Growth faltering is associated with altered brain functional connectivity and cognitive outcomes in urban Bangladeshi children exposed to early adversity

Growth in early infancy drives optimal brain functional connectivity which predicts cognitive flexibility in later childhood

Functional brain network organization, measured by functional connectivity (FC), reflects key neurodevelopmental processes for healthy development. Early exposure to adversity, e.g. undernutrition, affects neurodevelopment, observable via disrupted FC, and leads to poorer outcomes from preschool age onward. We assessed longitudinally the impact of early growth trajectories on developmental FC in a rural Gambian population from age 5 to 24 months. To investigate how these early trajectories relate to later childhood outcomes, we assessed cognitive flexibility at 3-5 years. We observed that early physical growth before the fifth month of life drove optimal developmental trajectories of FC that in turn predicted cognitive flexibility at pre-school age. In contrast to previously studied developmental populations, this Gambian sample exhibited long-range interhemispheric FC that decreased with age. Our results highlight the measurable effects that poor growth in early infancy has on brain development and the subsequent impact on pre-school age cognitive development, underscoring the need for early life interventions throughout global settings of adversity.

Identifying biomarkers and trajectories of executive functions and language development in the first 3 years of life: Design, methods, and findings of the Germina cohort study

This paper reports the methods and preliminary findings of Germina, an ongoing cohort study to identify biomarkers and trajectories of executive functions and language development in the first 3 years of life. 557 mother-infant dyads (mean age of mothers 33.7 years, 65.2% white, 48.7% male infants) have undergone baseline and are currently collecting data for other timepoints. A linear regression was used to predict baseline Bayley-III using scores derived from data-driven sparse partial least squares utilizing a multiple holdout framework of 15 domains. Significant associations were found between socioeconomic/demographic characteristics (B = 0.29), epigenetics (B = 0.11), EEG theta (B = 0.14) and beta activity (B = 0.11), and microbiome functional pathways (B = 0.08) domains, and infant development measured by the Bayley-III at T1, suggesting potential interventions to prevent impairments.

Association of Chronic Malnutrition, and Not Anemia, with Cognitive Development in Ethiopian Schoolchildren: A Cross-Sectional Study

This study assesses the associations between nutritional status and cognitive development of schoolchildren. A unit increase in height-for-age Z-score was associated with 0.12 SD, 0.08 SD and 0.12 SD increase in standardized digit span, Raven's colored progressive metrics, and performance index of visual search task, respectively. A unit increase in body-mass-index-for-age Z-score was associated with 0.11 SD increase in standardized digit span. Hemoglobin concentration was not associated with any of the cognitive outcomes. Chronic malnutrition was associated with cognitive development in schoolchildren while thinness and hemoglobin concentrations were associated with selected or no cognitive outcomes, respectively.

Improving infant Neurocognitive Development and Growth Outcomes with micronutrients (INDiGO): A protocol for an efficacy trial in rural Gambia

Background

Undernutrition during the early years of life has a harmful and irreversible impact on child growth and cognitive development. Many of the interventions tested to improve outcomes across infancy have had disappointing or inconsistent impact, a common feature being the absence of any attempt to provide nutritional supplements to infants during the first six months. With increasing evidence of micronutrient deficiencies in this age group, alongside strong evidence that growth and developmental deficits begin before six months, a renewed focus on the micronutrient status of infants is required.

Methods

This study is a five-arm, double-blind, placebo-controlled, randomised efficacy trial of micronutrient supplementation to mothers (during pregnancy or pregnancy and lactation) and infants (Day 8 to six months of age) in rural Gambia, where rates of micronutrient deficiencies are high. 600 pregnant women (<20 weeks gestation) will be enrolled into one of five trial arms and followed to 12 months post-partum. The primary outcome will be infant brain development at six months, with micronutrient status, growth and neurocognitive development to 12 months as secondary outcomes.

Discussion

This novel research will identify the most efficacious way of improving micronutrient status in infancy, and assess impact on infant developmental outcomes, providing an evidence base for future effectiveness trials and policy recommendations.

Trial registration

ISRCTN registry ( ISRCTN15063705, 09/07/2021); Pan African Clinical Trials Registry ( PACTR202201552774601, 21/01/2022).

Malnutrition: From Mother to Child

Malnutrition in children, defined as a child who is more than 2 standard deviations below the norm for height- or weight-for-age, is a pervasive, population-wide problem in low- and middle-income countries. Malnutrition is associated with increased infant mortality and delayed neurocognitive development. A recent pooled analysis of more than 30 longitudinal cohort studies demonstrated that the conditions mothers lived in during pregnancy, and their access to adequate nutrition, was a major factor in the subsequent growth and health of their children. We review here this analysis and the hypothesis that interventions to address childhood malnutrition need to start before birth and continue throughout the critical first 1,000 days of life.

Neonatal Physical Growth Predicts Electroencephalography Power in Rural South African Children

Anthropometric measures at birth, indexing prenatal growth, are associated with later cognitive development. Children in low- and middle-income countries (LMIC) are at elevated risk for impaired prenatal and early postnatal growth and enduring cognitive deficits. However, the associations of neonatal physical growth with neural activity are not well-characterized in LMIC contexts, given the dearth of early childhood neuroimaging research in these settings. The current study examined birth length, weight, and head circumference as predictors of EEG relative power over the first three years of life in rural Limpopo Province, South Africa, controlling for postnatal growth and socioeconomic status (SES). A larger head circumference at birth predicted lower relative gamma power, lower right hemisphere relative beta power, and higher relative alpha and theta power. A greater birth length also predicted lower relative gamma power. There were interactions with timepoints such that the associations of birth head circumference and length with EEG power were most pronounced at the 7-month assessment and were attenuated at the 17- and 36-month assessments. The results identify birth head circumference and length as specific predictors of infant neural activity within an under-resourced context.

