A guide for monitoring child development in low- and middle-income countries

Methodology for adapting a co-created early childhood development intervention and implementation strategies for use by frontline workers in India and Guatemala: a systematic application of the FRAME-IS framework

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies.

Adapting Child Development Assessment Tools to the Rural Indian Context

BACKGROUND

Child development assessment tests serve many purposes, including educational placement, identifying cognitive weaknesses, and initiating early interventions. Much of the research associated with developmental testing has been conducted in high-income countries, offering limited guidance on adapting these tests to other settings.

OBJECTIVES

As part of the first phase of a study exploring the impact of childhood vaccines on cognition and school attainment, we aimed to assess the feasibility of enrolling children from the community, documenting immunization, and conducting child development assessments for children between 18 months and 8 years of age in a rural setting in Haryana, India.

METHODS

To ensure assessments are optimally tailored to the context, child development assessment tests require valid translation and cultural adaptation. This report describes the rigorous seven-step adaptation process we designed for the contextually appropriate adaptation of the following three child development assessment tests: the Bayley Scales of Infant Development-IV, the Stanford Binet Intelligence Scale Fifth Ed. for Early Childhood, and the Wechsler Intelligence Scale for Children IV.

RESULTS

This process involved translating tests into the local language, back-translating them for accuracy, adapting them to the rural context via several iterations, and field-testing to refine and validate adaptation quality.

CONCLUSIONS

This adaptation process may be beneficial for other researchers involved in adapting child development assessment tests to other settings. Further, this adaptation process may inform other researchers involved in adapting tests for diverse settings.

Scalable Transdiagnostic Early Assessment of Mental Health (STREAM): a study protocol

INTRODUCTION

Early childhood development forms the foundations for functioning later in life. Thus, accurate monitoring of developmental trajectories is critical. However, such monitoring often relies on time-intensive assessments which necessitate administration by skilled professionals. This difficulty is exacerbated in low-resource settings where such professionals are predominantly concentrated in urban and often private clinics, making them inaccessible to many. This geographic and economic inaccessibility contributes to a significant 'detection gap' where many children who might benefit from support remain undetected. The Scalable Transdiagnostic Early Assessment of Mental Health (STREAM) project aims to bridge this gap by developing an open-source, scalable, tablet-based platform administered by non-specialist workers to assess motor, social and cognitive developmental status. The goal is to deploy STREAM through public health initiatives, maximising opportunities for effective early interventions.

METHODS AND ANALYSIS

The STREAM project will enrol and assess 4000 children aged 0-6 years from Malawi (n=2000) and India (n=2000). It integrates three established developmental assessment tools measuring motor, social and cognitive functioning using gamified tasks, observation checklists, parent-report and audio-video recordings. Domain scores for motor, social and cognitive functioning will be developed and assessed for their validity and reliability. These domain scores will then be used to construct age-adjusted developmental reference curves.

ETHICS AND DISSEMINATION

Ethical approval has been obtained from local review boards at each site (India: Sangath Institutional Review Board; All India Institute of Medical Science (AIIMS) Ethics Committee; Indian Council of Medical Research-Health Ministry Screening Committee; Malawi: College of Medicine Research and Ethics Committee; Malawi Ministry of Health-Blantyre District Health Office). The study adheres to Good Clinical Practice standards and the ethical guidelines of the 6th (2008) Declaration of Helsinki. Findings from STREAM will be disseminated to participating families, healthcare professionals, policymakers, educators and researchers, at local, national and international levels through meetings, academic journals and conferences.

The net impact of clinical seizures on outcome characteristics in infants with neonatal encephalopathies at 12 months of age

PURPOSE

To assess the impact of clinical neonatal seizures on outcome characteristics of preterm and term newborns with neonatal encephalopathy (NE).

METHODS

We designed a prospective comparative study with 53 babies (preterm neonates: 26 and term neonates: 27) with NE: group 1 (preterm neonates with seizures, n = 13), group 2 (preterm neonates without seizures, n = 13), group 3 (term neonates with seizures, n = 13) and group 4 (term neonates without seizures, n = 14). The functional outcome characteristics of the survivors were assessed by the Ankara Developmental Screening Inventory (ADSI) and the Guide for Monitoring Child Development (GMCD) at 12 months of age.

RESULTS

Clinically defined acute symptomatic seizures were diagnosed with prompt conventional EEG / amplitude-integrated EEG in preterm (92.3%) and term neonates (81.4%) with etiology-specific diagnoses of NE. There were no differences between the study groups regarding seizure semiology and EEG characteristics. A primary adverse outcome was defined in 22 (41.5%) of the cohort. However, only 15.3% of infants had an unfavorable functional outcome with ADSI at 12 months. Among the survivors, there was no significant difference between the study groups regarding ADSI scores. The GMDC test revealed normal development in 50% of survivors with seizures in the preterm group and 83% in the term group.

CONCLUSION

There was no significant difference between the characteristics of functional outcomes at 12 months in preterm and term neonates with NE for clinical seizures.

The Clinical Characteristics and Outcomes of Infantile Seizures in the First Year of Life: A Single-Center Study

BACKGROUND

Epilepsy has a high incidence among infants during their first year of life, yet the prognosis can vary significantly. Although considerable research has been conducted on infantile spasms, studies examining infantile-onset epilepsy, excluding infantile spasms, remain limited, particularly concerning the factors influencing outcomes. Therefore, our study aims to elucidate seizure control, developmental outcomes, and prognostic factors in infants with epilepsy during their first year of life, within a single-center study in Malaysia.

METHODS

We retrieved data from patients who experienced seizures before age 12 months and were followed for over two years, using electronic patient records at Hospital Raja Perempuan Zainab II in Kelantan, a state in Malaysia's east coast. We retrospectively reviewed these records and assessed clinical outcomes based on the last follow-up.

RESULTS

Of 75 patients, 61 (81.3%) achieved good seizure control or remission. At the last follow-up, 24 (32%) exhibited developmental delay, whereas 19 (25.3%) displayed abnormal neuroimaging. Patients with abnormal background electroencephalographic (EEG) activity, as well as abnormal radiological findings, were more likely to experience poor seizure control and unfavorable developmental outcomes (P < 0.05).

CONCLUSIONS

Our study underscores that most infants with epilepsy can achieve seizure remission. However, poor seizure control and developmental delay are associated with abnormal EEG background and characteristics, as well as neuroimaging abnormalities. The management of infantile-onset epilepsies may necessitate substantial resources and precise interventions to enhance overall outcomes.

Developmental characteristics of Williams-Beuren syndrome and evaluation of adaptive behavioral skills

Background/aim

Williams-Beuren syndrome (WBS) is a rare genetic disorder with delays in language and cognitive development, but, with increased awareness of clinical features and a reliable diagnostic test, WBS is becoming more widely recognized in childhood. Adaptive behavior skills and/or maladaptive behavior are important for the prognosis of individuals with WBS. The aim of this study was to investigate the clinical and developmental characteristics of patients with WBS and further increase awareness about it by evaluating the adaptive skills and maladaptive behaviors of the patients.

Materials and methods

The data of WBS patients followed-up at the Developmental Behavioral Pediatrics Unit were reviewed. Patient data on perinatal and postnatal history, developmental stages, physical and neurological examination findings were collected. The International Guide for Monitoring Child Development (GMCD) was administered to each child. In addition, semistructured interviews were conducted with the parents using the Vineland Adaptive Behavior Scales, Second edition (Vineland-II).

Results

A total of 12 patients diagnosed with WBS via detection of the 7q11.23 deletion, of whom 6 were girls, were retrospectively reviewed. The mean age at the time of review was 54.6 ± 32.5 months. The mean age at first presentation to the Developmental Behavioral Pediatrics Outpatient Clinic was 15 ± 11.5 months. In the first developmental evaluation using the GMCD, there was a delay in fine and gross motor domains in 6 patients, in the language domains in 4 patients, and in all of the domains in 2 patients. Findings with Vineland-II showed socialization and communication domains as strengths, but the daily living skills and motor skills domains were weaknesses. In terms of maladaptive behavior, the patients tended to frequently have behavioral problems, neurodevelopmental disease, anxiety disorders, eating problems, and sleeping problems.

