Factors associated with children's cognitive, language, and motor development in deprived urban settings in Bangladesh

BACKGROUND

Children's development is multifactorial. Although there have been several studies exploring the association of children's development with maternal, child, and environmental factors, we are unaware of any study that assessed those factors in children whose mothers were enrolled in a social safety net programme in low- and middle-income countries. This study aimed to identify the factors associated with disadvantaged children's cognitive, language, and motor development at age 6-16 months in deprived settings of urban Bangladesh and to identify relative importance of these factors of children's development. We also explored if there were any gender differences in child development.

METHODS

This cross-sectional study was conducted in a deprived setting of urban Bangladesh. Bayley III was used for assessing children's cognitive, language, and motor development. Multivariable linear regression model was used to find the factors associated with children's development, and dominance analysis was used to explore the relative importance of the factors.

RESULTS

Out of the total 599 mother-child dyads, 303 (50.58%) were girls. The factors associated with children's development were length-for-age Z-score (cognitive: B = 1.21 [95% CI = 0.31, 2.11], P = 0.008; language: 1.67 [0.79, 2.55] P < 0.001; motor: 2.15 [1.01, 3.29] P < 0.001) and home environment (cognitive: 0.58 [0.27, 0.89] P < 0.001; language: 0.59 [0.27, 0.92], P < 0.001; motor: 0.44 [0.09, 0.79] P = 0.013). Girls had higher cognitive (1.90 [0.17, 3.6], P = 0.031) and language (2.53 [0.55, 4.51], P = 0.013) development compared with boys. Families with a higher number of under five children within the households had lower language (-1.57 [-2.78, -0.36], P = 0.011) development. Violence against the mother and the families' food security status were not associated with the children's development. Children's length-for-age Z-score (27%) and home stimulation environment (23%) were the most important factors of cognitive development.

CONCLUSION

Children's nutritional status and home environment are important factors for disadvantaged children's development in deprived urban settings of Bangladesh. Both early child development-focussed parenting and nutrition interventions should be considered when designing child development programmes in urban settings in low- and middle-income countries.

Adapting Reach Up and Learn in Crisis and Conflict Settings: An Exploratory Multiple Case Study

OBJECTIVES

In 2019, >71 million children aged <5 had spent their entire lives in conflict-affected settings. Compounding adversities including violence, poverty, and displacement have immediate and long-term effects on early childhood development, health, behavior, and well-being. In response, adaptations of Reach Up have been implemented in conflict and crisis settings.

METHODS

This article uses exploratory multiple case study methodology, drawing from implementation and qualitative data from 3 interventions: a mobile phone-based intervention promoting nurturing care among Rohingya and crisis-affected host communities in Bangladesh; Reach Up amid acute violence and displacement in Northeast Syria; and Reach Up group sessions and home visits integrated with health services for an indigenous population in Venezuela.

RESULTS

In Bangladesh, tailoring interactive voice response messages improved responsiveness to the developmental needs of young children, yet complementary in-person services were identified as a key program enhancement. In Syria, rapid adaptations of Reach Up addressed the needs of families in acute crisis, including social-emotional learning games for school-aged children. In Venezuela, Reach Up, coupled with complementary lactation counseling, yielded high rates of uptake and satisfaction, and children's language development was highlighted as a key area of growth.

CONCLUSIONS

Recommendations to promote early childhood development in crisis and conflict settings include: (1) cultural adaptation based on a holistic understanding of children and caregivers' needs; (2) the integration of child and family safety and linkages with complementary services on the basis of community needs and priorities, and (3) the importance of designing for scale through blended models and costing analyses.

Hair, serum and urine chromium levels in children with cognitive defects: A systematic review and meta-analysis of case control studies

Environmental chromium exposure may cause impaired development of children. We conducted a systematic review and meta-analysis. Electronic databases including PubMed, Embase, Web of Science and CINAHL were searched to identify case-control studies that reported childhood Cr exposure and cognitive development. The Newcastle-Ottawa Scale (NOS) was used to ensure the quality of the included studies. Cr levels were compared in cases and controls, and a random effect meta-analysis was performed using Stata version 16. Twelve of 61 studies identified in the literature search were eligible for this analysis. Hair, serum and urine Cr measurements were reported by seven, two and one studies, respectively. In addition, one study reported both serum and hair Cr exposure and another reported urine and hair Cr exposure. The pooled standard mean differences (SMD) showed that hair Cr levels were non-significantly lower among children with cognitive defects (-0.01 μg/g, 95% CI: -0.04, 00, p = 0.27). In serum and urine, the pooled SMD was higher in children with cognitive deficits compared with healthy control children (0.32 μg/g, 95% CI: -0.78, 1.42, p = 0.56 and 0.64 μg/g, CI: -0.07,1.36, p = 0.08; respectively). In summary, this systematic review found no significant differences in hair, serum and urine Cr levels between children with cognitive deficits and healthy control children when all study data were pooled in the meta-analysis. Larger studies using standardized criteria and longitudinal assessment of cognitive development are needed to determine whether there is a dose response effect of childhood Cr exposure on cognitive development of children.

The Shishu Pushti Trial-Extended Peer Counseling for Improving Feeding Practices and Reducing Undernutrition in Children Aged 0-48 Months in Urban Bangladesh: Protocol for a Cluster-Randomized Controlled Trial

BACKGROUND

The aim of this study is to assess if peer counseling of women improves breastfeeding, complementary feeding practices, and child growth, and thus reduces the prevalence of undernutrition in children up to 4 years of age.

OBJECTIVE

Lack of exclusive breastfeeding and inappropriate complementary feeding are critical factors in reducing child undernutrition, morbidity, and mortality. There are reported trials of peer counseling to improve breastfeeding; however, they did not examine the efficacy of peer counseling to improve complementary feeding or the long-term impacts on child growth and development.

