Undernourished children have different temperaments than better-nourished children in rural Bangladesh

Neurodevelopmental, cognitive, behavioural and mental health impairments following childhood malnutrition: a systematic review

BACKGROUND

Severe childhood malnutrition impairs growth and development short-term, but current understanding of long-term outcomes is limited. We aimed to identify studies assessing neurodevelopmental, cognitive, behavioural and mental health outcomes following childhood malnutrition.

METHODS

We systematically searched MEDLINE, EMBASE, Global Health and PsycINFO for studies assessing these outcomes in those exposed to childhood malnutrition in low-income and middle-income settings. We included studies assessing undernutrition measured by low mid-upper arm circumference, weight-for-height, weight-for-age or nutritional oedema. We used guidelines for synthesis of results without meta-analysis to analyse three outcome areas: neurodevelopment, cognition/academic achievement, behaviour/mental health.

RESULTS

We identified 30 studies, including some long-term cohorts reporting outcomes through to adulthood. There is strong evidence that malnutrition in childhood negatively impacts neurodevelopment based on high-quality studies using validated neurodevelopmental assessment tools. There is also strong evidence that malnutrition impairs academic achievement with agreement across seven studies investigating this outcome. Eight of 11 studies showed an association between childhood malnutrition and impaired cognition. This moderate evidence is limited by some studies failing to measure important confounders such as socioeconomic status. Five of 7 studies found a difference in behavioural assessment scores in those exposed to childhood malnutrition compared with controls but this moderate evidence is similarly limited by unmeasured confounders. Mental health impacts were difficult to ascertain due to few studies with mixed results.

CONCLUSIONS

Childhood malnutrition is associated with impaired neurodevelopment, academic achievement, cognition and behavioural problems but evidence regarding possible mental health impacts is inconclusive. Future research should explore the interplay of childhood and later-life adversities on these outcomes. While evidence on improving nutritional and clinical therapies to reduce long-term risks is also needed, preventing and eliminating child malnutrition is likely to be the best way of preventing long-term neurocognitive harms.

PROSPERO REGISTRATION NUMBER

CRD42021260498.

Malnutrition in early life and its neurodevelopmental and cognitive consequences: a scoping review

The negative impact of stunting and severe underweight on cognitive neurodevelopment of children is well documented; however, the effect of overweight/obesity is still unclear. The 2018 Global Nutrition Report reported that stunting and overweight concurrently affect 189 million children worldwide. As existing reviews discuss undernutrition and overweight/obesity separately, this scoping review aims to document the impact of mild/moderate and severe underweight, stunting, and overweight/obesity among children aged 0-60 months on their cognitive neurodevelopmental trajectories. Twenty-six articles were analysed to extract significant information from literature retrieved from PubMed and Cochrane databases published from 1 January 2009 to 31 October 2019. Length gain is associated with cognitive neurodevelopment in normo-nourished and stunted children aged under 24 months. Among stunted children, it seems that cognitive and neurodevelopmental deficits can potentially be recovered before 8 years of age, particularly in those whose nutritional status has improved. The impact of overweight/obesity on cognitive neurodevelopment appears to be limited to attention, gross motor skills and executive control. Parental education level, birth weight/length, breastfeeding duration, and sanitation level are some identifiable factors that modify the impact of undernutrition and overweight/obesity on cognitive and neurodevelopment. In conclusion, underweight, stunting and overweight/obesity have a significant impact on cognitive neurodevelopment. Multidimensional approaches with various stakeholders should address all issues simultaneously, such as improving sanitation levels, assuring parental job security and adequate social welfare, and providing access to adequate nutrients for catch-up growth among underweight or stunted children and to affordable healthy foods for those who are overweight/obese and from low socio-economic status.