Conclusion

This retrospective review of 12 patients indicated a general delay in overall development, and confirmed impairment in both adaptive and maladaptive functioning in WBS.

Parents' Evaluation of Developmental Status and Strength and Difficulties Questionnaire as Screening Measures for Children in India: A Scoping Review

Due to the limited availability of suitable measures, screening children for developmental delays and social-emotional learning has long been a challenge in India. This scoping review examined the use of the Parents' Evaluation of Developmental Status (PEDS), PEDS: Developmental Milestones (PEDS:DM), and the Strength and Difficulties Questionnaire (SDQ) with children (<13 years old) in India. The scoping review was conducted following the Joanna Briggs Institute Protocol to identify primary research studies that examined the use of the PEDS, PEDS:DM, and SDQ in India between 1990 and 2020. A total of seven studies for the PEDS and eight studies for the SDQ were identified for inclusion in the review. There were no studies using the PEDS:DM. Two empirical studies used the PEDS, while seven empirical studies used the SDQ. This review represents the first step in understanding the use of screening tools with children in India.

Comparison of developmental outcomes in children with permanent and transient congenital hypothyroidism

OBJECTIVES

Congenital hypothyroidism (CH) is still one of the most common causes of preventable cognitive impairment in children, and its early detection and treatment prevent irreversible neurodevelopmental delay. Depending on the underlying cause, cases with CH may be transient or permanent. This study aimed to compare the developmental evaluation results of transient and permanent CH patients and to reveal any differences.

METHODS

A total of 118 patients with CH, who were followed up jointly in pediatric endocrinology and developmental pediatrics clinics, were included. The patients' progress was evaluated per the International Guide for Monitoring Child Development (GMCD).

RESULTS

Of the cases, 52 (44.1%) were female, and 66 (55.9%) were male. While 20 (16.9%) cases were diagnosed with permanent CH, 98 (83.1%) were diagnosed with transient CH. According to the results of the developmental evaluation made with GMCD, the development of 101 (85.6%) children was compatible with their age, while 17 (14.4%) children had delays in at least one developmental area. All 17 patients had a delay in expressive language. Developmental delay was detected in 13 (13.3%) of those with transient CH and 4 (20%) with permanent CH.

CONCLUSIONS

There is difficulty in expressive language in all cases of CH with developmental delay. No significant difference was found between the developmental evaluations of permanent and transient CH cases. The results revealed the importance of developmental follow-up, early diagnosis and interventions in those children. GMCD is thought to be an important guide to help monitoring the development of patients with CH.

Training packages for the use of child development tools in low/middle-income countries: a review

BACKGROUND

We are now moving beyond the focus of 'child survival' to an era which promotes children thriving and developing rather than simply 'surviving'. In doing so, we are becoming more aware of the large variation of child development screening tools available globally, but in particular, those in low/middle-income countries (LMICs).

METHODS

This narrative review identifies 24 child development tools used in LMICs. We aimed to identify information on training accessibility and training design, assessment methods and cost of training. For those tools with no training information identified or for any tools identified as providing online training, the tool author was contacted individually to obtain information on the features of the tool's training package.

RESULTS

Information on training features was identified for 18 tools. All of the tools are identified as screening tools with some also identified as surveillance or assessment tools. The training material for the majority of the tools was not readily accessible and most training packages were proprietary and only available with a face-to-face training design. Other training options included a user manual, training videos or training through an online platform.

CONCLUSIONS

Training is a key factor when selecting a child development screening or surveillance tool particularly in a low-income or middle-income setting where funds may be limited. The accessibility of training can have a key impact on the implementation and utilisation of tools desperately needed for use in LMICs.

Role of Pediatricians, Pediatric Associations, and Academic Departments in Ensuring Optimal Early Childhood Development Globally: Position Paper of the International Pediatric Association

ABSTRACT

Early childhood (birth-8 years), particularly the first 3 years, is the most critical time in development because of the highly sensitive developing brain. Providing appropriate developmental care (i.e., nurturing care, as defined by the World Health Organization [WHO]) during early childhood is key to ensuring a child's holistic development. Pediatricians are expected to play a critical role in supporting early childhood development (ECD) through providing developmental services such as developmental monitoring, anticipatory guidance, screening, and referral to medical and/or community-based services when delay is identified. Pediatricians are also expected to serve as advocates within their clinics and communities for improved delivery of ECD services, such as advocating for increasing funding for ECD initiatives, increasing insurance coverage of ECD services, and working to increase other pediatricians' awareness of the principles of ECD and how to deliver developmental services. However, this does not always occur. Typically, pediatricians' training and practice emphasizes treating disease rather than enhancing ECD. Pediatricians are further hindered by a lack of uniformity across nations in guidelines for developmental monitoring and screening. In this article, we present the vision of the International Pediatric Association (IPA) of the roles that pediatricians, academic departments, medical training programs, and pediatric associations should fulfill to help support ECD, including raising ECD to higher levels of priority in routine pediatric care. First, we present the challenges that face these goals in supporting ECD. We then propose, with supportive literature, strategies and resources to overcome these challenges in collaboration with local and international stakeholders, including the IPA, the WHO, UNICEF, and the World Bank.

Designing and validating the Dubai Tool for Developmental Screening (DTDS)

Background

Early detection of developmental problems is vital for facilitating early access to targeted intervention and augmenting its beneficial outcomes. Standardized developmental screening tools are known to enhance detection rates of developmental problems compared to clinical judgment alone and are widely recommended to be used in infants and young children. Most of the available developmental screening tools have been developed in Western countries. Many of their items may not be suitable for other cultures while others are expensive. Currently, none of the developmental screening tools have been validated in the United Arab Emirates (UAE), with only a few available in the Arabic language.

Objective

To create and validate a developmental screening tool, in both English and Arabic, that is simple, quick to use, and culturally relevant to the United Arab Emirates (UAE) child population aged 9-48 months.

Methods

The available literature was used to create a list of developmental milestones in five domains for children aged 9-48 months, divided into seven age groups. The selected milestones were used to create questionnaires in both English and Arabic, which were pilot tested twice. Each time, the results were analyzed and used to select, modify, and rephrase questions. Validation of the Dubai Tool for Developmental Screening (DTDS) was done against Parents' Evaluation of Developmental Status (PEDS) as a gold standard instrument. The DTDS and PEDS were administered cross-sectionally to parents of 1,400 children in seven age groups. Sensitivity, specificity, and kappa agreement of the DTDS compared with PEDS were calculated.

Results

The DTDS had a sensitivity of 100% in four age groups and 75-78% in the other three age groups. Specificity ranged from 96 to 99% across all age groups. The kappa measure showed substantial agreement in five age groups, a moderate agreement in one age group, and a fair agreement in one age group.

Conclusions

The DTDS is a valid screening tool for early identification of developmental delays and disabilities in early childhood.

Applicability of the Guide for Monitoring Child Development as a Telehealth Delivered Intervention During the Pandemic

BACKGROUND

Early intervention delivered through telehealth is critically needed during crises, particularly for children in low and middle-income countries (LMICs). We aimed to determine the applicability of the international Guide for Monitoring Child Development (GMCD) intervention delivered through telehealth during the COVID-19 lockdown in Turkey.

METHODS

Using a mixed-methods longitudinal design, we recruited children with developmental difficulties aged 0-42 months with an appointment during the first lockdown at Ankara University Developmental Pediatrics Division and seen face-to-face only once before. Developmental pediatricians applied the GMCD intervention during a single telephone call. As a novel intervention component, caregivers were asked to record and send back videos of the child's development when there were doubts about the child's functioning. Caregivers were called 1 year later by blinded independent researchers and a semi-structured interview on applicability was conducted. Applicability of the caregiver recorded video component of the intervention was assessed by a blinded observer using the GMCD Video Observation Tool.

