Neurocognitive testing in West African children 3-6 years of age: Challenges and implications for data analyses

How Do Neurocognitive Tests Relate to Reported Child Difficulties at 6 Years of Age in Benin?

OBJECTIVE

The aim of this study was to examine the relationship between children's difficulties perceived by parents in the Ten Questions questionnaire (TQ) and children's assessments by the Kaufman Assessment Battery for Children, Second Edition (KABC-II) and the Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2).

METHODS

The study was carried out in the district of Allada, a semi-rural area of Benin, involving a cohort of 562 6-year-old children. A response was considered positive if the parent reported a difficulty for their child compared to other children.

RESULTS

The proportion of TQ-reported difficulties was 34.2%. More difficulties were reported by parents when their child had lower scores on the KABC-II (p < 0.001) and on the BOT-2 (p < 0.01). Greater family wealth, higher maternal education, and better child school attendance were associated with higher KABC-II Mental Processing Index (MPI) scores, higher BOT-2 scores, and fewer reported difficulties on the TQ. The likelihood of parents reporting difficulties was ˃60% when KABC-II MPI scores were low. When considering the KABC-II as the gold standard to define mild delays (mean minus 1 SD), the TQ demonstrated a sensitivity of 51.0% and specificity of 69.4%, which increased to 58% and 72%, respectively, when children attended school.

CONCLUSION

Objective assessments of children's abilities were associated with parents' perceived difficulties. In a low-resource rural setting in sub-Saharan Africa, the TQ is a useful tool for screening neurodevelopmental difficulties, particularly for children attending school.

Prenatal Hemoglobin Concentration and Long-Term Child Neurocognitive Development

Anemia in pregnancy, defined by a hemoglobin level (Hb) of less than 110 g/L, contributes to infant mortality and morbidity in sub-Saharan Africa. Maternal Hb changes physiologically and pathologically during pregnancy. However, the impact of these changes on long-term child neurocognitive function is unknown. This study therefore investigates the association between Hb at specific antenatal care visits and prenatal Hb trajectories during pregnancy and long-term child neurocognitive function. We analyzed data from a prospective cohort study that included 6-year-old singleton children born to women enrolled before 29 weeks of gestation into an antimalarial drug clinical trial. Hemoglobin level was analyzed from venous blood collected at least twice during pregnancy and at delivery. We used group-based trajectory modeling to identify distinct prenatal Hb trajectories. In total, 478 children (75.1% of eligible children) had assessment of cognitive and motor functions at 6 years of age. Three distinct Hb trajectories were identified: persistently anemic (Hb <110 g/L throughout the second and third trimesters), anemic to nonanemic (Hb <110 g/L at second trimester with increasing Hb toward the third trimester to Hb ≥110 g/L), and persistently nonanemic (Hb ≥110 g/L throughout the second and third trimesters). Children of women in the persistently anemic and anemic-to-nonanemic groups had significantly lower neurocognitive scores than children of women in the persistently nonanemic group (β = -6.8, 95% CI: -11.7 to -1.8; and β = -6.3, 95% CI: -10.4 to -2.2, respectively). The study shows that maintaining an elevation of Hb at or above 110 g/L from the second to third trimester of pregnancy may be associated with optimal long-term child neurocognitive function.

Usability and psychometric properties of a battery of tools to assess intelligence, executive functioning, and sustained attention in Tanzanian children

BACKGROUND

Measuring neurocognitive functioning in children requires validated, age-appropriate instruments that are adapted to the local cultural and linguistic context. We sought to evaluate the usability and psychometric properties of five tools that assess general intelligence, executive functioning, and sustained attention among Tanzanian children.

METHODS

We adapted five age-appropriate neurocognitive assessment batteries from previously published assessment materials to the Tanzanian context. We enrolled children 6 months to 12 years of age residing in the rural ward of Yombo, Pwani Region. Feasibility and acceptability of all instruments was assessed qualitatively and quantitatively, including measurement of refusal rates, ceiling or floor effects, and time requirements. We assessed internal consistency using Cronbach's alpha and convergent validity using standard correlation analysis. Score gradients across age were explored using polynomial regression analysis.

FINDINGS

All five instruments required minimal adaptations to the Tanzanian context. Two-hundred sixty one children aged 6 months to 12 years completed the assessment. Refusal rates were consistently low (5.9% at the highest) and no ceiling or floor effects of measurements were observed. Feedback from assessors and caregivers indicated adequate test durations and generally high acceptability of instruments. All instruments showed good internal consistency with Cronbach alphas at least 0.84 for all tests. We found satisfactory convergent validity; all test scores strongly correlated with age.

