Child growth and neurodevelopment after maternal antenatal antibiotic treatment

OBJECTIVE

To assess whether intermittent preventive treatment of pregnant women (IPTp) with sulfadoxine-pyrimethamine (SP) and azithromycin (AZI) in a malaria-endemic area leads to sustained gains in linear growth and development in their offspring.

DESIGN

Follow-up study of a randomised trial.

SETTING

Mangochi District in rural southern Malawi.

PARTICIPANTS

1320 pregnant women and their offspring.

INTERVENTIONS

IPTp monthly with SP and twice with AZI (AZI-SP group), monthly with SP but no AZI (monthly SP), or twice with SP (control). No intervention was given to children.

MAIN OUTCOME MEASURES

Cognitive performance using Raven's Coloured Progressive Matrices (CPM) at 13 years of age; mean height and height-for-age Z-score (HAZ), cumulative incidence and prevalence of stunting (HAZ <-2); weight, body mass index, mid-upper-arm circumference and head circumference.

RESULTS

At approximately 13 years of age, the mean CPM score was 14.3 (SD 3.8, range 6-29, maximum 36), with no differences between groups. Children in the AZI-SP group were on average 0.4 cm (95% CI -0.9 to 1.7, p=0.6) taller than those in the control group. For cumulative incidence of stunting, the HR in the AZI-SP group was 0.72 (95% CI 0.61 to 0.84, p<0.001) compared with the control and 0.76 (95% CI 0.65 to 0.90, p<0.001) compared with the monthly SP groups. There was no intergroup difference in stunting prevalence or anthropometric measurements.

CONCLUSIONS

In rural Malawi, maternal intensified infection control during pregnancy reduces offspring's cumulative incidence of ever being stunted by 13 years of age. In this study, there was no evidence of a positive impact on cognitive performance.

TRIAL REGISTRATION NUMBER

NCT00131235.

Neurodevelopment in early treated HIV-infected infants participating in a developmental stimulation programme compared with controls

BACKGROUND

Neurodevelopmental stimulation programmes can improve developmental outcomes. Antiretroviral therapy (ART) started soon after birth potentially limits the invasion of HIV into the central nervous system. A combination of developmental stimulation and early ART initiation may reduce developmental delays in children with perinatally acquired HIV infection.

METHODS

At a single site in Johannesburg, South Africa, we enrolled 36 HIV-infected neonates on ART into an intervention group (IG) participating in a yearlong home-based, neurodevelopmental stimulation programme. Bayley Scales of Infant and Toddler Development-3rd Edition (BSID-III) assessments were conducted at 12 months. Scores were compared with 24 early treated HIV-infected infants in an observational group (OG). BSID-III assessments were also conducted for older children in an OG at 24 or 36 months. Cognitive, language and motor scaled and composite scores were analysed.

RESULTS

BSID-III scaled and composite scores were all higher in the IG apart from the gross motor scaled score (9.25 vs. 10, p = 0.1954). Receptive communication scaled score was significantly higher in the IG (10.96 vs. 9, p = 0.0331). IG composite scores were all higher than OG scores. OG children assessed at 24 or 36 months had lower composite scores in all subscales than 12-month OG scores.

CONCLUSIONS

Early treated HIV-infected children participating in a neurodevelopmental stimulation programme achieved higher BSID-III scores at 12 months compared with early treated HIV-infected children who did not receive the programme.

Differential influences of early growth and social factors on young children's cognitive performance in four low-and-middle-income birth cohorts (Brazil, Guatemala, Philippines, and South Africa)

Background

Studies relating childhood cognitive development to poor linear growth seldom take adequate account of social conditions related to both, leading to a focus on nutrition interventions. We aimed to assess the roles of both biological and social conditions in determining early childhood cognition, mediated by birthweight and early linear growth.

Methods

After exploratory structural equation modelling to identify determining factors, we tested direct and indirect paths to cognitive performance through birthweight and child height-for-age at 2 years, assessed between 4 and 8.5 years of age among 2448 children in four birth cohort studies in low-and-middle-income countries (Brazil, Guatemala, Philippines and South Africa). Determinants were compared across the cohorts.

Findings

Three factors yielded excellent fit, comprising birth endowment (primarily maternal age and birth order), household resources (crowding, dependency) and parental capacity (parental education). We estimated their strength together with maternal height in determining cognitive performance. Percentage shares of total effects of the four determinants show a marked transition from mainly biological determinants of birth weight (birth endowment 34%) and maternal height (30%) compared to household resources (25%) and parental capacity (11%), through largely economic determinants of height at 2 years (household resources (60%) to cognitive performance being predominantly determined by parental capacity (64%) followed by household resources (29%). The largely biological factor, birth endowment (maternal age and birth order) contributed only 7% to childhood cognitive performance and maternal height was insignificant. In summary, the combined share of social total effects (household resources and parental capacity) rises from 36∙2% on birth weight, to 78∙2% on height for age at 24 m, and 93∙4% on cognitive functioning.

Interpretation

Across four low- and middle-income contexts, cognition in childhood is influenced more by the parental capacity of families and their economic resources than by birth weight and early linear growth. Improving children's cognitive functioning requires multi-sectoral interventions to improve parental education and enhance their economic wellbeing, interventions that are known to improve also early childhood growth.