RESULTS

Of 122 children that received the telehealth delivered GMCD intervention, 114 (93.4%) were included in the 1-year outcome study. Most were boys (51.8%); median age was 16.5 (IQR: 10.0-29.0) months, 51.0% had chronic health conditions, and 66.7% had developmental delay. All caregivers that received the intervention were mothers; 75.4% had at least high school education. The intervention was reported as applicable by 80.7% with high levels of satisfaction. On multivariate regression analysis, absence of chronic health related conditions was significantly associated with applicability (OR = 2.87, 95% CI = 1.02-8.09). Of 31 caregivers that were asked for videos, 19 sent back 93 videos that were technically observable. One or more developmental domains were observed in all videos; in 52.6%, caregivers provided early learning opportunities.

CONCLUSIONS

The findings of this study imply that the telehealth delivered GMCD intervention for children with developmental difficulties is applicable during the pandemic. The intervention content and frequency needs to be augmented for children with chronic health conditions. Further research is required to examine applicability and effectiveness of the GMCD intervention in other settings, particularly in LMICs.

The association of a novel digital tool for assessment of early childhood cognitive development, 'DEvelopmental assessment on an E-Platform (DEEP)', with growth in rural India: A proof of concept study

BACKGROUND

There is an urgent need to fill the gap of scalable cognitive assessment tools for preschool children to enable identification of children at-risk of sub-optimal development and to support their timely referral into interventions. We present the associations between growth in early childhood, a well-established marker of cognitive development, and scores on a novel digital cognitive assessment tool called DEvelopmental Assessment on an E-Platform (DEEP) on a sample of 3-year old pre-schoolers from a rural region in north India.

METHODS

Between February 2018 and March 2019, 1359 children from the Sustainable Programme Incorporating Nutrition and Games (SPRING) programme were followed up at 3-years age and data on DEEP, anthropometry and a clinical developmental assessment, the Bayley's Scale of Infant and Toddler Development, 3rd edition (BSID-III) was collected. DEEP data from 200 children was used to train a machine learning algorithm to predict their score on the cognitive domain of BSID-III. The DEEP score of the remaining 1159 children was then predicted using this algorithm to examine the cross-sectional and prospective association of growth with the DEEP score.

FINDINGS

The magnitude of the concurrent positive association between height-for-age and cognitive z-scores in 3-year olds was similar when cognition was measured by BSID-III (0.20 standard deviations increase for every unit change in specifically age-adjusted height (HAZ), 95% CI = 0.06-0.35) and DEEP (0.26 CI, 0.11-0.41). A similar positive prospective relationship was found between growth at 18 (0.21 CI, 0.17-0.26) and 12-months (0.18 CI, 0.13-0.23) and DEEP score measured at 3-years. Additionally, the relationship between growth and cognitive development was found to be dependant on socioeconomic status (SES).

INTERPRETATION

In this study, we suggest the utility of DEEP, a scalable, digital cognitive assessment tool, to measure cognition in preschool children. Further validation in different and larger datasets is necessary to confirm our findings.

FUNDING

The SPRING Programme was funded through a Wellcome Trust programme grant and the follow-up study by the Corporate Social Responsibility initiative grant from Madura Microfinance Ltd.

Developmental delay in a resource-constrained environment: Screening, surveillance and diagnostic assessment

The range and severity of developmental delays vary, and a systematic approach to ensuring early detection for early intervention is essential. The formative years are considered critical for nurturing and maximising developmental potential. In this article, the authors describe a clinical approach to developmental delay within resource-constrained environments of South Africa. The article unpacks the history and examination, developmental screening, surveillance and diagnostic assessment and social determinants of health. For timely interventions to occur, early and accurate assessment is necessary. Medical officers and other health professionals such as nurses, general practitioners and therapists working in low-resourced contexts may use this information in their approach to the assessment of developmental delay.

Academy of Nutrition and Dietetics Nutrition Research Network: The Saqmolo' Project Rationale and Study Protocol for a Randomized Controlled Trial Examining the Influence of Daily Complementary Feeding of Eggs on Infant Development and Growth in Guatemala

Adequate nutrition during the complementary feeding period is critical for optimal child growth and development and for promoting long-term educational attainment and economic potential. To prioritize limited public health resources, there is a need for studies that rigorously assess the influence of multicomponent integrated nutrition interventions in children younger than age 2 years in different contexts. This study aimed to describe the rationale and protocol for the Saqmolo' Project using the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. The Saqmolo' (ie, "egg" in the Mayan language, Kaqchiquel) Project is an individually randomized, partially blinded, controlled comparative effectiveness trial to evaluate the influence of adding delivery of a single whole egg per day to local standard nutrition care (ie, growth monitoring, medical care, deworming medication, multiple micronutrient powders for point-of-use food fortification [chispitas], and individualized complementary and responsive feeding education for caregivers) for 6 months, compared with the local standard nutrition care package alone, on child development, growth, and diet quality measures in rural indigenous Mayan infants aged 6 to 9 months at baseline (N = 1,200). The study is being executed in partnership with the Wuqu' Kawoq/Maya Health Alliance, a primary health care organization located in central Guatemala. Primary outcomes for this study are changes in global development scores, assessed using the Guide for Monitoring Global Development and the Caregiver Reported Child Development Instruments. Secondary outcomes include changes in infant hemoglobin, anthropometric measures (including z scores for weight for age, length for age, weight for length, and head circumference for age), and diet quality as measured using the World Health Organization's infant and young child feeding indicators. The results of the Saqmolo' Project may help to inform public health decision making regarding resource allocation for effective nutrition interventions during the complementary feeding period.

Referral Trends in Two Pioneering Developmental-Behavioral Pediatric Centers in Turkey

OBJECTIVE

To inform professionals pioneering developmental-behavioral pediatrics (DBP) services in low- and middle-income countries (LMICs), we aimed to examine referral trends in 2 pioneering DBP centers at different locations in Turkey and to ascertain whether the official establishment of DBP as a subspecialty affected these trends.

METHOD

This longitudinal observational study included all children referred to Ankara (AUDPD) and Inonu (IUDPD) Universities' Developmental Pediatrics Divisions between 2010 and 2018. We examined the sources of referrals and the independent effects of time and the establishment of DBP as a subspecialty on referral volume using Negative Binomial Regression (NBR) models.

RESULTS

Of 8,051 children, most were boys (58%) and under 24 months of age (72%). Most referrals were from the pediatric and pediatric surgery department clinics (85%); less than 1% were from child and adolescent psychiatry, and none were from family physicians. The NBR models showed that yearly, the referral volume increased significantly, 1.18-fold (95% confidence interval [CI] = 1.09-1.28) and 1.48-fold (95% CI = 1.20-1.82) for AUDPD and IUDPD, respectively. Compared with the trend of referrals before, the trend after the establishment of DBP as a subspecialty increased significantly at AUDPD, but not IUDPD.

CONCLUSION

The increase in referrals to DBP over time is encouraging to professionals working to advance DBP services and training in LMICs even if DBP is not officially established as a subspecialty. Additional efforts may be needed to improve recognition and use of DBP services by community physicians and allied disciplines that provide services to children.

Hybrid type 1 effectiveness/implementation trial of the international Guide for Monitoring Child Development: protocol for a cluster-randomised controlled trial

INTRODUCTION

More than 40% of children under 5 years of age in low-income and middle-income countries are at risk of not reaching their developmental potential. The international Guide for Monitoring Child Development (GMCD) early intervention package is a comprehensive programme to address developmental difficulties using an individualised intervention plan for young children and their families. We will conduct a hybrid type 1 effectiveness-implementation evaluation of the GMCD intervention in rural India and Guatemala.

METHODS AND ANALYSIS

Using a cluster-randomised design, 624 children aged 0-24 months in 52 clusters (26 in India, 26 in Guatemala) will be assigned to usual care or the GMCD intervention plus usual care delivered by frontline workers for 12 months. After 12 months, the usual care arm will cross over to the intervention, which will continue for 12 additional months (24 total). The intervention will be delivered using a digital mobile device interface. Effectiveness will be assessed for developmental functioning (Bayley Scales of Infant Development, 3rd edition) and nurturing care (Home Observation for Measurement of the Environment Scale) outcomes. Implementation will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. Explanatory qualitative analysis guided by the Consolidated Framework for Implementation Research will explore determinants between clusters with high versus low implementation effectiveness.