Neurodevelopment of children exposed to prolonged anesthesia in infancy: GABA study interim analysis of resting-state brain networks at 2, 4, and 10-months old

BACKGROUND

Previous studies have raised concerns regarding neurodevelopmental impacts of early exposures to general anesthesia and surgery. Electroencephalography (EEG) can be used to study ontogeny of brain networks during infancy. As a substudy of an ongoing study, we examined measures of functional connectivity in awake infants with prior early and prolonged anesthetic exposures and in control infants.

METHODS

EEG functional connectivity was assessed using debiased weighted phase lag index at source and sensor levels and graph theoretical measures for resting state activity in awake infants in the early anesthesia (n = 26 at 10 month visit, median duration of anesthesia = 4 [2, 7 h]) and control (n = 38 at 10 month visit) groups at ages approximately 2, 4 and 10 months. Theta and low alpha frequency bands were of primary interest. Linear mixed models incorporated impact of age and cumulative hours of general anesthesia exposure.

RESULTS

Models showed no significant impact of cumulative hours of general anesthesia exposure on debiased weighted phase lag index, characteristic path length, clustering coefficient or small-worldness (conditional R2 0.05-0.34). An effect of age was apparent in many of these measures.

CONCLUSIONS

We could not demonstrate significant impact of general anesthesia in the first months of life on early development of resting state brain networks over the first postnatal year. Future studies will explore these networks as these infants grow older.

Brain Functional Correlates of Resting Hypnosis and Hypnotizability: A Review

This comprehensive review delves into the cognitive neuroscience of hypnosis and variations in hypnotizability by examining research employing functional magnetic resonance imaging (fMRI), positron emission tomography (PET), and electroencephalography (EEG) methods. Key focus areas include functional brain imaging correlations in hypnosis, EEG band oscillations as indicators of hypnotic states, alterations in EEG functional connectivity during hypnosis and wakefulness, drawing critical conclusions, and suggesting future research directions. The reviewed functional connectivity findings support the notion that disruptions in the available integration between different components of the executive control network during hypnosis may correspond to altered subjective appraisals of the agency during the hypnotic response, as per dissociated and cold control theories of hypnosis. A promising exploration avenue involves investigating how frontal lobes' neurochemical and aperiodic components of the EEG activity at waking-rest are linked to individual differences in hypnotizability. Future studies investigating the effects of hypnosis on brain function should prioritize examining distinctive activation patterns across various neural networks.

Early childhood malnutrition impairs adult resting brain function using near-infrared spectroscopy

Introduction

Early childhood malnutrition affects 200+ million children under 5 years of age worldwide and is associated with persistent cognitive, behavioral and psychiatric impairments in adulthood. However, very few studies have investigated the long-term effects of childhood protein-energy malnutrition (PEM) on brain function using a functional hemodynamic brain imaging technique.

Objective and methods

This study aims to investigate functional brain network alterations using near infrared spectroscopy (NIRS) in adults, aged 45-51 years, from the Barbados Nutrition Study (BNS) who suffered from a single episode of malnutrition restricted to their first year of life (n = 26) and controls (n = 29). A total of 55 individuals from the BNS cohort underwent NIRS recording at rest.

Results and discussion

Using functional connectivity and permutation analysis, we found patterns of increased Pearson's correlation with a specific vulnerability of the frontal cortex in the PEM group (ps < 0.05). Using a graph theoretical approach, mixed ANCOVAs showed increased segregation (ps = 0.0303 and 0.0441) and decreased integration (p = 0.0498) in previously malnourished participants compared to healthy controls. These results can be interpreted as a compensatory mechanism to preserve cognitive functions, that could also be related to premature or pathological brain aging. To our knowledge, this study is the first NIRS neuroimaging study revealing brain function alterations in middle adulthood following early childhood malnutrition limited to the first year of life.

Stunting in infancy is associated with atypical activation of working memory and attention networks

Stunting is associated with poor long-term cognitive, academic and economic outcomes, yet the mechanisms through which stunting impacts cognition in early development remain unknown. In a first-ever neuroimaging study conducted on infants from rural India, we demonstrate that stunting impacts a critical, early-developing cognitive system-visual working memory. Stunted infants showed poor visual working memory performance and were easily distractible. Poor performance was associated with reduced engagement of the left anterior intraparietal sulcus, a region involved in visual working memory maintenance and greater suppression in the right temporoparietal junction, a region involved in attentional shifting. When assessed one year later, stunted infants had lower problem-solving scores, while infants of normal height with greater left anterior intraparietal sulcus activation showed higher problem-solving scores. Finally, short-for-age infants with poor physical growth indices but good visual working memory performance showed more positive outcomes suggesting that intervention efforts should focus on improving working memory and reducing distractibility in infancy.

Growth Anthropometrics as a Metric of Malnutrition Disparities Among Young Children Affected by HIV who are Orphaned Maternally, Paternally, or Totally in Western Kenya: A Retrospective Chart Review

This retrospective study investigated growth outcomes of Kenyan children born to women living with HIV, comparing children who were orphaned maternally, paternally, and totally (both parents deceased) to those who were non-orphaned. We reviewed HIV clinic visits performed in Kenya from January 2011 to August 2016 in children 0 to 4 years of age. Malnutrition was assessed using stunting, underweight status, and wasting (z-scores of ≤-2). Descriptive statistics, Chi-square, t-tests, multivariable logistic regression, and ANCOVA models were performed. Of 15 027 total children in the study population, 3.5% (n = 520) were orphaned maternally, 8.1% (n = 1222) were orphaned paternally, and 2.2% (n = 336) were orphaned totally. Children who were orphans had higher rates of malnutrition compared to non-orphans (P < .001). Children who were orphaned maternally and totally had lower anthropometric mean scores, presented to clinic later, and were more likely to be living with HIV. Children who are orphaned maternally or totally should be targeted in interventional strategies.