The Benefits and Risks of Iron interventionS in Children (BRISC) trial: Statistical analysis plan

Background: The Benefits and Risks of Iron interventionS in Children (BRISC) trial will evaluate the impact of universal supplementation with iron supplements or iron-containing multiple micronutrient powders (MNPs) compared with placebo given for 3 months on child development, growth, morbidity, laboratory indices of anaemia, iron deficiency, and inflammation at end of intervention and after a further 9 months post intervention in children aged 8 months living in rural Bangladesh. This paper describes the statistical analysis plan. Methods: BRISC is a multi-site, three-arm, double-dummy blinded, parallel group, randomised control superiority trial in 3300 children. The statistical analysis plan was developed by the trial statistician in consultation with the trial steering committee and trial management committee based on the protocol, data collection forms, and study outcomes available in the blinded study database.   Conclusion: This detailed statistical analysis plan published prior to unblinding the allocated treatments will support the statistical analyses and reporting of the BRISC trial to be undertaken after unblinding. It allows for transparency as well as reproducibility of statistical analyses and reporting. Registration: Australian New Zealand Clinical Trials Registry ACTRN12617000660381 (registered on 8 May 2017); World Health Organization Universal Trial Number U1111-1196-1125.

Association of vitamin D nutrition with neuro-developmental outcome of infants of slums in Bangladesh

The association of vitamin D with neuro-behavioral outcomes of young children is unclear, particularly of those who reside in tropical countries and are otherwise exposed to adequate sun light. To investigate this association, we analysed the existing data of poor infants, who participated in an observational, prospective-cohort (MalED) study, conducted in a slum of Dhaka-city. We assessed 265 infants aged 6–8 months for cognitive, motor, language and behavior development using Bayley-III. Information about infants’ temperament and communicative skills were provided by the mothers through a culturally modified “temperament-scale” and a “communicative-developmental inventory”. Serum concentration of vitamin D [25(OH)D] was measured in 205 infants. Around 28.3% of infants in this community had low level vitamin D, with the cut-off at <50 nmol/L. After controlling for all possible covariates, a multivariable-adjusted linear regression showed that children with vitamin D levels <50 nmol/L had significantly lower scores in two dimensions of temperament: activity (B±SE 1.64±0.78; 95%CI 0.10, 3.18; p = 0.037; effect size 0.37 SDs) and soothabilty (2.02±0.70; 0.64, 3.41; p = 0.004; 0.53 SDs), compared to children with vitamin D levels of ≥50nmol/L. These infants also scored low in word comprehensions (1.28±0.62; 0.05, 2.51; p = 0.042; 0.23 SDs) and were less active during test-procedures (0.33±0.16; 0.02, 0.64; p = 0.035; 0.27 SDs). Both the groups tested similarly in cognitive and motor scores. This study found, despite adequate sunlight-exposure, one in four infants of this slum-community are suffering from a subclinical vitamin D deficiency. Higher levels of vitamin D in these infants showed a positive association with temperament, language and behavior but not with cognitive and motor development. Our findings highlight the early-detected extra-skeletal neuro-behavioral role of vitamin D. Future studies in this area will give more insight.

The Neonatal Eating Assessment Tool: Development and Content Validation

PURPOSE

To develop and content validate the Neonatal Eating Assessment Tool (NeoEAT), a parent-report measure of infant feeding.

DESIGN

The NeoEAT was developed in three phases. Phase 1: Items were generated from a literature review, available assessment tools, and parents' descriptions of problematic feeding in infants.Phase 2: Professionals rated items for relevance and clarity. Content validity indices were calculated. Phase 3: Parent understanding was explored through cognitive interviews.

SAMPLE

Phase 1: Descriptions of infant feeding were obtained from 12 parents of children with diagnosed feeding problems and 29 parents of infants younger than seven months. Phase 2: Nine professionals rated items. Phase 3: Sixteen parents of infants younger than seven months completed the cognitive interview.

MAIN OUTCOME VARIABLE

Content validity of the NeoEAT.

