Maternal alcohol use and children's emotional and cognitive outcomes in rural South Africa

Associations between parental adherence to healthy lifestyles and cognitive performance in offspring: A prospective cohort study in China

BACKGROUND

Previous studies have reported associations of specific maternal and paternal lifestyle factors with offspring's cognitive development during early childhood. This study aimed to investigate the prospective associations between overall parental lifestyle and offspring's cognitive performance during adolescence and young adulthood in China.

METHODS

We included 2531 adolescents aged 10-15 years at baseline in 2010 from the China Family Panel Studies. A healthy parental lifestyle score (ranged 0-5) was constructed based on the following five modifiable lifestyle factors: Smoking, drinking, exercise, sleep, and diet. Generalized estimating equation models were used to examine the association between baseline parental healthy lifestyle scores and offspring's fluid and crystallized intelligence in subsequent years (2012, 2014, 2016, and 2018).

RESULTS

Offspring in the top tertile of parental healthy lifestyle scores performed better in overall fluid intelligence (multivariable-adjusted β = 0.53, 95% confidence interval [CI]: 0.29-0.77) and overall crystallized intelligence (multivariable-adjusted β = 0.35, 95% CI: 0.16-0.54) than those in the bottom tertile of parental healthy lifestyle scores. The results were similar after further adjustment for the offspring's healthy lifestyle scores and persisted across the subgroups of parental socioeconomic status. Additionally, maternal and paternal healthy lifestyle scores were independently associated with better offspring's cognitive performance, with significant contribution observed for paternal never-smoking, weekly exercise, and diversified diet. When both parents and offspring adhered to a healthier lifestyle, we observed the highest level of the offspring's overall crystallized intelligence.

CONCLUSIONS

Our study indicates that parental adherence to a healthier lifestyle is associated with significantly better offspring's cognitive performance during adolescence and early adulthood, regardless of socioeconomic status. These findings highlight the potential cognitive benefits of promoting healthy lifestyles among parents of adolescents.

Are Social Vulnerability and Family Social Support Associated with Children's Psychiatric Symptoms?

Social influence can shape early childhood at different levels. We explored the association between social vulnerability and lifetime caregiver alcohol use with children's psychiatric symptoms. Multivariable logistic regression assessed the association between child psychiatric symptoms and social vulnerability among 1275 preschool child-caregiver pairs with lifetime caregiver alcohol used as a control variable. Of the children, 15.78% (95% CI 15.17-16.42) had internalizing symptoms, 2.49% (95% CI 2.19-2.83) had externalizing symptoms, and 9.36% (95% CI 8.88-9.86) had internalizing/externalizing symptoms. High social vulnerability was positively correlated with internalizing (aRRR 1.54; 95% CI 1.41-1.68) and internalizing/externalizing symptoms (aRRR 1.77; 95% CI 1.58-2.00). Low family support was strongly associated with internalizing/externalizing symptoms (aRRR 2.60; 95% CI 2.20-3.10). Lifetime caregiver alcohol use was positively correlated with all three psychiatric symptoms (aRRR 1.33; 95% CI 1.18-1.51; aRRR 1.13; 95% CI 1.06-1.59; and aRRR 1.26; 95% CI 1.12-1.42). Their association with children's mental health outcomes calls for social policy changes at the macrosystem level.

Association between caregiver and household alcohol use and child behavior problems in KwaZulu Natal, South Africa

We explored the association between household alcohol use and behavior problems among South-African children, using data from the Asenze study, a population-based cohort of South African children and their caregivers. Household alcohol use and child behavior were assessed when children were 6-8 years old. To examine the association, we performed linear regressions. The sample included 1383 children with complete data under the care of 1251 adults. Children living in a household where self-reported caregiver alcohol use was scored as hazardous (4.6%) had higher levels of problem behavior (β = 1.94, 95% CI 0.06-3.82). There were no statistically significant associations between reported hazardous alcohol use by another member of the household (14.5%) and child problem behavior. Hazardous household alcohol use was associated with child problem behavior and this effect appeared to be mainly driven by primary caregiver use.