METHODS

This study has used a community-based, cluster-randomized controlled trial with a superiority design and 2 parallel treatment arms. It is assessing the impact of peer counseling, starting in late pregnancy up to 1 year after delivery, on child feeding practices, growth, and development with follow-up until 48 months of age. The study site was Mirpur, a densely populated area in Dhaka. Using satellite maps and geographic information system mapping, we constructed 36 clusters with an average population of 5000 people. We recruited pregnant women in the third trimester aged 16-40 years, with no more than 3 living children. Trained peer counselors visited women at home twice before delivery, 4 times in the first month, monthly from 2 to 6 months, and again at 9 and 12 months. Trained research assistants collected anthropometric measurements. The primary outcome will be differences in child stunting and mean length for age at 6, 12, 15, and 18 months. Secondary outcomes will be differences in the percentage of women exclusively breastfeeding in the mean duration of any breastfeeding and in the percentage of children at 6 and 9 months of age who receive solid, semisolid, or soft foods; and the percentage of children consuming foods from 4 or more food groups at 9, 12, 15, and 18 months. We will assess the mean cognitive function scores from the Ages and Stages Questionnaire (9 and 18 months) and Bayley tests (24 and 36 months).

RESULTS

We identified 65,535 people in mapped residences, from which we defined 36 clusters and randomly allocated them equally to intervention or control groups stratified by cluster socioeconomic status. From July 2011 to May 2013, we identified 1056 pregnant women and 993 births in the intervention group and 994 pregnancies and 890 births in the control group. At 18 months, 692 children remained in the intervention group and 551 in the control group. From January 2015 to February 2017, we conducted the long-term follow-up of the cohort. We have now completed the data collection and processing and have started analyses.

CONCLUSIONS

This study will help fill the evidence gap about the short- and long-term impact of peer counseling on improving infant feeding, preventing childhood undernutrition, and enhancing child cognitive development.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01333995; https://clinicaltrials.gov/ct2/show/NCT01333995.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/31475.

Preanalytic and analytic factors affecting the measurement of haemoglobin concentration: impact on global estimates of anaemia prevalence

The accuracy of haemoglobin concentration measurements is crucial for deriving global anaemia prevalence estimates and monitoring anaemia reduction strategies. In this analysis, we examined and quantified the factors affecting preanalytic and analytic variation in haemoglobin concentrations. Using cross-sectional data from three field studies (in children, pregnant and nonpregnant women), we examined the difference in haemoglobin concentration between venous-drawn and capillary-drawn blood measured by HemoCue (ie, preanalytic) and modelled how the bias observed may affect anaemia prevalence estimates in population surveys and anaemia public health severity classification across countries. Using data from an international quality assurance programme, we examined differences due to instrumentation from 16 different haematology analyzers (ie, analytic). Results indicated that capillary and venous haemoglobin concentrations are not in agreement (bias +5.7 g/L (limits of agreement (LoA) -11.2, 22.6) in preschool age children; range from -28 g/L to +20 g/L in pregnant women; bias +8.8 g/L (LoA -5.2, 22.9) in non-pregnant women). The bias observed could introduce changes in population survey estimates of anaemia of up to -20.7 percentage points in children and -28.2 percentage points in non-pregnant women after venous adjustment. Analytic variation was minimal and unlikely to influence the diagnosis of anaemia. These findings suggest that global estimates of anaemia prevalence derived from capillary haemoglobin, as they often are, may be inaccurate and lead to erroneous public health severity classification, but that point-of-care, or other, instruments should not introduce variation if properly used.

Immediate impact of stay-at-home orders to control COVID-19 transmission on socioeconomic conditions, food insecurity, mental health, and intimate partner violence in Bangladeshi women and their families: an interrupted time series

BACKGROUND

Stay-at-home orders (lockdowns) have been deployed globally to control COVID-19 transmission, and might impair economic conditions and mental health, and exacerbate risk of food insecurity and intimate partner violence. The effect of lockdowns in low-income and middle-income countries must be understood to ensure safe deployment of these interventions in less affluent settings. We aimed to determine the immediate impact of COVID-19 lockdown orders on women and their families in rural Bangladesh.

METHODS

An interrupted time series was used to compare data collected from families in Rupganj upazila, rural Bangladesh (randomly selected from participants in a randomised controlled trial), on income, food security, and mental health a median of 1 year and 2 years before the COVID-19 pandemic to data collected during the lockdown. We also assessed women's experiences of intimate partner violence during the pandemic.

RESULTS

Between May 19 and June 18, 2020, we randomly selected and invited the mothers of 3016 children to participate in the study, 2424 of whom provided consent. 2414 (99·9%, 95% CI 99·6-99·9) of 2417 mothers were aware of, and adhering to, the stay-at-home advice. 2321 (96·0%, 95·2-96·7) of 2417 mothers reported a reduction in paid work for the family. Median monthly family income fell from US$212 at baseline to $59 during lockdown, and the proportion of families earning less than $1·90 per day rose from five (0·2%, 0·0-0·5) of 2422 to 992 (47·3%, 45·2-49·5) of 2096 (p<0·0001 comparing baseline with lockdown period). Before the pandemic, 136 (5·6%, 4·7-6·6) of 2420 and 65 (2·7%, 2·1-3·4) of 2420 families experienced moderate and severe food insecurity, respectively. This increased to 881 (36·5%, 34·5-38·4) of 2417 and 371 (15·3%, 13·9-16·8) of 2417 during the lockdown; the number of families experiencing any level of food insecurity increased by 51·7% (48·1-55·4; p<0·0001). Mothers' depression and anxiety symptoms increased during the lockdown. Among women experiencing emotional or moderate physical violence, over half reported it had increased since the lockdown.

INTERPRETATION

COVID-19 lockdowns present significant economic, psychosocial, and physical risks to the wellbeing of women and their families across economic strata in rural Bangladesh. Beyond supporting only the most socioeconomically deprived, support is needed for all affected families.

FUNDING

National Health and Medical Research Council, Australia.

Prenatal and childhood arsenic exposure through drinking water and food and cognitive abilities at 10 years of age: A prospective cohort study

BACKGROUND

Our studies of children in a rural Bangladeshi area, with varying concentrations of arsenic in well-water, indicated modest impact on child verbal cognitive function at 5 years of age.