RESULTS

Three versions were developed: NeoEAT Breastfeeding (72 items), NeoEAT Bottle Feeding (74 items), and NeoEAT Breastfeeding and Bottle Feeding (89 items).

Child stunting is associated with weaker human capital among native Amazonians

OBJECTIVES

We assessed associations between child stunting, recovery, and faltering with schooling and human capital skills in a native Amazonian society of horticulturalists-foragers (Tsimane').

METHODS

We used cross-sectional data (2008) from 1262 children aged 6 to 16 years in 53 villages to assess contemporaneous associations between three height categories: stunted (height-for-age Z score, HAZ<-2), moderately stunted (-2 ≤ HAZ≤-1), and nonstunted (HAZ>-1), and three categories of human capital: completed grades of schooling, test-based academic skills (math, reading, writing), and local plant knowledge. We used annual longitudinal data (2002-2010) from all children (n = 853) in 13 villages to estimate the association between changes in height categories between the first and last years of measure and schooling and academic skills.

RESULTS

Stunting was associated with 0.4 fewer completed grades of schooling (∼24% less) and with 13-15% lower probability of showing any writing or math skills. Moderate stunting was associated with ∼20% lower scores in local plant knowledge and 9% lower probability of showing writing skills, but was not associated with schooling or math and writing skills. Compared with nonstunted children, children who became stunted had 18-21% and 15-21% lower probabilities of showing math and writing skills, and stunted children had 0.4 fewer completed grades of schooling. Stunted children who recovered showed human capital outcomes that were indistinguishable from nonstunted children.

CONCLUSIONS

The results confirm adverse associations between child stunting and human capital skills. Predictors of growth recovery and faltering can affect human capital outcomes, even in a remote, economically self-sufficient society.

Could nutrition help behaviours associated with personality disorders? A narrative review

Personality disorders are common, and the core problems of interpersonal dysfunction and social disturbance are difficult to treat. One area gaining international attention is the impact that diet and nutrients can have on psychiatric/psychological symptoms. There are no empirical studies studying the specific relationship between nutrition and personality disorders. A systematic search revealed longitudinal studies following malnourished children, either during pregnancy or in early life that reported malnourishment is a risk factor that can express as maladaptive behaviours later in life. Other studies show associations between nutrient intake and personality styles. A small body of literature reveals a potential benefit of consuming nutrients therapeutically in order to address behaviours often associated with personality disorders. If we consider the broad patterns of behaviour that typify personality disorders, such as cognition, affectivity, interpersonal functioning and impulse control, there is a research rationale for studying the role that nutrition could play in protecting against the development of these problems as well as possibly modifying them. Whether it is too late to intervene with nutrition once the pathological behaviours are entrenched is unknown. Given the dearth of good evidence-based treatments currently available for people with personality disorders, it is an area worth investing in.

The role of zinc and iron-folic acid supplementation on early child temperament and eating behaviors in rural Nepal: a randomized controlled trial

Child eating behaviors play an important role in nutrient intake, ultimately affecting child growth and later outcomes in adulthood. The study assessed the effects of iron-folic acid and zinc supplementation on child temperament and child eating behaviors in rural Nepal. Children (N = 569) aged 4–17 months in Sarlahi district, southern Nepal were randomized to receive daily supplements of placebo, iron-folic acid, zinc, or zinc plus iron-folic acid and followed for approximately 1 year. At baseline and four follow-up visits mothers completed questionnaires including information on demographic characteristics and child temperament and eating behaviors. The main effects of zinc and iron-folic acid supplementation on temperament and eating behaviors were assessed through crude and adjusted differences in mean cumulative score changes between visits 1 and 5. The adjusted rate-of-change for these outcomes was modeled using generalized estimating equations. Mean changes in temperament scores and in eating behavior scores between visits 1 and 5 were not significant in either the zinc or non-zinc group. Children in the iron-folic acid group increased temperament scores by 0.37 points over 5 visits (95% CI 0.02, 0.7), which was not significant after adjustment. Neither the adjusted rate-of-change in temperament scores between zinc and non-zinc (β = −0.03, 95% CI −0.3, 0.2) or iron-folic acid and non-iron-folic acid (β = 0.08, 95% CI −0.2, 0.3) were significantly different. Adjusted rate of change analysis showed no significant difference between zinc and non-zinc (β = −0.14, 95% CI −0.3, 0.04) or between iron and non-iron eating behavior scores (β = −0.11, 95% CI −0.3, 0.1). Only among children with iron-deficiency anemia at baseline was there a significant decrease in eating behavior score, indicating better eating behaviors, when supplemented with zinc (β = −0.3, 95% CI −0.6, −0.01), Ultimately, this effect of zinc on eating behaviors was the only effect we observed after approximately one year of micronutrient supplementation.