CONCLUSION

The five instruments identified to assess general intelligence, executive functioning, and sustained attention constructs in Tanzanian children seem to work well in this setting.

Neurocognitive Profile and Associated Factors Among Children Affected by Sickle Cell Disease in Kinshasa, Democratic Republic of Congo: A Cross-Sectional Study

BACKGROUND/OBJECTIVES

Understanding the neurocognitive profile of children with sickle cell disease in the Democratic Republic of Congo is essential, as this condition can significantly affect their development. Our study aims to assess these children's neurocognitive and developmental profiles and identify related factors.

METHODS

We conducted a descriptive cross-sectional study involving 287 children, aged 0 to 68 months, using the Mullen Scales of Early Learning and the Gensini Gavito Scale. We also screened for maternal depression using the Hopkins Symptoms Checklist-10.

RESULTS

More than half of the participants were boys, with an average age of 4 years. Remarkably, 95.8% (score T < x¯ +2 SD) of children scored below average on the Mullen Scales. Significant associations were found between early neurocognitive development and factors like maternal depression, socioeconomic status, maternal education, age of weaning, and responses to the Ten-Questions Questionnaire (p < 0.005). Conclusion, children with sickle cell disease show below-average cognitive development, with maternal depression being a critical factor. Longitudinal studies are vital to understanding the long-term cognitive effects of sickle cell disease, particularly in the Democratic Republic of Congo, where targeted support is urgently needed.

Neurodevelopment in preschool children exposed and unexposed to Zika virus in utero in Nicaragua: a prospective cohort study

BACKGROUND

Data on long-term neurodevelopmental outcomes of normocephalic children (born with normal head circumference) exposed to Zika virus in utero are scarce. We aimed to compare neurodevelopmental outcomes in normocephalic children up to age 48 months with and without Zika virus exposure in utero.

METHODS

In this prospective cohort study, we included infants from two cohorts of normocephalic children born in León and Managua, Nicaragua during the 2016 Zika epidemic. In León, all women pregnant during the two enrolment periods were eligible. In Managua, mother-child pairs were included from three districts in the municipality of Managua: all women who became pregnant before June 15, 2016, and had a due date of Sept 15, 2016 or later were eligible. Infants were serologically classified as Zika virus-exposed or Zika virus-unexposed in utero and were followed up prospectively until age 48 months. At 36 months and 48 months of age, the Mullen Scales of Early Learning (MSEL) assessment was administered. Primary outcomes were MSEL early learning composite (ELC) scores at 30-48 months in León and 36-48 months in Managua. We used an inverse probability weighting generalised estimating equations model to assess the effect of Zika virus exposure on individual MSEL cognitive domain scores and ELC scores, adjusted for maternal education and age, poverty status, and infant sex.

FINDINGS

The initial enrolment period for the León cohort was between Jan 31 and April 5, 2017 and the second was between Aug 30, 2017, and Feb 22, 2018. The enrolment period for the Managua cohort was between Oct 24, 2019, and May 5, 2020. 478 mothers (482 infants) from the León cohort and 615 mothers (609 infants) from the Managua cohort were enrolled, of whom 622 children (303 from the León cohort; 319 from the Managua cohort) were included in the final analysis; four children had microcephaly at birth and thus were excluded from analyses, two from each cohort. 33 (11%) of 303 children enrolled in León and 219 (69%) of 319 children enrolled in Managua were exposed to Zika virus in utero. In both cohorts, no significant differences were identified in adjusted mean ELC scores between Zika virus-exposed and unexposed infants at 36 months (between-group difference 1·2 points [95% CI -4·2 to 6·5] in the León cohort; 2·8 [-2·4 to 8·1] in the Managua cohort) or at 48 months (-0·9 [-10·8 to 8·8] in the León cohort; 0·1 [-5·1 to 5·2] in the Managua cohort). No differences in ELC scores between Zika virus-exposed and unexposed infants exceeded 6 points at any time between 30 months and 48 months in León or between 36 months and 48 months in Managua, which was considered clinically significant in other settings.

INTERPRETATION

We found no significant differences in neurodevelopmental scores between normocephalic children with in-utero Zika virus exposure and Zika virus-unexposed children at age 36 months or 48 months. These findings are promising, supporting typical neurodevelopment in Zika virus-exposed normocephalic children, although additional follow-up and research is warranted.