ETHICS AND DISSEMINATION

The study has been approved by the Institutional Review Boards of Brigham and Women's Hospital, Mahatma Gandhi Institute of Medical Sciences and Maya Health Alliance; and by the Indian Council of Medical Research/Health Ministry Screening Committee. Key study findings will be published in international open-access journals.

TRIAL REGISTRATION NUMBER

NCT04665297, CTRI/2020/12/029748.

PROTOCOL VERSION

1.0 (12 November 2020).

Child Development Monitoring in Well-baby Clinics in Kenya

BACKGROUND

Maternal and child health (MCH) clinics represent an integrated approach for providing healthcare to pregnant women and children 0-59 months of age. Although MCH clinics are also charged with monitoring child development, which involves tracking developmental milestones, it is unclear how these services are provided or perceived within the clinic. This study aimed to describe self-reported knowledge, perceptions, and practice of developmental monitoring in selected MCH clinics in western Kenya.

METHODS

This cross-sectional descriptive study was conducted within six clinics. We administered a descriptive survey to measure caregiver and healthcare staff attitudes towards and awareness of developmental monitoring; we also reviewed MCH booklets to identify services received at the clinic. Data collection occurred over a period of one day at each of the six clinic sites. The data were analyzed using descriptive statistics.

RESULTS

During the study period, 78 caregiver-child pairs presented to the clinics and had their MCH booklets reviewed. The median child age was three months (interquartile range [IQR]: 1-8 months). Most caregivers were aware of weight monitoring and immunization services; however, when asked specifically about developmental monitoring, only 2.6% of caregivers were aware this service was available at the clinics. Nearly 80% of caregivers reported that they would be very interested in developmental monitoring services. Thirty-three MCH healthcare staff were interviewed about services provided and goals of clinical care. Fewer healthcare staff (60.6%) identified their roles in developmental monitoring compared to their roles in growth (90.9%) and nutritional monitoring (84.8%). Developmental milestones had not been recorded in any of the 78 MCH booklets. However, 78.1% of healthcare staff indicated support for developmental screening.

CONCLUSION AND GLOBAL HEALTH IMPLICATIONS

While developmental monitoring was valued by healthcare providers, it was not consistently performed at the six clinics in our study. We recommend further work to raise awareness about developmental monitoring and to measure the implications of increased caregiver knowledge and perceptions on developmental monitoring practice.

Does in utero HIV exposure and the early nutritional environment influence infant development and immune outcomes? Findings from a pilot study in Pretoria, South Africa

Background

As mother-to-child transmission of HIV decreases, and the population of infants who are born HIV-exposed, but uninfected (HEU) continues to rise, there is a growing need to understand the development and health outcomes of infants who are HEU to ensure that they have the healthiest start to life.

Methods

In a prospective cohort pilot study at Kalafong Hospital, Pretoria, South Africa, we aimed to determine if we could recruit new mothers living with HIV on antiretrovirals (ART; n = 20) and not on ART (n = 20) and new mothers without HIV (n = 20) through our clinics to study the effects of HEU on growth and immune- and neurodevelopment in infants in early life, and test the hypothesis that infants who were HEU would have poorer health outcomes compared to infants who were HIV-unexposed, uninfected (HUU). We also undertook exploratory analyses to investigate relationships between the early nutritional environment, food insecurity and infant development. Infant growth, neurodevelopment (Guide for Monitoring Child Development [GMCD]) and levels of monocyte subsets (CD14, CD16 and CCR2 expression [flow cytometry]) were measured in infants at birth and 12 weeks (range 8–16 weeks).

Results

We recruited 33 women living with HIV on ART and 22 women living without HIV within 4 days of delivery from June to December 2016. Twenty-one women living with HIV and 10 without HIV returned for a follow-up appointment at 12 weeks postpartum. The high mobility of this population presented major challenges to participant retention. Preliminary analyses revealed lower head circumference and elevated CCR2+ (% and median fluorescence intensity) on monocytes at birth among infants who were HEU compared to HUU. Maternal reports of food insecurity were associated with lower maternal nutrient intakes at 12 weeks postpartum and increased risk of stunting at birth for infants who were HEU, but not infants who were HUU.

Conclusions

Our small feasibility pilot study suggests that HEU may adversely affect infant development, and further, infants who are HEU may be even more vulnerable to the programming effects of suboptimal nutrition in utero and postnatally. This pilot and preliminary analyses have been used to inform our research questions and protocol in our ongoing, full-scale study.

Development and validation of Egyptian developmental screening chart for children from birth up to 30 months

Background

Detecting developmental delay in children is an ongoing world commitment, especially for those below three years. To accurately assess the development of children; a culturally appropriate screening tool must be used. Egypt lacks such tool and multiple studies have shown that western tools are not suitable in other cultures.

Objectives

To develop and validate an easy, rapid, culturally appropriate and applicable screening chart for early detection of developmental delay among Egyptian children from birth up to 30 months and develop a Z-score chart for motor and mental development follow up based on our Egyptian screening chart.

Methods

A cross sectional randomized study was carried out on 1503 Egyptian children of both genders aged from birth up to 30 months assumed to have normal development according to the inclusion and exclusion criteria. They were selected from vaccination centers and well-baby clinics. Developmental milestones from Baroda development screening test (BDST) were applied on them after items were translated and adapted to Egyptian culture. Egyptian children developmental milestones scores were analyzed and carefully prepared in tables and charts. A 97% pass level of developmental achievements represents the threshold below which children are considered delayed. A Z-score chart for motor and mental development follow up was designed by calculating each age group achievement. The developed Egyptian developmental screening chart (EDSC) was validated against Ages and Stages Questionnaires (ASQ-3) as a reference standard in another different sample of 337 children in different age groups.

Results

The developed EDSC is represented in a chart format with two curves 50% and 97% pass level. Children considered delayed when the score below 97% pass level. Results revealed a statistically significant difference between EDSC and BDST at 50% and 97% pass levels. A Z-score chart for motor and mental development follow up was designed by calculating each age group achievement. EDSC sensitivity and specificity were calculated 84.38 (95% CI [67.21%–94.72%]) and 98.36 (95% CI [96.22%–99.47%]) respectively with an overall test accuracy 97.03 (95% CI [94.61%–98.57%]) (p ≤ .001). Agreement between EDSC and ASQ-3 was high (kappa score was 0.827) with negative and positive agreement 98.36 and 84.38, respectively.

Conclusions

Extensive revision of the BDST was needed in order to create and validate a more culturally appropriate Egyptian screening chart. This is the first study to create and validate an Egyptian-specific screening tool, to be rapid and easy to use in Egypt for early detection of developmental delay and enabling early intervention practices. A Z-score curve is reliable for follow up motor and mental development by calculating each age group achievement.

Screening tools for early identification of children with developmental delay in low- and middle-income countries: a systematic review

OBJECTIVE

To systematically review, identify and report the screening tools used for early identification of developmental delay in low- and middle-income countries.

DESIGN

Systematic review.

DATA SOURCES

Four bibliographic databases: Medline (1946 to 13 July 2020), Embase (1974 to 13 July 2020), Scopus (1823 to 11 July 2020) and PsycINFO (1987 to July week 1 2020).

ELIGIBILITY CRITERIA

Peer-reviewed original articles published in English addressing validated culturally sensitive developmental screening tools among children aged <5 years were included in this review.

DATA EXTRACTION AND SYNTHESIS

One author (CK, medical librarian) developed the search strategy. Three authors conducted the database search (phase I: CK; phase II: IJ and MKI). Three authors (TF, IJ and MKI) independently screened the title and abstracts. TF, MKI and GK independently performed the full-text review of the screened articles. During each step of the study selection process, disagreements were resolved through discussion. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement was used to guide the systematic review. Data extraction and analysis were performed using MS Excel. Meta-analysis was not possible due to heterogeneity of the study findings.