Investigating blood alcohol concentrations in injury-related deaths before and during the COVID-19 National lockdown in Western Cape, South Africa: A cross-sectional retrospective review

BACKGROUND

Alcohol is a significant contributor to injury-related morbidity and mortality in South Africa (SA).  During the COVID-19 global pandemic, restrictions to movement and to the legal access of alcohol* were introduced in SA.  This study aimed to investigate the effect of alcohol bans during the COVID-19 lockdown periods on injury-related mortality and the blood alcohol concentrations (BAC) in these deaths.

METHODS

A retrospective, cross-sectional analysis of injury-related deaths in Western Cape (WC) province, SA, between 1 January 2019 to 31 December 2020 was conducted. Cases where BAC testing was performed were further examined according to the periods of lockdown (AL5-1) and alcohol restrictions.

RESULTS

A total of 16,027 injury-related cases were admitted to Forensic Pathology Service mortuaries in the WC over the two-year period.  An average decrease of 15.7% injury-related deaths in 2020 compared to 2019 was noted, as well as a 47.7% decrease in injury-related deaths during hard lockdown (April -May 2020) compared to the same period in 2019. In the injury-related deaths, 12,077 (75.4%) had blood specimens collected for BAC testing. In 5,078 (42.0%) of submitted cases, a positive BAC (≥0.01g/100 mL) was reported. No significant difference was observed in the mean positive BAC between 2019 and 2020, however in April and May 2020, the mean BACs observed (0.13 g/100 mL) was less than that in 2019 (0.18 g/100 mL). A high number of positive BACs in the 12-17-year age group (±23.4%) was observed.

CONCLUSION

There was a clear decrease in injury-related deaths in the WC during the COVID-19-related lockdown periods that coincided with the alcohol ban and restriction of movement and an increase following relaxation of restrictions on alcohol sales and movement. The data illustrated that mean BACs were similar between all periods of alcohol restriction compared to 2019, apart from hard lockdown in April-May, 2020.  This coincided with a smaller mortuary intake during the level 5 and 4 lockdown periods.   Keywords: Alcohol; blood alcohol concentration; COVID-19; injury; lockdown; South Africa; violent death; Western Cape   * Alcohol refers to ethanol.

Maternal depression, alcohol use, and transient effects of perinatal paraprofessional home visiting in South Africa: Eight-year follow-up of a cluster randomized controlled trial

BACKGROUND

South African mothers confront synergistic challenges from depression, alcohol use, and HIV/AIDS. The importance of maternal functioning for child development motivates interventions, yet long-term outcomes seldom are tracked. Furthermore, little is known about trajectories and the role of social-cultural factors in maternal depression and alcohol use across parenthood in low- and middle-income countries.

METHODS

We examined maternal outcomes at 5- and 8-years' post-birth, from the Philani Intervention Program (PIP), a randomized controlled trial of a prenatally-initiated home visiting intervention lasting through 6 months' post-birth which yielded some benefits for children and mothers through 3 years. Longitudinal Bayesian mixed-effects models assessed intervention effects for maternal depression and alcohol use from pre-birth through 8 years post-birth. We plotted trajectories of depression and alcohol use and analyzed their relationship over time.

RESULTS

Maternal benefits appeared limited and intervention outcomes differed at 5 and 8 years. Reduced depression in PIP versus standard care (SC) mothers at 3 years disappeared by 5 and 8 years. Depression prevalence declined from 35.1% prenatally to 5.5% at 8 years, independent of intervention or alcohol use. Alcohol use in both groups rebounded from a post-birth nadir; fewer PIP than SC mothers drank alcohol and reported problematic use at 5 but not 8 years. HIV+ prevalence did not differ by condition and increased from 26% to 45% over the reported period.