FUNDING

National Institute of Child Health and Development, National Institute of Allergy and Infectious Diseases, and Fogarty International Center.

TRANSLATION

For the Spanish translation of the abstract see Supplementary Materials section.

Is Neurodevelopmental Assessment in Early Childhood Predictive of Performance Assessed Later in Childhood and Adolescence in Sub-Saharan Africa? A Systematic Review of the Literature

BACKGROUND

Most neurodevelopmental tests used to assess child development in sub-Saharan Africa were developed in western or high-income countries, raising the question of their usefulness with African children.

OBJECTIVE

This systematic review identified and synthesized key findings from studies measuring development in children in Sub-Saharan Africa in early childhood and again at school age, to assess neurocognitive associations longitudinally from infancy through middle childhood.

METHODS

The study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method, selecting articles referenced in the PubMed, PsycInfo, and Embase databases using the following inclusion criteria: published between 2000 and 2022, written in French or English, and presenting results dealing with the objective assessment of child's neurodevelopment. All articles were registered in the Zotero reference manager and analyzed by title, abstract, and full text.

RESULTS

Several of the seven selected studies confirmed that attention and working memory in infancy can predict children's neurocognitive performance, including mathematical ability, at school age. In two of the studies, children with poor mental development at 1 year of age are more likely to present with poorer behavioral development at school age, including learning difficulties in school and risk for grade repetition.

CONCLUSION

Cognitive ability assessed in early childhood is strongly associated with performance at school age in cohorts of African children followed longitudinally. Even with assessments adapted cross-culturally, infants and preschoolers at risk for poor developmental outcomes can be identified to better receive strategic early interventions to enhance their development.

Characterising school-age health and function in rural Zimbabwe using the SAHARAN toolbox

INTRODUCTION

We developed the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox to address the shortage of school-age assessment tools that combine growth, physical and cognitive function. Here we present i) development, acceptability and feasibility of the SAHARAN toolbox; ii) characteristics of a pilot cohort; and iii) associations between the domains measured in the cohort.

METHODS

Growth was measured with anthropometry, knee-heel length and skinfold thicknesses. Bioimpedance analysis measured lean mass index and phase angle. Cognition was assessed using the mental processing index, derived from the Kaufman Assessment Battery for Children version 2, a fine motor finger-tapping task, and School Achievement Test (SAT). Physical function combined grip strength, broad jump and the 20m shuttle-run test to produce a total physical score. A caregiver questionnaire was performed in parallel.

RESULTS

The SAHARAN toolbox was feasible to implement in rural Zimbabwe, and highly acceptable to children and caregivers following some minor modifications. Eighty children with mean (SD) age 7.6 (0.2) years had mean height-for-age (HAZ) and weight-for-age Z-scores (WAZ) of -0.63 (0.81) and -0.55 (0.85), respectively. Lean mass index and total skinfold thicknesses were related to WAZ and BMI Z-score, but not to HAZ. Total physical score was associated with unit rises in HAZ (1.29, 95% CI 0.75, 1.82, p<0.001), and lean mass index (0.50, 95% CI 0.16, 0.83, p = 0.004), but not skinfold thicknesses. The SAT was associated with unit increases in the mental processing index and child socioemotional score. The caregiver questionnaire identified high levels of adversity and food insecurity.

CONCLUSIONS

The SAHARAN toolbox provided a feasible and acceptable holistic assessment of child growth and function in mid-childhood. We found clear associations between growth, height-adjusted lean mass and physical function, but not cognitive function. The SAHARAN toolbox could be deployed to characterise school-age growth, development and function elsewhere in sub-Saharan Africa.

Predictive validation of Ugandan infant eye-tracking test for memory of human faces

We provide initial evidence that an eye-tracking based measure of infant attention and working memory (gaze preference for novel human faces) can predict aspects of neurocognitive performance years later among Ugandan children. 49 HIV-exposed/uninfected Ugandan children (22 boys, 27 girls) 6-12 months old were tested with the Mullen Scales of Early Learning and a modified Fagan Test of Infant Intelligence (FTII). Modified FTII measures pertaining to attention are correlated to the KABC-II Mental Processing Index (MPI) (rp = -0.40), p Cognitive assessments adapted to eye-tracking instrumentation can be useful to evaluate attention and working memory in HIV-affected children living in low- and middle-income countries.

