Monitoring psychomotor development in a resource-limited setting: an evaluation of the Kilifi Developmental Inventory

Nutritional supplementation in children with severe pneumonia in Uganda and Kenya (COAST-Nutrition): a phase 2 randomised controlled trial

Background

Severe pneumonia in African children results in poor long-term outcomes (deaths/readmissions) with undernutrition as a key risk factor. We hypothesised additional energy/protein-rich Ready-to-Use Therapeutic Foods (RUTF) would meet additional nutritional requirements and improve outcomes.

Methods

COAST-Nutrition was an open-label Phase 2 randomised controlled trial in children (aged 6 months-12 years) hospitalised with severe pneumonia (and hypoxaemia, SpO2 <92%) in Mbale, Soroti, Jinja, Masaka Regional Referral Hospitals, Uganda and Kilifi County Hospital, Kenya (ISRCTN10829073 (registered 6th June 2018) PACTR202106635355751 (registered 2nd June 2021)). Children were randomised (ratio 1:1) to enhanced nutritional supplementation with RUTF (plus usual diet) for 56 days vs usual diet (control). The primary outcome was change in mid-upper arm circumference (MUAC) at 90 days as a composite with mortality. Secondary outcomes include anthropometric status, mortality, and readmissions at Days 28, 90 and 180.

Findings

Between 12 August 2018 and 22 April 2022, 846 eligible children were randomised, 424 to RUTF and 422 to usual diet, and followed for 180-days [12 (1%) lost-to-follow-up]. RUTF supplement was initiated in 417/419 (>99%). By Day 90, there was no significant difference in the composite endpoint (probabilistic index 0.49, 95% CI 0.45-0.53, p = 0.74). Respective 90-day mortality (13/420 3.1% vs 14/421 3.3%) and MUAC increment (0.54 (SD 0.85) vs 0.55 (SD 0.81)) were similar between arms. There was no difference in any anthropometric secondary endpoints to Day 28, 90 or 180 except skinfold thickness at Day 28 and Day 90 was greater in the RUTF arm. Serious adverse events were higher in the RUTF arm (n = 164 vs 108), mainly due to hospital readmission for acute illness (54/387 (14%) vs 37/375 (10%).

Interpretation

Our study suggested that nutritional supplementation with RUTF did not improve outcomes to 180 days in children with severe pneumonia.

Funding

This trial is part of the EDCTP2 programme (grant number RIA-2016S-1636-COAST-Nutrition) supported by the European Union, and UK Joint Global Health Trials scheme: Medical Research Council, Department for International Development, Wellcome Trust (grant number MR/L004364/1, UK).

Is child anemia associated with early childhood development? A cross-sectional analysis of nine Demographic and Health Surveys

Anemia is a significant public health problem in many low- and middle-income countries (LMICs), with young children being especially vulnerable. Iron deficiency is a leading cause of anemia and prior studies have shown associations between low iron status/iron deficiency anemia and poor child development outcomes. In LMICs, 43% of children under the age of five years are at risk of not meeting their developmental potential. However, few studies have examined associations between anemia status and early childhood development (ECD) in large population-based surveys. We examined the associations between severe or moderate anemia and ECD domains (literacy-numeracy, physical, social-emotional, and learning) and an overall ECD index among children age 36-59 months. Nine Demographic and Health Surveys (DHS) from phase VII of The DHS Program (DHS-7) that included the ECD module and hemoglobin testing in children under age five years were used. Bivariate and multivariate logistic regressions were run for each of the five outcomes. Multivariate models controlled for early learning/interaction variables, child, maternal, and paternal characteristics, and socio-economic and household characteristics. Results showed almost no significant associations between anemia and ECD domains or the overall ECD index except for social-emotional development in Benin (AOR = 1.00 p < 0.05) and physical development in Maldives (AORs = 0.97 p < 0.05). Attendance at an early childhood education program was also significantly associated with the outcomes in many of the countries. Our findings reinforce the importance of the Nurturing Care Framework which describes a multi-sectoral approach to promote ECD in LMICs.

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.

Construction and validation of ShaMaq developmental screening tool

INTRODUCTION

The diagnosis of developmental delay and early intervention ameliorates long-term sequelae. There is a need for an appropriate, regionally adapted and reliable developmental screening tool to be used in low and middle-income countries with scarce resources.

AIM

The aim of this research is to construct and validate a screening tool for identifying developmental delay in Pakistani children.

METHOD

ShaMaq developmental screening tool (SDST) was developed consisting of five proformas to be administered at different age groups: 6-8 weeks (Group 1), 6-10 months (Group 2), 18-24 months (Group 3), 3-3.5 years (Group 4), and 4.5-5.5 years (Group 5). On an average, Groups 1-3 took 10-15 min, whereas Groups 4 and 5 took 20-25 min. We sampled children between the ages of 6 weeks to 5.5 years and tested them all within their designated age groups. Internal consistency was assessed by Cronbach's alpha. Interobserver testing was done for reliability and concurrent validity was undertaken by using the senior consultant developmental paediatrician's final diagnosis as the gold standard.

RESULTS

Out of 550 healthy children, 8-19% in the five groups were found to have some form of developmental delay using SDST. Approximately 50% of the families were in the low-to-moderate income bracket, and nearly 93% lived in a joint family system. Internal consistency of items in the five groups ranged from 0.784 to 0.940, whereas both interobserver reliability and concurrent validity ranged from 0.737 to 1.0. SDST showed 94.4% sensitivity and 92.9% specificity.

CONCLUSION

SDST is an effective tool for identifying delay in healthy children with good internal consistency, reliability, and validity.

Gross motor developmental delay and associated factors among under-five children attending public health facilities of Dessie city, Ethiopia

BACKGROUND

Child psychomotor development and factors affecting it today is the subject of interest of many studies, in particular by the experts involved in the protection and improvement of children's health. There is limited evidence on developmental delay among under-five children in low-income countries like Ethiopia. The aim of this study was to assess gross motor developmental delay and associated factors among under-five children attending public health facilities of Dessie city, Ethiopia.

METHODS

Facility based cross sectional study design was used among under-five children attending under-five OPD in public health facilities of Dessie town from July 1, 2020 to August 15, 2021. A total of, 417 under-five children were systematically selected based on their average number of clients in a month. A pretested structured questionnaire was used for data collection, and data was entered into Epi-data 3.1 version and it was exported to STATA version 14 for analysis. Binary logistic regression analysis was used to identify factors associated with the outcome variable. Odds ratio with 95% confidence interval was used to show the strength and direction of association respectively and P-value less than 0.05 is used to declare statistical significance.

RESULTS

The overall proportion of gross motor developmental delay among under-five children attending health facilities of Dessie city, Ethiopia was 16.31%, 95% CI: (13.05, 20.19). Increased age of the child [AOR = 0.97, 95% CI: (0.96, 0.99)], increased gestational age during pregnancy [AOR = 0.47, 95% CI: (0.37, 0.65)], being male [AOR = 5.26, 95% CI: (1.76, 15.67)], having history of alcohol intake during pregnancy [AOR = 7.40, 95% CI: (2.36, 23.25)], taking iron during pregnancy [AOR = 0.04, 95% CI: (0.01, 0.15)], facing fetal and/or maternal complication [AOR = 4.98, 95% CI: (1.20, 20.62)], having instrumental delivery [AOR = 9.78, 95% CI: (2.48, 38.60)] were significantly associated with gross motor developmental delay.