OBJECTIVES

Follow-up of arsenic exposure and children's cognitive abilities at school-age.

METHODS

In a nested sub-cohort of the MINIMat supplementation trial, we assessed cognitive abilities at 10 years of age (n = 1523), using Wechsler Intelligence Scale for Children (WISC-IV). Arsenic in maternal urine and erythrocytes in early pregnancy, in child urine at 5 and 10 years, and in hair at 10 years, was measured using Inductively Coupled Plasma Mass Spectrometry.

RESULTS

Median urinary arsenic at 10 years was 58 µg/L (range 7.3-940 µg/L). Multivariable-adjusted regression analysis showed that, compared to the first urinary arsenic quintile at 10 years (<30 µg/L), the third and fourth quintiles (30-45 and 46-73 µg/L, respectively) had 6-7 points lower Full developmental raw scores (B: -7.23, 95% CI -11.3; -3.18, and B: -6.37, 95% CI -10.5; -2.22, respectively), corresponding to ~0.2 SD. Verbal comprehension and Perceptual reasoning seemed to be affected. Models with children's hair arsenic concentrations showed similar results. Maternal urinary arsenic in early pregnancy, but not late pregnancy, showed inverse associations with Full developmental scores (quintiles 2-4: B: -4.52, 95% CI -8.61; -0.43, B: -5.91, 95% CI -10.0; -1.77, and B: -5.98, 95%CI -10.2; -1.77, respectively, compared to first quintile), as well as with Verbal comprehension, Perceptual reasoning, and Processing speed, especially in girls (p < 0.05 for interaction of sex with Full developmental scores and Perceptual reasoning). In models with all exposure time points included, both concurrent exposure at 10 years and early prenatal exposure remained associated with cognitive abilities.

CONCLUSIONS

Both early prenatal and childhood arsenic exposure, even at low levels (about 50 µg/L in urine), was inversely associated with cognitive abilities at school-age, although the estimates were modest.

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.

The D-score: a metric for interpreting the early development of infants and toddlers across global settings

INTRODUCTION

Early childhood development can be described by an underlying latent construct. Global comparisons of children's development are hindered by the lack of a validated metric that is comparable across cultures and contexts, especially for children under age 3 years. We constructed and validated a new metric, the Developmental Score (D-score), using existing data from 16 longitudinal studies.

METHODS

Studies had item-level developmental assessment data for children 0-48 months and longitudinal outcomes at ages >4-18 years, including measures of IQ and receptive vocabulary. Existing data from 11 low-income, middle-income and high-income countries were merged for >36 000 children. Item mapping produced 95 'equate groups' of same-skill items across 12 different assessment instruments. A statistical model was built using the Rasch model with item difficulties constrained to be equal in a subset of equate groups, linking instruments to a common scale, the D-score, a continuous metric with interval-scale properties. D-score-for-age z-scores (DAZ) were evaluated for discriminant, concurrent and predictive validity to outcomes in middle childhood to adolescence.

RESULTS

Concurrent validity of DAZ with original instruments was strong (average r=0.71), with few exceptions. In approximately 70% of data rounds collected across studies, DAZ discriminated between children above/below cut-points for low birth weight (<2500 g) and stunting (-2 SD below median height-for-age). DAZ increased significantly with maternal education in 55% of data rounds. Predictive correlations of DAZ with outcomes obtained 2-16 years later were generally between 0.20 and 0.40. Correlations equalled or exceeded those obtained with original instruments despite using an average of 55% fewer items to estimate the D-score.

CONCLUSION

The D-score metric enables quantitative comparisons of early childhood development across ages and sets the stage for creating simple, low-cost, global-use instruments to facilitate valid cross-national comparisons of early childhood development.

Burden of major depressive disorder and quality of life among mothers of children with autism spectrum disorder in urban bangladesh

This cross-sectional study examined the burden of depression and quality of life (QoL) among mothers of children with autism spectrum disorder (ASD) attending six schools offering special educational services for children with ASD in urban Dhaka, Bangladesh. All consenting mothers were 18 years of age and older and met criteria for major depressive disorder (MDD) on the Structured Interview for DSM-V-TR Research Version-non patient edition administered by trained raters. QoL was assessed by the EuroQol five-dimensional standardized questionnaire. MDD was diagnosed in 45% of mothers and was proportionally higher among those who did not work outside the home, had no childcare support at home, expressed low level of satisfaction with the quality of providers when they had sought care for their children with ASD, and reported being recipient of negative attitudes from neighbors toward their children with ASD. QoL was negatively associated with MDD, mothers' illness, and low satisfaction with the health care providers for children with ASD, as well as experiencing a negative attitude by neighbors toward their children. QoL was positively associated with the reported family monthly income and improvement of the children with ASD on school attendance. The prevalence of MDD among mothers of children with ASD was high and associated with poor QoL. Integrating mental health services and supports for mothers in the ASD care of children is likely to address the high burden of depression they face, and improve their overall quality of life. Autism Res 2020, 13: 284-297. © 2019 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: The levels of depression were assessed among mothers of children with autism spectrum disorder (ASD) attending six schools offering special educational services for children with ASD in urban Dhaka, Bangladesh. Almost one in two mothers was found to have major depression. The quality of life of these mothers was generally poor. Integrating mental health services for mothers with ASD care in children is likely to address the burden of depression among the mothers of children with ASD and improve overall quality of life.

Creation of the WHO Indicators of Infant and Young Child Development (IYCD): metadata synthesis across 10 countries

BACKGROUND

Renewed global commitment to the improvement of early child development outcomes, as evidenced by the focus of the United Nations Sustainable Development Goal 4, highlights an increased need for reliable and valid measures to evaluate preventive and interventional efforts designed to affect change. Our objective was to create a new tool, applicable across multicultures, to measure development from 0 to 3 years through metadata synthesis.

METHODS

Fourteen cross-sectional data sets were contributed on 21 083 children from 10 low/middle-income countries (LMIC), assessed using seven different tools (caregiver reported or directly assessed). Item groups, measuring similar developmental skills, were identified by item mapping across tools. Logistic regression curves displayed developmental trajectories for item groups across countries and age. Following expert consensus to identify well-performing items across developmental domains, a second mapping exercise was conducted to fill any gaps across the age range. The first version of the tool was constructed. Item response analysis validated our approach by putting all data sets onto a common scale.