Association of psychosocial adversity and social information processing in children raised in a low-resource setting: an fNIRS study

Social cognition skills and socioemotional development are compromised in children growing up in low SES contexts, however, the mechanisms underlying this association remain unknown. Exposure to psychosocial risk factors early in life alters the child's social milieu and in turn, could lead to atypical processing of social stimuli. In this study, we used functional Near Infrared Spectroscopy (fNIRS) to measure cortical responses to a social discrimination task in children raised in a low-resource setting at 6, 24, and 36 months. In addition, we assessed the relation between cortical responses to social and non-social information with psychosocial risk factors assessed using the Childhood Psychosocial Adversity Scale (CPAS). In line with previous findings, we observed specialization to social stimuli in cortical regions in all age groups. In addition, we found that risk factors were associated with social discrimination at 24 months (intimate partner violence and verbal abuse and family conflict) and 36 months (verbal abuse and family conflict and maternal depression) but not at 6 months. Overall, the results show that exposure to psychosocial adversity has more impact on social information processing in toddlerhood than earlier in infancy.

EEG functional connectivity analysis in the source space

There is a growing interest in using electroencephalography (EEG) and source modeling to investigate functional interactions among cortical processes, particularly when dealing with pediatric populations. This paper introduces two pipelines that have been recently used to conduct EEG FC analysis in the cortical source space. The analytic streams of these pipelines can be summarized into the following steps: 1) cortical source reconstruction of high-density EEG data using realistic magnetic resonance imaging (MRI) models created with age-appropriate MRI templates; 2) segmentation of reconstructed source activities into brain regions of interest; and 3) estimation of FC in age-related frequency bands using robust EEG FC measures, such as weighted phase lag index and orthogonalized power envelope correlation. In this paper we demonstrate the two pipelines with resting-state EEG data collected from children at 12 and 36 months of age. We also discuss the advantages and limitations of the methods/techniques integrated into the pipelines. Given there is a need in the research community for open-access analytic toolkits that can be used for pediatric EEG data, programs and codes used for the current analysis are made available to the public.

Effects of Routine Health Care Combined with Oral Vitamin D on Linear Growth in 5-Year-Old Children

Objective

The aim is to evaluate the effects of routine health care combined with oral vitamin D on linear growth in 5-year-old children.

Materials and Methods

The 5-year-old children who received routine health care in Shiyan Maternal and Child Health Care Hospital from January 2019 to January 2021 were retrospectively analyzed. They were divided into the supplement group and the non-supplement group according to whether or not they received oral vitamin D, and reasons for not taking oral vitamin D and its influence on children's linear growth were analyzed.

Results

A total of 368 children were enrolled, including 228 children in the supplement group, accounting for 61.96%. The analysis of the influencing factors of vitamin D supplementation showed that the proportion of children with well-educated parents and living in cities and towns was higher (all P < 0.05). Comparing the general situation of children in the two groups, it was found that the height, weight, and head circumference of children in the supplement group were notably higher than those in the non-supplement group (all P < 0.05). At age 4 and 5, the height of the supplement group was significantly higher than that of the non-supplement group (all P < 0.001). Linear analysis showed that the relationship between height and age in the supplement group was Y (height, cm) = 10.07 × X (age, years) + 61.18, while that in the non-supplement group was Y (height, cm) = 8.296 × X (age, years) + 62.81, with significant difference (all P < 0.05). Serum 25-hydroxyvitamin D concentration in the supplement group was significantly higher than that in the non-supplement group, and the proportion of children ≥75 nmol/L was evidently higher than that in the supplement group (all P < 0.05). In addition, the incidence of vitamin D-related hypercalcemia in the supplement group was significantly higher than that in the non-supplement group (all P < 0.05).

Conclusion

There are still more children without vitamin D supplement, which is closely related to their parents' education background and place of residence. Additionally, vitamin D supplementation can promote growth and improve 25-hydroxyvitamin D levels in children, but with the risk of related complications.

Time-frequency analysis methods and their application in developmental EEG data

EEG provides a rich measure of brain activity that can be characterized as neuronal oscillations. However, most developmental EEG work to date has focused on analyzing EEG data as Event-Related Potentials (ERPs) or power based on the Fourier transform. While these measures have been productive, they do not leverage all the information contained within the EEG signal. Namely, ERP analyses ignore non-phase-locked signals and Fourier-based power analyses ignore temporal information. Time-frequency analyses can better characterize the oscillations contained in the EEG data. By separating power and phase information across different frequencies, time-frequency measures provide a closer interpretation of the neurophysiological mechanisms, facilitate translation across neurophysiology disciplines, and capture processes not observed by ERP or Fourier-based analyses (e.g., connectivity). Despite their unique contributions, a literature review of this journal reveals that time-frequency analyses of EEG are yet to be embraced by the developmental cognitive neuroscience field. This manuscript presents a conceptual introduction to time-frequency analyses for developmental researchers. To facilitate the use of time-frequency analyses, we include a tutorial of accessible scripts, based on Cohen (2014), to calculate time-frequency power (signal strength), inter-trial phase synchrony (signal consistency), and two types of phase-based connectivity (inter-channel phase synchrony and weighted phase lag index).