CONCLUSIONS

The gross motor developmental delay among under-five children was higher as compared to other literatures. This study indicated that, age and sex of the child, iron and alcohol intake during pregnancy, gestational age, mode of delivery and any complication to her and or her neonate were independent variables which showed statistical significant association. The physicians should advise mothers to take iron-folic acid supplement properly and to avoid intake of alcohol during pregnancy. In addition, they should focus on those mothers who faced any complication to her and/or her neonate and better to discourage instrumental delivery unless there are no other options.

The creation of the Global Scales for Early Development (GSED) for children aged 0-3 years: combining subject matter expert judgements with big data

INTRODUCTION

With the ratification of the Sustainable Development Goals, there is an increased emphasis on early childhood development (ECD) and well-being. The WHO led Global Scales for Early Development (GSED) project aims to provide population and programmatic level measures of ECD for 0-3 years that are valid, reliable and have psychometrically stable performance across geographical, cultural and language contexts. This paper reports on the creation of two measures: (1) the GSED Short Form (GSED-SF)-a caregiver reported measure for population-evaluation-self-administered with no training required and (2) the GSED Long Form (GSED-LF)-a directly administered/observed measure for programmatic evaluation-administered by a trained professional.

METHODS

We selected 807 psychometrically best-performing items using a Rasch measurement model from an ECD measurement databank which comprised 66 075 children assessed on 2211 items from 18 ECD measures in 32 countries. From 766 of these items, in-depth subject matter expert judgements were gathered to inform final item selection. Specifically collected were data on (1) conceptual matches between pairs of items originating from different measures, (2) developmental domain(s) measured by each item and (3) perceptions of feasibility of administration of each item in diverse contexts. Prototypes were finalised through a combination of psychometric performance evaluation and expert consensus to optimally identify items.

RESULTS

We created the GSED-SF (139 items) and GSED-LF (157 items) for tablet-based and paper-based assessments, with an optimal set of items that fit the Rasch model, met subject matter expert criteria, avoided conceptual overlap, covered multiple domains of child development and were feasible to implement across diverse settings.

CONCLUSIONS

State-of-the-art quantitative and qualitative procedures were used to select of theoretically relevant and globally feasible items representing child development for children aged 0-3 years. GSED-SF and GSED-LF will be piloted and validated in children across diverse cultural, demographic, social and language contexts for global use.

Piloting the adaptation of the Kaufman Assessment Battery for Children—2nd edition (KABC-II) to assess school-age neurodevelopment in rural Zimbabwe

Background: Neurodevelopment assessment tools for low-resource settings are urgently needed. However, most available tools were developed in high-income settings and may lack cross-cultural validity. Methods: We piloted and adapted two subtests (pattern reasoning and story completion) within the Kaufman Assessment Battery for Children-2nd edition (KABC-II) for use in rural Zimbabwean children aged 7 years old, both within the planning domain. After initial assessments of face validity, we substituted and added items in the test battery through a co-design process with fieldworkers and child development experts. To assess how successful the changes were, T-tests adjusting for unequal variances were used to compare scores between the original and adapted versions of the same subtest. ANOVA and pairwise analysis was performed to compare the performance of KABC-II subtests across domains. Intraclass correlation coefficient was calculated to explore the variability between domains. Results: Initial test scores on the planning domain were significantly lower than the other three domains of learning, sequential memory and simultaneous reasoning (P<0.001) in 50 children. Modified subtests were administered to another 20 children, who showed story completion scores that were 0.7 marks higher (95% CI 0.0, 1.4; P=0.05) and pattern reasoning scores 1.8 marks higher (95% CI 0.5, 3.2; P=0.01). Overall, the planning domain mean score increased from 8.1 (SD 2.9) to 10.6 (SD 3.4). The intra class correlation coefficient between all four KABC-II domains was initially 0.43 (95% CI 0.13, 0.64) and after modification was 0.69 (95% CI 0.37, 0.87), suggesting an increase in the construct validity. Conclusions: The KABC-II planning domain was successfully adapted to improve cross-cultural validity. Construct validity was enhanced, based on increased inter-correlations among scales. This pilot has since been applied to the SHINE follow-up study. The process of co-design to modify tests for new settings may be beneficial for other commonly used neurodevelopmental tools.

Health professionals' experiences with the PEDI-UG: What do Ugandan occupational therapists say about the utility and value of the Pediatric Evaluation of Disability Inventory (PEDI-UG) for children with disabilities?

BACKGROUND

The Uganda version of Pediatric Evaluation of Disability Inventory (PEDI-UG) was culturally adapted and validated from the PEDI-US, a tool used to evaluate the functional capability of children with or without disability aged 6 months to 7.5 years in the areas of self-care, mobility and social domains. A group of Ugandan occupational therapists with experience of using PEDI-UG participated in this study to explore the question: What do Ugandan occupational therapists say about the utility and value of the PEDI-UG for children with disabilities?

METHODS

A qualitative research design was chosen to explore the participants' viewpoints concerning the utility and value of the PEDI-UG for children with disabilities. Purposive sampling was used to recruit health professionals for the focus group discussions. Focus group discussions were carried out with 18 occupational therapists and nurses. Thematic analysis was performed to establish patterns and themes.

RESULTS

Several challenges concerning the contextual use of PEDI-UG were reported. For example, PEDI-UG being culturally adapted in two languages (English and Luganda) makes it difficult for health professionals to use it for children whose caregivers are non-English or non-Luganda speakers. In addition, participants reported adapting the way they asked the assessment questions, struggling with how they interpreted the scores and observing the child's skills if required during PEDI-UG interviews with caregivers.

CONCLUSIONS

The findings of this study suggest that health professionals are challenged with the use of the PEDI-UG assessment in diverse cultural contexts and/or languages. These challenges are important considerations for the PEDI-UG translation in different Uganda cultural languages and training health professionals on the use and value of PEDI-UG for children with disabilities.

Psychomotor development in two-year-old Ivorian and Ghanaian children - Psychometric properties of the Kilifi Developmental Inventory

The assessment of psychomotor development in young children from low- and middle-income countries is impeded due to the lack of tools specifically designed for these resource-constrained contexts. This cross-sectional study aimed at analysing the measurement properties of the Kilifi Developmental Inventory (KDI) in two-year-old children. We administered the KDI to 289 children from Côte d'Ivoire and 230 children from Ghana. The postulated internal structure with two first-order latent variables (locomotor performance and eye-hand coordination) that loaded on a second-order latent variable (psychomotor functioning) was supported. The reliability of most factors and scales was sufficient. Interrater reliability of most items was acceptable. Correlations were weak between the scale scores and age and gender, respectively. The findings are limited by the restricted age range of the sample. Overall, the KDI showed promising measurement properties for the assessment of psychomotor performance in children from sub-Saharan countries.

Low Hemoglobin Levels Are Associated with Reduced Psychomotor and Language Abilities in Young Ugandan Children

Children living in Sub-Saharan Africa are vulnerable to developmental delay, particularly in the critical first five years due to various adverse exposures including disease and nutritional deficiencies. Anemia and iron deficiency (ID) are highly prevalent in pregnant mothers and young children and are implicated in abnormal brain development. However, available evidence on the association between anemia, ID and neurodevelopment in sub-Saharan Africa is limited. Using data from the Entebbe Mother and Baby Study prospective birth cohort, we examined the effect of maternal and child hemoglobin (Hb) levels and child iron status on developmental scores in 933 and 530 pre-school Ugandan children respectively. Associations between Hb levels, iron status and developmental scores were assessed using regression analyses adjusting for potential confounders. Lower maternal and child Hb levels were associated with reduced psychomotor scores at 15 months, while only lower Hb levels in infancy were associated with reduced language scores. We found no evidence that anemia or ID was associated with cognitive or motor scores at five years. This study emphasizes the importance of managing anemia in pregnancy and infancy and highlights the need for further studies on the effects of anemia and ID in children living in Sub-Saharan Africa.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Development and validation of the Ibadan Simplified Developmental Screening chart

BACKGROUND

Developmental assessment remains an integral part of the routine evaluation of the wellbeing of every child. Children in resource-poor countries are not routinely assessed for signs of developmental delay and developmental disorders are frequently overlooked. A major gap exists in the availability of culturally appropriate and cost-effective developmental screening tools in many low and middle income countries (LMICs) with large populations.