Association of cord blood levels of lead, arsenic, and zinc and home environment with children neurodevelopment at 36 months living in Chitwan Valley, Nepal

Background

Inconsistent results continue to be reported from studies linking low-level prenatal lead exposure and child development. Because of limited earlier epidemiological studies with birth cohort follow up design, it still remains inconclusive that either the associations of cord blood level of toxic, and essential elements, and postnatal raising environment on neurodevelopment of children remains constant throughout childhood or change over time.

Aims

This study aims to investigate the influence of in utero toxic [lead (Pb) and arsenic (As)] and essential elements [zinc (Zn)] levels on neurodevelopment of 36 months children in Chitwan valley, Nepal taking the postnatal environment into account.

Study Designs and Subjects

In this birth cohort study, participants (N=100 mother-infants’ pairs) were recruited in Chitwan district, Nepal. We measured Pb, As and Zn concentrations in cord blood. Postnatal raising environment (i.e., Home score or home environment hereafter) was evaluated using Home Observation for Measurement of Environment (HOME) scale. Neurodevelopment of children at 36 months of age (n=70) were assessed using Bayley Scale of Infant Development, Second Edition (BSID II). Multivariate regression was performed (n=70) to see the association of in utero toxic and essential elements level and home environment with neurodevelopment score adjusted for covariates.

Results

Cord blood levels of Pb, As and Zn were not associated with any BSID II cluster scores of 36 months children. The children with relatively superior HOME score and concurrent nutritional status (weight at 36 months) showed better cognitive development (i.e., MDI scores) and motor functions than their counterparts, respectively.

Conclusion

In this general population in Nepal, prenatal Pb, As and Zn levels are not important determinants of the neurodevelopment of 36- month-old children while a consistent beneficial effect of a stimulating home environment on neurodevelopmental indicators is continued.

A practical approach to classifying and managing feeding difficulties

Many young children are thought by their parents to eat poorly. Although the majority of these children are mildly affected, a small percentage have a serious feeding disorder. Nevertheless, even mildly affected children whose anxious parents adopt inappropriate feeding practices may experience consequences. Therefore, pediatricians must take all parental concerns seriously and offer appropriate guidance. This requires a workable classification of feeding problems and a systematic approach. The classification and approach we describe incorporate more recent considerations by specialists, both medical and psychological. In our model, children are categorized under the 3 principal eating behaviors that concern parents: limited appetite, selective intake, and fear of feeding. Each category includes a range from normal (misperceived) to severe (behavioral and organic). The feeding styles of caregivers (responsive, controlling, indulgent, and neglectful) are also incorporated. The objective is to allow the physician to efficiently sort out the wide variety of conditions, categorize them for therapy, and where necessary refer to specialists in the field.

