Care for Child Development: an intervention in support of responsive caregiving and early child development.

BACKGROUND: An estimated 43% of children younger than 5 years of age are at elevated risk of failing to achieve their human potential. In response, the World Health Organization and UNICEF developed Care for Child Development (CCD), based on the science of child development, to improve sensitive and responsive caregiving and promote the psychosocial development of young children. METHODS: In 2015, the World Health Organization and UNICEF identified sites where CCD has been implemented and sustained. The sites were surveyed, and responses were followed up by phone interviews. Project reports provided information on additional sites, and a review of published studies was undertaken to document the effectiveness of CCD for improving child and family outcomes, as well as its feasibility for implementation in resource-constrained communities. RESULTS: The inventory found that CCD had been integrated into existing services in diverse sectors in 19 countries and 23 sites, including child survival, health, nutrition, infant day care, early education, family and child protection and services for children with disabilities. Published and unpublished evaluations have found that CCD interventions can improve child development, growth and health, as well as responsive caregiving. It has also been reported to reduce maternal depression, a known risk factor for poor pregnancy outcomes and poor child health, growth and development. Although CCD has expanded beyond initial implementation sites, only three countries reported having national policy support for integrating CCD into health or other services. CONCLUSIONS: Strong interest exists in many countries to move beyond child survival to protect and support optimal child development. The United Nations Sustainable Development Goals depend on children realizing their potential to build healthy and emotionally, cognitively and socially competent future generations. More studies are needed to guide the integration of the CCD approach under different conditions. Nevertheless, the time is right to provide for the scale-up of CCD as part of services for families and children.

Even transient rapid infancy weight gain is associated with higher BMI in young adults and earlier menarche.

BACKGROUND: Early postnatal rapid 'catch-up' weight gain has been consistently associated with subsequent higher obesity risk and earlier pubertal development. In many low- and middle-income countries, infancy catch-up weight gain is transient and often followed by growth faltering. We explored the hypothesis that even transient catch-up weight gain during infancy is associated with later obesity risk and earlier puberty. METHODS: A total of 2352 (1151 male, 1201 female) black South African children in the birth to twenty prospective birth cohort study (Johannesburg-Soweto) underwent serial measurements of body size and composition from birth to 18 years of age. At the age of 18 years, whole-body fat mass and fat-free mass were determined using dual-energy X-ray absorptiometry. Pubertal development was assessed by the research team between ages 9 and 10 years, and it was recorded annually from the age of 11 years using a validated self-assessment protocol. RESULTS: Catch-up weight gain from birth to the age of 1 year, despite being followed by growth faltering between ages 1 and 2 years, was associated with greater mid-upper arm circumference (P=0.04) and skinfold thickness (P=0.048) at 8 years of age, and with higher weight (P<0.001) and body mass index (P=0.001) at 18 years of age after adjustment for sex, age, smoking during pregnancy, birth order, gestational age, formula-milk feeding and household socio-economic status. Infancy catch-up weight gain was also associated with younger age at menarche in girls (P<0.001). This association persisted after adjustment for smoking during pregnancy, birth order, gestational age, formula-milk feeding and household socio-economic status (P=0.005). CONCLUSION: Transient catch-up weight gain from birth to the age of 1 year among children born in a low-income area of South Africa was associated with earlier menarche and greater adiposity in early adulthood. This observation suggests that modifiable determinants of rapid infancy weight gain may be targeted in order to prevent later obesity and consequences of earlier puberty in girls.

Parental childhood growth and offspring birthweight: pooled analyses from four birth cohorts in low and middle income countries.

OBJECTIVE: Associations between parental and offspring size at birth are well established, but the relative importance of parental growth at different ages as predictors of offspring birthweight is less certain. Here we model parental birthweight and postnatal conditional growth in specific age periods as predictors of offspring birthweight. METHODS: We analyzed data from 3,392 adults participating in four prospective birth cohorts and 5,506 of their offspring. RESULTS: There was no significant heterogeneity by study site or offspring sex. 1SD increase in maternal birthweight was associated with offspring birthweight increases of 102 g, 1SD in maternal length growth 0-2 year with 46 g, and 1SD in maternal height growth Mid-childhood (MC)-adulthood with 27 g. Maternal relative weight measures were associated with 24 g offspring birth weight increases (2 year- MC) and 49 g for MC-adulthood period but not with earlier relative weight 0-2 year. For fathers, birthweight, and linear/length growth from 0-2 year were associated with increases of 57 and 56 g in offspring birthweight, respectively but not thereafter. CONCLUSIONS: Maternal and paternal birthweight and growth from birth to 2 year each predict offspring birthweight. Maternal growth from MC-adulthood, relative weight from 2-MC and MC-adulthood also predict offspring birthweight. These findings suggest that shared genes and/or adequate nutrition during early life for both parents may confer benefits to the next generation, and highlight the importance of maternal height and weight prior to conception. The stronger matrilineal than patrilineal relationships with offspring birth weight are consistent with the hypothesis that improving the early growth conditions of young females can improve birth outcomes in the next generation.