OBJECTIVE

To bridge the existing gap, we describe the process of the development and validation of the Ibadan Simplified Developmental Screening (ISDS) chart, for routine developmental screening in Nigerian children.

METHODS

We developed an item pool across 4 domains of development namely, the gross motor, vision-fine motor, communication and socio-behavioural domains. The ISDS chart consists of 3-4 item questions for each domain of development, and responses are to be provided by the caregiver. Each chart is age-specific, from 6 weeks to 12 months. A total score derived from the summation of the scores in each domain are plotted on the ISDS scoring guide with a pass or fail score. Each child was evaluated by the Ages and Stages Questionnaire as the standard.

RESULTS

A total of 950 infants; 453 males and 497 females were enrolled. The estimates of internal consistency between the two instruments ranged between 0.7-1.0. Using the ASQ as the gold standard, the ISDS chart demonstrated a sensitivity of 98.8%, 78.4% and 99.7% in the gross motor, communication and the social and emotional domains respectively, for detecting infants who might require further assessment for developmental delays.

CONCLUSION

The indigenous tool fills a major gap in the need for cost-effective interventions for developmental monitoring in LMICs. Future work should include the deployment of the tool in the wider population, using digital health approaches that could underpin policy making in the region.

Children's Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies.   Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).

Children's Oxygen Administration Strategies And Nutrition Trial (COAST-Nutrition): a protocol for a phase II randomised controlled trial

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies.   Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).

Validation of the Infant and Young Child Development (IYCD) Indicators in Three Countries: Brazil, Malawi and Pakistan

Background: The early childhood years provide an important window of opportunity to build strong foundations for future development. One impediment to global progress is a lack of population-based measurement tools to provide reliable estimates of developmental status. We aimed to field test and validate a newly created tool for this purpose. Methods: We assessed attainment of 121 Infant and Young Child Development (IYCD) items in 269 children aged 0–3 from Pakistan, Malawi and Brazil alongside socioeconomic status (SES), maternal educational, Family Care Indicators and anthropometry. Children born premature, malnourished or with neurodevelopmental problems were excluded. We assessed inter-rater and test-retest reliability as well as understandability of items. Each item was analyzed using logistic regression taking SES, anthropometry, gender and FCI as covariates. Consensus choice of final items depended on developmental trajectory, age of attainment, invariance, reliability and acceptability between countries. Results: The IYCD has 100 developmental items (40 gross/fine motor, 30 expressive/receptive language/cognitive, 20 socio-emotional and 10 behavior). Items were acceptable, performed well in cognitive testing, had good developmental trajectories and high reliability across countries. Development for Age (DAZ) scores showed very good known-groups validity. Conclusions: The IYCD is a simple-to-use caregiver report tool enabling population level assessment of child development for children aged 0–3 years which performs well across three countries on three continents to provide reliable estimates of young children’s developmental status.

Early intervention for children with developmental disabilities in low and middle-income countries - the case for action

In the last two decades, the global community has made significant progress in saving the lives of children <5 y of age. However, these advances are failing to help all children to thrive, especially children with disabilities. Most early child development research has focussed on the impact of biological and psychosocial factors on the developing brain and the effect of early intervention on child development. Yet studies typically exclude children with disabilities, so relatively little is known about which interventions are effective for this high-risk group. In this article we provide an overview of child development and developmental disabilities. We describe family-centred care interventions that aim to provide optimal stimulation for development in a safe, stable and nurturing environment. We make the case for improving opportunities for children with developmental disabilities to achieve their full potential and thrive, including through inclusive early childhood development intervention. Finally, we call for the global research community to adopt a systematic approach for better evidence for and implementation of early interventions for children with developmental disabilities in low-resource settings.

[Formula: see text]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.

Cultural adaptation of the Bayley Scales of Infant and Toddler Development, 3rd Edition for use in Kenyan children aged 18-36 months: A psychometric study

BACKGROUND

The Bayley Scales of Infant and Toddler Development, 3rd Edition (Bayley-III) is frequently used in international child development research. No studies examine its psychometric properties when culturally adapted within the Kenyan context.

AIMS

To culturally adapt the Bayley-III for use in Kenya and evaluate its validity and reliability.

METHODS AND PROCEDURES

Forward and backward translation, cognitive interviews, and a brief pilot of culturally adapted items were performed. This psychometric study was part of another study on children born to mothers with HIV in Eldoret, Kenya. One hundred seventy-two children aged 18-36 months were assessed for cognition, receptive/expressive communication, and fine/gross motor domains using the Bayley-III. Confirmatory factor analysis (CFA), inter-scale Pearson correlations, internal consistency, t-tests, and test-retest reliability were performed.

OUTCOMES AND RESULTS

The mean age of children was 22.8 (SD 4.5) months old; 52.7 % (n = 89) were male. CFA revealed that both two- and three-factor indices had good and comparable fit. Pearson correlations were high between fine motor and receptive communication (r >0.70). Internal consistency was very strong for all of the subtests, with Cronbach coefficient alpha scores ranging from 0.88 to 0.96. Known groups/convergent validity was confirmed with stunting and parental concern for delays. Test-retest reliability was good and did not differ substantially across groups.

CONCLUSIONS AND IMPLICATIONS

The Kenyan adapted Bayley-III is a psychometrically acceptable tool to assess child development. The scaled and composite scores should not be used to define Kenyan developmental norms, but it can be useful for comparing groups within research settings.

Last Mile Access to Enriched Children's Complementary Food: Mitigating Malnutrition in Kenya

Commercial complementary foods are not accessible at the last mile of delivery, despite a veritable stunted growth explosion in Kenya. A Mile for the Brain aims to reduce child malnutrition by solving the pervasive distribution bottlenecks and prohibitive pricing challenges. This paper presents the systematized measurement for change process. We focus on the selection of off-the-shelf complementary foods, training of women entrepreneurs responsible for commercializing these complementary foods, coaching given to mothers on appropriate feeding education, and lastly the learning cycle revolving around feeding mothers, entrepreneurs for the Mile for the Brain social enterprise itself. We highlight the real-life challenges involved in this process in the context of adversity and constrained resources. The results, findings, and policy implications of this study will be reported elsewhere.

Comparison of psychomotor development among children conceived through icsi in-vitro-fertilisation and naturally at 5 through 30 months of age, Vietnam

OBJECTIVE(S)

To compare psychomotor development during 5 months to 30 months of age among children who were conceived via ICSI in-vitro fertilization to those conceived naturally.

STUDY DESIGN

Prospective cohort study was conducted during 2017-2018 with children visiting Tu Du Hospital for scheduled health checks. We randomly recruited 935 five-to-thirty-month-old children and distributed them into two groups for comparison: a group of 426 ICSI/IVF children and a group of 509 Naturally Conceived (NC) children. A team of pediatric mental health professionals used the revised Brunet-Lézine scale to directly examine those children and assess their Developmental Quotient (DQ). Controlling confounders with Propensity Score Matching (PSM), we analyzed and compared psychomotor development in 421 IVF children conceived by intracytoplasmic sperm injection (ICSI) against 421 NC.