Clinical and behavioral attributes leading to sleep disorders in children on the autism spectrum

Sleep disorders are a common comorbid condition in children diagnosed with autism spectrum disorder ("autism"). However, the relationship between the clinical features of autism and sleep disorders remains unclear. A better understanding of the inherent autism-related characteristics linked to comorbid sleep disorders would improve comprehensive assessment and management. This study examined the relationship between sociodemographics, autism symptoms, sleep problems, cognitive status, behavioral attributes, and sensory profiles. Using data from 1268 participants who took part in the Australian Autism Biobank, sleep-related measurements using the Child Sleep Habits Questionnaire (CSHQ) were compared between autistic children aged 2 to 17 (N = 969), their siblings (N = 188), and unrelated children without an autism diagnosis (N = 111). The known relationship between sleep problems and autism was further explored by including scores from the Autism Diagnostic Observation Schedule-2, Mullen Scales of Early Learning, Vineland Adaptive Behavioral Scale-II and the Short Sensory Profile-2; which were included in analyses for autistic participants who had a completed CSHQ. Multiple regression models were used to identify clinical/behavioral variables associated with CSHQ subscales. The autism group had a significantly higher total CSHQ score than the sibling and comparison groups (p < 0.001), indicating worse sleep quality. Within the autism group, lower adaptive behaviors (i.e., VABS-II) and sensory issues (i.e., SSP-2 subclass scores) were positively associated with the severity of sleep problems (i.e., the CSHQ subclass scores) (p < 0.001). The significant functional impact of poor sleep on autistic children warrants an assessment of sleep as a critical part of a holistic approach to supporting autistic children and their families. LAY SUMMARY: Autistic children generally have co-occurring conditions. Sleep disorders impact approximately 50%-80% of autistic children. The impact on the quality of life for both the children and their families can be significant. This study compares sleep problems in autistic children and adolescents with their siblings and children without a diagnosis of autism, and investigates the relationship between specific autistic traits, daily life behaviors and sleep problems. The findings highlight the importance of a holistic assessment for autistic children and matching appropriate sleep intervention and supports where indicated.

The Effects of Malaria in Pregnancy on Neurocognitive Development in Children at 1 and 6 Years of Age in Benin: A Prospective Mother-Child Cohort

BACKGROUND

Malaria in pregnancy (MiP) contributes significantly to infant mortality rates in sub-Saharan Africa and has consequences on survivors, such as preterm birth and low birth weight. However, its impact on long-term neurocognitive development in children remains unknown.

METHODS

Our prospective cohort included pregnant women and their live-born singletons from the Malaria in Pregnancy Preventive Alternative Drugs clinical trial. MiP was assessed using microscopy and real-time quantitative polymerase chain reaction (qPCR). Neurocognitive development in children was assessed using the Mullen Scales of Early Learning and the Kaufman Assessment Battery for Children, 2nd edition (KABC-II), at 1 and 6 years of age, respectively.

RESULTS

Of 493 pregnant women, 196 (40%) were infected with malaria at least once: 121 (31%) with placental malaria diagnosed by qPCR. Multiple linear regression B-coefficients showed that impaired gross motor scores were associated with MiP at least once (-2.55; confidence interval [95% CI]: -5.15, 0.05), placental malaria by qPCR (-4.95; 95% CI: -7.65, -2.24), and high parasite density at delivery (-1.92; 95% CI: -3.86, 0.02) after adjustment. Malaria and high parasite density at the second antenatal care visit were associated with lower KABC-II Non-Verbal Index scores at 6 years (-2.57 [95% CI: -4.86, -0.28] and -1.91 [-3.51, -0.32]), respectively.

CONCLUSIONS

This prospective cohort study provides evidence that MiP, particularly late term, could have important negative consequences on child development at 1 and 6 years of age. Mechanisms behind this association must be further investigated and diagnostic methods in low-income countries should be strengthened to provide adequate treatment.

CLINICAL TRIALS REGISTRATION

NCT00811421.