Impact of COVID-19 lockdown on low birthweight in Soweto, South Africa.

BACKGROUND: Pregnant women were indirectly affected by the COVID-19 pandemic owing to heightened stress, fear of mother-to-child transmission of COVID-19 and the disruption of antenatal health services. Increased stress and lack of antenatal healthcare could result in an increase in adverse birth outcomes such as preterm birth or low birthweight. OBJECTIVES: Using a case-control design, to compare the prevalence of low birthweight among infants born before and during the pandemic in Soweto, South Africa. METHOD: Infants born before the pandemic and national lockdown were included in the control group, while infants who were in utero and born during the pandemic were included in the case group. Only infants born ≥37 weeks' gestation with no birth complications were included. Multivariable logistic regression was employed to determine whether the pandemic was associated with an increase in low birthweight. A birthweight <2.5 kg was classified as low birthweight. RESULTS: In total, 199 mother-infant pairs were included in the control group, with 201 mother-infant pairs in the case group. The prevalence of low birthweight was 4% in the control group and 11% in the case group, with those born during the pandemic at a higher risk of being of low birthweight. CONCLUSION: The high prevalence of low birthweight in infants born ≥37 weeks' gestation during the pandemic could result in an increase in child stunting and poor development. Future research should measure early child development and growth in infants born during the pandemic to assess whether there is a need to intervene and provide additional support to minimise the negative effects.

Differential influences of early growth and social factors on young children's cognitive performance in four low-and-middle-income birth cohorts (Brazil, Guatemala, Philippines, and South Africa).

BACKGROUND: Studies relating childhood cognitive development to poor linear growth seldom take adequate account of social conditions related to both, leading to a focus on nutrition interventions. We aimed to assess the roles of both biological and social conditions in determining early childhood cognition, mediated by birthweight and early linear growth. METHODS: After exploratory structural equation modelling to identify determining factors, we tested direct and indirect paths to cognitive performance through birthweight and child height-for-age at 2 years, assessed between 4 and 8.5 years of age among 2448 children in four birth cohort studies in low-and-middle-income countries (Brazil, Guatemala, Philippines and South Africa). Determinants were compared across the cohorts. FINDINGS: Three factors yielded excellent fit, comprising birth endowment (primarily maternal age and birth order), household resources (crowding, dependency) and parental capacity (parental education). We estimated their strength together with maternal height in determining cognitive performance. Percentage shares of total effects of the four determinants show a marked transition from mainly biological determinants of birth weight (birth endowment 34%) and maternal height (30%) compared to household resources (25%) and parental capacity (11%), through largely economic determinants of height at 2 years (household resources (60%) to cognitive performance being predominantly determined by parental capacity (64%) followed by household resources (29%). The largely biological factor, birth endowment (maternal age and birth order) contributed only 7% to childhood cognitive performance and maternal height was insignificant. In summary, the combined share of social total effects (household resources and parental capacity) rises from 36∙2% on birth weight, to 78∙2% on height for age at 24 m, and 93∙4% on cognitive functioning. INTERPRETATION: Across four low- and middle-income contexts, cognition in childhood is influenced more by the parental capacity of families and their economic resources than by birth weight and early linear growth. Improving children's cognitive functioning requires multi-sectoral interventions to improve parental education and enhance their economic wellbeing, interventions that are known to improve also early childhood growth.

A longitudinal perspective on violence in the lives of South African children from the Birth to Twenty Plus cohort study in Johannesburg-Soweto.