RESULT(S)

At DQ cut-off point of 85, study data pinpointed no difference in such single DQs as motor posture, sociability and global scores between the two cohort groups. However, there was a difference in coordination and language DQs. IVF group's low-score proportion for coordination was 2.16 times that of NC group [95 % CI: 1.11-4.21] and its low-score proportion for language was 2.15 times that of NC group [95 % CI: 1.15-4.01].

CONCLUSION

This study showed that IVF was not completely free from adverse effects. At the age of five to thirty months, IVF children would develop language and motor coordination more slowly than NC children, suggesting IVF should be done only when needed.

Associations between individual variations in visual attention at 9 months and behavioral competencies at 18 months in rural Malawi

Theoretical and empirical considerations suggest that individual differences in infant visual attention correlate with variations in cognitive skills later in childhood. Here we tested this hypothesis in infants from rural Malawi (n = 198-377, depending on analysis), who were assessed with eye tracking tests of visual orienting, anticipatory looks, and attention to faces at 9 months, and more conventional tests of cognitive control (A-not-B), motor, language, and socioemotional development at 18 months. The results showed no associations between measures of infant attention at 9 months and cognitive skills at 18 months, either in analyses linking infant visual orienting with broad cognitive outcomes or analyses linking specific constructs between the two time points (i.e., switching of anticipatory looks and manual reaching responses), as correlations varied between -0.08 and 0.14. Measures of physical growth, and family socioeconomic characteristics were also not correlated with cognitive outcomes at 18 months in the current sample (correlations between -0.10 and 0.19). The results do not support the use of the current tests of infant visual attention as a predictive tool for 18-month-old infants' cognitive skills in the Malawian setting. The results are discussed in light of the potential limitations of the employed infant tests as well as potentially unique characteristics of early cognitive development in low-resource settings.

The Role of Iron in Brain Development: A Systematic Review

One-third of children falter in cognitive development by pre-school age. Iron plays an important role in many neurodevelopmental processes, and animal studies suggest that iron sufficiency in pregnancy and infancy is particularly important for neurodevelopment. However, it is not clear whether iron deficiency directly impacts developmental outcomes, and, if so, whether impact differs by timing of exposure or developmental domain. We searched four databases for studies on iron deficiency or iron supplementation in pregnancy, or at 0-6 months, 6-24 months, or 2-4 years of age. All studies included neurodevelopmental assessments in infants or children up to 4 years old. We then qualitatively synthesized the literature. There was no clear relationship between iron status and developmental outcomes across any of the time windows or domains included. We identified a large quantity of low-quality studies, significant heterogeneity in study design and a lack of research focused on pregnancy and early infancy. In summary, despite good mechanistic evidence for the role of iron in brain development, evidence for the impact of iron deficiency or iron supplementation on early development is inconsistent. Further high-quality research is needed, particularly within pregnancy and early infancy, which has previously been neglected.

Vitamin D Status Is Not Associated with Cognitive or Motor Function in Pre-School Ugandan Children

Vitamin D deficiency is common worldwide and young children are among the most affected groups. Animal studies suggest a key role for vitamin D in brain development. However, studies investigating the effects of vitamin D on neurobehavioural outcomes in children are inconclusive and evidence is limited in sub-Saharan Africa. We evaluated the effect of vitamin D status on cognitive and motor outcomes using prospective data from the Entebbe Mother and Baby Study birth cohort. We analysed data from 302 Ugandan children with 25-hydroxyvitamin D (25(OH)D) measurements below five years and developmental measures at five years of age. We used multivariable linear regression, adjusted for potential confounders, to estimate the effect of 25(OH)D on cognitive and motor outcomes. Of 302 children, eight (2.7%) had 25(OH)D levels <50 nmol/L, 105 (35.8%) had levels 50-75 nmol/L and 189 (62.6%) had levels >75 nmol/L. There was no evidence that earlier vitamin D status was associated with cognitive and motor outcomes in five-year-old Ugandan children. This study adds to the sparse literature and highlights the need for further longitudinal studies on vitamin D and neurobehavioural outcomes in children living in sub-Saharan Africa.

Neonatal jaundice and developmental impairment among infants in Kilifi, Kenya

BACKGROUND

Neonatal jaundice (NNJ) is common in sub-Saharan Africa (SSA), and it is associated with sepsis. Despite the high incidence, little has been documented about developmental impairments associated with NNJ in SSA. In particular, it is not clear if sepsis is associated with greater impairment following NNJ.

METHODS

We followed up 169 participants aged 12 months (57 cases and 112 controls) within the Kilifi Health Demographic Surveillance System. The diagnosis of NNJ was based on clinical laboratory measurement of total serum bilirubin on admission, whereas the developmental outcomes were assessed using the Developmental Milestones Checklist and Kilifi Development Inventory.

RESULTS

There were significant differences between the cases and controls in all developmental domains. Cases scored lower in language functioning (mean [M] = 6.5, standard deviation [SD] = 4.3 vs. M = 8.9, SD = 4.6; p < .001); psychomotor functioning (Mdn = 23, interquartile range [IQR] = 17-34 vs. Mdn = 31.0, IQR = 22.0-44.0; Mann-Whitney U = 4,122, p = .002); and socio-emotional functioning ([Mdn = 30.0, IQR = 27.0-33.0 vs. Mdn = 34.0, IQR = 30.0-37.0], Mann-Whitney U = 4,289, p < .001). There was no evidence of association between sepsis and psychomotor (r_pb = -.2, p = .214), language (r_pb = -.1, p = .510), and socio-emotional functioning (r_pb = .0, p = .916). Significant and medium to large portions of the variance (34-64%) in the developmental outcomes among children who survived NNJ were associated with home birth, low maternal education, and feeding problems during the first days of life.

CONCLUSIONS

NNJ is associated with developmental impairments in the early childhood years; however, NNJ associated with sepsis does not lead to more severe impairment. Prenatal and postnatal care services are needed to reduce the negative impact of NNJ for children from low resourced settings.

ERP markers are associated with neurodevelopmental outcomes in 1-5 month old infants in rural Africa and the UK

INTRODUCTION

Infants and children in low- and middle-income countries are frequently exposed to a range of poverty-related risk factors, increasing their likelihood of poor neurodevelopmental outcomes. There is a need for culturally objective markers, which can be used to study infants from birth, thereby enabling early identification and ultimately intervention during a critical time of neurodevelopment.

METHOD

In this paper, we investigate developmental changes in auditory event related potentials (ERP) associated with habituation and novelty detection in infants between 1 and 5 months living in the United Kingdom and The Gambia, West Africa. Previous research reports that whereas newborns' ERP responses are increased when presented with stimuli of higher intensity, this sensory driven response decreases over the first few months of life, giving rise to a cognitively driven, novelty-based response. Anthropometric measures were obtained concurrently with the ERP measures at 1 and 5 months of age. Neurodevelopmental outcome was measured using the Mullen Scales of Early Learning (MSEL) at 5 months of age.

RESULTS

The described developmental change was observed in the UK cohort, who exhibited an intensity-based response at 1 month and a novelty-based response at 5 months of age. This change was accompanied by greater habituation to stimulus intensity at 5 compared to 1 month. In the Gambian cohort we did not see a change from an intensity-to a novelty-based response, and no change in habituation to stimulus intensity across the two age points. The degree of change from an intensity towards a novelty-based response was further found to be associated with MSEL scores at 5 months of infant age, whereas infants' growth between 1 and 5 months was not.

DISCUSSION

Our study highlights the utility of ERP-based markers to study young infants in rural Africa. By implementing a well-established paradigm in a previously understudied population we have demonstrated its use as a culturally objective tool to better understand early learning in diverse settings world-wide. Results offer insight into the neurodevelopmental processes underpinning early neurocognitive development, which may in the future contribute to early identification of infants at heightened risk of adverse neurodevelopmental outcome.