RESULTS

789 individual items were identified across tools in the first mapping and 129 item groups selected for analysis. 70 item groups were then selected through consensus, based on statistical performance and perceived importance, with a further 50 items identified at second mapping. A tool comprising 120 items (23 fine motor, 23 gross motor, 20 receptive language, 24 expressive language, 30 socioemotional) was created. The linked data sets on a common scale showed a curvilinear trajectory of child development, highlighting the validity of our approach through excellent coverage by age and consistency of measurement across contributed tools, a novel finding in itself.

CONCLUSIONS

We have created the first version of a prototype tool for measuring children in the early years, developed using novel easy to apply methodology; now it needs to be feasibility tested and piloted across several LMICs.

How Does Family Structure Relate With Children's Language Development? A Cross Sectional Experience from Urban Slums in Dhaka

Family structure is an important factor for children's overall development. In this cross sectional study, we explored how single parenting relates to child's language development in slums of Dhaka city, Bangladesh from 31st August 2010 to 9th February 2011. Children aged 10 to 24 months (n=133), living with mother only and those living with both parents were included. Children's comprehensive and expressive language development was assessed using the Bengali version of Mac Arthur's Communicative Development Inventory (MCDI). Family care indicators (FCI) were used to assess quality of psychosocial stimulation at home, maternal depression was assessed using Centre for Epidemiological Studies - Depression (CES-D) questionnaire and socioeconomic status (SES) of the family was determined using a previously tested questionnaire. We analyzed the data using multivariate analysis. Maternal depression scores were higher in single mothers compared to those living with their husband and more depressed mothers provided less stimulating environment for the child. Children in the single parent families had lower scores on FCI and their comprehension and expression scores were slightly lower. Multiple regressions analysis showed that children's comprehension {B (95%CI), 0.19 (0.07, 0.32), p=0.003} and expression {0.18 (0.02, 0.35), p=0.032} scores were significantly higher in those living with both parents. Steps to educate parents on the importance of a healthy family life needs to be taken in order to ensure development of children to achieve their full potentials. Further long-term effects of living without father on children's development needs to be explored in Bangladesh.

Manganese in Drinking Water and Cognitive Abilities and Behavior at 10 Years of Age: A Prospective Cohort Study

BACKGROUND

Cross-sectional studies have indicated impaired neurodevelopment with elevated drinking water manganese concentrations (W-Mn), but potential susceptible exposure windows are unknown.

OBJECTIVES

We prospectively evaluated the effects of W-Mn, from fetal life to school age, on children's cognitive abilities and behavior.

METHODS

We assessed cognitive abilities and behavior in 1,265 ten-year-old children in rural Bangladesh using the Wechsler Intelligence Scale for Children (WISC-IV) and the Strengths and Difficulties Questionnaire (SDQ), respectively. Manganese in drinking water used during pregnancy and by the children at 5 y and 10 y was measured using inductively coupled plasma mass spectrometry.

RESULTS

The median W-Mn was 0.20 mg/L (range 0.001–6.6) during pregnancy and 0.34mg/L (<0.001–8.7) at 10 y. In multivariable-adjusted linear regression analyses, restricted to children with low arsenic (As) exposure, none of the W-Mn exposures was associated with the children’s cognitive abilities. Stratifying by gender (p for interaction in general <0.081) showed that prenatal W-Mn (3 mg/L) was positively associated with cognitive ability measures in girls but not in boys. W-Mn at all time points was associated with an increased risk of conduct problems, particularly in boys (range 24–43% per mg/L). At the same time, the prenatal W-Mn was associated with a decreased risk of emotional problems [odds ratio (OR)=0.39 (95% CI: 0.19, 0.82)] in boys. In girls, W-Mn was mainly associated with low prosocial scores [prenatal W-Mn: OR=1.48 (95% CI: 1.06, 1.88)].

CONCLUSIONS

Elevated prenatal W-Mn exposure was positively associated with cognitive function in girls, whereas boys appeared to be unaffected. Early life W-Mn exposure appeared to adversely affect children's behavior. https://doi.org/10.1289/EHP631.

Effect of a food supplementation and psychosocial stimulation trial for severely malnourished children on the level of maternal depressive symptoms in Bangladesh

BACKGROUND

Maternal depression is associated with poor child development and growth in low-income countries. This paper evaluates the effect of a community-based trial providing psychosocial stimulation and food supplements to severely malnourished children on maternal depressive symptoms in Bangladesh.

METHODS

Severely underweight (weight-for-age Z-score < -3) hospitalized children aged 6-24 months (n = 507), were randomly assigned to: psychosocial stimulation (PS), food supplementation (FS), PS+FS, clinic control (CC) and hospital control (CH) at discharge. PS included play sessions with children and parental counselling to mothers during fortnightly follow-up visit at community clinics, conducted by trained play leaders for 6 months. FS involved cereal-based supplements (150-300 kcal/day) for 3 months. All groups received medical care, micronutrient supplements and growth monitoring. We used Bayley scales, Home Observation for Measurement of Environment (HOME) inventory and a parenting questionnaire to assess child development, home stimulation and mothers' child-rearing practices, respectively. We assessed mothers' depressive symptoms using a modified version of Centre for Epidemiologic Studies Depression Scale at baseline and at 6 months post intervention.

RESULTS

Maternal depressive symptoms were significantly lower in the CH group at baseline (P = 0.014). After 6 months of intervention there was no significant effect of intervention after adjusting for baseline scores and all possible confounders. Maternal depressive symptoms were higher among poorer (P = 0.06), older (P = 0.057) and less educated (P = 0.019) mothers, who were housewives (P = 0.053), and whose husbands had more unstable jobs (P = 0.058). At 6 months post intervention, children's cognitive (P = 0.045) and motor (P = 0.075) development, HOME (P = 0.012) and mother's parenting score (P = 0.057) were higher among mothers with lower depressive symptoms.