RESULTS

We identified 3349 articles, of which 18 studies from 10 countries, reporting 16 screening tools, were selected for qualitative synthesis. Six cultural contexts were explored. Twelve general, two motor and two speech-language tools were identified. Seven of them found to be parent-completed ones. Five screening tools (American Speech-Language and Hearing Association, Guide for Monitoring Child Development, Infant Neurological International Battery, New Delhi-Development Screening Questionnaire and Woodside Screening Technique) reported relatively higher sensitivity (82.5%-100%) and specificity (83%-98.93%).

CONCLUSIONS

Limited number of culturally sensitive developmental screening tools were validated for children aged <5 years in low- and middle-income countries. Revising existing screening tools in different ethnic and cultural settings and subsequent validation with normative value should be a research priority.

Sleep Patterns and Development of Children with Atopic Dermatitis

INTRODUCTION

Atopic dermatitis (AD) is a chronic inflammatory disease that begins in early childhood. Sleep problems have increased in children with AD. The aim of this study was to evaluate sleep patterns and the development of children with AD at an early age.

METHODS

This is a cross-sectional study consisting of a total of 80 children aged 0-36 months with AD. Patients were evaluated by the Brief Infant Sleep Questionnaire and International Guide for Monitoring Child Development.

RESULTS

The median age (IQR) of the patients was 6 (4.25-9) months, 63.7% of them were male and 50% of them had sleep problems. Male sex (OR: 3.78, p = 0.024, 95% CI, 0.083-0.837), patients with AD who were in the first 3 months after diagnosis (OR: 3.56; 95% CI, 1.220-10.43, p = 0.020), and moderate-severe AD (OR: 5.09; 95% CI, 1.649-15.748, p = 0.005) were determined as risk factors for sleep problems. In all, 12.5% of the patients needed support for one or more developmental areas (gross motor skills, expressive language and communication, receptive language, fine motor skills, relationship, and play). Developmental delay was higher in patients with sleep problems (p = 0.037). Multiple siblings (OR: 14.381; 95% CI, 1.557-132.871, p = 0.019) and the presence of sleep problems (OR: 8.011; 95% CI, 1.764-36.387, p = 0.024) were found to be risk factors for developmental delay.

CONCLUSION

Boys with moderate-severe AD within the first 3 months of diagnosis were at increased risk for sleep problems. Children with AD who have multiple siblings and sleep problems should be evaluated for developmental delay and monitored closely.

INTERGROWTH-21st Project international INTER-NDA standards for child development at 2 years of age: an international prospective population-based study

OBJECTIVES

To describe the construction of the international INTERGROWTH-21st Neurodevelopment Assessment (INTER-NDA) standards for child development at 2 years by reporting the cognitive, language, motor and behaviour outcomes in optimally healthy and nourished children in the INTERGROWTH-21st Project.

DESIGN

Population-based cohort study, the INTERGROWTH-21st Project.

SETTING

Brazil, India, Italy, Kenya and the UK.

PARTICIPANTS

1181 children prospectively recruited from early fetal life according to the prescriptive WHO approach, and confirmed to be at low risk of adverse perinatal and postnatal outcomes.

PRIMARY MEASURES

Scaled INTER-NDA domain scores for cognition, language, fine and gross motor skills and behaviour; vision outcomes measured on the Cardiff tests; attentional problems and emotional reactivity measured on the respective subscales of the preschool Child Behaviour Checklist; and the age of acquisition of the WHO gross motor milestones.

RESULTS

Scaled INTER-NDA domain scores are presented as centiles, which were constructed according to the prescriptive WHO approach and excluded children born preterm and those with significant postnatal/neurological morbidity. For all domains, except negative behaviour, higher scores reflect better outcomes and the threshold for normality was defined as ≥10th centile. For the INTER-NDA's cognitive, fine motor, gross motor, language and positive behaviour domains these are ≥38.5, ≥25.7, ≥51.7, ≥17.8 and ≥51.4, respectively. The threshold for normality for the INTER-NDA's negative behaviour domain is ≤50.0, that is, ≤90th centile. At 22-30 months of age, the cohort overlapped with the WHO motor milestone centiles, showed low postnatal morbidity (<10%), and vision outcomes, attentional problems and emotional reactivity scores within the respective normative ranges.

CONCLUSIONS

From this large, healthy and well-nourished, international cohort, we have constructed, using the WHO prescriptive methodology, international INTER-NDA standards for child development at 2 years of age. Standards, rather than references, are recommended for population-level screening and the identification of children at risk of adverse outcomes.

Development, feasibility and acceptability of a gamified cognitive DEvelopmental assessment on an E-Platform (DEEP) in rural Indian pre-schoolers - a pilot study

Background: Assessment of cognitive development is essential to identify children with faltering developmental attainment and monitor the impact of interventions. A key barrier to achieving these goals is the lack of standardized, scalable tools to assess cognitive abilities.

Objective: This study aimed to develop a tablet-based gamified assessment of cognitive abilities of 3-year-old children which can be administered by non-specialist field workers.

Methods: Workshops among domain experts, literature search for established and gamified paradigms of cognitive assessments and rapid review of mobile games for 3-year-old children was done to conceptualize games for this study. Formative household visits (N = 20) informed the design and content of the games. A cross-sectional pilot study (N = 100) was done to assess feasibility of the tool and check if increasing levels of difficulty and the expected variability between children were evident in game metrics. In-depth interviews (N = 9) were conducted with mothers of participating children to assess its acceptability.

Results: Six cognitive domains were identified as being integral to learning – divided attention, response inhibition, reasoning, visual form perception and integration and memory. A narrative, musical soundtrack and positive reinforcement were incorporated into the tool to enhance participant engagement. Child performance determined level timers and difficulty levels in each game. Pilot data indicate that children differ in their performance profile on the tool as measured by the number of game levels played and their accuracy and completion time indicating that it might be possible to differentiate children based on these metrics. Qualitative data suggest high levels of acceptability of the tool amongst participants.

Conclusions: A DEvelopmental assessment on an E-Platform (DEEP) has been created comprising distinct games woven into a narrative, which assess six cognitive domains, and shows high levels of acceptability and generates metrics which may be used for validation against gold standard cognitive assessments.

Physical growth: is it a good indicator of development in early childhood in low- and middle-income countries?

Background

Growth and early development (ECD) are vital outcomes for children. This study aimed to examine the association between child growth and overall development in children aged 3 to 5 years in low- and middle-income countries.

Methods

A secondary analysis of nationally representative data collected in UNICEF’s Multiple Indicator Cluster Surveys (MICS) and national Demographic and Health Surveys (DHS). The early development of children aged 3 to 5 years from the randomly selected households was ascertained using a 10-item scale which assessed four developmental domains: language-cognitive, physical, socio-emotional, and approaches to learning with a total development score ranging from 0 (the least optimal) to 10 (the most optimal). Children’s growth, the height-for-age Z score (HAZ), was calculated using the WHO Child Growth Standards. Unadjusted (Pearson’s correlation coefficient, r) and adjusted estimations (standardised mean difference (SMD) adjusted for child sex, child age, and household wealth index) of the magnitude of the association between HAZ and ECD scores were calculated for each country.

Results

Data contributed by 178,393 children aged 36 to 59 months from 55 countries were included in the analyses. The pooled r between HAZ and standardised ECD scores was 0.12 and the pooled adjusted SMD was 0.06. The r ranged from ~ 0 in Barbados, Lebanon, and Moldova to 0.32 in Pakistan and 0.36 in Nigeria. Overall, 47/55 countries had correlation coefficients less than the cut-off for a small association. The adjusted SMDs were ~ 0 in 20 countries. All SMDs were lower than the cut-off for a small effect size. The magnitudes of the association were highest in South Asia and lowest in Middle East and North Africa, and lowest in the highest HDI group.

Conclusions

The association between growth and development in early childhood appears to be primarily a co-occurrence because the magnitude of the association varies among settings from no association in higher-income countries to a moderate level in low-income countries. In low-income countries, interventions targeting child growth and ECD should be integrated given their common risks frequency in these settings. Overall, growth is not a sensitive and therefore suitable indicator of child development.

Electronic supplementary material

The online version of this article (10.1186/s12887-019-1654-9) contains supplementary material, which is available to authorized users.

