Julie M Meeks Gardner

Child development: risk factors for adverse outcomes in developing countries

Poverty and associated health, nutrition, and social factors prevent at least 200 million children in developing countries from attaining their developmental potential. We review the evidence linking compromised development with modifiable biological and psychosocial risks encountered by children from birth to 5 years of age. We identify four key risk factors where the need for intervention is urgent: stunting, inadequate cognitive stimulation, iodine deficiency, and iron deficiency anaemia. The evidence is also sufficient to warrant interventions for malaria, intrauterine growth restriction, maternal depression, exposure to violence, and exposure to heavy metals. We discuss the research needed to clarify the effect of other potential risk factors on child development. The prevalence of the risk factors and their effect on development and human potential are substantial. Furthermore, risks often occur together or cumulatively, with concomitant increased adverse effects on the development of the worlds poorest children.

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.

A randomized controlled trial of a home-visiting intervention on cognition and behavior in term low birth weight infants.

OBJECTIVES To determine whether early psychosocial intervention with low birth weight term (LBW-T) infants improved cognition and behavior and to compare LBW-T with normal birth weight (NBW) infants. STUDY DESIGN A randomized controlled trial was carried out in Kingston, Jamaica, with 140 LBW-T infants (weight<2500 g). The intervention comprised weekly home visits by paraprofessionals for the first 8 weeks of life aimed at improving maternal-child interaction. LBW-T and 94 matched NBW (weight 2500 to 4000 g) infants were recruited from the main maternity hospital. Main outcome measures were problem solving (2 means-end tests: cover and support) and 4 behavior ratings at 7 months. Analyses used were the t test for intervention effects and multiple regression to compare LBW and NBW infants. RESULTS LBW-T intervened infants had higher scores than LBW-T control infants on the cover test (P<.05) and were more cooperative (P<.01) and happy (P<.05). LBW-T control infants had poorer scores on both the cover (P<.001) and support tests (P<.01), vocalized less (P<.02), and were less cooperative (P<.001), happy (P<.02), and active (P<.02) than NBW infants. LBW-T intervened infants had lower scores than NBW infants only on the support test (P<.05). CONCLUSIONS Early low-cost intervention can improve cognition and behavior of LBW-T infants in developing countries.

Zinc supplementation and psychosocial stimulation: effects on the development of undernourished Jamaican children

BACKGROUND Undernourished children have poor levels of development that benefit from stimulation. Zinc deficiency is prevalent in undernourished children and may contribute to their poor development. OBJECTIVE We assessed the effects of zinc supplementation and psychosocial stimulation given together or separately on the psychomotor development of undernourished children. DESIGN This was a randomized controlled trial with 4 groups: stimulation alone, zinc supplementation alone, both interventions, and control (routine care only). Subjects were 114 children aged 9-30 mo and below -1.5 z scores of the National Center for Health Statistics weight-for-age references who were recruited from 18 health clinics. Clinics were randomly assigned to receive stimulation or not; individual children were randomly assigned to receive zinc or placebo. The stimulation program comprised weekly home visits during which play was demonstrated and maternal-child interactions were encouraged. The supplementation was 10 mg Zn as sulfate daily or placebo. Development (assessed by use of the Griffiths Mental Development Scales), length, and weight were measured at baseline and 6 mo later. Weekly morbidity histories were taken. RESULTS Significant interactions were found between zinc supplementation and stimulation. Zinc benefited the developmental quotient only in children who received stimulation, and benefits from zinc to hand and eye coordination were greater in stimulated children. Zinc supplementation alone improved hand and eye coordination, and stimulation alone benefited the developmental quotient, hearing and speech, and performance. Zinc supplementation also reduced diarrheal morbidity but did not significantly improve growth. CONCLUSION Zinc supplementation benefits development in undernourished children, and the benefits are enhanced if stimulation is also provided.

Zinc supplementation: effects on the growth and morbidity of undernourished Jamaican children

Objective: We investigated whether there was a growth or morbidity response to zinc supplementation.Design: The study was randomized, placebo-controlled, and double-blind.Setting: Children were recruited at clinics in Kingston, Jamaica, and supplemented at home.Subjects: Children selected were singletons aged 6–24 months, and stunted (<–2.0 s.d. length for age, NCHS references). They were stratified by sex and age and randomly assigned to receive zinc supplement (n=31) or placebo (n=30). Four children were excluded because of hospitalization; all others had all measurements. Adequately nourished children (n=24) were recruited from a well-baby clinic.Interventions: The supplement provided 5 mg elemental zinc in a syrup daily for 12 weeks; the placebo comprised the syrup only.Main outcome measures: Caretakers were interviewed to obtain social background data, number of clinic visits and hospitalizations. Anthropometric measurements were done on enrolment, and after 6 weeks, 12 weeks and 12 months. Childrens health was determined by weekly questionnaire to caretakers of the undernourished groups during the supplementation period.Results: The supplemented and placebo groups were similar on enrolment. The adequately nourished children were from significantly better socio-economic circumstances. Mean initial hair zinc content was 5.5±4.8μmol/g (supplemented group) and 6.7±12.1 μmol/g (placebo)(n.s.). Regression analyses showed that there were no significant effects of supplementation on length, height or head circumference, nor on the incidence of any morbidity symptom. Mean duration of the episodes was significantly shorter for skin rashes in the supple-mented group compared with the control group (ANCOVA, P=0.02), and longer for vomiting (P=0.02). The incidence of hospitalization was significantly greater in the control group (Fishers exact test, P=0.02).Conclusions: Zinc supplementation reduced the hospitalizations which probably reflect severity of morbidity, but did not improve growth.Sponsorship: The study was funded by the Commonwealth Caribbean Medical Research Council and a Research and Publications Grant, University of the West Indies, Mona. Tropivite Vitamin Drops were donated by Federated Pharmaceutical Co. Ltd, Jamaica; and zinc sulphate donated by Lascelles Laboratories Ltd., Jamaica.