BACKGROUND: Violence against children is a significant cause of personal suffering and long-term ill health, poor psychological adjustment, and a range of social difficulties, including adverse effects intergenerationally. OBJECTIVES: Using a large corpus of longitudinal data collected in the Birth to Twenty Plus cohort, to give an overview of exposure to and experience of violence, as well as perpetration of violence, across childhood, reported contemporaneously by several informants. This overcomes limitations of retrospectively recalled information collected from one person at one point in time. METHODS: We identified 280 data points relating to exposure to and perpetration of violence in 14 of the 21 waves of data collection from birth to 22 years of age. Data were classified into four developmental stages (preschool, primary school years, adolescence and young adulthood) and seven categories (exposure to violence in the community, home and school; exposure to peer violence; being a victim of violence, excluding sexual violence; sexual violence; and perpetration of violence). Both descriptive and inferential statistics were employed to analyse the data. RESULTS: Over the past two decades, only 1% of the sample had not been exposed to or experienced violence in their home, school and/or community. Two-thirds of children of schoolgoing age were reported as having been exposed to community violence, and more than half of all children to violence in their home. Reports of sexual violence increased from 10% among primary school-aged children to ~30% among adolescents and young adults. Over the course of their lives, ~40% of children were reported as having been exposed to or being victims of five or six of the categories of violence coded in this analysis. High levels of violence perpetration were reported across childhood. Age and gender differences in exposure to and experience and perpetration of violence were evident, and all categories of violence were more prevalent among poorer and more disadvantaged groups. CONCLUSIONS: Very high levels of violence were reported in all the settings of urban South African children's lives: home, community, school, among peers and in their intimate relationships. Children and youth were also reported to perpetrate high levels of violence. The personal and social costs of violence are very high, resulting in major public health problems due to its avoidable effects on short- and long-term mental and physical health and social adjustment, and intergenerationally.

The associations between interpersonal violence and psychological distress among rural and urban young women in South Africa.

BACKGROUND: Approximately 25% of the world's population consists of young people. The experience of violence peaks during adolescence and the early adult years. A link between personal experience of violence and mental health among young people has been demonstrated but rural-urban differences in these associations are less well known in low to middle income countries. The aim of this study was to investigate the associations between interpersonal violence and psychological distress among rural and urban young women. METHODS: Data on experiences of violence and psychological distress were collected from a total of 926 non-pregnant young women aged between 18 and 22 years of age in rural and urban sites in South Africa. The General Health Questionnaire-28 was used to assess psychological distress as an indicator of mental health. Generalised structural equation models were employed to assess potential pathways of association between interpersonal violence and psychological distress. RESULTS: Thirty-four percent of the urban young women (n = 161) reported psychological distress compared to 18% of rural young women (n = 81). In unadjusted analysis, exposure to interpersonal violence doubled the odds of psychological distress in the urban adolescents and increased the odds 1.6 times in the rural adolescents. In adjusted models, the relationship remained significant in the urban area only (OR 1.84, 95% CI 1.13-3.00). Rural residence seemed protective against psychological distress (OR 0.41, 95% CI 0.24-0.69). Structural equation modelling did not reveal any direct association between exposure to interpersonal violence and psychological distress among rural young women. Stressful household events were indirectly associated with psychological distress, mediated by violence among young women in the urban area. CONCLUSION: The relationship between violence and psychological distress differs between urban and rural-residing young women in South Africa, and is influenced by individual, household and community (contextual) factors.

Early life risk exposure and stunting in urban South African 2-year old children.

Stunting is a measure of overall nutritional status and is a major public health concern because of its association with child mortality and morbidity and later adult performance. This study examined the effects of pregnancy events, birth characteristics and infant risk exposure on stunting at age 2 years. The study, established in 1990 in Soweto, an urban South African township, included 1098 mother-infant pairs enroled in the Birth to Twenty Plus longitudinal birth cohort study. In total, 22% of children were stunted at age 2 years, with males at greater risk than females [24.8 v. 19.4%, odds ratio (OR)=1.38; 95% confidence interval (CI): 1.03, 1.83]. In unadjusted analysis, male sex, household socio-economic status (SES), overcrowding, maternal age, maternal education, single motherhood, ethnicity, birth weight, gestational age and duration of infant breastfeeding were all significantly associated with stunting. In multivariable analysis, higher birth weight was protective against stunting for both sexes. Higher maternal education was protective for females only (adjusted odds ratio (AOR)=0.35; 95% CI: 0.14, 0.87), whereas wealthier household SES protected males (AOR for richest SES group=0.39; 95% CI: 0.16, 0.92). In this and other similar settings, current stunting prevention efforts focussing on primarily providing targeted proximal interventions, such as food supplements, risk undermining the critical importance of addressing key distal determinants of stunting such as SES and maternal education.

Sex differences in obesity incidence: 20-year prospective cohort in South Africa.