How Young Children Learn Language and Speech

Pediatric clinicians are on the front line for prevention of language and speech disorders. This review uses prevailing theories and recent data to justify strategies for prevention, screening and detection, diagnosis, and treatment of language and speech disorders. Primary prevention rests on theories that language learning is an interaction between the child's learning capacities and the language environment. Language learning occurs in a social context with active child engagement. Theories support parent education and public programs that increase children's exposure to child-directed speech. Early detection of delays requires knowledge of language milestones and recognition of high-risk indicators for disorders. Male sex, bilingual environments, birth order, and chronic otitis media are not adequate explanations for significant delays in language or speech. Current guidelines recommend both general and autism-specific screening. Environmental and genetic factors contribute to primary language and speech disorders. Secondary and tertiary prevention requires early identification of children with language and speech disorders. Disorders may be found in association with chromosomal, genetic, neurologic, and other health conditions. Systematic reviews find that speech-language therapy, alone or in conjunction with other developmental services, is effective for many disorders. Speech-language interventions alter the environment and stimulate children's targeted responding to improve their skills.

Turkish Neonatal Society guideline for the follow-up of high-risk newborn infants

Developments in perinatal and neonatal care have increased the survival rate of high-risk newborns but led to a rise in chronic diseases seen in these infants. A significant number of them attend primary and secondary health care centers after discharge; however, there are very few standard protocols for the long-term follow-up of these babies. Therefore, we aimed to establish a follow-up guideline that emphasizes on universal screening schemes and takes into consideration national data. The guide presented here provides brief recommendations for physicians in light of evidence-based data for the follow-up of high-risk newborn infants. The steps taken to monitor and solve the problems of all high-risk infants may vary. We hope the use of such a standard approach in evaluating each infant in daily routine will improve the life quality of these high-risk infants.

Validation of the International Guide for Monitoring Child Development demonstrates good sensitivity and specificity in four diverse countries

AIM

It is of critical importance to have internationally constructed tools to address early childhood development. The aim of this second phase of a two-phase study was to examine the sensitivity and specificity of the Guide for Monitoring Child Development (GMCD) in identifying developmental delay in four diverse countries.

METHODS

The first phase of this 2011-2015 back-to-back study included 4949 children up to 42 months of age from primary healthcare centres in Argentina, India, South Africa and Turkey. Distribution curves were generated to show the ages when the children attained GMCD milestones and those that could be used across sexes and countries were placed in age ranges corresponding to the 85th and 97th percentile point estimates. Phase two examined a separately recruited sample of children in those countries to determine sensitivity and specificity of the GMCD.

RESULTS

The validation phase of the 85 milestones in the GMCD identified delayed development in 30% of the 1731 children in the four countries. The sensitivity and specificity ranged from 0.71-0.94 and 0.69-0.82, respectively, for the total sample and the different age groups.

CONCLUSION

The GMCD standardised in four diverse countries has appropriate accuracy for identification of children with developmental delay.

Developmental performance of 5-year-old Bulgarian children-An example of translational neuroscience in practice

RATIONALE, AIMS, AND OBJECTIVES

Developmental testing is essential for early recognition of the various developmental impairments. The tools used should be composed of items that are age specific, adapted, and standardized for the population they are applied to. The achievements of neurosciences, medicine, psychology, pedagogy, etc. are applied in the elaboration of a comprehensive examination tool that should screen all major areas of development. The key age of 5 years permits identification of almost all major developmental disabilities leaving time for therapeutic intervention before school entrance. The aim of the research is to evaluate the developmental performance of 5-year-old Bulgarian children using the approach of translation neuroscience.

METHOD

A comprehensive test program was developed composed of 89 items grouped in the following domains: fine and gross motor development, coordination and balance, central motor neuron disturbances, language development and articulation, perception, attention and behavior, visual acuity, and strabismus. The overall sample comprises 434 children of mean age 63.5 months (SD-3.7). Male to female ratio is 1:1.02. From this group, 390 children are between 60 and 71 months of age. The children are examined in 51 kindergartens in 21 villages and 18 cities randomly chosen in southern Bulgaria. Eight children were excluded from the final analysis because they fulfilled less than 50% of the test items (7 children did not cooperate and 1 child was with autistic spectrum disorder).

RESULTS

The items with abnormal response in less than 5% of the children are 43. The items with abnormal response in 6% to 35% of the children are 37. The items with high abnormal response (more than 35%) rate are only 9.

CONCLUSIONS

The test is an example of a translational approach in neuroscience. On one hand, it is based on the results of several sciences studying growth and development from different perspective. On the other hand, the results from the present research may be implemented in other fields of child development-education, psychology, speech and language therapy, and intervention programs.

Piloting a Developmental Screening Tool Adapted for East African Children

There is a need for developmental screening that is easily administered in resource-poor settings. We hypothesized that known risk factors would predict failed developmental screening on an adapted screening tool in East African children living in poverty. The sample included 100 healthy Ugandan children aged 6–59 months. We adapted a parent-reported developmental screener based on the Child Development Review chart. The primary outcome was failure to meet age-appropriate milestones for any developmental domain. Venous blood was analyzed for lead, and caregivers completed a demographics questionnaire. We used multivariate logistic regression models to determine if elevated blood lead and stunting predicted failure on the screener, controlling for maternal education level, age in months past the lower bound of the child’s developmental age group, and absence of home electricity. In the sample, 14% (n = 14) of children failed one or more milestones on the screener. Lead levels or stunting did not predict failing the screener after controlling for covariates. Though this tool was feasibly administered, it did not demonstrate preliminary construct validity and is not yet recommended for screening in high-risk populations. Future research should include a larger sample size and cognitive interviews to ensure it is contextually relevant.

Physician Awareness of Developmental Screening and Referral in the State of Kuwait

OBJECTIVE

In the State of Kuwait, family physicians and pediatricians are responsible for identifying and referring children at risk of disability. The aims of this study were to better understand physician (1) use of developmental screening instruments, (2) referral practices for children at risk of developmental disability, (3) interpretation of screening results, and (4) anticipatory guidance topics prioritized over child screening.

METHODS

A nonprobability volunteer, self-selection sample of family physicians, general practitioners, and pediatricians (n = 398) completed a 60-item paper questionnaire. Items assessed included: (1) practitioner familiarity with, belief in, and use of screening instruments; (2) familiarity with early childhood intervention services; (3) perceived barriers to screening implementation; and (4) anticipatory topics prioritized over screening. Logistic regression was used to test a priori hypotheses.

RESULTS

In general, family doctors and pediatricians practicing in public hospitals and primary health care centers in the State of Kuwait do not use or know how to use a developmental screening instrument, while over half prioritized immunization counseling over child screening. Screening confidence and training on using screening instruments increased the likelihood of tool use. Staff shortages, time constraints, and a perceived lack of Arabic screening instruments were barriers to tool use.

CONCLUSION

Raising health care providers' awareness of standardized developmental screening instruments and establishment of an early identification system in the State of Kuwait are needed. Standardization and adaptation of technically sound Arabic-language screening tools for use in the State of Kuwait and physician training programs on screening are recommended.

Similarities and differences in child development from birth to age 3 years by sex and across four countries: a cross-sectional, observational study

BACKGROUND

Knowledge about typical development is of fundamental importance for understanding and promoting child health and development. We aimed to ascertain when healthy children in four culturally and linguistically different countries attain developmental milestones and to identify similarities and differences across sexes and countries.

METHODS

In this cross-sectional, observational study, we recruited children aged 0-42 months and their caregivers between March 3, 2011, and May 18, 2015, at 22 health clinics in Argentina, India, South Africa, and Turkey. We obtained a healthy subsample, which excluded children with a low birthweight, perinatal complications, chronic illness, undernutrition, or anaemia, and children with missing health data. Using the Guide for Monitoring Child Development, caregivers described their child's development in seven domains: expressive and receptive language, gross and fine motor, play, relating, and self-help. Clinicians examining the children also completed a checklist about the child's health status. We used logit and probit regression models based on the lowest deviance information criterion to generate Bayesian point estimates and 95% credible intervals for the 50th percentile ages of attainment of 106 milestones. We assessed the significance of differences between sexes and countries using predefined criteria and regions of practical equivalence.