Home environment and cord blood levels of lead, arsenic, and zinc on neurodevelopment of 24 months children living in Chitwan Valley, Nepal

In a birth cohort living in Chitwan Valley, lowland Nepal, we have previously reported inverse associations between in utero levels of lead (Pb), arsenic (As) and neurodevelopment at birth measured by the Brazelton Neonatal Behavioral Assessment Scale, third edition (NBAS III). In the present paper, a follow-up of the same cohort was made on 24-month-old infants regarding the neurodevelopmental effects of these metals, taking the postnatal environment into account. In total, the same100 mother-infant pairs as the previous study, whose Pb, As, and Zn concentrations in cord blood were known, were recruited. Postnatal raising environment was evaluated using the Home Observation for Measurement of Environment (HOME) scale. Neurodevelopment of children at 24 months of age (n=74) was assessed using the Bayley Scale of Infant Development, Second Edition (BSID II). Multivariable regression adjusting for covariates was performed to determine the associations of in utero levels of toxic and essential elements and the home environment with neurodevelopment scores. Unlike the NBAS III conducted for newborns, none of the BSID II cluster scores in 24-month-old infants were associated with cord blood levels of Pb, As, and Zn. The total HOME score was positively associated with the mental development scale (MDI) score (coefficient=0.67, at 95% CI=0.03 to 1.31). In this cohort, a detrimental effect of in utero Pb and As on neurodevelopmental indicators observed at birth disappeared at 24 months, while an association between neurodevelopment and home environment continued.

The domestic piglet: an important model for investigating the neurodevelopmental consequences of early life insults

Insults in the prenatal and early postnatal period increase the risk for behavioral problems later in life. One hypothesis is that pre- and postnatal stressors influence structural and functional brain plasticity. Understanding the mechanisms is important, but progress has lagged because certain studies in human infants are impossible, while others are extremely difficult. Furthermore, results from popular rodent models are difficult to translate to human infants owing to the substantial differences in brain development and morphology. Because it overcomes some of these obstacles, the domestic piglet has emerged as an important model. Piglets have a gyrencephalic brain that develops similar to the human brain and that can be assessed in vivo by using clinical-grade neuroimaging instruments. Furthermore, owing to their precocial nature, piglets can be weaned at birth and used in behavioral testing paradigms to assess cognitive behavior at an early age. Thus, the domestic piglet represents an important translational model for investigating the neurodevelopmental consequences of early life insults.

A neonatal piglet model for investigating brain and cognitive development in small for gestational age human infants

The piglet was investigated as a potential model for studying brain and cognitive deficits associated with being born small for gestational age (SGA). Naturally farrowed SGA (0.7-1.0 kg BW) and average for gestational age (AGA, 1.3-1.6 kg BW) piglets were obtained on postnatal day (PD) 2, placed in individual cages, and provided a nutritionally adequate milk replacer diet (285 ml/kg/d). Beginning at PD14, performance in a spatial T-maze task was assessed. At PD28, piglets were anesthetized for magnetic resonance (MR) imaging to assess brain structure (voxel-based morphometry), connectivity (diffusion-tensor imaging) and metabolites in the hippocampus and corpus callosum (proton MR spectroscopy). Piglets born SGA showed compensatory growth such that BW of SGA and AGA piglets was similar (P>0.05), by PD15. Birth weight affected maze performance, with SGA piglets taking longer to reach criterion than AGA piglets (p<0.01). Total brain volume of SGA and AGA piglets was similar (P<0.05), but overall, SGA piglets had less gray matter than AGA piglets (p<0.01) and tended to have a smaller internal capsule (p = 0.07). Group comparisons between SGA and AGA piglets defined 9 areas (≥ 20 clusters) where SGA piglets had less white matter (p<0.01); 2 areas where SGA piglets had more white matter (p<0.01); and 3 areas where SGA piglets had more gray matter (p<0.01). The impact of being born SGA on white matter was supported by a lower (p<0.04) fractional anisotropy value for SGA piglets, suggesting reduced white matter development and connectivity. None of the metabolites measured were different between groups. Collectively, the results show that SGA piglets have spatial learning deficits and abnormal development of white matter. As learning deficits and abnormalities in white matter are common in SGA human infants, the piglet is a tractable translational model that can be used to investigate SGA-associated cognitive deficits and potential interventions.