BACKGROUND: Prospective data spanning childhood and adolescence are needed to better understand obesity incidence among children and to identify important periods for intervention. OBJECTIVE: To describe gender differences in overweight and obesity from infancy to late adolescence in a South African cohort. METHODS: We analysed body mass index at 1-2 years, 4-8 years, 11-12 years, 13-15 years and 16-18 years among 1172 participants in the South African Birth-to-Twenty cohort. RESULTS: Among boys, overweight and obesity prevalence declined from age 1-2 years to 16-18 years. Among girls, overweight and obesity prevalence increased from 4-8 years to 16-18 years. Obesity incidence was highest from 4-8 years to 11-12 years in boys (6.8 cases per 1000 person-years) and from 11-12 years to 13-15 years in girls (11.2 cases per 1000 person-years). Among girls, obesity at 16-18 years was associated with overweight (odds ratio [OR] = 3.6; 95% confidence interval [CI] 1.8-7.2) or obesity (OR = 8.0; 95% CI 3.7-17.6) at 1-2 years and overweight (OR = 6.8; 95% CI 3.3-13.9) or obesity (OR = 42.3; 95% CI 15.0-118.8) at 4-8 years; for boys, obesity at 16-18 years was associated with overweight at 1-2 years (OR = 5.6; 95% CI 1.7-18.0) and obesity at 4-8 years (OR = 19.7; 95% CI 5.1-75.9). CONCLUSIONS: Among girls, overweight and obesity increased throughout childhood. Overweight and obesity were not widely prevalent among boys. Early childhood and post-puberty may be important periods for intervention among girls.

AIDS-related knowledge, attitudes and behaviour among South African street youth: reflections on power, sexuality and the autonomous self.

Street children in South Africa are, in the main, between the ages of 11 and 17 years. Rape, prostitution, sexual bartering and exchange, casual sex and romantic sexual relationships all occur in the experiences of young people who live and work on inner-city streets. In this study, the AIDS-related knowledge, attitudes and behaviour of 141 street youth, living in seven large cities in South Africa, were elicited in focus group discussions. At the time of the study, 79 boys (56%) were living in shelters run by nongovernmental and welfare organisations, while 62 boys (44%) were sleeping "rough". The results, both qualitative and quantitative, indicated that the AIDS knowledge of South African street children was comparable to levels reported for groups of "hard-to-reach" youth in other parts of the world. Fear of HIV infection did not appear in a list of day-to-day priorities constructed by the children, a list dominated by survival concerns with food, money and clothes. However, more than half of the boys conceded that they engaged in sex for money, goods or protection, several boys indicated that they had been raped, and most reported being sexually active with "girlfriends", who themselves frequently engaged in transactional sex. The findings are interpreted in terms of the relationships between power dynamics surrounding race and age, and how they affect self-initiated controls over sexuality and sexual protection.

AIDS-risk among street children and youth: implications for intervention.

PIP: 141 males aged 11-18 years (mean age, 15 years), 79 of whom were enrolled in shelter programs and the remainder living independently on the streets, participated in 14 focus group discussions held in Pietermaritzburg, Johannesburg, Soweto, Pretoria, East London, Cape Town, Durban, and Bloemfontein, South Africa. The discussions focused upon knowledge about the transmission of AIDS and prevention, attitudes toward AIDS and people with AIDS, and sexual and other behaviors related to AIDS risk. Each group comprised 8-10 boys, each person remaining anonymous except for providing his age and a first name to use in the group discussions. All but two participants had heard of AIDS and knew that it was incurable and sexually transmitted. 93% endorsed the idea that condoms can prevent infection, but all were overwhelmingly negative about condom use and people with AIDS. None had heard of HIV and none were able to specify sperm and blood as the media for transmission. Vulnerability to AIDS was attributed to casual sex and sex with particular groups of people, but not to the act of unprotected penetrative sex. 68% were certain that they could not get AIDS from someone who looks healthy. The boys harbored other misinformation on how one may contract AIDS. All agreed that selling sex, to both men and women, is the best way to get money on the streets. They reported earning R10-200 per day depending upon the city, the customer's gender, and other circumstances. Their clients usually insisted upon unprotected penetrative oral, anal, or vaginal sex. They also engaged in survival sex to enlist or mollify powerful others, in exchange for protection, accommodation, or other goods and services; had sex with their girlfriends, many of whom also work as prostitutes; and commonly used alcohol and other drugs. Once intoxicated, the boys are more likely to have risky sex; their vulnerability to being raped also increases. These youths are neither more nor less informed or misinformed about the transmission of AIDS than their counterparts in other countries. Information alone, however, is unlikely to induce behavior change. Study results are discussed in terms of their implications for intervention and the inadequacies of the Health Belief Model and related theories as the sole theoretical foundation for the design of intervention programs.^ieng

The reliability of hand-written and computerised records of birth data collected at Baragwanath hospital in Soweto.