CONCLUSION

The study did not show a significant effect of the intervention on the level of maternal depressive symptoms. Interventions with higher intensity and/or of longer duration focusing directly on maternal psychosocial functioning are probably needed to reduce maternal depressive symptoms.

The prevalence and impact of intimate partner violence on maternal distress in a community of low-income Bangladeshi and displaced ethnic Bihari mothers: Dhaka, 2008-2009

Low-income, ethnic, and/or displaced mothers are frequently victimized; we explored the burden of intimate partner violence (IPV) among such women. Teams administered IPV and maternal distress questionnaires to quantify victimization after the birth of a child. Of 250 mothers reporting abuse, 133 (53%) reported their husband hitting; 111 (44%) kicking, dragging, or beating; 61 (24%) choking or burning; and 33 (13%) injuring them with a knife or gun (12 case-patients per 100 person-years). Women who experienced more forms of victimization reported more distress (p = .01). Mothers in this low-income community experienced severe victimization and distress.

Integrating early child development programs into health and nutrition services in Bangladesh: benefits and challenges

Bangladesh is one of the poorest countries of the world with the highest population density. The Bangladesh government recognizes the educational and financial benefits of early childhood development (ECD) and has incorporated ECD into the national plan of action. However, ECD activities are not fully established in the country and there have been few evaluations. In this paper, we present ECD programs that are integrated into health and nutrition services in Bangladesh. We present four evaluation reports of such programs and we also include seven published research projects showing evidence that such integrations are feasible. We provide short reviews on coverage, methodology, and effects of the published reports and share our experience of challenges faced and steps taken to solve them. Overall, very few programs are based on scientific evidence and fewer are even evaluated. The research projects so far conducted are promising and there is sufficient evidence on feasibility of integrating ECD activities into nutrition and health programs. Suggestions are made on measures to overcome the implementation problems and on suitable methods to establish high-quality ECD programs in Bangladesh and in other low- and middle-income countries.

Elevated manganese concentrations in drinking water may be beneficial for fetal survival

BACKGROUND

Elevated exposure to the essential element manganese (Mn) can be toxic. Manganese concentrations in ground water vary considerably, and reported associations between Mn and early-life mortality and impaired development have raised concern. We assessed the effects of drinking water Mn exposure during pregnancy upon fetal and infant survival.

METHODS

In this population-based cohort study, we identified the outcomes of pregnancies registered between February 2002 and April 2003 in Matlab, Bangladesh. Using inductively coupled plasma mass spectrometry, we measured the concentrations of Mn and other elements in the pregnant women's drinking water.

RESULTS

A total of 1,875 women were included in the analysis of spontaneous abortions (n=158) and 1,887 women in the perinatal mortality analysis (n=70). Water Mn ranged from 3.0-6,550 µg/L (median=217 µg/L). The adjusted odds ratio (OR) for spontaneous abortion was 0.65 (95% CI 0.43-0.99) in the highest water Mn tertile (median=1,292 µg/L) as compared to the lowest tertile (median=56 µg/L). The corresponding OR for perinatal mortality was 0.69 (95% CI 0.28-1.71), which increased to 0.78 (95% CI 0.29-2.08) after adjustment for BMI and place of delivery (home/health facility; n=1,648).

CONCLUSIONS

Elevated water Mn concentrations during pregnancy appear protective for the fetus, particularly in undernourished women. This effect may be due to the element's role in antioxidant defense.

The relation between age of attainment of motor milestones and future cognitive and motor development in Bangladeshi children

There is a need for easily administered, low-cost measures to assess child development in large field studies. Many researchers evaluate the age of attainment of motor milestones, but there is little information on their validity. A large longitudinal study (MINIMat) was conducted in a poor rural area of Bangladesh and we assessed the age of attainment of motor milestones in a subsample of over 2000 children. We examined their association with scores on the Bayley psychomotor development index (PDI) and mental development index (MDI) at 18 months and with scores on the Movement Assessment Battery for Children and with intelligence quotient (IQ) on the Wechsler Preschool and Primary Scale of Intelligence at 64 months. A field worker visited the children's homes monthly from 3 to 12 months of age and then at 15 months and examined the children. Mothers recorded the date of attainment of the milestones. Age of attainment of walking and standing alone was moderately correlated with the PDI and had significant but low associations with later motor development. They were as good as the PDI in predicting later motor development and could be used in field studies for that purpose. Milestone age of attainment had significant but low correlations with MDI and later IQ. Height for age at 15 months was related to milestones and later IQ and motor development and accounted for some of the association between milestones and IQ. Milestone age of attainment may not be sensitive enough to be used as an indicator of later IQ.

Occurrence and levels of organochlorine compounds in human breast milk in Bangladesh

In low-income countries, the use of some organochlorine pesticides is still common in order to increase food production. Monitoring the chemical exposure is an important step in risk-reducing strategies. This is the first study to report concentrations of organochlorines in breast milk of women from Bangladesh where farming is the main income source. Organochlorines such as p,p'-DDT, o,p'-DDT, p,p'-DDE, p,p'-DDD (i.e., ∑DDT), HCB, α-, β- and γ-HCH, trans-chlordane, cis-chlordane, oxy-chlordane, trans-nonachlor, cis-nonachlor, mirex and polychlorinated biphenyls (CB 28, 52, 99, 101, 105, 114, 118, 123, 128, 138, 141, 149, 153, 156, 157, 163, 167, 170, 180, 183, 187, 189, 194) were analyzed in breast milk collected in 2002 from 72 first-time mothers (median age 20years) living in the rural area Matlab, Bangladesh. While the concentrations of PCBs and many of the pesticides were low, the concentrations of p,p'-DDT and its metabolite p,p'-DDE were high (median 349 and 1645ngg(-1)lipid, respectively) in comparison to other countries. The median value of ∑DDT was 2123ngg(-1)lipid. The estimated daily exposure to p,p'-DDT, p,p'-DDE and ∑DDTs was 10, 30 and 42μgkg(-1) body weight, respectively, in 3months old infants. The p,p'-DDE/p,p'-DDT ratio ranged from 1 to 23, where 58% of the mothers had a ratio below 5 indicating recent or ongoing DDT exposure. This study reports infant exposure and maternal body burden of organochlorines through breast milk. Although the findings give no reason to limit breast-feeding, it is essential to identify the main exposure sources and find means to decrease the exposure.

