes are stunting rate, and maternal depression (PHQ-9 score). In addition, a process evaluation and costing study will be conducted.

Discussion

This trial will be the first to assess an early child development intervention, delivered in private GP clinics for poor urban communities in Pakistan. If found to be effective, this public–private model may offer a more sustainable, and feasible option for populations in poor urban settings, where private GP clinics are the most accessible provider of primary health care. There is scope for scale-up at provincial level, should the intervention be effective.

Trial registration

The trial has been registered with the Current Controlled Trials ISRCTN48032200.

Assessment of Gross Motor Development in the who Multicentre Growth Reference Study

The World Health Organization (WHO) Multicentre Growth Reference (MGRS) data management protocol was designed to create and manage a large data bank of information collected from multiple sites over a period of several years. Data collection and processing instruments were prepared centrally and used in a standardized fashion across sites. The data management system contained internal validation features for timely detection of data errors, and its standard operating procedures stipulated a method of master file updating and correction that maintained a clear trail for data auditing purposes. Each site was responsible for collecting, entering, verifying, and validating data, and for creating site-level master files. Data from the sites were sent to the MGRS Coordinating Centre every month for master file consolidation and more extensive quality control checking. All errors identified at the Coordinating Centre were communicated to the site for correction at source. The protocol imposed transparency on the sites' data management activities but also ensured access to technical help with operation and maintenance of the system. Through the rigorous implementation of what has been a highly demanding protocol, the MGRS has accumulated a large body of very high-quality data.

CDC Kerala 16: Early Detection of developmental delay/disability among children below 6 y--a district model

OBJECTIVE

To develop a district model for establishing early detection of childhood disability below 6 y of age and to develop appropriate referral linkages for confirmation of the diagnosis and establish home based early intervention therapy to all needy children.

METHODS

Trained Accredited Social Health Activist (ASHA) workers conducted the preliminary survey for identifying developmental delay/disability among children below 6 y of age using Trivandrum Developmental Screening Chart (TDSC) (0-6 y) and a team of experts assessed the screen positives in developmental evaluation camps conducted at primary health centres (PHCs).

RESULTS

Community survey was carried out and 1,01,438 children below 6 y of age in Thiruvananthapuram district were screened by ASHA workers and 2,477 (2.45%) positive cases (TDSC two or more item delay) were identified and these children were called for the developmental evaluation camps conducted at 80 PHCs in the district. Among the 1,329 children who reached the evaluation camps 43.1% were normal. 24.98% children had speech and language delay and 22.95% children had multiple disabilities. Developmental delay was observed among 49.89% children and cerebral palsy in 8.43% and intellectual disability 16.85% were confirmed. Visual impairment in 3.31% and neuromuscular disorders in 1.35 were found among children evaluated in the camp.

CONCLUSIONS

The results of this district wide early detection of disability survey by trained ASHA workers among children below 6 y of age showed a community prevalence of 3.08% observed, based on two or more item delay in TDSC and among these children, 43.1% were normal, 49.89% had developmental delay, 24.98% had speech and language delay and 22.95% had multiple disabilities.

Impact of maternal depressive symptoms and infant temperament on early infant growth and motor development: results from a population based study in Bangladesh

BACKGROUND

Evidence linking maternal depressive symptoms with infant's growth and development in low-income countries is inadequate and conflicting. This study investigated the independent effect of maternal perinatal depressive symptoms on infant's growth and motor development in rural Bangladesh.

METHODS

A cohort of 720 pregnant women was followed from the third trimester of pregnancy to 6-8 months postpartum. For growth and developmental outcomes, 652 infants at 2-3 months and 6-8 months were assessed. Explanatory variables comprised maternal depressive symptoms, socioeconomic status, and infant's health and temperament. Outcome measures included infant's underweight, stunting and motor development. Multiple linear regression analyses identified predictors of infant growth and development.

