Early Life Child Micronutrient Status, Maternal Reasoning, and a Nurturing Household Environment have Persistent Influences on Child Cognitive Development at Age 5 years: Results from MAL-ED.

BACKGROUND: Child cognitive development is influenced by early-life insults and protective factors. To what extent these factors have a long-term legacy on child development and hence fulfillment of cognitive potential is unknown. OBJECTIVE: The aim of this study was to examine the relation between early-life factors (birth to 2 y) and cognitive development at 5 y. METHODS: Observational follow-up visits were made of children at 5 y, previously enrolled in the community-based MAL-ED longitudinal cohort. The burden of enteropathogens, prevalence of illness, complementary diet intake, micronutrient status, and household and maternal factors from birth to 2 y were extensively measured and their relation with the Wechsler Preschool Primary Scales of Intelligence at 5 y was examined through use of linear regression. RESULTS: Cognitive T-scores from 813 of 1198 (68%) children were examined and 5 variables had significant associations in multivariable models: mean child plasma transferrin receptor concentration (ß: -1.81, 95% CI: -2.75, -0.86), number of years of maternal education (ß: 0.27, 95% CI: 0.08, 0.45), maternal cognitive reasoning score (ß: 0.09, 95% CI: 0.03, 0.15), household assets score (ß: 0.64, 95% CI: 0.24, 1.04), and HOME child cleanliness factor (ß: 0.60, 95% CI: 0.05, 1.15). In multivariable models, the mean rate of enteropathogen detections, burden of illness, and complementary food intakes between birth and 2 y were not significantly related to 5-y cognition. CONCLUSIONS: A nurturing home context in terms of a healthy/clean environment and household wealth, provision of adequate micronutrients, maternal education, and cognitive reasoning have a strong and persistent influence on child cognitive development. Efforts addressing aspects of poverty around micronutrient status, nurturing caregiving, and enabling home environments are likely to have lasting positive impacts on child cognitive development.

Early childhood growth and cognitive outcomes: Findings from the MAL-ED study.

Although many studies around the world hope to measure or improve developmental progress in children to promote community flourishing and productivity, growth is sometimes used as a surrogate because cognitive skills are more difficult to measure. Our objective was to assess how childhood measures of anthropometry correlate with measures of child development in low-income settings with high prevalence of poor nutrition and enteric disease, to inform studies considering growth outcomes in the absence of direct child developmental skill assessment. Children from the MAL-ED study were followed from birth to 24 months of age in field sites in 8 low- and middle-income countries across 3 continents. Monthly weight, length, and head circumference measurements were performed. At 24 months, the Bayley Scales of Infant and Toddler Development was administered. We correlated cognitive measures at 24 months with anthropometric measurements from birth to 2 years comparing 3 constructs: absolute attained monthly measures, summative difference in measures from the mean growth curve, and rate of change in measures. Growth faltering at multiple time periods is related to Bayley cognitive outcomes at 24 months. Birthweight, overall growth by 18-24 months, and rate of growth in the 6- to 18-month period were most associated with 24-month developmental scores. In this study, head circumference measurements, compared with length, was more closely linked to cognitive scores at 24 months. Notably, all studies between growth and cognitive outcomes exhibited low r2 values (0.001-0.049). Anthropometric measures, particularly head circumference, were related to cognitive development, although explaining a low percent of variance. When feasible, direct measures of child development may be more useful.

Bhaktapur, Nepal: the MAL-ED birth cohort study in Nepal.