Adolescent health series: Adolescent neurocognitive development in Western and Sub-Saharan African contexts

The transitional period of adolescence has long been associated with physical, social and behavioural change. During this time, adolescents start to develop their own self-identity, make important life decisions and acquire the necessary skills to successfully transition to adulthood. More recently, advances in brain imaging technology have enabled increased understanding of structural and functional changes in the human brain during this developmental period, and how they relate to social, emotional, motivational and cognitive development. The ability to integrate these developing cognitive processes in increasingly complex social contexts is a key aspect of mature decision-making, which has implications for adolescent health, educational, economic and social outcomes. Insights from the field of developmental cognitive neuroscience could increase our understanding of this influential stage of life and thus inform potential interventions to promote adolescent health, a critical goal for global health research. Many social changes occur during adolescence and the social environment shapes both brain and cognitive development and the decisions adolescents make. Thus, it is important to study adolescent neurocognitive development in socio-cultural context. Yet, despite evidence from Western studies that socio-cultural and economic factors impact on adolescent neurocognitive development, existing studies of adolescent neurocognitive development in sub-Saharan Africa are relatively scarce. We summarise research findings from Western and sub-Saharan African contexts and highlight areas where research is lacking. Longitudinal studies from more diverse global samples will be needed to build a comprehensive model of adolescent development, that characterises both commonalities in developmental trajectories, as well as the way these can meaningfully differ between both individuals and contexts.

Neurodevelopment and exposure to neurotoxic metal(loid)s in environments polluted by mining, metal scrapping and smelters, and e-waste recycling in low and middle-income countries

This review covers a wide body of literature to gain an understanding of the impacts of informal activities related to metal extraction (primary mining and recycling) on early life exposure to neurotoxicants and on neurodevelopment. In primary mining, gold extraction with Hg amalgamation is the main environmental cause of Hg pollution in most artisanal small-scale gold mining (ASGM) activities around the world. Nevertheless, in Sub-Saharan Africa (SSA), Pb disrupted from gold-related ores, mining, and artisanal cookware production are an important neurotoxicant that seriously contaminates the affected population, with devastating effects on children. In e-waste recycling settings, the range of neurotoxic substances that contaminate mothers and children is wider than in primary mining environments. Thus, Hg and Pb are major pre- and postnatal neurotoxicants affecting children in the informal metal extraction activities and SSA countries show the highest record of human contamination and of neurotoxic effects on children. There are additional sources of neurotoxic contamination from mining and metal processing activities (cyanide tailing in South America and SSA) and/or co-exposure to Hg-containing products such as cosmetics (soaps and Hg-based skin lightning creams in Africa) and pediatric Thimerosal-containing vaccines (TCVs, that breaks down to ethyl-mercury) in current use in middle and low income countries. However, the action of these neurotoxicants (per se or in combination) on children needs more attention and research. Studies show a negative association between biomarkers of all environmental metal(loid)s (As, Cd, Hg, Mn, and Pb) studied and neurodevelopment in young children. Sadly, in many unregulated activities, child labor is widely employed, thus presenting an additional occupational exposure. Children living in polluted environments related to metal processing are disproportionately exposed to a wide range of co-occurring neurotoxic substances. The review showed compelling evidence from highly representative parts of the world (Africa, Asia, and Latin America) that the studied neurotoxic substances negatively affected areas of the brain associated with language, memory and executive function, as well as psychosocial behavior. Protecting the environment and children from unregulated and highly polluting metal extraction and processing are inextricably intertwined and deserve urgent attention.

Neurodevelopmental assessment at one year of age predicts neuropsychological performance at six years in a cohort of West African Children

Rural children from Benin, west Africa were evaluated with the Mullen Scales of Early Learning (MSEL) at one year of age and then at six years with the Kaufman Assessment Battery for Children (KABC-II), the visual computerized Tests of Variables of Attention (TOVA), and the Bruininks-Oseretsky Test (BOT-2) of motor proficiency (N = 568). Although both the MSEL and KABC-II were available to the assessors in French, instructions to the mother/child were in local language of Fon. Mothers were evaluated with the Edinburgh Postpartum Depression Scale (EPDS), Caldwell HOME Scale, educational level and literacy, and a Socio-Economic Scale - also in their local language (Fon). After adjusting for maternal factors, MSEL cognitive composite was correlated with KABC-II with moderate effect sizes, but not with TOVA scores. Overall eta-squared effect for the multivariate models were moderately to strongly correlated (.07 to .37). Neurodevelopmental assessments in early childhood adapted cross-culturally are predictive of school-age neuropsychological cognitive ability.

Defeating Paediatric Tuberculous Meningitis: Applying the WHO "Defeating Meningitis by 2030: Global Roadmap"

Children affected by tuberculous meningitis (TBM), as well as their families, have needs that lie at the intersections between the tuberculosis and meningitis clinical, research, and policy spheres. There is therefore a substantial risk that these needs are not fully met by either programme. In this narrative review article, we use the World Health Organization (WHO) “Defeating Meningitis by 2030: global roadmap” as a starting point to consider key goals and activities to specifically defeat TBM in children. We apply the five pillars outlined in the roadmap to describe how this approach can be adapted to serve children affected by TBM. The pillars are (i) prevention; (ii) diagnosis and treatment; (iii) surveillance; (iv) support and care for people affected by meningitis; and (v) advocacy and engagement. We conclude by calling for greater integration between meningitis and TB programmes at WHO and at national levels.