Children Receiving a Nutrition and High-Quality Early Childhood Education Intervention Are Associated with Greater Math and Fluid Intelligence Scores: The Guatemala City Municipal Nurseries

Background: About 47% of children < 5 years of age are stunted in Guatemala. In this study, the investigators aimed to compare growth and cognitive outcomes between children in second grade that attended five Guatemala City Municipal Nurseries (GCMN) vs. same sex, grade, and age-matched children. Methods: A cross-sectional design nested in a retrospective cohort was implemented between 2015 and 2019. Children that attended the GCMN and matched controls completed a math test and validated receptive language and fluid intelligence tests. The primary caregivers completed a sociodemographic survey. General and generalized linear mixed effect models were used to compare children that attended the GCMN vs. controls. The models were adjusted by maternal education, sex, asset score, and other relevant covariates. Results: Children that attended the GCMN exhibited greater math and fluid intelligence scores relative to the controls in the adjusted models (ß = 6.48; 95% CI (2.35−10.61)) and (ß = 1.20; 95% CI (0.12−2.29)), respectively. Lower odds of stunting were significant for children who went to any early childcare institution (AOR = 0.28; 95% CI (0.09−0.89)). Conclusions: The importance of integrating nutrition and high-quality early childhood education interventions in cognitive and growth outcomes is highlighted in this study. The GCMN model may be a scalable model in similar low-resource settings.

Systemic inflammation during the first year of life is associated with brain functional connectivity and future cognitive outcomes

The first years of life are a sensitive period of rapid neural and immune system development vulnerable to the impact of adverse experiences. Several studies support inflammation as a consequence of various adversities and an exposure negatively associated with developmental outcomes. The mechanism by which systemic inflammation may affect brain development and later cognitive outcomes remains unclear. In this longitudinal cohort study, we examine the associations between recurrent systemic inflammation, defined as C-reactive protein elevation on ≥ 2 of 4 measurements across the first year of life, electroencephalography (EEG) functional connectivity (FC) at 36 months, and composite cognitive outcomes at 3, 4, and 5 years among 122 children living in a limited-resource setting in Dhaka, Bangladesh. Recurrent systemic inflammation during the first year of life is significantly negatively associated with cognitive outcomes at 3, 4, and 5 years, after accounting for stunting and family care indicators (a measure of stimulation in the home environment). Recurrent systemic inflammation is significantly positively associated with parietal-occipital FC in the Beta band at 36 months, which in turn is significantly negatively associated with composite cognitive scores at 3 and 4 years. However, FC does not mediate the relationship between recurrent systemic inflammation and cognitive outcomes.

Prevalence of undernutrition and associated factors in young children in Malaysia: A nationwide survey

INTRODUCTION

Undernutrition in young children is a significant public health problem globally. We determined the prevalence of and factors predisposing to stunting and underweight in children aged 1 to 5 years in Malaysia.

MATERIALS AND METHODS

Data were extracted from a cross-sectional nationwide campaign involving healthy children aged 1-5 years conducted over a 4-month period in 2019. We obtained information on demography, parental height and risk factors of undernutrition and anthropometric measurements (height and weight) of children enrolled. Age and sex-specific z-score for length/height-for-age (HAZ), weight-for-age (WAZ), body mass index (BMI) z-score (BAZ) and weight-for-height/length (WFH) z-score (WFHZ) were obtained using World Health Organization growth standards. The following definitions were used: (a) HAZ < -2 SD as stunted and -2 to -1 SD as at risk of stunting; (b) WFHZ < -3 SD as severe, -3 to < -2 SD as moderate wasting, and -2 to < +1 SD as normal; (c) WAZ -2 to -1 as at risk of underweight; (d) BAZ +1 to < +2 SD as at risk of and > +2 SD as overweight.

RESULTS

Of the 15,331 children surveyed, prevalence of stunting and at risk of stunting were 16.1 and 20.0%, severe and moderate wasting were 4.0 and 6.1%, while 21.1% was at risk of underweight. Prevalence of at risk of and overweight 14.2 and 7.3%, respectively. One in fifth (25.0%) children had at least one form of undernutrition (stunting and/or underweight/wasting). Of the 1,412 (13.2%) children reported to have risk factors of undernutrition, 47.2% had feeding difficulties, 44.8% had poor dietary intake and 8.0% had both. Boys, paternal height < 156 cm and poor dietary intake were significantly associated with stunting and/or wasting. Compared with children with no risk factors, children with feeding difficulties were more likely to be wasted (AOR: 1.48, 95% CI: 1.18-1.85), and had at least one form of undernutrition (AOR: 1.45, 95% CI: 1.25-1.69).

CONCLUSIONS

In Malaysian children aged 1 to 5 years, dual burden of under- and overnutrition are common. Poor dietary intake and feeding difficulties were risk factors for undernutrition.

Neonatal stunting and early childhood caries: A mini-review

The nutritional status of pregnant women greatly determines their newborn outcome. Deficiencies of several micronutrients are associated with stunting in early childhood, affecting health into adulthood. However, apart from the systemic disease that has been a concern so far, fetal undernutrition can also be associated with dental caries in a child's early life, especially since the primary teeth begin to form during the mother's gestation period. The important thing to underline regarding the intrauterine formation of primary teeth is especially in terms of enamel formation. One of the causes of developmental enamel defects that will contribute to the emergence of early childhood caries is the malnutrition of the pregnant mother. This mini-review aims to understand the linkage mechanism behind neonatal stunting to early childhood caries. This concept is expected to generate further research to help prevent both growth stunting and early childhood caries. In addition, with some evidence-based research, the importance of the first dental visit can be further promoted.

Brain morphometry and diminished physical growth in Bangladeshi children growing up in extreme poverty: A longitudinal study

Diminished physical growth is a common marker of malnutrition and it affects approximately 200 million children worldwide. Despite its importance and prevalence, it is not clear whether diminished growth relates to brain development and general cognitive ability. Further, diminished growth is more common in areas of extreme poverty, raising the possibility that it may mediate previously shown links between socioeconomic status (SES) and brain structure. To address these gaps, 79 children growing up in an extremely poor, urban area of Bangladesh underwent MRI at age six years. Structural brain images were submitted to Mindboggle software, a Docker-compliant and high-reproducibility tool for tissue segmentation and regional estimations of volume, surface area, cortical thickness, sulcal depth, and mean curvature. Diminished growth predicted brain morphometry and mediated the link between SES and brain morphometry most consistently for subcortical and white matter subcortical volumes. Meanwhile, brain volume in left pallidum and right ventral diencephalon mediated the relationship between diminished growth and full-scale IQ. These findings offer malnutrition as one possible pathway through which SES affects brain development and general cognitive ability in areas of extreme poverty.