A randomized control trial of phototherapy and 20% albumin versus phototherapy and saline in Kilifi, Kenya

Objective

The study evaluated the efficacy of phototherapy and 20% albumin infusion to reduce total serum bilirubin (TSB) in neonates with severe hyperbilirubinemia. The primary outcome was a reduction of TSB at the end of treatment. The secondary outcomes were the need for exchange transfusion, inpatient mortality, neurological outcomes at discharge, and development outcomes at 12-months follow-up.

Results

One hundred and eighteen neonates were randomly assigned to phototherapy and 20% albumin (n = 59) and phototherapy and saline (n = 69). The median age at admission was 5 (interquartile range (IQR) 3–6) days, and the median gestation was 36 (IQR 36–38) weeks. No significant differences were found in the change in TSB (Mann–Whitney U =609, p = 0.98) and rate of change in TSB per hour after treatment (Mann–Whitney U = 540, p = 0.39) between the two groups. There were no significant differences between the two groups in the proportion of participants who required exchange transfusion (χ² (2) = 0.36, p = 0.546); repeat phototherapy (χ² (2) = 2.37, p = 0.123); and those who died (χ² (2) = 0.92, p = 0.337). Trial registration The trial was registered in the International Standardized Randomized Controlled Trial Number (ISRCTN); trial registration number ISRCTN89732754.

fNIRS for Tracking Brain Development in the Context of Global Health Projects

Over the past 25 years, functional near-infrared spectroscopy (fNIRS) has emerged as a valuable tool to study brain function, and it is in younger participants where it has found, arguably, its most successful application. Thanks to its infant-friendly features, the technology has helped shape research in the neurocognitive development field by contributing to our understanding of the neural underpinnings of sensory perception and socio-cognitive skills. Furthermore, it has provided avenues of exploration for markers of compromised brain development. Advances in fNIRS instrumentation and methods have enabled the next step in the evolution of its applications including the investigation of the effects of complex and interacting socio-economic and environmental adversities on brain development. To do this, it is necessary to take fNIRS out of well-resourced research labs (the majority located in high-income countries) to study at-risk populations in resource-poor settings in low- and middle-income countries (LMICs). Here we review the use of this technology in global health studies, we discuss the implementation of fNIRS studies in LMICs with a particular emphasis on the Brain Imaging for Global Health (BRIGHT) project, and we consider its potential in this emerging field.

Associations of plasma total phospholipid fatty acid patterns with feeding practices, growth, and psychomotor development in 6-month-old South African infants

The objective of this study was to assess plasma fatty acid (FA) patterns of 6-month-old South African infants and to determine their association with feeding practices, growth, and psychomotor development. Plasma total phospholipid FA composition (% of total FAs) of 6-month-old infants (n = 353) from a peri-urban township was analysed, and principal component and factor analysis were performed to identify plasma FA patterns. Feeding practices, anthropometric measurements, and psychomotor development scores were determined. Four major plasma phospholipid FA patterns were identified: A plant-based C18 FA, a high n-6 long-chain polyunsaturated fatty acids (LCPUFA), a C16:1 and long-chain saturated fatty acid (SFA), and a high n-3 and low n-6 LCPUFA pattern. Formula feeding was associated with higher, whereas breastfeeding was associated with lower scores for the plant-based C18 FA and C16:1 and long-chain SFA patterns. On the other hand, breastfeeding, the consumption of cow's milk, and the consumption of semisolid foods were associated with higher scores, whereas formula feeding was associated with lower scores for the high n-6 LCPUFA pattern. Breastfeeding and the consumption of semisolids were also associated with higher high n-3 and low n-6 LCPUFA pattern scores. The C16:1 and long-chain SFA and high n-3 and low n-6 LCPUFA patterns were positively associated with psychomotor development scores. In 6-month-old South African infants, we identified distinct plasma FA patterns that presumably represent the FA quality of their diet and that are associated with psychomotor development. Our results suggest that breast milk is an important source of n-6 LCPUFAs and formula-fed infants may be at risk of inadequate LCPUFA intake.

Diagnostic accuracy of the Molteno Adapted Scale for developmental delay in South African toddlers

Background: There is currently a great need in South Africa for culturally appropriate neurodevelopmental screening measures in order to facilitate early identification of neurodevelopmental problems in children. Neurodevelopmental screening has the potential to decrease the burden at health-care facilities as it is time, resource and cost effective. Aim: To assess the use of the Molteno Adapted Scale (MAS), a locally developed screening measure, to suggest an optimal cut-off score and investigate its accuracy in detecting developmental delays. Method: The MAS was assessed by evaluating three components: accuracy, efficacy and usefulness. For each of 136 participants, MAS scores were compared with dichotomised scores from the Griffiths Mental Development Scales (GMDS). Receiver operating characteristic (ROC) curves were generated to determine the accuracy of the MAS in identifying developmental delay defined by the GMDS. Sensitivity, specificity and predictive values were calculated for potential MAS cut-off scores. Results: The MAS had an excellent area under the ROC curve, indicating good test accuracy. A developmental quotient of 83 was identified as optimal for screening purposes, with acceptable sensitivity (71.4%) and specificity (90.7%) as well as predictive values (29.4% positive predictive value and 98.3% negative predictive value) for developmental delay on the GMDS. Conclusion: The present study provides preliminary evidence supporting the use of the MAS for screening.

Counting outcomes, coverage and quality for early child development programmes

Improved measurement in early child development (ECD) is a strategic focus of the WHO, UNICEF and World Bank Nurturing Care Framework. However, evidence-based approaches to monitoring and evaluation (M&E) of ECD projects in low-income and middle-income countries (LMIC) are lacking. The Grand Challenges Canada®-funded Saving Brains® ECD portfolio provides a unique opportunity to explore approaches to M&E of ECD programmes across diverse settings. Focused literature review and participatory mixed-method evaluation of the Saving Brains portfolio was undertaken using an adapted impact framework. Findings related to measurement of quality, coverage and outcomes for scaling ECD were considered. Thirty-nine ECD projects implemented in 23 LMIC were evaluated. Projects used a 'theory of change' based M&E approach to measure a range of inputs, outputs and outcomes. Over 29 projects measured cognitive, language, motor and socioemotional outcomes. 18 projects used developmental screening tools to measure outcomes, with a trade-off between feasibility and preferred practice. Environmental inputs such as the home environment were measured in 15 projects. Qualitative data reflected the importance of measurement of project quality and coverage, despite challenges measuring these constructs across contexts. Improved measurement of intervention quality and measurement of coverage, which requires definition of the numerator (ie, intervention) and denominator (ie, population in need/at risk), are needed for scaling ECD programmes. Innovation in outcome measurement, including intermediary outcome measures that are feasible and practical to measure in routine services, is also required, with disaggregation to better target interventions to those most in need and ensure that no child is left behind.

Effect of small-quantity lipid-based nutrient supplements on growth, psychomotor development, iron status, and morbidity among 6- to 12-mo-old infants in South Africa: a randomized controlled trial

Background

Evidence on the effect of small-quantity lipid-based nutrient supplements (SQ-LNSs) on early child growth and development is mixed.

Objective

This study assessed the effect of daily consumption of 2 different SQ-LNS formulations on linear growth (primary outcome), psychomotor development, iron status (secondary outcomes), and morbidity in infants from age 6 to 12 mo within the context of a maize-based complementary diet.