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study site in Nepal is located in the Bhaktapur municipality, 15 km east of Kathmandu, the capital city of Nepal. Bhaktapur, an ancient city famous for its traditional temples and buildings, is included on UNESCO's World Heritage List and is a major tourist attraction in Nepal. Nepal is a land-locked country located in South Asia between China and India with an area of 147 181 km(2), ranging from sea-level plains to Mount Everest, the world's highest peak. The total population as of the 2011 census was 26.6 million, with an average annual population growth rate of 1.4. Nepal is one of the world's least developed countries and is ranked 157 of 186 in the 2013 Human Development Report; one-third of the Nepali population lives below the poverty line. The current under-5 mortality rate is 54 per 1000 live births, the infant mortality rate is 46 per 1000 live births, and the neonatal mortality rate is 33 per 1000 live births. Vaccine coverage for all Expanded Program on Immunization vaccines is >80%. Among children, the most common diseases contributing to significant morbidity and mortality are acute respiratory infection and dehydration from severe diarrhea. In this article, we report on the geographic, demographic, and socioeconomic features of the Bhaktapur MAL-ED site and describe the data that informed our cohort recruitment strategy.

The MAL-ED cohort study: methods and lessons learned when assessing early child development and caregiving mediators in infants and young children in 8 low- and middle-income countries.

More epidemiological data are needed on risk and protective factors for child development. In The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) cohort study, we assessed child development in a harmonious manner across 8 sites in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa, and Tanzania. From birth to 24 months, development and language acquisition were assessed via the Bayley Scales of Infant and Toddler Development and a modified MacArthur Communicative Development Inventory. Other measures were infant temperament, the child's environment, maternal psychological adjustment, and maternal reasoning abilities. We developed standard operating procedures and used multiple techniques to ensure appropriate adaptation and quality assurance across the sites. Test adaptation required significant time and human resources but is essential for data quality; funders should support this step in future studies. At the end of this study, we will have a portfolio of culturally adapted instruments for child development studies with examination of psychometric properties of each tool used.

Early Life Experiences and Trajectories of Cognitive Development.

BACKGROUND: Multiple factors constrain the trajectories of child cognitive development, but the drivers that differentiate the trajectories are unknown. We examine how multiple early life experiences differentiate patterns of cognitive development over the first 5 years of life in low-and middle-income settings. METHODS: Cognitive development of 835 children from the Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) multisite observational cohort study was assessed at 6, 15, 24 (Bayley Scales of Infant and Toddler Development), and 60 months (Wechsler Preschool and Primary Scale of Intelligence). Markers of socioeconomic status, infection, illness, dietary intake and status, anthropometry, and maternal factors were also assessed. Trajectories of development were determined by latent class-mixed models, and factors associated with class membership were examined by discriminant analysis. RESULTS: Five trajectory groups of cognitive development are described. The variables that best discriminated between trajectories included presence of stimulating and learning resources in the home, emotional or verbal responsivity of caregiver and the safety of the home environment (especially at 24 and 60 months), proportion of days (0-24 months) for which the child had diarrhea, acute lower respiratory infection, fever or vomiting, maternal reasoning ability, mean nutrient densities of zinc and phytate, and total energy from complementary foods (9-24 months). CONCLUSIONS: A supporting and nurturing environment was the variable most strongly differentiating the most and least preferable trajectories of cognitive development. In addition, a higher quality diet promoted cognitive development while prolonged illness was indicative of less favorable patterns of development.

Assessing development across cultures: Invariance of the Bayley-III Scales Across Seven International MAL-ED sites.

The Bayley's Scales of Infant and Toddler Development-Third Edition (Bayley-III) were used to measure the development of 24-month-old children (N = 1,452) in the Interactions of Malnutrition and Enteric Infections: Consequences for Child Health and Development (MAL-ED) study (an international, multisite study on many aspects of child development). This study examined the factor structure and measurement equivalence/invariance of Bayley-III scores across 7 international research sites located in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, and South Africa. Exploratory and confirmatory factor analyses were used to identify the factor structure of Bayley-III scores. Subsequently, reliability analyses and item response theory analyses were applied, and invariance was examined using multiple-indicator, multiple-cause modeling. The findings supported the validity, but not invariance, of Bayley-III language scores at all seven sites and of the cognitive and motor scores at six sites. These findings provide support for the use of scores for research purposes, but mean comparison between sites is not recommended. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Global Disability: Empowering Children of all Abilities.