Soil-transmitted helminth infection in pregnancy and long-term child neurocognitive and behavioral development: A prospective mother-child cohort in Benin

Background

An estimated 30% of women in Sub-Saharan Africa suffer from soil-transmitted helminth infection during pregnancy (SHIP), which has been shown to increase risk of pre-term birth, low birth weight, and maternal anemia. A previous study in Benin found that SHIP was associated with impaired cognitive and gross motor development scores in 635 one-year-old children. The objective of the present study was to follow children prospectively to investigate whether the association between SHIP and child neurocognitive and behavioral development persisted at age six.

Principal findings

Our prospective child cohort included 487 live-born singletons of pregnant women enrolled in the Malaria in Pregnancy Preventive Alternative Drugs clinical trial in Allada, Benin. SHIP was assessed at three antenatal visits (ANVs) through collection and testing of stool samples. Neurocognitive and behavioral development was assessed in six-year-old children by trained investigators using the Kaufman Assessment Battery for Children 2^nd edition and the parent-reported Strengths and Difficulties Questionnaire (SDQ). Multiple linear regression models generated coefficients and 95% confidence intervals and potential mediating factors were tested. Prevalence of SHIP was 13% at the 1^st ANV, 9% at the 2^nd ANV, and 1% at delivery. SHIP was not associated with low neurocognitive scores in children at six years. Higher SDQ internalizing scores, indicating increased emotional impairments in children, were associated with helminth infection at the 2^nd ANV/delivery 1.07 (95% CI 0.15, 2.00) and at least once during pregnancy 0.79 (95% CI 0.12, 1.46) in adjusted models. Mediation analysis did not reveal significant indirect effects of several mediators on this association.

Conclusions

Our study shows that while SHIP is not associated with impaired long-term neurocognitive development, infections may have significant negative impacts on emotional development in six-year-old children. SHIP remains a critical public health issue, and adequate prevention and treatment protocols should be enforced in low- and middle-income countries.

Soil-transmitted helminth infections impact 1.5 billion individuals, primarily in low- and middle- income countries, each year and contribute to malnutrition, anemia, and impaired neurocognitive development in children. However, these infections in pregnancy and their impact on offspring have been less studied. One previous study found associations between soil-transmitted helminth infection during pregnancy and impaired cognitive functioning in offspring one year after birth. The current study aimed to follow these children prospectively until six years in order to confirm whether these associations persisted or not. Infections during pregnancy were no longer associated with cognitive or motor functioning in children; however, infections were associated with impaired behavioral development. Animal-based models have hypothesized maternal inflammation and poor birth outcomes to be the mechanisms behind this relationship; however, our findings did not support these mechanisms. This is one of very few prospective cohort studies in Sub-Saharan Africa to investigate these associations, and more research is needed to corroborate results. Limitations include limited power and the possibility that results are due to chance from multiple statistical tests. Adequate and accessible prevention and treatment efforts in pregnancy and childhood should be provided to populations in low- and middle- income countries at high risk of infection.

Growth, clinical and neurodevelopmental outcomes at school age are similar for children who received 1-year lamivudine or lopinavir/ritonavir HIV prophylaxis in early life

In the ANRS 12174 trial, HIV-exposed uninfected African neonates who received lopinavir-ritonavir (LPV/r) prophylaxis for 1 year exhibited slower growth from birth to week 50 compared with those receiving lamivudine (3TC). We assessed whether this difference in growth persisted over time, and was accompanied by differences in neuropsychological and clinical outcomes. Between February 2017 and February 2018, we conducted a cross-sectional clinical evaluation among former trial participants who completed the 50-week follow-up and who were not HIV-infected. In addition to clinical examination, neuropsychological outcomes were assessed using the tests Kaufman-ABCII, Test of Variables of Attention, Movement Assessment Battery for Children and the Strengths and Difficulties questionnaire, parent version. Of 1101 eligible children, aged 5–7 years, 553 could be traced and analysed (274 in the LPV/r and 279 in the 3TC groups). Growth, clinical and neuropsychological outcomes did not differ between treatment groups. At school age, children exposed to LPV/r and 3TC at birth for 1 year had comparable growth and neuropsychological outcomes without evidence of long-term side-effects of LPV/r. It provides reassuring data on clinical outcomes for all HIV-infected children treated with this antiretroviral drug in early life.