What was learned from studying the effects of early institutional deprivation

The effect of experiences in infancy on human development is a central question in developmental science. Children raised in orphanage-like institutions for their first year or so of life and then adopted into well-resourced and supportive families provide a lens on the long-term effects of early deprivation and the capacity of children to recover from this type of early adversity. While it is challenging to identify cause-and-effect relations in the study of previously institutionalized individuals, finding results that are consistent with animal experimental studies and the one randomized study of removal from institutional care support the conclusion that many of the outcomes for these children were induced by early institutional deprivation. This review examines the behavioral and neural evidence for altered executive function, declarative memory, affective disorders, reward processing, reactivity to threat, risk-taking and sensation-seeking. We then provide a brief overview of the neurobiological mechanisms that may transduce early institutional experiences into effects on brain and behavior. In addition, we discuss implications for policy and practice.

Using different methods for calculating frontal alpha asymmetry to study its development from infancy to 3 years of age in a large longitudinal sample

Frontal electroencephalography (EEG) alpha asymmetry (FAA), defined as the difference in frontal alpha power observed over the right and left frontal scalp regions, has been widely used in developmental research as a measure of multiple aspects of child behavior, such as temperament. Studies have used different equations to calculate FAA, which renders comparison of results across studies challenging. Furthermore, few studies have examined FAA's longitudinal stability across infancy and early childhood, which is a desirable feature of a temperament measure. We investigated the cross-sectional and the longitudinal correlations of FAA values from four different equations to calculate FAA used in the literature. We used baseline EEG data from a longitudinal sample of 321 infants and 168 3-year-old children (149 of whom had data at both timepoints). Consistent with previous work, FAA values calculated using two commonly used equations were highly correlated with each other cross-sectionally but not with values from a different equation that used log-transformed relative power. The log-transformed relative power FAA values were the only values that showed significant longitudinal stability. These findings suggest that researchers interested in FAA as a trait-like measure in children should consider using the relative power equation that renders stability across ages.

Effect of Oral Nutritional Supplementation on Growth in Children with Undernutrition: A Systematic Review and Meta-Analysis

Oral nutritional supplements (ONS) are used to promote catch-up growth in children with undernutrition. We conducted a systematic review and meta-analysis to summarize the evidence of ONS intervention effects on growth for 9-month- to 12-year-old children who were undernourished or at nutritional risk. Eleven randomized controlled trials met the inclusion criteria; trials compared changes in anthropometric measures in children using ONS or ONS + DC (dietary counselling) to measures for those following usual diet or placebo or DC alone. The RCTs included 2287 children without chronic diseases (mean age 5.87 years [SD, 1.35]; 56% boys). At follow-up time points up to 6 months, results showed that children in the ONS intervention group had greater gains in weight (0.423 kg, [95% confidence interval 0.234, 0.613], p < 0.001) and height (0.417 cm [0.059, 0.776], p = 0.022) versus control; greater gains in weight (0.089 kg [0.049, 0.130], p < 0.001) were evident as early as 7–10 days. Longitudinal analyses with repeated measures at 30, 60, and 90 days showed greater gains in weight parameters from 30 days onwards (p < 0.001), a trend towards greater height gains at 90 days (p = 0.056), and significantly greater gains in height-for-age percentiles and Z-scores at 30 and 90 days, respectively (p < 0.05). Similar results were found in subgroup analyses of studies comparing ONS + DC to DC alone. For children with undernutrition, particularly those who were mildly and moderately undernourished, usage of ONS in a nutritional intervention resulted in significantly better growth outcomes when compared to control treatments (usual diet, placebo or DC alone).

Associations of socioeconomic and other environmental factors with early brain development in Bangladeshi infants and children

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Research from high-income countries shows that experiences impact neural development.

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We examine EEG in relation to wealth and psychosocial factors in 6 and 36-month-olds from Bangladesh.

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Wealth and maternal stress is associated with EEG oscillations in 36-month-olds.

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Neither wealth nor maternal stress is associated with EEG oscillations in 6-month-olds.

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Environmental influences on EEG may emerge between 6 and 36 months of age.

Studies of infants growing up in high-income countries reveal developmental changes in electroencephalography (EEG) power whereby socioeconomic factors - specifically, low SES and low income - are associated with lower EEG power in infants aged newborn to nine months. In the current paper we explore relationships of spectral EEG power across three regions (frontal, central, and parietal) and four frequency bands (theta, alpha, beta, and gamma) with socioeconomic and psychosocial factors in a cohort of n = 160 6-month-old infants and n = 187 36-month-old children living in Dhaka, Bangladesh. Household wealth is assessed as a multi-dimensional composite score encompassing income, assets, and housing materials. Psychosocial factors include maternal perceived stress and family caregiving activities. Among the 6-month-old infants we do not observe any association of household wealth or psychosocial factors with EEG power. Among the 36-month-old children, we find that household wealth is negatively associated absolute power in the beta and gamma bands across frontal, central, and parietal electrodes. We also find that higher reports of maternal perceived stress are associated with more absolute theta power in frontal and central regions in the 36-month-old children. The finding of a negative relationship of household wealth with beta and gamma power in 36-month-old children differs from findings previously observed in infants in high-income countries. Overall, findings suggest that children’s environment continues to influence the development of EEG oscillations and provide support for the utility of EEG to quantify developmental effects of early life experiences on neural functional outcomes in low income countries.