RESULTS

Maternal postpartum depressive symptoms independently predicted infant's underweight and impaired motor development, and antepartum depressive symptoms predicted infant's stunting. Infant's unadaptable temperament was inversely associated with infant's weight-for-age and motor development, and fussy and unpredictable temperament with height-for-age and motor development.

LIMITATIONS

Repeated measures design might threaten the internal validity of the results 8.3% of the participant does not participate in the measurements at different times. As the study was conducted in two sub-districts of rural Bangladesh, it does not represent the urban scenario and cannot be generalized even for other rural areas of the country.

CONCLUSION

This study provides evidence that maternal ante- and postpartum depressive symptoms predict infant's growth and motor development in rural Bangladesh. It is recommended to integrate psychosocial components in maternal and child health interventions in order to counsel mothers with depressive symptoms.

Variations in early gross motor milestones and in the age of walking in Japanese children

BACKGROUND

Gross motor development is usually assessed in terms of age of achievement of motor milestones. Although there is generally an impression of faster development if the milestones are achieved at younger ages, no longitudinal studies have been done on the associations between the milestones, especially in Japan. As a part of the Japan Children's Study, the purpose of the present study was to determine whether the achievement of gross motor milestones in infancy is related with the age of walking.

METHODS

This was a prospective cohort study of 290 healthy and term infants born in a district of Osaka City, Japan. Three milestones (rolling over, sitting, and crawling) were observed in the laboratory for infants aged at 4 and 9 months by a pediatrician and a developmental psychologist, and the age of walking was confirmed in questionnaires filled in by the parents at 18 and 27 months.

RESULTS

Children who could roll over at 4 months, and sit and crawl at 9 months, walked earlier than children who could not roll over, sit and crawl, respectively. With regard to crawling, children who were creeping had a 1 month delay in walking, and those who could not move forward had a 2 month delay compared to typical crawlers. On multiple regression analysis these three milestones were positively associated with walking: rolling over (β= 0.567), sitting (β= 1.973) and crawling (β= 1.473).

CONCLUSION

The age and the patterns of sitting, crawling and rolling over were all related to the age of independent walking among Japanese infants. Consideration of milestone definition and variations is essential in medical check-up.

Screening for psychosocial development among infants in an urban slum of Delhi

OBJECTIVE

Psychosocial developmental screening of the infants in an urban slum of Delhi and studying the factors influencing the development.

METHODS

In this cross-sectional study 202 infants and their mothers were included. Psychosocial Development Screening Test developed by Indian Council of Medical Research was used to asses the development status of infants, and the mothers were interviewed for socio-demographic details

RESULTS

Infants who achieved milestones in time were 92.5% for personal skills, 91.8% for hearing language and concept development and 90.6% for gross motor milestones, respectively. These percentages were lower for Vision and fine motor (88.6) and social skills (81.4). Sex of the infant and socioeconomic status of their families significantly influences the few domains of development. Other factors like age of the infant, literacy of their mothers were not significantly influencing the development of infants.

CONCLUSION

The objective evaluation and screening for psychosocial development of infants living tin urban slums is necessary for early detection and intervention.

Prevalence and aetiology of congenital birth defects, infant mortality and mental retardation in Lahore, Pakistan: a prospective cohort study

AIM

To study the health and development of children in a developing and low-income country.

METHODS

The health and development of children in Lahore in northern Pakistan have been studied since 1981 in a collaborative project between Pakistani and Swedish university institutions and the Swedish Agency for Research Cooperation with Developing Countries (SAREC). The study described in this paper comprised four different areas in Lahore with different degrees of urbanization and different social conditions. All pregnancies in the four areas were registered during the period March 1984 to July 1986 and were followed up from the 5th month of pregnancy. All 1476 children born after 1 September 1984 were followed up from birth to 12 y of age.