Comparison of growth models to describe growth from birth to 6 years in a Beninese cohort of children with repeated measurements

OBJECTIVE

To select a growth model that best describes individual growth trajectories of children and to present some growth characteristics of this population.

SETTINGS

Participants were selected from a prospective cohort conducted in three health centres (Allada, Sekou and Attogon) in a semirural region of Benin, sub-Saharan Africa.

PARTICIPANTS

Children aged 0 to 6 years were recruited in a cohort study with at least two valid height and weight measurements included (n=961).

PRIMARY AND SECONDARY OUTCOME MEASURES

This study compared the goodness-of-fit of three structural growth models (Jenss-Bayley, Reed and a newly adapted version of the Gompertz growth model) on longitudinal weight and height growth data of boys and girls. The goodness-of-fit of the models was assessed using residual distribution over age and compared with the Akaike Information Criterion (AIC) and Bayesian Information Criterion (BIC). The best-fitting model allowed estimating mean weight and height growth trajectories, individual growth and growth velocities. Underweight, stunting and wasting were also estimated at age 6 years.

RESULTS

The three models were able to fit well both weight and height data. The Jenss-Bayley model presented the best fit for weight and height, both in boys and girls. Mean height growth trajectories were identical in shape and direction for boys and girls while the mean weight growth curve of girls fell slightly below the curve of boys after neonatal life. Finally, 35%, 27.7% and 8% of boys; and 34%, 38.4% and 4% of girls were estimated to be underweight, wasted and stunted at age 6 years, respectively.

CONCLUSION

The growth parameters of the best-fitting Jenss-Bayley model can be used to describe growth trajectories and study their determinants.

Reliability and Validity of an Adapted and Translated Version of the Mullen Scales of Early Learning (AT-MSEL) in Rural Guatemala

BACKGROUND

A growing literature base supports the use of tests developed in high-income countries to assess children in low resource settings when carefully translated, adapted, and applied. Evaluation of psychometric properties of adapted and translated measures within populations is necessary. The current project sought to evaluate the reliability and validity of an adapted and translated version of the Mullen Scales of Early Learning (AT-MSEL) in rural Guatelama.

METHODS

The reliability and validity of the AT-MSEL in rural Guatemala were analyzed for children ages 0-5 years.

RESULTS

Interrater reliability coefficients (ICC = 0.99-1.0) and internal consistency (Cronbach's alpha = 0.91-0.93) were excellent for all subscales. General linear models utilizing paired data showed consistency between standard scores (p < 0.0001). Mean raw scores increased with chronological age, as expected. Across age groups, subscales were significantly, positively correlated with one another (p < 0.05 - < 0.001) with one exception, visual reception and expressive language at the 0-10 month age range (p = 0.43).

CONCLUSIONS

The AT- MSEL showed strong psychometric properties in a sample of young children in rural Guatemala. Findings demonstrate that the AT-MSEL can be used validly and reliably within this specific population of children. This work supports the concept that tests developed in high-income countries can be used to assess children in low resource settings when carefully translated, adapted and applied.

Neurocognitive and functional impairment in adult and paediatric tuberculous meningitis

In those who survive tuberculous meningitis (TBM), the long-term outcome is uncertain; individuals may suffer neurocognitive, functional and psychiatric impairment, which may significantly affect their ability to lead their lives as they did prior to their diagnosis of TBM. In children who survive, severe illness has occurred at a crucial timepoint in their development, which can lead to behavioural and cognitive delay. The extent and nature of this impairment is poorly understood, particularly in adults. This is in part due to a lack of observational studies in this area but also inconsistent inclusion of outcome measures which can quantify these deficits in clinical studies. This leads to a paucity of appropriate rehabilitative therapies available for these individuals and their caregivers, as well as burden at a socioeconomic level. In this review, we discuss what is known about neurocognitive impairment in TBM, draw on lessons learnt from other neurological infections and discuss currently available and emerging tools to evaluate function and cognition and their value in TBM. We make recommendations on which measures should be used at what timepoints to assess for impairment, with a view to optimising and standardising assessment of neurocognitive and functional impairment in TBM research.