Factors determining cognitive, motor and language scores in low birth weight infants from North India

BACKGROUND

Children born with low birth weight (LBW) tend to have lower neurodevelopmental scores compared to term normal birth weight children. It is important to determine factors that influence neurodevelopment in these low birth weight children especially in the first 2-3 years of life that represents a period of substantial brain development.

METHODS

This secondary data analysis was conducted using data from LBW infants enrolled soon after birth in an individually randomized controlled trial (RCT) and followed up till end of 1st year. Neurodevelopmental assessment was done at 12 months of corrected age by trained psychologists using Bayley Scales of Infant and Toddler Development 3rd edition (Bayley-III). Factors influencing cognitive, motor and language scores were determined using multivariable linear regression model.

RESULTS

Linear growth (i.e., length for age z score, LAZ) [cognitive: Standardized ẞ-coefficient = 2.19, 95% CI; 1.29, 3.10; motor: 2.41, 95% CI; 1.59, 3.23; language: 1.37, 95% CI; 0.70, 2.04], stimulation at home [cognitive: 0.21, 95% CI; 0.15, 0.27; motor: 0.12, 95% CI; 0.07, 0.17; language: 0.21, 95% CI; 0.16, 0.25] and number of diarrhoeal episodes [cognitive: -2.87, 95% CI; -4.34, -1.39; motor: -2.62, 95% CI; -3.93, -1.29; language: -2.25, 95% CI; -3.32, -1.17] influenced the composite scores in all three domains i.e., cognitive, language and motor. While increase in LAZ score and stimulation led to increase in composite scores; an increase in number of diarrhoeal episodes was associated with decrease in scores. Weight for height z scores (WHZ) were associated with motor and language but not with cognitive scores. Additionally, a negative association of birth order with cognitive and language scores was noted.

CONCLUSIONS

The findings indicate the possible importance of promoting nutrition and preventing diarrhoea as well as ensuring optimal stimulation and nurturance at home for enhancing child development in LBW infants.

Neurodevelopmental effects of childhood malnutrition: A neuroimaging perspective

Approximately one in five children worldwide suffers from childhood malnutrition and its complications, including increased susceptibility to inflammation and infectious diseases. Due to improved early interventions, most of these children now survive early malnutrition, even in low-resource settings (LRS). However, many continue to exhibit neurodevelopmental deficits, including low IQ, poor school performance, and behavioral problems over their lifetimes. Most studies have relied on neuropsychological tests, school performance, and mental health and behavioral measures. Few studies, in contrast, have assessed brain structure and function, and to date, these have mainly relied on low-cost techniques, including electroencephalography (EEG) and evoked potentials (ERP). The use of more advanced methods of neuroimaging, including magnetic resonance imaging (MRI) and functional near-infrared spectroscopy (fNIRS), has been limited by cost factors and lack of availability of these technologies in developing countries, where malnutrition is nearly ubiquitous. This report summarizes the current state of knowledge and evidence gaps regarding childhood malnutrition and the study of its impact on neurodevelopment. It may help to inform the development of new strategies to improve the identification, classification, and treatment of neurodevelopmental disabilities in underserved populations at the highest risk for childhood malnutrition.

Growth Faltering and Developmental Delay in HIV-Exposed Uninfected Ugandan Infants: A Prospective Cohort Study

BACKGROUND

HIV-exposed but uninfected (HEU) infants are at increased risk of impaired early linear growth and cognitive development. We examined associations between prenatal and postnatal growth and subsequent neurodevelopment in Ugandan HEU infants, hypothesizing that early insults may explain alterations in both somatic growth and brain development.

METHODS

We prospectively followed a cohort of HEU infants from birth to 18 months of age, and measured length/height, weight, head, and arm circumference longitudinally. The Malawi Development Assessment Tool (MDAT, 12 and 18 months) and the Color Object Association Test (18 months) were used for developmental assessments.

RESULTS

Among 170 HEU infants, the prevalence of low-birth weight and failure to thrive was 7.6% and 37%, respectively. HEU infants had MDAT scores that were similar to the reference population. The mean (SD) score on the Color Object Association Test was 5.5 (3.1) compared with 6.9 (5.3) in developmentally normal children. Developmental ability at age 18 months showed strong cross-sectional correlation with weight-for-age (ρ = 0.36, P < 0.0001), length/height-for-age (ρ = 0.41, P < 0.0001), head circumference-for-age (ρ = 0.26, P = 0.0011), and mid-upper arm circumference-for-age (ρ = 0.34, P = 0.0014). There was a statistically significant correlation between birth weight and MDAT z-score at 18 months (ρ = 0.20, P = 0.010). Failure to thrive was associated with lower MDAT z-score [median -0.13 (IQR -0.75 to +0.14) versus +0.14 (IQR -0.44 to +0.63), P = 0.042].

CONCLUSION

Growth faltering in HEU infants was associated with lower attainment of developmental milestones at age 18 months. Our findings point to a simple screening method for identifying HEU infants at risk for developmental intervention.

Exploring the Use and Appeal of Playpens to Protect Infants from Exposure to Animals, Animal Feces, and Dirt in Rural Ethiopia

The persistence and pervasiveness of growth stunting in low- and middle-income countries spur reexamination of disease transmission pathways related to water, sanitation, and hygiene. Animal feces constitute a more important reservoir of enteric pathogens in homes in low-income countries than previously recognized, and exploratory object mouthing and direct ingestion of soil and animal feces represent underexplored exposure pathways. The effectiveness, adoption, constraints, and scale-up potential of measures for reducing infant and young children's exposure to fecal pathogens are recently beginning to be systematically explored. This mixed methods study tested the feasibility and appeal of using playpens to establish a hygienic "safe zone" for infants in rural Ethiopia. We conducted home trials of three playpen designs, including two models made from locally available materials through user-centered design. After using playpens for several weeks, caregivers reported extensive benefits, ranging from perceived safety to developmental and hygiene benefits for infants and relief from physical stress and worry for caregivers. We observed many playpens contaminated with Escherichia coli after weeks of use, though at concentrations below those of the common room floor on which infants might otherwise have played. Caregivers reported daily playpen use, but for intervals likely insufficient to protect infants from pathogen exposure affecting growth. We determine that playpens alone cannot plausibly protect infants from environmental contamination, but our results support further exploration of the potential benefits and commercial viability of scaling up use of playpens in rural, agricultural households as part of a comprehensive approach to child development and women's empowerment.