Pre- and postnatal arsenic exposure and body size to 2 years of age: a cohort study in rural Bangladesh

BACKGROUND

Exposure to arsenic via drinking water has been associated with adverse pregnancy outcomes and infant morbidity and mortality. Little is known, however, about the effects of arsenic on child growth.

OBJECTIVE

We assessed potential effects of early-life arsenic exposure on weight and length of children from birth to 2 years of age.

METHODS

We followed 2,372 infants born in a population-based intervention trial in rural Bangladesh. Exposure was assessed by arsenic concentrations in urine (U-As) of mothers (gestational weeks 8 and 30) and children (18 months old). Child anthropometry was measured monthly in the first year and quarterly in the second. Linear regression models were used to examine associations of U-As (by quintiles) with child weight and length, adjusted for age, maternal body mass index, socioeconomic status, and sex (or stratified by sex).

RESULTS

Median (10th-90th percentiles) U-As concentrations were about 80 (25-400) µg/L in the mothers and 34 (12-159) µg/L in the children. Inverse associations of maternal U-As with child's attained weight and length at 3-24 months were markedly attenuated after adjustment. However, associations of U-As at 18 months with weight and length at 18-24 months were more robust, particularly in girls. Compared with girls in the first quintile of U-As (< 16 µg/L), those in the fourth quintile (26-46 µg/L) were almost 300 g lighter and 0.7 cm shorter, and had adjusted odds ratios (95% confidence interval) for underweight and stunting of 1.57 (1.02-2.40) and 1.58 (1.05-2.37), respectively, at 21 months.

CONCLUSIONS

Postnatal arsenic exposure was associated with lower body weight and length among girls, but not boys.

Association of postpartum maternal morbidities with children's mental, psychomotor and language development in rural Bangladesh

Little is known from developing countries about the effects of maternal morbidities diagnosed in the postpartum period on children's development. The study aimed to document the relationships of such morbidities with care-giving practices by mothers, children's developmental milestones and their language, mental and psychomotor development. Maternal morbidities were identified through physical examination at 6-9 weeks postpartum (n=488). Maternal care-giving practices and postnatal depression were assessed also at 6-9 weeks postpartum. Children's milestones of development were measured at six months, and their mental (MDI) and psychomotor (PDI) development, language comprehension and expression, and quality of psychosocial stimulation at home were assessed at 12 months. Several approaches were used for identifying the relationships among different maternal morbidities, diagnosed by physicians, with children's development. After controlling for the potential confounders, maternal anaemia diagnosed postpartum showed a small but significantly negative effect on children's language expression while the effects on language comprehension did not reach the significance level (p=0.085). Children's development at 12 months was related to psychosocial stimulation at home, nutritional status, education of parents, socioeconomic status, and care-giving practices of mothers at six weeks of age. Only a few mothers experienced each specific morbidity, and with the exception of anaemia, the sample-size was insufficient to make a conclusion regarding each specific morbidity. Further research with a sufficient sample-size of individual morbidities is required to determine the association of postpartum maternal morbidities with children's development.

Critical windows of exposure for arsenic-associated impairment of cognitive function in pre-school girls and boys: a population-based cohort study

BACKGROUND

Exposure to arsenic through drinking water has been associated with impaired cognitive function in school-aged children in a few cross-sectional studies; however, there is little information on critical windows of exposure.

METHODS

We conducted a population-based longitudinal study in rural Bangladesh. We assessed the association of arsenic exposure, based on urinary arsenic (U-As; twice during pregnancy and twice in childhood), with the development of about 1700 children at 5 years of age using Wechsler Pre-school and Primary Scale of Intelligence [intelligence quotient (IQ)].

RESULTS

Median maternal U-As in pregnancy was 80 µg/l (10-90 percentiles: 25-400 µg/l). Children's urine contained 35 (12-155) µg/l and 51 (20-238) µg/l at 1.5 and 5 years, respectively. Using multivariable-adjusted regression analyses, controlling for all potential confounders and loss to follow-up, we found that verbal IQ (VIQ) and full scale IQ (FSIQ) were negatively associated with (log) U-As in girls. The associations were consistent, but somewhat stronger with concurrent arsenic exposure [VIQ: B = -2.4, 95% confidence interval (CI) = -3.8 to -1.1; FSIQ: B = -1.4, 95% CI = -2.7 to -0.1, n = 817), compared with that at 1.5 years (VIQ: B = -0.85, 95% CI = -2.1 to 0.4; FSIQ: B = -0.74, 95% CI = -1.9 to 0.4, n = 902), late gestation (VIQ: B = -1.52, 95% CI = -2.6 to -0.4; FSIQ: B = -1.35, 95% CI = -2.4 to -0.3, n = 874) and early gestation (VIQ: B = -1.23, 95% CI = -2.4 to -0.06; FSIQ: B = -0.92, 95% CI = -2.0 to -0.2, n = 833). In boys, U-As showed consistently low and non-significant associations with all IQ measures. An effect size calculation indicated that 100 µg/l U-As was associated with a decrement of 1-3 points in both VIQ and FSIQ in girls.

CONCLUSION

We found adverse effects of arsenic exposure on IQ in girls, but not boys, at 5 years of age.