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We aimed to investigate separate and combined biological and social determination of young children’s cognitive performance.

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We used path analysis of longitudinal data from birth cohort studies in four differing low-and-middle countries.

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We distinguished biological and social factors, as well as household resources from parental capacity.

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Biological factors determine birthweight, 2-year height depends on social factors, and the latter drive child cognitive performance.

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No single domain intervention provides both necessary and sufficient support for young children’s unfolding development.

A description of early neurodevelopment in a cohort of HIV-exposed uninfected children

Introduction: Successful strategies preventing mother-to-child HIV transmission have resulted in increasing numbers of uninfected children exposed to maternal HIV and ART in-utero, and while breastfeeding. Some reports describe exposure as impacting neurodevelopment. Methods: This cross-sectional analysis included 49 of the 70 HIV-exposed uninfected (HEU) birth-enrolled children as the control arm of an observational cohort study of early treatment in HIV-infected infants in Johannesburg, South Africa. We used the Bayley Scales of Infant and Toddler Development-3rd Edition (BSID-III) to assess neurodevelopment at 12 months of age. Cognitive, language and motor subscale composite scores and performance categories were analysed. We evaluated associations between BSID-III performance categories and cohort variables. Results: Evaluating composite scores according to performance categories showed a higher percentage of scores in the average, high average and superior categories as compared to test reference norms. Maternal BMI ≥ 25 kg/m² and mid-upper arm circumference ≥ 32 cm were associated with higher than average infant language scores. Six children scored below average (<90) - three in the cognitive and three in the language subscale. Conclusion: No developmental delay was found in ART-exposed HEU children at 12 months of age. A small number of at-risk children suggest ongoing screening, referral and follow-up is needed.

Value of the Goodenough Drawing Test as a research tool to detect developmental delay in South African preschool children

There is a need for simple, cost-effective research tools to detect developmental delay in preschool children in low- and middle-income countries where insufficient resources are often a barrier to detection and management. The Goodenough Draw-a-Person test is freely available, easily administered, and requires limited language ability and equipment; it is thus potentially useful in resource-constrained settings. We aimed to determine the diagnostic accuracy of the Draw-a-Person test to identify developmental delay in 5-year-old preschool children using the Griffiths Mental Developmental Scales-Extended Revised eye-hand coordination subquotient as the gold standard. This was a cross-sectional analysis of drawings by South African preschool children from low-income families, whose Griffiths Mental Developmental Scales-Extended Revised assessments included a human figure drawing. Draw-a-Person test quotients were estimated independently by a developmental paediatrician and two medical officers to calculate inter-rater agreement. The paediatrician’s scores were used to determine the diagnostic accuracy of the Draw-a-Person test quotient (<85) to predict developmental delay with the eye-hand coordination subquotient (<75). A total of 125 children were included, with a mean age of 60.8 months (range 59–66 months) of which 48.8% were boys. The mean Draw-a-Person test score was 94 (standard deviation 15) with 28 Draw-a-Person test scores below 85. Applying the Draw-a-Person test cut-off of 85, sensitivity of the Draw-a-Person test to the eye-hand coordination subquotient was 80% and specificity 89%. The area under the receiver operator characteristic curve was 0.87 (95% confidence interval [0.78–0.96]). The Goodenough Draw-a-Person test could thus be a useful research tool for detecting fine motor and visuoperceptual delay in South African preschool children.

The Strengths and Difficulties Questionnaire (SDQ) in Africa: a scoping review of its application and validation

BACKGROUND

Child and adolescent mental health in Africa remains largely neglected. Quick and cost-effective ways for early detection may aid early intervention. The Strengths and Difficulties Questionnaire (SDQ) is globally used to screen for mental health problems, but little is known about its use in Africa. We set out to perform a scoping review to examine existing studies that have used the SDQ in Africa.

METHODS

A comprehensive scoping review methodology was used to identify all peer-reviewed studies ever published that have used the SDQ in Africa. Data were extracted and analysed to assess the countries, languages and SDQ versions used, the purpose of the SDQ studies, psychometric properties of the SDQ, and to consider knowledge gaps for future in-country and cross-country studies.

RESULTS

Fifty-four studies from 12 African countries were identified, most from South Africa. Many different languages were used, but authorized SDQs in those languages were not always available on the SDQinfo website. Authors frequently commented on challenges in the translation and backtranslation of mental health terminology in African languages. The SDQ was typically used to investigate internalisation/externalization disorders in different clinical populations, and was most frequently used in the evaluation of children and adolescents affected by HIV/AIDS. Sixteen studies (29.6%) administered the SDQ to participants outside the intended age range, only 4 (7.4%) used triangulation of all versions to generate assessments, and eight studies (14.8%) used only subscales of the SDQ. Only one study conducted thorough psychometric validation of the SDQ, including examination of internal consistency and factor analysis. Where 'caseness' was defined in studies, UK cut-off scores were used in all but one of the studies.

CONCLUSIONS

The SDQ may be a very useful tool in an African setting, but the scoping review suggested that, where it was used in Africa researchers did not always follow instrument guidelines, and highlighted that very little is known about the psychometric properties of the SDQ in Africa. We recommend comprehensive evaluation of the psychometric properties of the SDQ in various African languages, including internal consistency, factor structure, need for local cut-off values and ensuring cultural equivalence of the instrument.