RESULTS

The perinatal mortality in the whole material was 5.4%. It was highest in the periurban slum (7.5%) and lowest in the upper-middle class cohort (3.3%). Overall infant mortality was 10%. It was highest (14%) in the periurban slum and lowest (2%) in the upper-middle class group. Overall incidence of serious birth defects was 5%. It was highest in the periurban slum community (7%) and lowest in the upper-middle class cohort (3%). The overall cumulative incidence of severe mental retardation per 100 live births was 1.1. It was highest (2.2) in the periurban slum and lowest (0.4) in the upper-middle class group. The overall prevalence of mild mental retardation among 6-10-y-old children was 6.2 per 100. It was highest in the periurban slum (10.5) and lowest (1.3 per 100) in the upper-middle class group. Poverty, malnutrition, birth trauma and consanguinity were common causes of infant mortality and mental retardation in Lahore, Pakistan.

CONCLUSION

Preventive measures with provision of obstetric and health services, services for genetic information and risk evaluation, vaccination programmes and identification of children with retarded development for specific stimulation and habilitation measures, e.g. organized play activities, are important in developing and low-income countries.

Psychomotor development in Argentinean children aged 0-5 years

In Argentina, there is no information on ages of attainment of developmental milestones and very few data about environmental factors that influence them. A national survey on the psychomotor development of children under 6 years of age was carried out with the help of 129 paediatricians. Logistic regression was applied to a final sample of 3573 healthy, normal children in order to estimate selected centiles (25th, 50th, 75th and 90th), together with their respective confidence intervals, of the ages of attainment of 78 developmental items belonging to the following areas: personal-social (18 items), fine motor (19), language (18) and gross motor (23). The 50th centile obtained for each of the 43 comparable items was compared with those obtained in previously standardised tests: DDST, Denver II, Bayley and Chilean scales. Neither significant nor systematic differences were found between our results and those described in the tests used for comparison. Multiple logistic regressions showed that social class, maternal education and sex (female) were associated with earlier attainment of some selected developmental items, achieved at ages later than 1 year. Selected items achieved before the first year of life were not affected by any of the independent environmental variables studied. The information is useful in helping paediatricians in their daily practice for surveillance of development, as baseline information for epidemiological studies on development in our country and for cross-cultural analysis.

Effects of exclusive breastfeeding for four versus six months on maternal nutritional status and infant motor development: results of two randomized trials in Honduras

To examine whether the duration of exclusive breastfeeding affects maternal nutrition or infant motor development, we examined data from two studies in Honduras: the first with 141 infants of low-income primiparous women and the second with 119 term, low birth weight infants. In both studies, infants were exclusively breastfed for 4 mo and then randomly assigned to continue exclusive breastfeeding (EBF) until 6 mo or to receive high-quality, hygienic solid foods (SF) in addition to breast milk between 4 and 6 mo. Maternal weight loss between 4 and 6 mo was significantly greater in the exclusive breastfeeding group (EBF) group than in the group(s) given solid foods (SF) in study 1 (-0.7 +/- 1.5 versus -0.1 +/- 1.7 kg, P < 0.05) but not in study 2. The estimated average additional nutritional burden of continuing to exclusively breastfeed until 6 mo was small, representing only 0.1-6.0% of the recommended dietary allowance for energy, vitamin A, calcium and iron. Women in the EBF group were more likely to be amenorrheic at 6 mo than women in the SF group, which conserves nutrients such as iron. In both studies, few women (10-11%) were thin (body mass index <19 kg/m(2)), so the additional weight loss in the EBF group in study 1 was unlikely to have been detrimental. Infants in the EBF group crawled sooner (both studies) and were more likely to be walking by 12 mo (study 1) than infants in the SF group. Taken together with our previous findings, these results indicate that the advantages of exclusive breastfeeding during this interval appear to outweigh any potential disadvantages in this setting.

Fetal growth, early postnatal growth and motor development in Pakistani infants

BACKGROUND

Studies have often compared the postnatal motor development of 'small' versus 'normal' newborns. Not much is known about the associations between a broad spectrum of size at birth and motor development. The effect of early postnatal growth on motor development is little researched. Growth failure in terms of shortness and thinness should be differentiated, but not many studies have the data for this analysis.