FINDINGS

Of 10 246 children recruited, 4949 children (48·3%) were included in the healthy subsample. For the 106 milestones assessed, the median age of attainment was equivalent for 102 (96%) milestones across sexes and 81 (76%) milestones across the four countries. Across countries, median ages of attainment were equivalent for all play milestones, 20 (77%) of 26 expressive language milestones, ten (67%) of 15 receptive language milestones, nine (82%) of 11 fine motor milestones, 14 (88%) of 16 gross motor milestones, and eight (73%) of 11 relating milestones. However, across the four countries the median age of attainment was equivalent for only two (22%) of nine milestones in the self-help domain.

INTERPRETATION

The ages of attainment of developmental milestones in healthy children, and the similarities and differences across sexes and country samples might aid the development of international tools to guide policy, service delivery, and intervention research, particularly in low-income and middle-income countries.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development.

A retrospective review of the Pediatric Development Clinic implementation: a model to improve medical, nutritional and developmental outcomes of at-risk under-five children in rural Rwanda

Background

As more high-risk newborns survive the neonatal period, they remain at significant medical, nutritional, and developmental risk. However, no follow-up system for early intervention exists in most developing countries. In 2014, a novel Pediatric Development Clinic (PDC) was implemented to provide comprehensive follow-up to at-risk under-five children, led by nurses and social workers in a district hospital and surrounding health centers in rural Rwanda.

Methods

At each PDC visit, children undergo clinical/nutritional assessment and caregivers participate in counseling sessions. Social assessments identify families needing additional social support. Developmental assessment is completed using Ages and Stages Questionnaires. A retrospective medical record review was conducted to evaluate the first 24 months of PDC implementation for patients enrolled between April 2014–December 2015 in rural Rwanda. Demographic and clinical characteristics of patients and their caregivers were described using frequencies and proportions. Completion of different core components of PDC visits were compared overtime using Fisher’s Exact test and p-values calculated using trend analysis.

Results

426 patients enrolled at 5 PDC sites. 54% were female, 44% were neonates and 35% were under 6 months at enrollment. Most frequent referral reasons were prematurity/low birth weight (63%) and hypoxic-ischemic encephalopathy (34%). In 24 months, 2787 PDC visits were conducted. Nurses consistently completed anthropometric measurements (age, weight, height) at all visits. Some visit components were inconsistently recorded, including adjusted age (p = 0.003), interval growth, danger sign assessment, and feeding difficulties (p < 0.001). Completion of other visit components, such as child development counseling and play/stimulation activities, were low but improved with time (p < 0.001).

Conclusions

It is feasible to implement PDCs with non-specialized providers in rural settings as we were able to enroll a diverse group of high-risk infants. We are seeing an improvement in services offered at PDCs over time and continuous quality improvement efforts are underway to strengthen current gaps. Future studies looking at the outcomes of the children benefiting from the PDC program are underway.

Assessment of Neurodevelopment, Nutrition, and Inflammation From Fetal Life to Adolescence in Low-Resource Settings

Efforts to improve child neurodevelopment are critical to health, equity, and sustainable development, particularly in low-resource settings in the United States and globally. The colliding epidemics of food insecurity, infectious diseases, and noncommunicable diseases interact and impact neurodevelopment. Understanding the complex relationships between nutrition, inflammation, and neurodevelopment can inform clinical and public health interventions to improve outcomes. This article reviews key definitions, tools, and considerations for the assessment of nutrition, inflammation, and child neurodevelopment. The effectiveness of existing assessment tools to reflect status and biology, particularly in relation to each other, and to predict long-term changes in health is examined. The aim of this review is to present the extant evidence, identify critical research gaps, and suggest a research agenda for future longitudinal and intervention studies to address the assessment of nutrition, inflammation, and child neurodevelopment, particularly in low-resource settings. Despite research gaps, there is a strong relationship between nutrition, inflammation, environmental factors, and child neurodevelopment, which emphasizes the need to evaluate targeted, early interventions to improve long-term health and well-being.

Adaptation of the Ages and Stages Questionnaire for Remote Aboriginal Australia

A key challenge to providing quality developmental care in remote Aboriginal primary health care (PHC) centers has been the absence of culturally appropriate developmental screening instruments. This study focused on the cross-cultural adaptation of the Ages and Stages Questionnaires, 3rd edition (ASQ-3), with careful attention to language and culture. We aimed to adapt the ASQ-3 for use with remote dwelling Australian Aboriginal children, and to investigate the cultural appropriateness and feasibility of the adapted ASQ-3 for use in this context. We undertook a qualitative study in two remote Australian Aboriginal communities, using a six-step collaborative adaptation process. Aboriginal Health Workers (AHWs) were trained to use the adapted ASQ-3, and follow-up interviews examined participants' views of the cultural acceptability and usefulness of the adapted instrument. The adapted ASQ-3 was found to have high face validity and to be culturally acceptable and relevant to parents, AHWs, and early childhood development experts.

No data, no problem, no action: parenting programs in low-income countries. Making the social-emotional outcomes more visible

BACKGROUND

Parenting programs are delivered in many low income countries in an effort to address the effects of insufficient cognitive stimulation, major social-emotional risk factors related to inadequate caregiver sensitivity and responsiveness, maternal depression, violence and biological risk factors. However, the outcomes of these programs are often untested because of methodological limitations in the existing evaluation tools available for cross-cultural research, and especially those related to social-emotional development and functioning.

METHOD

This study takes an approach that involves organizing data from focus groups collected following caregiver participation in a parenting program, Learning Through Play (LTP) delivered in 11 low income countries. The LTP program has as its aim to increase parent knowledge and influence parental practice regarding the essential components of early development of children aged birth to 6 years. The purpose of systematically organizing focus group data was to illustrate a means by which program developers worldwide can discuss outcomes of program participation, particularly in social-emotional domains that have been overlooked in past studies on parenting programs.

RESULTS AND CONCLUSION

The findings from this study suggest that qualitative outcome data can be organized to make the social-emotional outcomes of participation in parenting programs more visible.

Child development assessment tools in low-income and middle-income countries: how can we use them more appropriately?

Global emphasis has shifted beyond reducing child survival rates to improving health and developmental trajectories in childhood. Optimum early childhood experience is believed to allow children to benefit fully from educational opportunities resulting in improved human capital. Investment in early childhood initiatives in low-income and middle-income countries (LMICs) is increasing. These initiatives use early childhood developmental assessment tools (CDATs) as outcome measures. CDATs are also key measures in the evaluation of programmatic health initiatives in LMICs, influencing public health policy. Interpretation of CDAT outcomes requires understanding of their structure and psychometric properties. This article reviews the structure and main methods of CDAT development with specific considerations when applied in LMICs.

Incorporating developmental screening and surveillance of young children in office practice

CONTEXT

Developmental concerns voiced by parents need to be responded to by structured developmental screening. Screening is the use of validated developmental screening tools to identify children with high risk of developmental delay out of an apparently normal population, while surveillance is the process of monitoring children identified as high risk by screening. Absence of routine screening can be attributed to problems at the level of parents, pediatricians or National policies. Hence vulnerable children are not detected early, and are denied benefit from appropriate developmental interventions. There are no definite guidelines for screening or for suitable tools for screening and surveillance.

OBJECTIVES

To review existing developmental screening and monitoring tools for children validated in Indian under-five children, and provide a proposed practice paradigm for developmental screening in office practice.

EVIDENCE ACQUISITION

Scientific papers were retrieved by an electronic database search using MeSH terms 'screening tool', 'developmental delay', and filter of 'children under 5 years'. Those relevant to office practice and validated internationally or in Indian children were reviewed.

RESULTS

Screening tools applicable to Indian office practice have been compared and certain tools have been recommended according to the level of risk of developmental delay. An algorithmic approach to screening has been given along with strategies for incorporation.

CONCLUSIONS

Screening and surveillance for high risk of developmental delay are essential components of child health care. It is possible to incorporate both into routine practice.