CONCLUSIONS

Dissipation of early child benefits from home visiting by age 8 years likely reflects lack of durable change in maternal behaviors compounded by social-cultural factors and cumulative effects of community deprivation. High prenatal rates warrant screening and treatment for depression in standard antenatal care. Low-and-middle income countries may need sustained interventions, including alcohol use reduction, to capitalize on initial gains from targeted interventions and address community social-cultural factors. HIV/AIDS continues to spread in this population.

Food security and diet quality in a racially diverse cohort of postpartum women in the USA

Food insecurity has been associated with poor diet, but few studies focused on the postpartum period - an important time for women's health. We examined associations between food security and diet quality in postpartum women and assessed whether participation in federal food assistance programmes modified this potential relation. Using longitudinal data, we analysed the association between food security at 3 months postpartum and a modified Alternate Healthy Eating Index-2010 (AHEI) at 6 months postpartum (excluding alcohol). We conducted multivariable linear regressions examining associations between food security and AHEI. We assessed two food assistance programmes as potential effect modifiers. The sample included 363 postpartum women from the Nurture study, located in the Southeastern USA (2013-2017). Among women, 64·4 % were Black and 45·7 % had a high school diploma or less. We found no evidence of an interaction between food security and two federal food assistance programmes. In adjusted models, marginal, low and very low food security were not associated with AHEI. However, low (β: -0·64; 95 % CI -1·15, -0·13; P = 0·01) and very low (β: -0·57; 95 % CI -1·02, -0·13; P = 0·01) food security were associated with greater trans fat intake. Food security status was not associated with overall diet quality but was associated with higher trans fat (low and very low) and more moderate alcohol (marginal) intake. Future studies should assess the consistency and generalisability of these findings.

Evaluation of a Physical Activity and Multi-Micronutrient Intervention on Cognitive and Academic Performance in South African Primary Schoolchildren

Executive functions (EFs) are essential for optimal academic development. Appropriate nutrition and physical activity (PA) have been shown to facilitate optimal cognitive development. Therefore, this study examined whether a 12-week school-based PA and multi-micronutrient supplementation (MMNS) intervention would improve cognitive and academic performance. A cluster-randomized controlled trial (RCT) was conducted. Children from four schools located in a peri-urban area of South Africa were randomly assigned to (i) PA + MMNS, (ii) PA + placebo, (iii) MMNS or (iv) placebo. Information processing and inhibitory control were measured with a computerized Flanker task. End-of-year results provided insight into academic achievement. Anthropometric measures were used to determine nutritional status. Data were analyzed with linear mixed-models, adjusting for baseline scores, school classes and age; 932 children (458 girls (49.1%), M_age (mean age) = 8.42 ± 1.94 years) completed baseline and post-intervention assessments. Cognitive performance improved among all four groups, with no significant group × time effects. For academic achievement, there was no significant interaction effect between the combined intervention group and placebo. We encourage future studies in this neglected area in order to determine the most optimal design of school-based nutrition and PA programs to enhance overall cognitive performance.

An evaluation of a combined psychological and parenting intervention for HIV-positive women depressed in the perinatal period, to enhance child development and reduce maternal depression: study protocol for the Insika Yomama cluster randomised controlled trial

BACKGROUND

The combination of poverty, HIV and depression in the perinatal period represents a major public health challenge in many Southern African countries. In some areas, up to a third of HIV-positive women experience perinatal depression. Perinatal depression is associated with negative effects on parenting and key domains of child development including cognitive, behavioural and growth, especially in socio-economically disadvantaged communities. Several studies have documented the benefits of psychological interventions for perinatal depression in low- and middle-income countries, but none have evaluated an integrated psychological and parenting intervention for HIV-positive women using task-sharing. This randomised controlled trial aims to evaluate the effect of a home-based intervention, combining a psychological treatment for depression and a parenting programme for perinatally depressed HIV-positive women.