METHODS

This is a longitudinal study of infants born in Lahore, Pakistan, between 1984 and 1987. Age at commencement of independent walking and age at 'building a 3-cube tower' were taken as indicators of gross and fine motor development, respectively. Size at birth was captured by length and thinness as continuous variables; postnatal growth from birth to 6 months of age was measured by changes in length and thinness. Adjustment for covariates and handling of censored cases were performed by generalized log gamma regression.

RESULTS

Thinness at birth and postnatal stunting and wasting had a linear, inverse association with gross motor development (each P < 0.05). Birth length had a non-linear, inverse association with this outcome (P < 0.05). Birth length, thinness at birth and postnatal wasting had a linear, inverse association with fine motor development (each P < 0.05).

CONCLUSION

Both fetal and early postnatal growth over a broad spectrum may affect infants' motor development. It is not just the babies who were very small at birth that suffered. Birth length appeared to be more influential than other anthropometric indicators.

Severe mental retardation in 2 to 24-month-old children in Lahore, Pakistan: a prospective cohort study

Severe mental retardation (developmental quotient (DQ) < 50) was investigated in 1303 children from 2 to 24 months of age, born during 1984-87 in four population groups representing different socio-economic levels in and around Lahore, Pakistan. The incidence per 1000 live births was 22 in the periurban slum, 9 in the urban slum, 7 in the village and 4 in the upper middle class group. The aetiology was prenatal in 79%, perinatal in 14% and untraceable in 7% of cases. Down's syndrome was the most common cause of severe mental retardation (36%). Impairments were studied at 2 years of age. Impairment of language was present in all, while locomotor dysfunction was seen in 89% of cases. Epilepsy and cerebral palsy were each present in 22% of cases. Mortality among these severely mentally retarded children was 36%.

Early child health in Lahore, Pakistan: III. Maternal and family situation

The family situation for mothers, in three areas differing in degree of urbanization and an upper middle class control group, in Lahore, Pakistan was described. Area differences in socio-economic, family composition, and housing and sanitary conditions were investigated. Data from a longitudinal sample (n = 1476 newborns) were compared with data from a cross-sectional population survey (n = 2998 families). Risk factors for child mortality and morbidity were common in the village and periurban slum area; conditions were somewhat better in the urban slum community. The sample was concluded to be representative of the population in the three areas and also for Pakistan in general. Two indices for cross-study comparisons were proposed, one for socio-economic background and the other for housing standard. The two indices were shown to be related to maternal weight for height at 9 months of pregnancy in the urban slum area; the socio-economic level was also functionally related to the weight for height measure in the village. The lower socio-economic and housing standard level, the lower was the mothers' relative weight just before childbirth. The findings were discussed in terms of risk factors for infant mortality, morbidity and psychological development.

Early child health in Lahore, Pakistan: II. Inbreeding

The prevalence of consanguineous marriages was studied in 940 families belonging to four different socio-economic groups in and around Lahore, Pakistan. The births occurring in these families from September 1984 to March 1987 were also investigated for birth defects. The overall prevalence of consanguineous marriages was 46%. The first cousin marriages were most common (67%), followed by the marriages between second cousins, 19%. The prevalence of consanguineous marriages was clearly associated with the socio-economic status of the study groups; 50% of the marriages was related in the periurban slum, 49% in the village, 44% in the urban slum and 31% in the upper middle class. The birth defects were also more prevalent in the poorer areas, being highest in the periurban slum (17.7%) followed by the urban slum (15.6%) and then the village (14.8%) and lowest in the upper middle class (12.3%). Although, the frequency of both consanguinity and birth defects were related with the socio-economic levels of the study groups, there was no association between inbreeding and birth defects. Perhaps, deleterious recessive genes for birth defects have been "bred out", because of continuous inbreeding over generations in this population. There was a significant predilection of major birth defects in boys without clear sex linkage. The conclusion is that the rate of consanguineous marriages was high, especially in the poorer areas, but the relationship between consanguineous marriages and birth defects was little or none. However, other child health indicators may be affected by consanguineous marriages.