Management of late-preterm and term infants with hyperbilirubinaemia in resource-constrained settings

Hyperbilirubinaemia is a ubiquitous transitional morbidity in the vast majority of newborns and a leading cause of hospitalisation in the first week of life worldwide. While timely and effective phototherapy and exchange transfusion are well proven treatments for severe neonatal hyperbilirubinaemia, inappropriate or ineffective treatment of hyperbilirubinaemia, at secondary and tertiary hospitals, still prevails in many poorly-resourced countries accounting for a disproportionately high burden of bilirubin-induced mortality and long-term morbidity. As part of the efforts to curtail the widely reported risks of frequent but avoidable bilirubin-induced neurologic dysfunction (acute bilirubin encephalopathy (ABE) and kernicterus) in low and middle-income countries (LMICs) with significant resource constraints, this article presents a practical framework for the management of late-preterm and term infants (≥35 weeks of gestation) with clinically significant hyperbilirubinaemia in these countries particularly where local practice guidelines are lacking. Standard and validated protocols were followed in adapting available evidence-based national guidelines on the management of hyperbilirubinaemia through a collaboration among clinicians and experts on newborn jaundice from different world regions. Tasks and resources required for the comprehensive management of infants with or at risk of severe hyperbilirubinaemia at all levels of healthcare delivery are proposed, covering primary prevention, early detection, diagnosis, monitoring, treatment, and follow-up. Additionally, actionable treatment or referral levels for phototherapy and exchange transfusion are proposed within the context of several confounding factors such as widespread exclusive breastfeeding, infections, blood group incompatibilities and G6PD deficiency, which place infants at high risk of severe hyperbilirubinaemia and bilirubin-induced neurologic dysfunction in LMICs, as well as the limited facilities for clinical investigations and inconsistent functionality of available phototherapy devices. The need to adjust these levels as appropriate depending on the available facilities in each clinical setting and the risk profile of the infant is emphasised with a view to avoiding over-treatment or under-treatment. These recommendations should serve as a valuable reference material for health workers, guide the development of contextually-relevant national guidelines in each LMIC, as well as facilitate effective advocacy and mobilisation of requisite resources for the optimal care of infants with hyperbilirubinaemia at all levels.

Moving beyond prevalence studies: screening and interventions for children with disabilities in low-income and middle-income countries

Research understanding the lives of children with disabilities in low-income and middle-income countries has predominantly focused on prevalence studies with little progress on evidence-based service development. At the same time, global attention in child health has shifted from child survival strategies to those that bring child survival and development together. This review examines whether intervention research can be better aligned with current theoretical constructs of disability and international guidelines that advocate for the realisation of rights for children with disabilities and inclusive early childhood development.

Assessment of neurodisability and malnutrition in children in Africa

Neurodevelopmental delay, neurodisability, and malnutrition interact to contribute a significant burden of disease in global settings. Assessments which are well integrated with plans of management or advice are most likely to improve outcomes. Assessment tools used in clinical research and programming to evaluate outcomes include developmental and cognitive tools that vary in complexity, sensitivity, and validity as well as the target age of assessment. Few tools have been used to measure socioemotional outcomes and fewer to assess the disabled child with malnutrition. There is a paucity of tools used clinically which actually provide families and professionals with advice to improve outcomes. Brain imaging, electroencephalography, audiology, and visual assessment can also be used to assess the effect of malnutrition on brain structure and function. The interaction of neurodisability and malnutrition is powerful, and both need to be considered when assessing children. Without an integrated approach to assessment and management, we will not support children and families to reach their best potential outcomes.

Avaliação da implementação de uma intervenção educativa em vigilância do desenvolvimento infantil com enfermeiros

Esta pesquisa teve como objetivo avaliar as dificuldades e facilidades enfrentadas por enfermeiros da Estratégia de Saúde da Família durante o processo de implementação de uma intervenção educativa em vigilância do desenvolvimento infantil. A abordagem utilizada foi qualitativa, com onze enfermeiros que participaram de oficinas de capacitação em vigilância do desenvolvimento no contexto da Atenção Integrada às Doenças Prevalentes na Infância. Os dados foram coletados nos meses de maio e junho de 2009 e analisados a partir do método de análise de conteúdo, utilizando-se a modalidade temática. Foram identificados quatro núcleos temáticos: avaliação do Curso de capacitação em vigilância do desenvolvimento infantil; pontos dificultadores para aplicar os conhecimentos adquiridos; pontos facilitadores proporcionados pelo curso e transformação da prática a partir dos conhecimentos adquiridos na capacitação. Destaca-se a premência de incorporar conteúdos que priorizem questões voltadas para a vigilância do desenvolvimento infantil no ensino de graduação em enfermagem e na residência em saúde da família.

Choosing the best child assessment instrument for a specific context: a methodology for engaging local experts applied in Chile

OBJECTIVE

Chile is considering expanding its system for early childhood development to include 5- to 7-year olds, but it has no consensus about how to identify at-risk children. This study facilitated a process for incorporating local priorities and best practices to choose a child assessment instrument.

METHODS

Using the priority-setting method of the Child Health and Nutrition Research Initiative (CHNRI), 21 Chilean experts defined and weighted ideal assessment instrument characteristics; 130 instruments were scored according to how closely they matched experts' ideal definitions. Instruments were ranked by score under different inclusion criteria.

RESULTS

Experts weighted instrument quality highest (95 on 1-100 scale), followed by administration site (87), domains assessed (82), cost (80), administrator (76), Spanish version (75), time (75), and prior use in Chile (53). Experts agreed that an ideal instrument (1) would reliably assess language, socioemotional well-being, mental health, and parenting abilities, (2) could be administered at schools or home, and (3) could be administered by teachers or parents. No single instrument matched all Chilean priorities. Three instruments met 11 of 13 priorities (age; quality; administration at school, home, or waiting rooms; assess language and socioemotional domains; administered by teachers, parents, or psychologists; time ≤30 minutes). Including mental health or parenting abilities ranked instruments whose composite scores were 35% lower.

CONCLUSION

Decisions about how to assess children at developmental risk should be informed by local context. The CHNRI method provided a useful process that made explicit mutually exclusive priorities, quantified trade-offs of different assessment strategies, and identified 3 of the instruments that best met local needs and priorities.

Priorities for early childhood development in low-income countries

The remarkable progress in reducing child mortality in low-income countries is now accompanied with a rapidly expanding population of child survivors and increased life expectancy. However, many have special health care needs in the early foundational years for optimal health and educational and vocational status. Investment in early childhood development (ECD) is therefore crucial but likely to be constrained by lack of adequate resources making priority-setting inevitable. A review of current ECD approaches in sub-Saharan Africa and South Asia shows that concerted multidisciplinary and cross-sectoral initiatives targeted at children with developmental disabilities across all crucial domains of ECD and guided by available evidence on optimal timing for interventions are urgently required. This focus would necessitate appropriate national ECD policies, modifications to the current global ECD programs in the developing world, and a more active collaboration between pediatricians and other related service providers.

Trial of a developmental screening tool in remote Australian Aboriginal communities: a cautionary tale

AIM

To trial the Brigance developmental screening tool as an instrument for identifying Australian Aboriginal children at risk of developmental disability and requiring diagnostic developmental assessment.

METHODS

We conducted a cross-sectional study of Australian Aboriginal children, aged 3-7 years, resident in three remote communities in the Northern Territory. Following informed consent, children were screened by a paediatrician using the Brigance screen.

RESULTS

There were 195 children identified as eligible, and 124 (64%) participated. All children screened, scored below the cut-off for detecting children likely to have developmental disabilities or academic delays. Furthermore, all children scored below the at-risk cut-offs that indicate high probability of disabilities in at-risk children.

CONCLUSIONS

The Brigance screen identified all children in these high-risk Aboriginal communities as well behind their age peers. Language and cultural relevance, and the method of administration limit the use of this screening tool. However, we cannot ignore the uniformly poor performance on a mainstream tool used with children expected to succeed in a mainstream educational setting. Recommendations include adapting an appropriate instrument to guide developmental surveillance and monitoring in remote Australian Aboriginal communities. This study further supports the pressing need for quality early childhood services that address the significant risk confronting Aboriginal children and prepare them in a way that ensures school and future success.