METHODS

This study is a cluster randomised controlled trial, consisting of 48-60 geospatial clusters. A total of 528 pregnant HIV-positive women aged ≥ 16 years who meet the criteria for depression on the Edinburgh Postnatal Depression Scale (EPDS, score ≥ 9)) are recruited from antenatal clinics in rural KwaZulu-Natal, South Africa. The geospatial clusters are randomised on an allocation ratio of 1:1 to either the intervention or Enhanced Standard of Care (ESoC). The intervention group receives 10 home-based counselling sessions by a lay counsellor (4 antenatal and 6 postnatal sessions) and a booster session at 16 months. The intervention combines behavioural activation for depression with a parenting programme, adapted from the UNICEF/WHO Care for Child Development programme. The ESoC group receives two antenatal and two postnatal counselling support and advice telephone calls. In addition, measures have been taken to enhance the routine standard of care. The co-primary outcomes are child cognitive development at 24 months assessed on the cognitive subscale of the Bayley Scales of Infant Development-Third Edition and maternal depression at 12 months measured by the EPDS.

ANALYSIS

The primary analysis will be a modified intention-to-treat analysis. The primary outcomes will be analysed using mixed-effects linear regression.

DISCUSSION

If this treatment is successful, policymakers could use this model of mental healthcare delivered by lay counsellors within HIV treatment programmes to provide more comprehensive services for families affected by HIV.

TRIAL REGISTRATION

ISRCTN registry # 11284870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).

Maternal emotional and physical intimate partner violence and early child development: investigating mediators in a cross-sectional study in a South African birth cohort

OBJECTIVES

This study investigated associations between recent maternal intimate partner violence (IPV) (emotional, physical and sexual) and child development at 2 years as well as whether maternal depression or alcohol use mediated these relationships.

DESIGN

Cross-sectional study nested in a South African birth cohort.

SETTING

Two primary care clinics in Paarl, South Africa.

PARTICIPANTS

626 mother-child pairs; inclusion criteria for maternal antenatal enrolment were clinic attendance and remaining in the study area for at least 1 year; women were excluded if a minor.

PRIMARY OUTCOME MEASURES

Child cognitive, language and motor development composite scores. These were assessed using the Bayley Scales of Infant and Toddler Development, third edition.

RESULTS

Emotional IPV was associated with lower cognitive (β=-0.32; 95% CI -0.60 to -0.04), language (β=-0.36; 95% CI -0.69 to -0.01) or motor composite scores (β=-0.58; 95% CI -0.95 to -0.20) in children at 2 years of age. Physical IPV was associated with lower motor scores (β=-0.42; 95% CI -0.75 to -0.09) at 2 years. Sexual IPV was unrelated to developmental outcomes, possibly due to low prevalence. Neither recent maternal depression nor alcohol use were shown to mediate the relationship between IPV and developmental outcomes.

CONCLUSIONS

Interventions to reduce maternal physical and emotional IPV and early-life interventions for infants and toddlers are needed to promote optimal child development.

Maternal drinking behaviour and co-exposure from smoking during and after pregnancy in relation to the neurocognitive function of school-children in the rural Western Cape

BACKGROUND

Maternal substance use and its long-term effect on the neurocognitive functions of children is a global public health issue. Despite an increase in substance use in rural areas of low to middle-income countries, research is limited in these populations.

OBJECTIVE

We have therefore explored the effect of maternal drinking and smoking behaviors on the neurocognitive functioning of rural school children.

METHOD

A cross-sectional analysis on the determinants of current, past and gestational maternal alcohol use and gestational smoking on child neurocognitive functions was conducted on school-children (N = 482), embedded within the child health agricultural cohort (CapSA) study across seven schools in rural Western Cape, South Africa. Standardised neurocognitive assessment tools included the Cambridge Automated Neuropsychological Battery (CANTAB) and the KIDSCREEN-10 to measure health-related quality of life via a child questionnaire. Maternal smoking and drinking behaviour were captured using a parent/guardian questionnaire.