Assessment of early-life lead exposure in rural Bangladesh

Lead is a well-known neurotoxic metal and one of the most toxic chemicals in a child's environment. The aim of this study was to assess early-life lead exposure in a pristine rural area of Bangladesh. The exposure was expected to be very low because of the absence of vehicle traffic and polluting industries. Lead was measured in erythrocytes, urine, and breast milk of 500 randomly selected pregnant women, participating in a randomized food and micronutrient supplementation trial in Matlab (MINIMat). Lead was also measured in urine of their children at 1.5 and 5 years of age, and in rice, well water, cooking pots, and materials used for walls and roof. All measurements were performed using ICPMS. We found that the women had relatively high median erythrocyte lead levels, which increased considerably from early pregnancy to late lactation (81-136microg/kg), probably due to release from bone. Urinary lead concentrations were unchanged during pregnancy (median approximately 3.5microg/L) and non-linearly associated with maternal blood lead levels. Children, at 1.5 and 5 years of age, had a median urinary lead concentration of 4microg/L, i.e., similar to that in their mothers. Rice, the staple food in Matlab, collected from 63 homes of the study sample, contained 1-89microg/kg (median 13microg/kg) dry weight and seems to be an important source of lead exposure. Other sources of exposure may be cooking pots and metal sheet roof material, which were found to release up to 380 and 4200microg/L, respectively, into acidic solutions. Based on breast milk lead concentrations (median 1.3microg/L) a median daily intake of 1.2microg was estimated for 3 months old infants. However, alternatives to breast-feeding are likely to contain more lead, especially rice-based formula. To conclude, lead exposure in women and their children in a remote unpolluted area was found to be surprisingly high, which may be due to their living conditions.

Household food security is associated with early childhood language development: results from a longitudinal study in rural Bangladesh

BACKGROUND

Although household food security (HHFS) has been linked to academic performance in school children, its association with early childhood development has received less attention, particularly in low-income countries. We investigated the association of HHFS with subsequent language development of children at 18 months of age in rural Bangladesh.

METHODS

We followed 1439 infants born in 2002-2003 to the mothers in Maternal and Infant Nutrition Intervention in Matlab study, a large intervention trial conducted in rural Bangladesh. A HHFS scale was created from data collected from mothers during pregnancy. At 18 months, children's language (expression and comprehension) development was assessed using a Bengali adaptation of MacArthur's Communicative Development Inventory which was based on mothers' report of their children's ability to comprehend and express words in different categories. General linear regression models were used to examine the association between HHFS and language development at 18 months of age adjusting for potential confounders.

RESULTS

Household food security was associated with language comprehension (B = 0.19, 95% CI = 0.09, 0.30, P < 0.001) and expression (B = 1.01, 95% CI = 1.00, 1.02, P < 0.01) at 18 months of age. Mean language comprehension and expression at 18 months of the children in higher quartiles of HHFS were higher (P < 0.05) than those of the children in lower quartiles.

CONCLUSIONS

Household food security is positively associated with subsequent language development of rural Bangladeshi children. Early language development has been reported to predict later child development. Therefore, strategies to ensure HHFS status in Bangladesh and similar settings should be considered for optimum child development.

Local production of anti-vibrio cholerae mucosal antibody in reproductive tract tissues after cholera

To investigate whether intestinal presentation of an antigen by Vibrio cholerae, a noninvasive organism, could induce an anatomically distant mucosal immune response in reproductive tract tissues, the endocervical immune responses of women in Bangladesh were evaluated after cholera. Endocervical secretions were analyzed for secretory IgA (sIgA) antibody against the B subunit of cholera toxin (CtxB) in 9 women with cholera and 8 women with diarrhea caused by neither V. cholerae nor heat labile enterotoxin-producing Escherichia coli. Women infected with V. cholerae developed significant sIgA anti-CtxB responses in endocervical samples (P< or =.02). Antibody subtype analysis of endocervical IgA was consistent with local mucosal production (P< or =.001). Women with cholera did not develop sIgA anti-CtxB responses in serum. The ability to generate specific mucosal immune responses in reproductive tract tissues after intestinal presentation of antigen could facilitate development of vaccines effective against reproductive tract pathogens.

Randomized controlled trial of the effect of zinc supplementation on the mental development of Bangladeshi infants

BACKGROUND

Zinc deficiency is thought to be common in young children in developing countries and some data suggest that it may detrimentally affect children's development.

OBJECTIVE

Our goal was to assess the effect of zinc supplementation on the developmental levels and behavior of Bangladeshi infants.

DESIGN

This was a randomized, double-blind, controlled trial conducted in Dhaka, Bangladesh. Three hundred one infants aged 1 mo were randomly assigned to receive either 5 mg elemental Zn or placebo daily for 5 mo, and subsequent growth and morbidity were observed. For the present study, developmental levels were assessed in a subsample of 212 infants at 7 and 13 mo of age with use of the Bayley Scales of Infant Development, and the infants' behavior during the tests was observed. The children's social backgrounds, weights, and lengths were also recorded.

RESULTS

The children's nutritional status was generally poor. The zinc-treated group had slightly lower scores on the mental development index of the Bayley Scales than did the placebo group (beta = 3.7, SE = 1.3, P < 0.005). This effect remained significant when nutritional status and social background were controlled for. No other significant differences between groups were noted.

CONCLUSIONS

The mental development index scores of the zinc-treated group were slightly but significantly lower than those of the placebo group. This finding may have been due to micronutrient imbalance. Caution should be exercised when supplementing undernourished infants with a single micronutrient.

Immune response of Bangladeshi children with acute diarrhea who subsequently have persistent diarrhea

BACKGROUND

Because altered immune responses may be a risk factor for persistent diarrhea, various aspects of the immune response were examined to elucidate the underlying immune mechanisms that may be involved in the development of persistent diarrhea.

METHODS

Children (7-12 months of age) with watery diarrhea for 6 to 8 days from the Dhaka Hospital of the International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B), were enrolled. Children were classified as having acute diarrhea (AD) or persistent diarrhea (PD) if diarrhea resolved within 14 days or persisted for more than 14 days, respectively. Uninfected control children (n = 13), from the Nutrition Follow-Up Unit of ICDDR,B were also enrolled. Of the 123 children with diarrhea who were enrolled, 85 had AD and 38 had PD. Comparisons were performed for clinical features, nutritional status (weight for age, plasma transferrin, and serum albumin levels), and immune responses: neutrophil function; peripheral blood mononuclear cell function, delayed-type hypersensitivity (DTH) responses, plasma levels of immunoglobulins, tumor necrosis factor-alpha, and interferon-gamma. Univariate analyses were conducted to assess differences among the three groups of children and between children with AD and PD. Logistic regression was performed to determine risk factors for PD.