Methods

Infants (n = 750) were randomly assigned to receive SQ-LNS, SQ-LNS-plus, or no supplement. Both SQ-LNS products contained micronutrients and essential fatty acids. SQ-LNS-plus contained, in addition, docosahexaenoic acid, arachidonic acid (important for brain and eye development), lysine (limiting amino acid in maize), phytase (enhances iron absorption), and other nutrients. Infants' weight and length were measured bimonthly. At age 6 and 12 mo, psychomotor development using the Kilifi Developmental Inventory and South African Parent Rating Scale and hemoglobin, plasma ferritin, C-reactive protein, and α1-acid glycoprotein were assessed. WHO Motor Milestone outcomes, adherence, and morbidity were monitored weekly through home visits. Primary analysis was by intention-to-treat, comparing each SQ-LNS group with the control.

Results

SQ-LNS-plus had a positive effect on length-for-age zscore at age 8 mo (mean difference: 0.11; 95% CI: 0.01, 0.22; P = 0.032) and 10 mo (0.16; 95% CI: 0.04, 0.27; P = 0.008) but not at 12 mo (0.09; 95% CI: -0.02, 0.21; P = 0.115), locomotor development score (2.05; 95% CI: 0.72, 3.38; P = 0.003), and Parent Rating Score (1.10; 95% CI: 0.14, 2.07; P = 0.025), but no effect for weight-for-age zscore. Both SQ-LNS (P = 0.027) and SQ-LNS-plus (P = 0.005) improved hemoglobin concentration and reduced the risk of anemia, iron deficiency, and iron-deficiency anemia. Both SQ-LNS products reduced longitudinal prevalence of fever, coughing, and wheezing but increased incidence and longitudinal prevalence of diarrhea, vomiting, and rash/sores.

Conclusions

Point-of-use fortification with SQ-LNS-plus showed an early transient effect on linear growth and improved locomotor development. Both SQ-LNS products had positive impacts on anemia and iron status. This trial was registered at clinicaltrials.gov as NCT01845610.

The association of malaria morbidity with linear growth, hemoglobin, iron status, and development in young Malawian children: a prospective cohort study

Background

Although poor complementary feeding is associated with poor child growth, nutrition interventions only have modest impact on child growth, due to high burden of infections. We aimed to assess the association of malaria with linear growth, hemoglobin, iron status, and development in children aged 6–18 months in a setting of high malaria and undernutrition prevalence.

Methods

Prospective cohort study, conducted in Mangochi district, Malawi. We enrolled six-months-old infants and collected weekly data for ‘presumed’ malaria, diarrhea, and acute respiratory infections (ARI) until age 18 months. Change in length-for-age z-scores (LAZ), stunting, hemoglobin, iron status, and development were assessed at age 18 months. We used ordinary least squares regression for continuous outcomes and modified Poisson regression for categorical outcomes.

Results

Of the 2723 children enrolled, 2016 (74.0%) had complete measurements. The mean (standard deviation) incidences of ‘presumed’ malaria, diarrhea, and ARI, respectively were: 1.4 (2.0), 4.6 (10.1), and 8.3 (5.0) episodes/child year. Prevalence of stunting increased from 27.4 to 41.5% from 6 to 18 months. ‘Presumed’ malaria incidence was associated with higher risk of stunting (risk ratio [RR] = 1.04, 95% confidence interval [CI] = 1.01 to 1.07, p = 0.023), anemia (RR = 1.02, 95%CI = 1.00 to 1.04, p = 0.014) and better socio-emotional scores (B = − 0.21, 95%CI = − 0.39 to − 0.03, p = 0.041), but not with change in LAZ, haemoglobin, iron status or other developmental outcomes. Diarrhea incidence was associated with change in LAZ (B = − 0.02; 95% CI = − 0.03 to − 0.01; p = 0.009), stunting (RR = 1.02; 95% CI = 1.01 to 1.03; p = 0.005), and slower motor development. ARI incidence was not associated with any outcome except for poorer socio-emotional scores.

Conclusion

In this population of young children living in a malaria-endemic setting, with active surveillance and treatment, ‘presumed’ malaria is not associated with change in LAZ, hemoglobin, or iron status, but could be associated with stunting and anemia. Diarrhea was more consistently associated with growth than was malaria or ARI. The findings may be different in contexts where active malaria surveillance and treatment is not provided.

Trial registration

NCT00945698 (July 24, 2009) and NCT01239693 (November 11, 2010).

Early Childhood Development in Children Born to HIV-Infected Mothers: Perspectives From Kenyan Clinical Providers and Caregivers

Objective. To understand the perspectives of clinical providers and caregivers regarding early childhood development (ECD) in children born to HIV-infected mothers in Kenya. Methods. This was a qualitative study of provider and caregiver perspectives on ECD at 5 Kenyan HIV clinics, using semistructured interviews and focus group discussions. Constant comparison and triangulation methods were employed to elucidate the concepts of ECD. Results. Twenty-five providers and 67 caregivers participated. While providers understood ECD in terms of milestones, caregivers strongly equated ECD with physical growth. Factors affecting ECD, such as nutrition, perinatal effects, and illness, were perceived differently by providers and caregivers. Both groups generally believed that HIV-infected children would have typical ECD if adherent to their HIV treatment. Conclusions. Important considerations regarding ECD in this population were uncovered. Understanding provider and caregiver perspectives’ on ECD in HIV-exposed children is critical for promoting ECD in this community.

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.

Piloting a Developmental Screening Tool Adapted for East African Children

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

Nutrition during pregnancy and early development (NuPED) in urban South Africa: a study protocol for a prospective cohort

BACKGROUND

Adequate nutrition during pregnancy is important to ensure optimal birth outcomes, maternal health and offspring development. However, little is known about the dietary intake and nutritional status of pregnant women residing in urban South Africa. Therefore, the Nutrition during Pregnancy and Early Development (NuPED) cohort study was initiated to assess early nutrition-related exposures predictive of early childhood development in urban South Africa.

METHODS

The aims of this prospective cohort study are: 1) to assess dietary intake and nutritional status of urban pregnant women in Johannesburg, South Africa, and 2) to determine associations with birth outcomes, measures of maternal health, as well as measures of offspring health and development. Pregnant women (< 18 weeks' gestation) (n = 250) are being recruited from primary healthcare clinics in Johannesburg and are followed-up at a provincial hospital. Participants' dietary intake and nutrient status (focus on micronutrients and fatty acids) are assessed at < 18, 22 and 36 weeks' gestation. Additional assessments during pregnancy include anthropometric and blood pressure measurements, obstetric ultrasound screens, and assessments of food security, maternal fatigue, prenatal depression, allergy, immune function, morbidity and gestational diabetes. At birth, maternal and neonatal health is assessed and an umbilical cord blood sample collected. Maternal and offspring health is followed-up at 6 weeks, as well as at 6, ≈7.5 and 12 months after birth. Follow-up assessments of mothers include anthropometric measures, diet history, nutrient status, blood pressure, breast milk composition, and measures of postnatal depression and fatigue. Follow-up assessments of the offspring include feeding practices, nutrient status, measures of growth, psychomotor, socio-emotional and immune development, morbidity, allergy, as well as analysis of the gut microbiome and the epigenome.

DISCUSSION

Ensuring adequate nutrition during pregnancy is one of the key actions endorsed by the South African Government to promote optimal early childhood development in an effort to eradicate poverty. The results from this study may serve as a basis for the development of context-specific nutritional interventions which can improve birth outcomes and long-term quality of life of the mother and her offspring.

The Uganda version of the Pediatric Evaluation of Disability Inventory (PEDI). Part I: Cross-cultural adaptation

BACKGROUND

The Pediatric Evaluation of Disability Inventory (PEDI) was developed and standardized to measure functional performance in American children. So far, no published study has examined the use of the PEDI in sub-Saharan Africa. This study describes the adaptation, translation, and validation process undertaken to develop a culturally relevant PEDI for Uganda (PEDI-UG).