RESULTS

Of the 482 parents/guardians who completed the survey, 29 % reported current drinking 27 % reported past drinking and 10 % reported maternal gestational drinking, while 31 % reported gestational smoking. Significant associations were observed between past and current maternal drinking and child's reduced rapid visual processing accuracy in attention [β:-0.03; 95 % confidence interval (CI): -0.05;-0.004] and between maternal drinking during pregnancy and reduced child's spatial working memory (β: -0.59; CI: -1.02; -0.15). Heavy (>5 cigarettes per day) gestational smoking was associated with lowered child's learning in memory (β:-1.69; 95 % CI: -3.05; -0.33) and lower health-related quality of life (β: -3.41; CI: -6.64; -0.17). The odds of a child repeating a grade were 1.69 (CI: 2.81-1.02) for those exposed to maternal gestational smoking and 1.68 (CI: 3.31-0.85) for those exposed to maternal gestational drinking compared to those who were not exposed.

CONCLUSION

The consistent negative associations across all four maternal substance use proxies, six neurocognitive health outcomes and one health symptom is suggestive of adverse health effects, warranting longitudinal follow-up. Health policies to eliminate gestational substance use are recommended.

Executive Function After Prenatal Alcohol Exposure in Children in a South African Population: Cross-sectional Study

Background

Alcohol is a teratogen; its consumption during pregnancy can lead to negative birth outcomes, collectively referred to as fetal alcohol spectrum disorders. Neurodevelopmental delays in higher-order cognitive functions that affect development of executive functions are a common feature. Studies on executive function in children have focused on children diagnosed with fetal alcohol spectrum disorder, and there is a lack of information on the impact on children not diagnosed with fetal alcohol spectrum disorder but who had been exposed to alcohol.

Objective

The aim of this study was to compare the development of executive function in children between 4 and 6 years of age with and without prenatal exposure to alcohol.

Methods

Children both exposed and not exposed to alcohol were recruited as part of a feasibility RCT evaluating a computer-based cognitive training program for improving executive function development. The study was conducted in a low–socioeconomic status community in South Africa with a high prevalence of fetal alcohol spectrum disorder. Neurodevelopment was assessed in participating children; NEPSY-II standardized scores for executive function domains were compared using a multivariate analysis of variance with group membership as the predictor variable.

Results

No significant differences in executive functions assessments (P=.39) were found between children in the alcohol-exposed group (n=76) and those in the nonexposed group (n=40). Both groups showed moderate to severe delays in domains. In all but one subtest, the average score for both groups was below the 25th percentile of expected norms.

Conclusions

We expected that alcohol exposure would have a measurable impact on executive function development. The lack of differences highlights the prevalence of developmental delays in low–socioeconomic status communities in South Africa and suggests that children are exposed to various threats to cognitive development.

International Registered Report Identifier (IRRID)

RR2-10.2196/14489

A Systematic Review of Household and Family Alcohol Use and Childhood Neurodevelopmental Outcomes in Low- and Middle-Income Countries

Childhood exposure to alcohol misuse by household adults has been related to childhood developmental delay, cognitive impacts, mental illness, and problem behaviours. Most evidence comes from high income countries. This systematic review only included studies from low- and middle-income countries (LMICs). Five databases were searched from 1990-2020. Twenty-eight studies of children 0-12 years were included, with 42,599 participants from 11 LMICs. The most common outcome was behavioural problems/disorders (19 studies). Despite varying study designs, this review found that alcohol misuse by household members in LMICs is associated with adverse child neurodevelopmental outcomes, although casual inferences cannot be drawn in the absence of well conducted prospective studies. Statistically significant correlations were described between parental alcohol misuse and child emotional and behavioural difficulties, cognitive delay, and risky behaviours. In future, prospective cohort studies are recommended, with adjustment for confounders.