RESULTS

There were no differences in clinical features and nutritional status among the groups of children studied. More children in whom PD developed had a negative DTH response to tuberculin than those with AD (P = 0.021). Also, a negative DTH response to tuberculin was a significant risk factor for PD (odds ratio [OR] = 3.8, 95% confidence interval [CI] = 1.5-9.9).

CONCLUSIONS

Children with acute diarrhea with a negative DTH response to tuberculin are more likely to have development of persistent diarrhea.

Immune response of children who develop persistent diarrhea following rotavirus infection

A prospective study was conducted with Bangladeshi children with rotavirus (RV) diarrhea to assess whether nutritional and clinical parameters, RV serotypes, levels of interleukin-10 (IL-10), tumor necrosis factor alpha (TNF-alpha), and gamma interferon (IFN-gamma), and RV-specific antibody titers in plasma and stool were associated with the development of persistent diarrhea. Children with watery diarrhea for 6 to 8 days, selected from the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B), were enrolled in the study and monitored until diarrhea improved. Children were classified as having acute diarrhea (AD) if diarrhea resolved within 14 days of onset and as having persistent diarrhea (PD) if diarrhea persisted for more than 14 days after onset. Uninfected, control children (n = 13) from the Nutrition Follow-Up Unit of ICDDR,B were also enrolled. Of the 149 children with diarrhea enrolled, 29 had diarrhea with RV alone, of which 19 had AD and 10 developed PD. Samples of stool and blood were collected from all children on enrollment. Stool samples were collected again from children when they developed PD. Of the 10 children who had an initial RV infection and then developed PD, only one had persistent RV infection. Plasma levels of IL-10 and TNF-alpha were higher in children with diarrhea compared to uninfected controls but were similar in children with AD and PD. Plasma IFN-gamma levels were higher in children who developed PD than in those with AD (P = 0.008) or uninfected controls (P = 0.001). In stools, the levels of TNF-alpha, the only cytokine detected, were similar in the three groups of children. RV-specific immunoglobulin G (IgG) titers in plasma were higher in uninfected children than in those with AD (P < 0.001) or PD (P = 0.024) but titers were similar in children with AD and PD. RV-specific IgA titers in plasma and stool were similar in the three groups of children. From all observed parameters, only elevated plasma IFN-gamma levels were associated with subsequent development of PD. However, a larger sample size is necessary to substantiate this observation.

Anticipating rotavirus vaccines: hospital-based surveillance for rotavirus diarrhea and estimates of disease burden in Bangladesh

OBJECTIVES

Rotavirus is the most common cause of severe diarrhea in children worldwide, and a vaccine may soon be licensed and available for use in immunization programs. To assess the need for a rotavirus vaccine in Bangladesh, we estimated the disease burden of rotavirus diarrhea from national vital statistics for births and diarrheal deaths, together with hospital surveillance data on the proportion of severe childhood diarrhea attributed to rotavirus.

METHODS

From 1990 through 1993, hospital surveillance was conducted of a systematic, random 4% sample of >80,000 patients with diarrhea who sought care each year at the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B).

RESULTS

Rotavirus was detected in 20% (1561 of 7709) of fecal specimens from children with diarrhea <5 years of age; 92% of all cases (1436) occurred in children <2 years of age, but only 3% (50) of cases occurred in infants <3 months of age. Children infected with rotavirus were more likely to have watery stools (P < 0.001), severe vomiting (P < 0.001) but less severe dehydration (P = 0.007) than children infected with other enteropathogens.

CONCLUSIONS

We estimate that in this setting, where 18% of children die by age 5 and about 25% of these succumb to diarrhea, between 14,850 and 27,000 of the 3 million Bangladeshi children born in 1994 will die of rotavirus by the age of 5 years, equivalent to 1 rotavirus death per 111 to 203 children. The estimated burden of rotavirus diarrhea in Bangladesh is sufficiently great to warrant field testing of rotavirus vaccines for possible inclusion in the current immunization program.

Reasons for failure of breast-feeding counselling: mothers' perspectives in Bangladesh

During the hospitalization in the Dhaka hospital of the international Centre for Diarrhoeal Disease Research, Bangladesh, of a group of partially breast-fed infants aged 1-12 weeks who had been admitted with acute diarrhoea, their mothers were individually counselled by breast-feeding counsellors to start exclusive breast-feeding. The counselling was repeated 1 week later at home, and the women's infant-feeding practices were evaluated 2 weeks after their infants had been discharged from hospital. A total of 25% of the mothers failed to breast-feed exclusively despite having been counselled. The case studies of these mothers illustrate that although they generally complained about having "insufficient breast milk" various factors such as domineering grandmothers, lack of financial support by their husbands, too much housework, or disinterest contributed to their failure to breast-feed exclusively. While family support is essential for all lactating mothers, women with familial or financial problems require special attention and extra counselling sessions so that they can be helped to identify how to achieve and sustain exclusive breast-feeding.

Reduced osmolarity oral rehydration salt in Cholera

In a controlled clinical trial conducted in 34 adults with severe cholera diarrhoea, the use of a relatively dilute oral rehydration salt (ORS) solution (sodium 67, potassium 20, chloride 66, citrate 7, glucose 89 mmol/l, osmolality 249 mOsmol/kg) caused a 29% (p=0.003) reduction in stool output over the first 24 h and a 37% (p=0.001) reduction over the first 48 h compared with 29 controls who received the hyperosmolar WHO/UNICEF ORS. No controls but 3 study-group patients had marked but asymptomatic hyponatraemia (sodium <125 mmol/l) at 24 h. Twenty-four % of controls and 12% of patients receiving the dilute ORS needed unscheduled intravenous therapy for recurrence of dehydration. The ORS intake was twice the 48 h stool volume in controls and 3 times in the study group. The test ORS with a reduced glucose and sodium concentration is more efficient than the WHO/UNICEF ORS in preserving net intestinal fluid balance in severe cholera.