Policies to Reduce Undernutrition Include Child Development

The Lancet Series on Maternal and Child Undernutrition highlights the damaging effects of undernutrition during the first 2 years of life on childrens survival, health, attained schooling, and ultimately their human capital. The Series also points out that, although there are effective nutritional interventions, the international nutrition system, comprising international and donor organisations, academia, civil society, and the private sector, is fragmented and in need of reform. An improved nutrition system will undoubtedly improve the lives of the millions of children who are undernourished. But there would still be major gaps in the educational success and improvement of human capital of millions of children in developing countries because nutritional adequacy alone is insufficient.

Caregiver knowledge, attitudes, and practices regarding childhood diarrhea and dehydration in Kingston, Jamaica

OBJECTIVE To study the knowledge, attitudes, and practices of caregivers in Kingston, Jamaica, regarding childhood diarrhea and dehydration in order to determine if limited caregiver knowledge about the prevention and treatment of diarrhea and dehydration puts children at increased risk of presenting at the hospital for these concerns. METHODS The study was an observational case-control study conducted between February 1997 and May 1997 at Bustamante Hospital for Children in Kingston. Convenience sampling was used and data were collected by face-to-face interviews with two groups of caregivers of children under 5 years of age. One group (n = 117) presented with children with acute gastroenteritis, and the other group (n = 98) presented with acute concerns unrelated to gastroenteritis. While 197 of the 215 caregivers interviewed were the mother of a child, there were also 9 guardians, 5 fathers, and 4 grandmothers in the sample. RESULTS The mean caregiver age, level of education, and socioeconomic status were similar for the two groups. The caregivers in the gastroenteritis group were more likely to present with younger children and to have less convenient access to running water or a refrigerator. Children of caregivers who had never heard of oral rehydration therapy were at increased risk of presenting with gastroenteritis and dehydration (odds ratio [OR], 4.6; 95% confidence interval [CI], 1.8-11.7), as were children of caregivers with low knowledge scores about the prevention and treatment of diarrhea and dehydration (OR, 3.7; 95% CI, 1.6-8.8). Another independent risk factor was a caregivers poor sense of self-reliance in managing a childs diarrhea (OR, 2.3; 95% CI, 1.1-4.9). CONCLUSIONS These findings highlight a need to enhance educational efforts that will empower caregivers to protect their children from diarrhea-associated morbidity and mortality.

Complementary foods in Jamaica: viscosity, energy density and feeding practices

OBJECTIVES To develop and validate a field method for measuring the viscosity of small quantities of weaning porridges, to measure the viscosity and energy density of porridges fed in urban and rural environments, and to relate the findings to ingredients used and feeding practices. DESIGN A new method for determining the viscosity of homogeneous, semi-solid weaning foods was developed. The viscosity and energy density of porridges fed to young children were measured, ingredients obtained by recall, and caregiver feeding behaviours observed. SETTING One urban and one rural community in Jamaica. SUBJECTS A purposive random sample of 70 children aged 3 to 14 months. RESULTS Most children (80%) were fed porridges with medium viscosity (1700-2900 mPa s) or thicker. The mean energy density was 3.18 +/- 0.92 kJ g(-1). Energy density was only moderately related to viscosity, being higher only in porridges > 4000 mPa s (analysis of variance (ANOVA), P < 0.05). Energy density was correlated (P < 0.05) with the amounts of sugar (r = 0.28) and milk powder (r = 0.24) used. Viscosity and energy density were lower in porridges fed by bottle than in those fed by spoon. Anthropometric status (weight-for-length and weight-for-age) was positively correlated with energy density of the porridge but not to the encouragement or persistence of the caregiver. CONCLUSIONS Porridges of adequate energy density were prepared by caregivers in Jamaica without raising viscosity to levels that might constrain intakes. Improvements in porridge preparation and more varied weaning diets may have contributed to the decline in undernutrition in Jamaica.

Undernutrition and elevated blood lead levels: effects on psychomotor development among Jamaican children

OBJECTIVE We examined whether or not the effect of elevated blood lead levels on childrens psychomotor development was modified by their nutritional status. DESIGN Anthropometry, developmental quotients (DQs), blood lead levels and haemoglobin were measured in lead exposed and unexposed children with different levels of nutritional status. Social background and maternal height and verbal intelligence were also measured. Testers, anthropometrists and interviewers established reliabilities with a trainer before the study began. SETTING Children were from two suburban areas in Kingston, Jamaica. All measurements on the children were carried out at a research unit. Social background and maternal measurements were carried out at the childrens homes. SUBJECTS The exposed group comprised 58 children (3-6 years) attending the same preschool which was situated in a lead contaminated environment. The unexposed group comprised 53 children attending a nearby preschool without lead contamination. RESULTS The exposed children had significantly higher blood lead levels and lower DQs, and their homes had poorer facilities than the unexposed children. The deficit in DQ was greater (10.6 points) among children with weight for height less than -1 SD (National Center for Health Statistics references) than among better nourished children (2 points). CONCLUSIONS Undernourished children exposed to lead may have more serious developmental deficits than better nourished children.