Converging neural and behavioral evidence for a rapid, generalized response to threat-related facial expressions in 3-year-old children

Electrophysiological studies on adults suggest that humans are efficient at detecting threat from facial information and tend to grant these signals a priority in access to attention, awareness, and action. The developmental origins of this bias are poorly understood, partly because few studies have examined the emergence of a generalized neural and behavioral response to distinct categories of threat in early childhood. We used event-related potential (ERP) and eye-tracking measures to examine children's early visual responses and overt attentional biases towards multiple exemplars of angry and fearful vs. other (e.g., happy and neutral) faces. A large group of children was assessed longitudinally in infancy (5, 7, or 12 months) and at 3 years of age. The final ERP dataset included 148 infants and 132 3-year-old children; and the final eye-tracking dataset included 272 infants and 334 3-year-olds. We demonstrate that 1) neural and behavioral responses to facial expressions converge on an enhanced response to fearful and angry faces at 3 years of age, with no differentiation between or bias towards one or the other of these expressions, and 2) a support vector machine learning model using data on the early-stage neural responses to threat reliably predicts the duration of overt attentional dwell time for threat-related faces at 3 years. However, we found little within-subject correlation between threat-bias attention in infancy and at 3 years of age. These results provide unique evidence for the early development of a rapid, unified response to two distinct categories of facial expressions with different physical characteristics, but shared threat-related meaning.

Stunting at birth and associated factors among newborns delivered at the University of Gondar Comprehensive Specialized Referral Hospital

Background

Stunting at birth is a chronic form of undernutrition majorly attributable to poor prenatal nutrition, which could persist in children’s later life and impact their physical and cognitive health. Although multiple studies have been conducted in Ethiopia to show the magnitude of stunting and factors, all are concentrated on children aged between 6 to 59 months. Therefore, this study was done to determine the prevalence and associated factors of stunting at birth among newborns delivered at the University of Gondar Comprehensive Specialized Referral Hospital, Northwest, Ethiopia.

Methods

An institution-based cross-sectional study was conducted from February 26^th to April 25^th/2020. A systematic random sampling technique was used, to select a total of 422 newborn-mother pairs. The binary logistic regression was employed to identify factors associated with stunting and all independent variables were entered into the multivariable logistic regression model to adjust for confounders. Variables that had significant association were identified based on p-value < 0.05 and the adjusted odds ratio with its respective 95% confidence interval was applied to determine the strength as well as the direction of the association.

Results

About 30.5% (95% CI: 26.3%, 35.1%) of newborns were stunted at birth. Being male [Adjusted odds ratio (AOR) = 2.9(1.62, 5.21)], newborns conceived in Kiremt(rainy season) [AOR = 2.7(1.49, 4.97)], being low birth weight [AOR = 3.1(1.64, 6.06)] were factors associated with stunting at birth. Likewise, newborns born to short stature mothers [AOR = 2.8(1.21, 6.62)] and chronically malnourished mothers [AOR = 15.3(8.12, 29.1)] were at greater risk of being stunted.

Conclusion

Just under a third of newborns are stunted at birth, implying a pressing public health problem. Newborns born to chronically malnourished and short stature mothers were more stunted. Besides, stunting was prevalently observed among male neonates, newborns conceived in Kiremet, and being low birth weight. Thus, policymakers and nutrition programmers should work on preventing maternal undernutrition through nutrition education to reduce the burden of low birth weight and stunting. Further, paying due attention to newborns conceived in Kiremet season to improve nutritional status is recommended.

Microbiota control of maternal behavior regulates early postnatal growth of offspring

Maternal behavior is necessary for optimal development and growth of offspring. The intestinal microbiota has emerged as a critical regulator of growth and development in the early postnatal period life. Here, we describe the identification of an intestinal Escherichia coli strain that is pathogenic to the maternal-offspring system during the early postnatal stage of life and results in growth stunting of the offspring. However, rather than having a direct pathogenic effect on the infant, we found that this particular E. coli strain was pathogenic to the dams by interfering with the maturation of maternal behavior. This resulted in malnourishment of the pups and impaired insulin-like growth factor 1 (IGF-1) signaling, leading to the consequential stunted growth. Our work provides a new understanding of how the microbiota regulates postnatal growth and an additional variable that must be considered when studying the regulation of maternal behavior.

Adversity in childhood is linked to mental and physical health throughout life

The prevalence of “toxic stress” and huge downstream consequences in disease, suffering, and financial costs make prevention and early intervention crucial, say Charles A Nelson and colleagues

Factors associated with head circumference and indices of cognitive development in early childhood

BACKGROUND

While head circumference (HC) has been related to intracranial volume and brain size, its association with cognitive function remains unclear. We sought to understand the relationship among various biological and socioeconomic risk factors, HC and cognitive development.

METHODS

We analysed data across resource-poor settings in Bangladesh, India, Nepal, Peru, South Africa and Tanzania from the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development longitudinal birth cohort study. Participating children were enrolled and followed up between 2009 and 2014. A final sample of 1210 children aged 0-24 months were included in the analyses. The main outcomes were HC for age Z-score and cognitive, gross motor and language scores from Bayley Scales of Infant Development-III tests. Length, weight and HC were measured monthly, and cognitive tests were administered at 6, 15 and 24 months of age. To disentangle the associations between risk factors and HC from linear growth and to distinguish the direct and indirect effects of these risk factors on cognitive function, we conducted mediation analysis using longitudinal models to account for all data measured during follow-up.