Infant responsiveness, alertness, haemoglobin and growth in rural Sidama, Ethiopia

Several recent studies have supported relations between infant behaviour (alertness and responsiveness) and nutrition in addition to investigating infant behaviour within the context of changes in iron status over time. Existing research is typically limited to the investigation of the effects of a single vitamin or mineral, and no studies have been found that examined the influence that early alertness and responsiveness have on growth in early infancy, despite the fact that relations between behaviour and nutritional status may be bidirectional. The current study used a sample of Ethiopian infants and investigated anthropometrics, haemoglobin, the frequency of alertness and the frequency of responsiveness at 6 and 9 months of age. Six-month weight-for-age predicted 9-month frequency of alertness, while 6-month haemoglobin predicted 9-month frequency of responsiveness. Compared with responsive infants, non-responsive infants at 6 months remained more non-responsive at 9 months, although weight-for-age for both groups converged at 9 months. Results support relations between nutrition and behaviour (alertness and responsiveness) and provide evidence of a potentially useful tool (the Laboratory Temperament Assessment Battery) that was adapted to evaluate these relations in Ethiopia.

Malnutrition in the first year of life and personality at age 40

BACKGROUND

Early childhood malnutrition is associated with cognitive and behavioral impairment during childhood and adolescence, but studies in adulthood are limited.

METHODS

Using the NEO-PI-R personality inventory, we compared personality profiles at 37-43 years of age (M 40.3 years, SD 1.9) of Barbadian adults who had experienced moderate-to-severe protein-energy malnutrition (PEM) in the first year of life (n = 77) with healthy controls, who were former classmates of the index cases and were matched for age, gender, and handedness in childhood (n = 57). The previously malnourished participants had been rehabilitated, with good health and nutrition documented up to 12 years of age, and study participants were followed longitudinally from childhood to 40 years. Group comparisons were adjusted for childhood and adolescent standard of living, with and without correcting for IQ.

RESULTS

At the broad domain or factor level, previously malnourished participants had higher scores on Neuroticism and lower scores on Extraversion, Openness, Agreeableness, and Conscientiousness than did the healthy controls. At the subdomain or facet level, previously malnourished participants reported more anxiety, vulnerability, shyness and lowered sociability, less intellectual curiosity, greater suspiciousness of others, a more egocentric than altruistic orientation, and a lowered sense of efficacy or competence.

CONCLUSIONS

Malnutrition limited to the first year of life with good health and nutrition documented up to 12 years of age is associated with a significant overrepresentation of adult personality trait scores outside of the average range. This outcome has important implications for a variety of important life and mental health outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSION

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

Child patterns of growth delay and cognitive development in a Bolivian mining city

OBJECTIVES

This study aims to (1) follow up and characterize infant growth patterns during the first year of life in Bolivia, and (2) determine whether there exists an association between weight gain and cognitive development in children living near contaminated mining industries.

METHODS

Data on 175 children participating to the ToxBol (Toxicity in Bolivia) birth cohort were analyzed. Rapid-growth during the first 6 months was defined as a change in weight z-score > 0.67 while slow-growth was defined as a weight z-score change of < -0.67. Neurodevelopment was evaluated using the Bayley Scales of Infant Development at 10.5-12.5 months of age. Mixed models were used to examine the association between cognitive development and weight gain.

RESULTS

Rapid growers weighed less at birth (P < 0.01). However, they revealed a higher body mass index at 12 months of age (0.70 ± 0.73, P < 0.01). After adjustment for confounding, rapid growth was not associated with cognitive development (coef = 0.49, 95% confidence interval = -4.10, 5.08).

CONCLUSIONS

In this Bolivian cohort, children born smaller were more likely to grow/develop faster and attain greater weight and length. Their cognitive development was not affected by their growth patterns.