METHOD

The cross-cultural adaptation and translation of the PEDI was performed in a series of steps. A project manager and a technical advisory group were involved in all steps of adaptation, translation, cognitive debriefing, and revision. Translation and back-translation between English and Luganda were performed by professional translators. Cognitive debriefing of two subsequent adapted revisions was performed by a field-testing team on a total of 75 caregivers of children aged 6 months to 7.5 years.

RESULTS

The PEDI-UG was established in both English (the official language) and Luganda (a local language) and comprises 185 items. Revisions entailed deleting irrelevant items, modifying wording, inserting new items, and incorporating local examples while retaining the meaning of the original PEDI. Item statements were rephrased as questions. Seven new items were inserted and 19 items deleted. To accommodate major differences in living conditions between rural and urban areas, 10 alternative items were provided.

CONCLUSIONS

The PEDI-UG is to be used to measure functional limitations in both clinical practice and research, in order to assess and evaluate rehabilitative procedures in children with developmental delay and disability in Uganda. In this study, we take the first step by translating and adapting the original PEDI version to the culture and life conditions in both rural and urban Uganda. In subsequent studies, the tool's psychometric properties will be examined, and the tool will be tested in children with developmental delay and disability.

A method to develop vocabulary checklists in new languages and their validity to assess early language development

BACKGROUND

Since the adoption of United Nations' Sustainable Goal 4.2 to ensure that all children have access to quality early child development (ECD) so that they are ready for primary education, the demand for valid ECD assessments has increased in contexts where they do not yet exist. The development of early language ability is important for school readiness. Our objective was to evaluate the validity of a method to develop vocabulary checklists in new languages to assess early language development, based on the MacArthur-Bates Communicative Development Inventories.

METHODS

Through asking mothers of young children what words their children say and through pilot testing, we developed 100-word vocabulary checklists in multilingual contexts in Malawi and Ghana. In Malawi, we evaluated the validity of the vocabulary checklist among 29 children age 17-25 months compared to three language measures assessed concurrently: Developmental Milestones Checklist-II (DMC-II) language scale, Malawi Developmental Assessment Tool (MDAT) language scale, and the number of different words (NDW) in 30-min recordings of spontaneous speech. In Ghana, we assessed the predictive validity of the vocabulary checklist at age 18 months to forecast language, pre-academic, and other skills at age 4-6 years among 869 children. We also compared the predictive validity of the vocabulary checklist scores to that of other developmental assessments administered at age 18 months.

RESULTS

In Malawi, the Spearman's correlation of the vocabulary checklist score with DMC-II language was 0.46 (p = 0.049), with MDAT language was 0.66 (p = 0.016) and with NDW was 0.50 (p = 0.033). In Ghana, the 18-month vocabulary checklist score showed the strongest (rho = 0.12-0.26) and most consistent (8/12) associations with preschool scores, compared to the other 18-month assessments. The largest coefficients were the correlations of the 18-month vocabulary score with the preschool cognitive factor score (rho = 0.26), language score (0.25), and pre-academic score (0.24).

CONCLUSIONS

We have demonstrated the validity of a method to develop vocabulary checklists in new languages, which can be used in multilingual contexts, using a feasible adaptation process requiring about 2 weeks. This is a promising method to assess early language development, which is associated with later preschool language, cognitive, and pre-academic skills.

Early and middle childhood developmental, cognitive, and psychiatric outcomes of Malawian children affected by retinopathy positive cerebral malaria

The objective is to determine the short -and long-term developmental, cognitive, and psychiatric effects of retinopathy positive cerebral malaria (CM-R) among young children in a prospective study assessing them around the onset of disease and again 2 years at preschool and again at school age. In total, 109 children were recruited from the Queen Elizabeth Central Hospital in Blantyre, Malawi, (N = 49) with CM-R and non-malaria controls  (N = 60). Children were assessed for overall motor, language, and social skills using the Malawi Developmental Assessment Tool (MDAT) at preschool age. At school age, the same children were then given the Kaufman Assessment Battery for Children, second edition (KABC-II), which assessed global cognitive performancememory, and learning; as well as the Test of Variables of Attention (TOVA), which assessed attention. The Achenbach Child Development Checklist (CBCL) was administered at both time points to assess emotional and behavioral patterns. Controls scored significantly better on all KABC-II global domains as well as on the mental processing index than their CM-R group counterparts, but showed no performance differences in the TOVA and CBCL assessments at school age, or in the MDAT and CBCL assessments at preschool age. The MDAT total score was significantly correlated with the KABC-II sequential processing, learning, and mental processing index among CM-R survivors but not among controls. Persisting neurocognitive effects of CM can be captured with the KABC-II at school age. The MDAT at preschool age is correlated with the KABC-II among CM-R survivors and can be used to capture early emerging developmental deficits due to CM-R.

Prevalence, risk factors and behavioural and emotional comorbidity of acute seizures in young Kenyan children: a population-based study

BACKGROUND

Acute symptomatic seizures and febrile seizures are common in children admitted to hospitals in Africa and may be markers of brain dysfunction. They may be associated with behavioural and emotional problems, but there are no published community-based studies in Africa.

METHODS

We screened 7047 children aged 1-6 years (randomly sampled from 50,000 in the community) for seizures (using seven questions) and invited those who screened positive and a proportion of negatives for a clinical assessment. Risk factors were identified using a parental questionnaire. Behavioural and emotional problems were examined using the Child Behaviour Checklist (CBCL) in 3273 children randomly selected from 7047. Generalised linear models with appropriate link functions were used to determine risk factors and associations between behavioural or emotional problems and acute seizures. Sobel-Goodman mediation tests were used to investigate if the association between acute seizures and CBCL scores was mediated by co-diagnosis of epilepsy.

RESULTS

Acute seizures were identified in 429 (6.1%) preschool children: 3.2% (95% confidence interval CI: 2.9-3.5%) for symptomatic seizures, and 2.9% (95% CI: 2.6-3.3%) for febrile seizures. Risk factors for acute seizures included family history of febrile seizures (odds ratio OR = 3.19; 95% CI: 2.03-5.01) and previous hospitalisation (OR = 6.65; 95% CI: 4.60-9.63). Total CBCL problems occurred more frequently in children with acute seizures (27%; 95% CI: 21-34%) than for those without seizures (11%; 95% CI: 11-12%; chi-squared p ≤ 0.001). Acute seizures were associated with total CBCL problems (adjusted risk ratio (aRR) = 1.92; 95% CI: 1.34-2.77), externalising problems (aRR = 1.82; 95% CI: 1.21-2.75) and internalising problems (aRR = 1.57; 95% CI: 1.22-2.02), with the proportion of the comorbidity mediated by a co-diagnosis of epilepsy being small (15.3%; 95% CI: 4.5-34.9%). Risk factors for this comorbidity included family history of febrile seizures (risk ratio (RR) = 3.36; 95% CI: 1.34-8.41), repetitive acute seizures (β = 0.36; 95% CI: 0.15-0.57) and focal acute seizures (RR = 1.80; 95% CI: 1.05-3.08).

CONCLUSIONS

Acute seizures are common in preschool children in this area and are associated with behavioural and emotional problems. Both conditions should be assessed and addressed in children.