Early child health in Lahore, Pakistan: XI. Growth

This work gives growth reference values at birth to 24 months of age for Pakistan based on upper middle class infants. Growth rate reference values are also included and they are given for various interval lengths. The growth was differently affected in infants living in three poorer areas; the stunting incidence at 24 months of age was 63% in periurban slum, 54% in the village and 26% in the urban slum. Less differences could be seen between the areas in weight for length. There was an age dependency in the incidence of reduced growth; a normal length gain was seen at birth to about six months of age, but they were highly reduced at 6 to 18 months of age. The weight gain was to some degree reduced during the first 12 months of life, followed by a catch-up growth period. The seasonal influence was also age dependent; weight was highly affected during the summer at birth to 24 months of age, but not in the winter. The seasonal effect in length was marginal at birth to 6 months, little at 6 to 12 months (although, constant below the normal) and large at 12 to 24 months of age. We did not see any seasonality of growth in the reference group. The incidence of reduced growth reflects the socio-economic differences in one restricted geographic area, i.e., in the city of Lahore, Pakistan.

Early child health in Lahore, Pakistan: XIII. Primary teeth emergence

The aim of this study was to investigate the number of emerged primary teeth at various ages from 6 to 24 months in 1347 longitudinally followed Pakistan infants sampled from four socio-economically different areas in Lahore, Pakistan; from a very poor periurban slum to a privileged upper middle class group. The emergence of the primary teeth was found to be little, or not all related to sex or to the area of living. However, in comparison with studies conducted in other continents, the Indo-Pak subcontinent population lags behind in primary teeth emergence, especially in early life. This genetic difference makes it necessary to create specific standards of primary teeth emergence for this population.

Early child health in Lahore, Pakistan: IV. Child care practices

Child care practices and hygiene measures were studied at 6 months of age in a longitudinally followed cohort of 1476 infants born between September 1984 to March 1987 in four socio-economically different areas in and around Lahore, Pakistan. Although, 76-98% of the mothers looked after their infants during health and 96-98% during a diarrhoeal illness, child care practices and hygiene measures differed significantly between the four areas. During a diarrhoeal episode, the mothers from the upper middle class took timely medical help, fed ample food and Oral Rehydration Salts (ORS) to the sick infants and provided uncontaminated food to them in clean surroundings. The mothers from the village and the periurban slum took their sick child, mostly after the second day of illness, to a doctor, but preferred home remedies. Fourteen percent of the mothers in the village and 6% in the periurban slum did not seek any medical help at all. One-third of the families, from these two areas, fed food to children 12 hours after cooking; the surroundings of the child were dirty with large numbers of flies present throughout the year, though the food was commonly kept covered with a lid. We constructed a simple measure of the surroundings of the child, rated as dirty, medium or clean; it was found to be associated to both parental illiteracy and child growth, but not with housing standard. The main conclusion is that any attempt to improve child-care practices and the hygienic environment for the child, should focus on maternal literacy and simple health messages.

Early child health in Lahore, Pakistan: VI. Morbidity

Morbidity patterns were studied according to the age, area of living, sex and season among 1476 monthly followed infants born during 1984-1987 in four socio-economically different areas in Lahore, Pakistan. Infections were responsible for 87.0% of the morbidity during the first two years of life. The overall monthly based morbidity was 77.0% between birth and 24 months of age; diarrhoeal diseases 30.3%, upper and lower acute respiratory tract infections (ARI) 22.4%, skin and eye infections 6.7% and skin rash 6.2%. The vaccine-preventable diseases were only 0.5% of the total. Anaemia and rickets were rare (2.0%), but commonly seen among the nutritional deficiencies. Diarrhoea, tetanus, septicaemia, ARI and infections of the skin and eyes were reported more during earlier ages and from the three poorer areas of living. Diarrhoeal diseases, respiratory tract, skin and eye infections, in particular, followed clear seasonal patterns, while scabies prevailed throughout the year. The presence of these many preventable infections and illnesses implies that proper planning of interventions must be forthcoming.