Receptive language skills among young children in rural Guatemala: The relationship between the Test de Vocabulario en Imagenes Peabody and a translated and adapted version of the Mullen Scales of Early Learning

BACKGROUND

Children in low- and lower middle income countries (LMICs) often have poorer language skills compared with children from high-income countries. Limited availability of culturally and linguistically appropriate assessment measures in LMICs, especially for young children, can hinder early identification and prevention efforts. Here, we describe receptive language (RL) skills among young children in rural Guatemala and report on the validity of a translated and culturally adapted developmental measure of RL.

METHODS

Children (n = 157; m = 53.6 months, range = 42-68 months) enrolled in a prospective cohort study of postnatally acquired Zika virus infection were administered the Test de Vocabulario en Imagenes Peabody (TVIP) and the RL scale from a translated and adapted version of the Mullen Scales of Early Learning (MSEL). Performance on the TVIP was compared with the Latin American normative sample. Correlational analysis examined the relationship between performance on the TVIP and the MSEL-RL.

RESULTS

Mean scores were significantly below the normative sample mean on the TVIP, t(126) = -11.04, p < .001; d = 1.00. Performance on the TVIP among children who passed the practice items (n = 127) was significantly positively associated with performance on the MSEL-RL (r = .50, p < .001), but not significantly associated with age or gender. Older age (p < .0001) and female gender (p = .018) were associated with passing the TVIP practice items.

CONCLUSIONS

Delays in RL vocabulary were identified among young children in rural Guatemala on the TVIP. The association between scores on the TVIP and the RL scale of the MSEL provides preliminary support for the construct validity of this translated and adapted version of the MSEL.

Rating early child development outcome measurement tools for routine health programme use

BACKGROUND

Identification of children at risk of developmental delay and/or impairment requires valid measurement of early child development (ECD). We systematically assess ECD measurement tools for accuracy and feasibility for use in routine services in low-income and middle-income countries (LMIC).

METHODS

Building on World Bank and peer-reviewed literature reviews, we identified available ECD measurement tools for children aged 0-3 years used in ≥1 LMIC and matrixed these according to when (child age) and what (ECD domains) they measure at population or individual level. Tools measuring <2 years and covering ≥3 developmental domains, including cognition, were rated for accuracy and feasibility criteria using a rating approach derived from Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

61 tools were initially identified, 8% (n=5) population-level and 92% (n=56) individual-level screening or ability tests. Of these, 27 tools covering ≥3 domains beginning <2 years of age were selected for rating accuracy and feasibility. Recently developed population-level tools (n=2) rated highly overall, particularly in reliability, cultural adaptability, administration time and geographical uptake. Individual-level tool (n=25) ratings were variable, generally highest for reliability and lowest for accessibility, training, clinical relevance and geographical uptake.

CONCLUSIONS AND IMPLICATIONS

Although multiple measurement tools exist, few are designed for multidomain ECD measurement in young children, especially in LMIC. No available tools rated strongly across all accuracy and feasibility criteria with accessibility, training requirements, clinical relevance and geographical uptake being poor for most tools. Further research is recommended to explore this gap in fit-for-purpose tools to monitor ECD in routine LMIC health services.

Adaptation of the Mullen Scales of Early Learning for use among infants aged 5- to 24-months in rural Gambia

Infants in low‐resource settings are at heightened risk for compromised cognitive development due to a multitude of environmental insults in their surroundings. However, the onset of adverse outcomes and trajectory of cognitive development in these settings is not well understood. The aims of the present study were to adapt the Mullen Scales of Early Learning (MSEL) for use with infants in a rural area of The Gambia, to examine cognitive development in the first 24‐months of life and to assess the association between cognitive performance and physical growth. In Phase 1 of this study, the adapted MSEL was tested on 52 infants aged 9‐ to 24‐months (some of whom were tested longitudinally at two time points). Further optimization and training were undertaken and Phase 2 of the study was conducted, where the original measures were administered to 119 newly recruited infants aged 5‐ to 24‐months. Infant length, weight and head circumference were measured concurrently in both phases. Participants from both phases were split into age categories of 5–9 m (N = 32), 10–14 m (N = 92), 15–19 m (N = 53) and 20–24 m (N = 43) and performance was compared across age groups. From the ages of 10–14 m, Gambian infants obtained lower MSEL scores than US norms. Performance decreased with age and was lowest in the 20–24 m old group. Differential onsets of reduced performance were observed in the individual MSEL domains, with declines in visual perception and motor performance detected as early as at 10–14 months, while reduced language scores became evident after 15–19 months of age. Performance on the MSEL was significantly associated with measures of growth.