This study examined the reliability of hand written and computerised records of birth data collected during the Birth to Ten study at Baragwanath Hospital in Soweto. The reliability of record-keeping in hand-written obstetric and neonatal files was assessed by comparing duplicate records of six different variables abstracted from six different sections in these files. The reliability of computerised record keeping was assessed by comparing the original hand-written record of each variable with records contained in the hospital's computerised database. These data sets displayed similar levels of reliability which suggests that similar errors occurred when data were transcribed from one section of the files to the next, and from these files to the computerised database. In both sets of records reliability was highest for the categorical variable infant sex, and for those continuous variables (such as maternal age and gravidity) recorded with unambiguous units. Reliability was lower for continuous variables that could be recorded with different levels of precision (such as birth weight), those that were occasionally measured more than once, and those that could be measured using more than one measurement technique (such as gestational age). Reducing the number of times records are transcribed, categorising continuous variables, and standardising the techniques used for measuring and recording variables would improve the reliability of both hand-written and computerised data sets.

Evidence of impact: health, psychological and social effects of adult HIV on children.

There is a growing evidence base on the immediate and short-term effects of adult HIV on children. We provide an overview of this literature, highlighting the multiple risks and resultant negative consequences stemming from adult HIV infection on the children they care for on an individual and family basis. We trace these consequences from their origin in the health and wellbeing of adults on whom children depend, through multiple pathways to negative impacts for children. As effective treatment reduces vertical transmission, the needs of affected children will predominate. Pathways include exposure to HIV in utero, poor caregiver mental or physical health, the impact of illness, stigma and increased poverty. We summarize the evidence of negative consequences, including those affecting health, cognitive development, education, child mental health, exposure to abuse and adolescent risk behaviour, including sexual risk behaviour, which has obvious implications for HIV-prevention efforts. We also highlight the evidence of positive outcomes, despite adversity, considering the importance of recognizing and supporting the development of resilience. This study is the first in a series of three commissioned by President's Emergency Plan for AIDS Relief (PEPFAR)/United States Agency for International Development (USAID), the summary provided here was used to inform a second study which seeks to identify insights from the broader child development field which will help us predict what long-term negative consequences children affected by HIV and AIDS are likely to experience. The third study discusses the design of a model to estimate these consequences. Although comprehensive, the review is often hampered by poor-quality research, inadequate design, small sample sizes and single studies in some areas.

Poverty, underdevelopment and infant mental health.

Very great advances have occurred in disciplinary and professional knowledge of infant development and its influence on subsequent development. This expertise includes the ways in which early experiences affect the capacity of mature individuals for social adjustment and productive competence, and promising methods of intervention to promote infant mental health and prevent adverse sequelae of risk conditions. However, very little of this knowledge has been applied in work among infants and children living in conditions of poverty and underdevelopment. This lack of application continues despite the enormous threats to the well-being of infants and young children brought about by the combined effects of poverty and the AIDS pandemic, especially in southern Africa. Protein-energy malnutrition, maternal depression, and institutional care of infants and small children are cited as illustrative of areas in which interventions, and their evaluation, are desperately needed in resource-poor countries. An argument is made for the critical importance of considering and addressing psychological factors in care givers and children in conditions of extreme material need. An example is provided of a simple intervention model based on sound developmental principles that can be implemented by trained non-professionals in conditions of poverty and underdevelopment.

HIV vaccine trials: critical issues in informed consent.

Informed consent (IC), a fundamental principle of ethics in medical research, is recognized as a vital component of HIV vaccine trials. There are different notions of IC, some legally based and others based on ethics. It is argued that, though legal indemnity is necessary, vaccine trials should be founded on fully ethical considerations. Various contentious aspects of IC are examined, especially the problem of social desirability and of adequate comprehension. The need for sensitivity to cultural norms in implementing IC procedures is critically reviewed, and some of the potential conflict between ethos and ethics is considered. The transmission of information is examined as a particular aspect of IC in HIV vaccine trials.

Electro-encephalography and performance in a poorly nourished South African population.

The electro-encephalographic (EEG) characteristics and psychometric performance of 'normal' black South African peri-urban children were assessed in the course of a large-scale normative study. Children identified as being poorly nourished according to growth standards were compared with a group of mildly growth-retarded children and with another group with normal growth. The socio-economic backgrounds of the three groups were checked and found to be the same. The children had had access to regular clinic attendance and none had ever been hospitalised for any serious illness--in particular malnutrition. Across the entire age range the poorly nourished children invariably were found to fare worse on both EEG and psychometric measures than the normal group.