Christine A Powell

Inequality in early childhood: Risk and protective factors for early child development

Inequality between and within populations has origins in adverse early experiences. Developmental neuroscience shows how early biological and psychosocial experiences affect brain development. We previously identified inadequate cognitive stimulation, stunting, iodine deficiency, and iron-deficiency anaemia as key risks that prevent millions of young children from attaining their developmental potential. Recent research emphasises the importance of these risks, strengthens the evidence for other risk factors including intrauterine growth restriction, malaria, lead exposure, HIV infection, maternal depression, institutionalisation, and exposure to societal violence, and identifies protective factors such as breastfeeding and maternal education. Evidence on risks resulting from prenatal maternal nutrition, maternal stress, and families affected with HIV is emerging. Interventions are urgently needed to reduce childrens risk exposure and to promote development in affected children. Our goal is to provide information to help the setting of priorities for early child development programmes and policies to benefit the worlds poorest children and reduce persistent inequalities.

Effects of early childhood psychosocial stimulation and nutritional supplementation on cognition and education in growth-stunted Jamaican children: prospective cohort study

Growth retardation affects about a third of children younger than age 5 years in developing countries and is associated with poor development. Previously, we did a trial of nutritional supplementation and psychosocial stimulation in stunted children aged 9-24 months. Non-stunted children were also assessed. Both types of intervention improved development. We now present the effects of early interventions on cognition and education in 103 of the 129 stunted children and compare them with 64 of the 84 non-stunted children now aged 17-18 years. We recorded no significant effects of nutritional supplementation. Compared with no intervention, stimulation resulted in higher full scale IQ scores (coefficient 0.38, 95% CI 0.06-0.71, p=0.02) and higher scores on the verbal subscale (0.37, 0.07-0.68, p=0.02), Peabody picture vocabulary test (7.84, 0.73-14.95, p=0.03), verbal analogies (0.26, 0.03-0.49, p=0.03), and reading tests (4.73, 1.31-8.14, p=0.007, and 2.7, 1.12-4.37, p=0.001). Overall, stunted non-stimulated participants had significantly poorer scores than the non-stunted group on 11 of 12 cognitive and educational tests. Stunting in early childhood is associated with cognitive and educational deficits in late adolescence, which are reduced by stimulation at a young age.

Effects of psychosocial stimulation and dietary supplementation in early childhood on psychosocial functioning in late adolescence: follow-up of randomised controlled trial

Abstract Objective To determine whether dietary supplementation or psychosocial stimulation given to growth retarded (stunted) children age 9-24 months has long term benefits for their psychosocial functioning in late adolescence. Design Sixteen year follow-up study of a randomised controlled trial. Setting Poor neighbourhoods in Kingston, Jamaica. Participants Of 129 stunted children identified at age 9-24 months, 103 adolescents aged 17-18 were followed up. Intervention Supplementation with 1 kg milk based formula each week or psychosocial stimulation (weekly play sessions with mother and child), or both, for two years. Main outcome measures Anxiety, depression, self esteem, and antisocial behaviour assessed by questionnaires administered by interviewers; attention deficit, hyperactivity, and oppositional behaviour assessed by interviews with parents. Results Primary analysis indicated that participants who received stimulation had significantly different overall scores from those who did not (F = 2.047, P = 0.049). Supplementation had no significant effect (F = 1.505, P = 0.17). Participants who received stimulation reported less anxiety (mean difference - 2.81, 95% confidence interval - 5.02 to - 0.61), less depression (- 0.43, - 0.78 to - 0.07), and higher self esteem (1.55, 0.08 to 3.02) and parents reported fewer attention problems (- 3.34, - 6.48 to - 0.19). These differences are equivalent to effect sizes of 0.40-0.49 standard deviations. Conclusions Stimulation in early childhood has sustained benefits to stunted childrens emotional outcomes and attention.

Nutrition, anaemia, geohelminth infection and school achievement in rural Jamaican primary school children

Objective: To determine whether nutritional status, anaemia and geohelminth infections were related to school achievement and attendance in Jamaican children.Design: A cross-sectional study using a randomly selected sample.Subjects: Eight hundred children aged 9–13 y randomly selected from those enrolled in grade 5 in 16 primary schools in rural Jamaica.Results: The mean height-for-age of the children was −0.37 z-score±1.0 s.d. with 4.9% having heights-for-age <−2 s.d. of the NCHS references. Anaemia (Hb<11 ;g/dl) was present in 14.7% of the children, 38.3% were infected with Trichuris trichiura and 19.4% with Ascaris lumbricoides. Achievement levels on the Wide Range Achievement Test were low, with children performing at grade 3 level. In multilevel analyses, controlling for socioeconomic status, children with Trichuris infections had lower achievement levels than uninfected children in spelling, reading and arithmetic (P<0.05). Children with Ascaris infections had lower scores in spelling and reading (P<0.05) Height-for-age (P<0.01) was positively associated with performance in arithmetic. Ascaris infection (P<0.001) and anaemia (P<0.01) predicted poorer school attendance.Conclusion: Despite mild levels, undernutrition and geohelminth infections were associated with achievement, suggesting that efforts to increase school achievement levels in developing countries should include strategies to improve the health and nutritional status of children.Sponsorship: Funding was provided by the Commonwealth Caribbean Medical Research Council and the Inter-American Development Bank.

Nutrition and health predictors of school failure in Jamaican children

In many developing countries a large number of children do poorly in school. Little attention has been paid to the possible role of poor health and nutrition. In Kingston, Jamaica all grade 5 children from five randomly selected primary schools, who were failing (n = 158) were compared with all those who were succeeding (n = 167) in a comprehensive number of nutrition, health and socio‐economic variables. Failing children had lower heights‐for‐age, weights‐for‐height, haemoglobin levels and poorer breakfasts. They had higher blood lead levels and were more likely to be ill as well as admitted to hospital for an injury. Failing children came from poorer homes, had fewer school materials and school uniforms. They attended school less and were more likely to be male. Poor health and nutrition contributed significantly to school failure and poor school attendance after controlling for the socio‐economic variables. Nearly all (90%) of the children were correctly placed in their achievement group using discrimi...