Association between breast milk intake at 9-10 months of age and growth and development among Malawian young children

World Health Organization recommends exclusive breastfeeding for infants for the first 6 months of life, followed by introduction of nutritious complementary foods alongside breastfeeding. Breast milk remains a significant source of nourishment in the second half of infancy and beyond; however, it is not clear whether more breast milk is always better. The present study was designed to determine the association between amount of breast milk intake at 9-10 months of age and infant growth and development by 12-18 months of age. The study was nested in a randomized controlled trial conducted in Malawi. Regression analysis was used to determine associations between breast milk intake and growth and development. Mean (SD) breast milk intake at 9-10 months of age was 752 (244) g/day. Mean (SD) length-for-age z-score at 12 months and change in length-for-age z-score between 12 and 18 months were -1.69 (1.0) and -0.17 (0.6), respectively. At 18 months, mean (SD) expressive vocabulary score was 32 (24) words and median (interquartile range) skills successfully performed for fine, gross, and overall motor skills were 21 (19-22), 18 (16-19), and 38 (26-40), respectively. Breast milk intake (g/day) was not associated with either growth or development. Proportion of total energy intake from breast milk was negatively associated with fine motor (β = -0.18, p = .015) but not other developmental scores in models adjusted for potential confounders. Among Malawian infants, neither breast milk intake nor percent of total energy intake from breast milk at 9-10 months was positively associated with subsequent growth between 12 and 18 months, or development at 18 months.

Infant Development at the Age of 6 Months in Relation to Feeding Practices, Iron Status, and Growth in a Peri-Urban Community of South Africa

Background: Evidence on the association between feeding practices, iron deficiency, anaemia, stunting, and impaired psychomotor development during infancy is limited. This study assessed the association between psychomotor development with early feeding practices, growth, iron status, and anaemia. Methods: This was cross-sectional baseline data of a randomised controlled trial which included 6-month-old infants and their mothers or primary caregivers (n = 750) in a peri-urban community in the North West province of South Africa. The Kilifi Developmental Inventory and a parent rating scale were used to assess psychomotor development. Feeding practices and anthropometric measurements were based on the World Health Organisation (WHO) guidelines. Anaemia and iron status were determined by blood sample analysis. Results: Prevalence of anaemia and stunting for the infants were 36.4% and 28.5%, respectively. Multiple regression analysis showed that birth weight was related to combined psychomotor scores (β = −3.427 (−4.603, 1.891), p < 0.001), as well as parent rating scores (β = −0.843 (−1.507, −0.180), p = 0.013). Length-for-age z-scores were associated with combined psychomotor scores (β = −1.419 (−2.466, 0.373), p = 0.008), as well as parent rating scores (β = −0.747 (−1.483, −0.010), p = 0.047). Conclusions: In this setting, with high prevalence of anaemia and stunting, important associations between lower psychomotor development scores and birthweight as well as length-for-age z-scores in 6-month-old infants were found. These findings warrant further investigation to develop a greater understanding of factors influencing the association between child growth and psychomotor development within the first 1000 days of life.

Children's Oxygen Administration Strategies Trial (COAST): A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia

Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO 2 > or = 80% (permissive hypoxia); andHigh flow using AIrVO 2 TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations <80%. Clinical trial registration: ISRCTN15622505 Trial status: Recruiting.

Predictors and pathways of language and motor development in four prospective cohorts of young children in Ghana, Malawi, and Burkina Faso

BACKGROUND

Previous reviews have identified 44 risk factors for poor early child development (ECD) in low- and middle-income countries. Further understanding of their relative influence and pathways is needed to inform the design of interventions targeting ECD.

METHODS

We conducted path analyses of factors associated with 18-month language and motor development in four prospective cohorts of children who participated in trials conducted as part of the International Lipid-Based Nutrient Supplements (iLiNS) Project in Ghana (n = 1,023), Malawi (n = 675 and 1,385), and Burkina Faso (n = 1,122). In two cohorts, women were enrolled during pregnancy. In two cohorts, infants were enrolled at 6 or 9 months. In multiple linear regression and structural equation models (SEM), we examined 22 out of 44 factors identified in previous reviews, plus 12 additional factors expected to be associated with ECD.

RESULTS

Out of 42 indicators of the 34 factors examined, 6 were associated with 18-month language and/or motor development in 3 or 4 cohorts: child linear and ponderal growth, variety of play materials, activities with caregivers, dietary diversity, and child hemoglobin/iron status. Factors that were not associated with child development were indicators of maternal Hb/iron status, maternal illness and inflammation during pregnancy, maternal perceived stress and depression, exclusive breastfeeding during 6 months postpartum, and child diarrhea, fever, malaria, and acute respiratory infections. Associations between socioeconomic status and language development were consistently mediated to a greater extent by caregiving practices than by maternal or child biomedical conditions, while this pattern for motor development was not consistent across cohorts.

CONCLUSIONS

Key elements of interventions to ensure quality ECD are likely to be promotion of caregiver activities with children, a variety of play materials, and a diverse diet, and prevention of faltering in linear and ponderal growth and improvement in child hemoglobin/iron status.

Children's Oxygen Administration Strategies Trial (COAST): A randomised controlled trial of high flow versus oxygen versus control in African children with severe pneumonia

Background: In Africa, the clinical syndrome of pneumonia remains the leading cause of morbidity and mortality in children in the post-neonatal period. This represents a significant burden on in-patient services. The targeted use of oxygen and simple, non-invasive methods of respiratory support may be a highly cost-effective means of improving outcome, but the optimal oxygen saturation threshold that results in benefit and the best strategy for delivery are yet to be tested in adequately powered randomised controlled trials. There is, however, an accumulating literature about the harms of oxygen therapy across a range of acute and emergency situations that have stimulated a number of trials investigating permissive hypoxia. Methods: In 4200 African children, aged 2 months to 12 years, presenting to 5 hospitals in East Africa with respiratory distress and hypoxia (oxygen saturation < 92%), the COAST trial will simultaneously evaluate two related interventions (targeted use of oxygen with respect to the optimal oxygen saturation threshold for treatment and mode of delivery) to reduce shorter-term mortality at 48-hours (primary endpoint), and longer-term morbidity and mortality to 28 days in a fractional factorial design, that compares: Liberal oxygenation (recommended care) compared with a strategy that permits hypoxia to SpO 2 > or = 80% (permissive hypoxia); andHigh flow using AIrVO 2TM compared with low flow delivery (routine care). Discussion: The overarching objective is to address the key research gaps in the therapeutic use of oxygen in resource-limited setting in order to provide a better evidence base for future management guidelines. The trial has been designed to address the poor outcomes of children in sub-Saharan Africa, which are associated with high rates of in-hospital mortality, 9-10% (for those with oxygen saturations of 80-92%) and 26-30% case fatality for those with oxygen saturations <80%. Clinical trial registration: ISRCTN15622505 Trial status: Recruiting.

[Formula: see text]Selecting measures for the neurodevelopmental assessment of children in low- and middle-income countries

Diseases affecting millions of children in low- and middle-income countries (LMICs), such as malnutrition, micronutrient deficiency, malaria, and HIV, can lead to adverse neurodevelopmental outcomes. Thus, a key health outcome in children is neurodevelopmental status. In this paper, the neurodevelopmental screening and testing measures most commonly utilized in LMICs are reviewed, and a matrix is presented to help researchers and clinicians determine which measures may be most useful for various LMIC inquiries. The matrix is based on an Internet literature review of 114 publications for the period January 1998 to February 2016, reporting the psychometric properties of instruments tested in LMIC children. The measures are classified as screening tests or more detailed tests that include both comprehensive batteries of general development and tests of specific domains. For completeness, two experts have reviewed this paper, as well as the authors. An overview of the tests used to date is presented, including the benefits and drawbacks of each test, in order to provide researchers and developmental clinicians with a way to decide which tests may be best suited to their developmental assessment goals. Remarkable progress has been made in neurodevelopmental testing in children in LMICs over the past two decades but there remains a need for additional research in this area to develop new tests, better evaluate and adapt current tests, and assess test validity and reliability across cultures.

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

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