Worldwide, children are often not meeting their developmental potential owing to malnutrition, infection, lack of stimulation, and toxic stress. Children with disabilities are more likely to experience poverty, neglect, and abuse, and are less likely to have adequate access to education and medical care. Early childhood developmental stimulation can improve language, learning, and future participation in communities. Therapeutic supports and endeavors to reduce stigma for people of all abilities strengthen communities and allow for human thriving.

Understanding parents' and professionals' knowledge and awareness of autism in Nepal.

Autism is a global phenomenon. Yet, there is a dearth of knowledge of how it is understood and its impact in low-income countries. We examined parents' and professionals' understanding of autism in one low-income country, Nepal. We conducted focus groups and semi-structured interviews with parents of autistic and non-autistic children and education and health professionals from urban and rural settings ( n = 106), asking questions about typical and atypical development and presenting vignettes of children to prompt discussion. Overall, parents of typically developing children and professionals had little explicit awareness of autism. They did, however, use some distinctive terms to describe children with autism from children with other developmental conditions. Furthermore, most participants felt that environmental factors, including in-utero stressors and birth complications, parenting style and home or school environment were key causes of atypical child development and further called for greater efforts to raise awareness and build community capacity to address autism. This is the first study to show the striking lack of awareness of autism by parents and professionals alike. These results have important implications for future work in Nepal aiming both to estimate the prevalence of autism and to enhance support available for autistic children and their families.

Measuring home environments across cultures: Invariance of the HOME scale across eight international sites from the MAL-ED study.

The home environment provides the context for much of a child's early development. Examples of important aspects of the home environment include safety, cleanliness, and opportunities for cognitive stimulation. This study sought to examine the psychometric properties of an adapted form of the Home Observation for the Measurement of the Environment (HOME; Caldwell & Bradley, 1984, 2003) across the eight international sites of the MAL-ED project (Dhaka, Bangladesh; Vellore, India; Bhakatapur, Nepal; Naushahro Feroze, Pakistan; Fortaleza, Brazil; Loreto, Peru; Venda, South Africa; Haydom, Tanzania), to identify a factor structure that fit the data at all sites, and to derive a subset of items that could be used to examine home environmental characteristics across sites. A three-factor structure (i.e., Emotional and Verbal Responsivity; Clean and Safe Environment; Child Cleanliness) was identified, and partial measurement equivalence/invariance across sites was supported. Overall, these findings lend support for the use of portions of this abbreviated and adapted version of the HOME for use among heterogeneous, cross-cultural groups in low- and middle-income nations.

Postpartum depressive symptoms across time and place: structural invariance of the Self-Reporting Questionnaire among women from the international, multi-site MAL-ED study.

BACKGROUND: The Self-Reporting Questionnaire (SRQ) is a screening instrument that has been shown to be an effective measure of depression in postpartum women and is widely used in developing nations. METHODS: The SRQ was administered to 2028 mothers from eight nations at two time points: one and six months postpartum. All data were obtained from the Interactions of Malnutrition and Enteric Infections: Consequences for Child Health and Development (MAL-ED) study. The sample included women from MAL-ED sites in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa, and Tanzania. This study examined three aspects of validity of SRQ scores including (a) structural validity, (b) cross-cultural invariance, and (c) invariance over time. RESULTS: A 16-item, one-factor structure with items reflecting somatic symptoms removed was deemed to be superior to the original structure in this postpartum population. Although differential item functioning (DIF) across sites was evident the one-factor model was a good fit to the data from seven sites, and the structure was invariant across the one- and six-month time points. LIMITATIONS: Findings are based on data from self-report scales. No information about the clinical status of the participants was available. CONCLUSIONS: Overall, findings support the validity of a modified model of the SRQ among postpartum women. Somatic symptoms (e.g., headaches, not sleeping well) may not reflect internalizing problems in a postpartum population. Implications for researchers and practitioners are discussed.