The association between early childhood stunting and weight status in late adolescence

Background:Cross-sectional studies have shown associations between stunting and overweight; however, there are few prospective studies of stunted children.Objectives:To determine whether stunting before age 2 years is associated with overweight and central adiposity at 17–18 years and whether growth in height among stunted children predicts body mass index (BMI) in late adolescence.Design:Prospective cohort study.Participants:One-hundred and three participants stunted by age 2 years and 64 non-stunted participants (78% of participants enrolled in childhood). Participants were measured in early childhood and at ages 7, 11 and 17 years.Results:Stunted subjects remained shorter and had lower BMIs, smaller skinfolds and circumferences than non-stunted subjects. Overweight (BMI ⩾25 m2) was not significantly different among stunted and non-stunted male subjects (5.2 and 12.5%) but non-stunted female subjects were more likely to be overweight than those who experienced early childhood stunting (11.1 and 34.4%, P=0.013). Centralization of fat (waist to hip ratio (WHR), subscapular/triceps skinfold ratio (SSF/TSF)) did not differ between stunted and non-stunted groups (mean WHR 0.77 and mean SSF/TSF 1.18 in both groups). Stunted subjects with greater increases in height-for-age for the intervals 3–7 and 7–11 years had higher BMI at age 17 years (P=0.04 and P=0.001, respectively).Conclusion:Participants stunted by age 2 years were less likely to be overweight than those who were never stunted. This suggests that cross-sectional studies of the association between stunting and overweight may be misleading. Among stunted children, greater linear growth during mid- to late childhood was associated with greater BMI at age 17 years.

Integrating a Parenting Intervention With Routine Primary Health Care: A Cluster Randomized Trial.

OBJECTIVE: More than 200 million children globally do not attain their developmental potential. We hypothesized that a parent training program could be integrated into primary health center visits and benefit child development. METHODS: We conducted a cluster randomized trial in the Caribbean (Jamaica, Antigua, and St Lucia). Fifteen centers were randomly assigned to the control (n = 250 mother-child pairs) and 14 to the intervention (n = 251 mother-child pairs) groups. Participants were recruited at the 6- to 8-week child health visit. The intervention used group delivery at 5 routine visits from age 3 to 18 months and comprised short films of child development messages, which were shown in the waiting area; discussion and demonstration led by community health workers; and mothers’ practice of activities. Nurses distributed message cards and a few play materials. Primary outcomes were child cognition, language, and hand-eye coordination and secondary outcomes were caregiver knowledge, practices, maternal depression, and child growth, measured after the 18-month visit. RESULTS: Eight-five percent of enrolled children were tested (control = 210, intervention = 216). Loss did not differ by group. Multilevel analyses showed significant benefits for cognitive development (3.09 points; 95% confidence interval: 1.31 to 4.87 points; effect size: 0.3 SDs). There were no other child benefits. There was a significant benefit to parenting knowledge (treatment effect: 1.59; 95% confidence interval: 1.01 to 2.17; effect size: 0.4). CONCLUSIONS: An innovative parenting intervention, requiring no additional clinic staff or mothers’ time, was integrated into health services, with benefits to child cognitive development and parent knowledge. This is a promising strategy that merits further evaluation at scale.

Early Childhood Stunting and Later Fine Motor Abilities.

Aim  The aim of this study was to determine the effects of early childhood stunting (height for age 2SD or more below reference values) and interventions on fine motor abilities at 11 to 12 years, and the relationship between fine motor abilities and school achievement and intelligence.

Behaviour of severely malnourished children in a Jamaican hospital

The behaviour of 18 children with severe malnutrition between the ages of six and 24 months was observed. They were compared with 21 age‐matched adequately nourished children in hospital with other diseases, and were given regular developmental assessments with the Griffiths test. On admission to hospital the malnourished children were less active and more apathetic than the controls when alone in their cots, while the controls were more distressed. When given toys, initially the malnourished children explored them less, using fewer play actions and touching fewer toys. These differences were not present on recovery. Initial behaviour did not predict later developmental levels.

Schoolchildren's diets and participation in school feeding programmes in Jamaica

OBJECTIVES To describe food consumption during the school day of rural Jamaican children and participation in two government school feeding programmes. To determine factors which were related to these. DESIGN Cross sectional. SETTING 16 primary schools in rural Jamaica. SUBJECTS 415 children in grades 2 and 5 (ages 7 and 10 years). RESULTS Consumption of sweets, sweet drinks and snacks was high. Mean intakes at lunch were: energy 1537 kJ (SD 756), protein 10.4 g (SD 7.6) and iron 1.5 mg (SD 1.2). The mean energy intake was 17-20% of the daily requirement for this age group. Two types of school feeding programmes were available in the schools, one provided a cooked meal and the other a bun and milk. Median availability of school meals (as a percentage of children enrolled in the schools) over three terms was 24.6% (range 0-85.4%). Twenty per cent of the children participated in one or other programme. Poorer children were more likely to participate in the bun and milk programme (odds ratio 2.1, 95% CI 1.3-3.5) but children with more money to purchase food participated in the more costly cooked meal programme (odds ratio 2.4, 95% CI 1.3-4.6). CONCLUSIONS Energy intakes at lunch in Jamaican children were somewhat below optimal levels and the reliance on sweets and snacks is an area of concern. Programme characteristics such as meal cost, may affect access to school feeding by poor children.