RESULTS

Average HC-for-age Z-score (HCAZ) was -0.54 (95% CI -0.47 to -0.62) near birth and -1.01 (95% CI -0.94 to -1.08) at 24 months. Children with higher enrolment weight (p<0.0001), higher socioeconomic score (p=0.00037) and taller mothers (p=0.00084) had higher HCAZ at all ages, while enteropathogen infection (p=0.013) and more febrile episodes (p=0.013) were associated with lower HCAZ. The associations between HCAZ and enrolment weight-for-age, maternal height, socioeconomic status or pathogen burden were partly mediated through their associations with length-for-age. HCAZ showed no association with cognitive, gross motor or language skills at 6, 15 and 24 months of age.

CONCLUSIONS

The main risk factors associated with HC are similar to those associated with body length, and HC is not related to cognitive function.

Relating anthropometric indicators to brain structure in 2-month-old Bangladeshi infants growing up in poverty: A pilot study

Anthropometric indicators, including stunting, underweight, and wasting, have previously been associated with poor neurocognitive outcomes. This link may exist because malnutrition and infection, which are known to affect height and weight, also impact brain structure according to animal models. However, a relationship between anthropometric indicators and brain structural measures has not been tested yet, perhaps because stunting, underweight, and wasting are uncommon in higher-resource settings. Further, with diminished anthropometric growth prevalent in low-resource settings, where biological and psychosocial hazards are most severe, one might expect additional links between measures of poverty, anthropometry, and brain structure. To begin to examine these relationships, we conducted an MRI study in 2-3-month-old infants growing up in the extremely impoverished urban setting of Dhaka, Bangladesh. The sample size was relatively small because the challenges of investigating infant brain structure in a low-resource setting needed to be realized and resolved before introducing a larger cohort. Initially, fifty-four infants underwent T1 sequences using 3T MRI, and resulting structural images were segmented into gray and white matter maps, which were carefully evaluated for accurate tissue labeling by a pediatric neuroradiologist. Gray and white matter volumes from 29 infants (79 ​± ​10 days-of-age; F/M ​= ​12/17), whose segmentations were of relatively high quality, were submitted to semi-partial correlation analyses with stunting, underweight, and wasting, which were measured using height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ) scores. Positive semi-partial correlations (after adjusting for chronological age and sex and correcting for multiple comparisons) were observed between white matter volume and HAZ and WAZ; however, WHZ was not correlated with any measure of brain volume. No associations were observed between income-to-needs or maternal education and brain volumetric measures, suggesting that measures of poverty were not associated with total brain tissue volume in this sample. Overall, these results provide the first link between diminished anthropometric growth and white matter volume in infancy. Challenges of conducting a developmental neuroimaging study in a low-resource country are also described.

Current Status of Malnutrition and Stunting in Pakistani Children: What Needs to Be Done?

Malnutrition is one of the greatest health challenges that affects about 2 billion people globally. Multiple factors including poverty, food insecurity, maternal health and nutritional status, mother's age at marriage and educational status, low birthweight or small for gestational age (SGA), premature births, suboptimal breastfeeding practices, unhealthy dietary and lifestyle patterns, health and immunization status of children, socioeconomic status of family, environmental and household conditions, together with cultural practices and myths, play vital role in affecting the growth of children at early age. Although child stunting has declined in Pakistan, the reduction rate is only 0.5%, which is very low. This may be due to ineffective or inappropriate intervention programs as they are mostly addressing only one issue at a time and don't use the multi-sector approach to address numerous determinants of stunting. It is therefore important to initiate cost-effective multi-tiered intervention approaches to be implemented at pre-conception, pregnancy and early postpartum stages to prevent the problems of malnutrition and stunting in Pakistani children. This review discusses the etiology of child malnutrition and stunting in Pakistan, role of various determinants of stunting and what type of intervention strategies and approaches should be developed and implemented to deal with these problems. Key teaching pointsMalnutrition is one of the greatest global health challenges.Poverty, food insecurity, socioeconomic status, unhealthy dietary patterns, maternal health and nutritional status, low birthweight, suboptimal breast feeding, environmental conditions, cultural practices and myths, are the main factors for child malnutrition and stunting in Pakistan.The slow reduction rate in child stunting may be due to inappropriate intervention programs.Cost-effective multi-tiered intervention approaches must be implemented at pre-conception, pregnancy and early postpartum stages to prevent child malnutrition and stunting in Pakistan.A holistic approach comprising nutrition and WASH interventions, together with strategies to improve the socioeconomic status be developed and implemented to resolve this dilemma.

Tackling the triple threats of childhood malnutrition

The term 'double burden of malnutrition' is usually interpreted in terms of the physical status of children: stunted and wasted children on the one hand and overweight/obese children on the other. There is a third category of malnutrition that can occur at either end of the anthropometric spectrum or, indeed, in children whose physical size may be close to ideal. This third type is most commonly articulated with the phrase 'hidden hunger' and is often illustrated by micronutrient deficiencies; thus, we refer to it here as 'undernutrition'. As understanding of such issues advances, we realise that there is a myriad of factors that may be influencing a child's road to nutritional health. In this BMC Medicine article collection we consider these influences and the impact they have, such as: the state of the child's environment; the effect this has on their risk of, and responses to, infection and on their gut; the consequences of poor nutrition on cognition and brain development; the key drivers of the obesity epidemic across the globe; and how undernourishment can affect a child's body composition. This collection showcases recent advances in the field, but likewise highlights ongoing challenges in the battle to achieve adequate nutrition for children across the globe.