Early life predictors of motor, cognitive, and language development: a pooled multi-country analysis
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1 Early life predictors of motor, cognitive, and language development: a pooled multi-country analysis Ayesha Sania Christopher Sudfeld Dana McCoy Goodarz Danaei Günther Fink Majid Ezzati Wafaie Fawzi
2 Background More than 250 million under-5 children in LMICs do not attain full development potential. Suboptimal development has long term effects on education and income attainment. The 2030 Sustainable Development Goals target early childhood development directly.
3 Background Exposure to risk and protective factors in 1000 days of life (conception through 24 months of age) is critical for children s development. Limited evidence on the role of early life risk factors on child development in LMIC. Majority of systematic review of evidence have primarily focused on physical development.
4 Objective To examine the association of early life factors for cognitive, motor and language development among children aged less than 7 years residing in LMICs.
5 Methods: datasets selection
6 Methods: the primary inclusion criterion - Assessment of at least one domain of child development: cognitive, motor, language and socioemotional - Use of a standard child development assessment instrument - Development assessment before the age of 7 years - Collection of at least one early life factor of interest
7 Methods: early life factors 14 factors included in the analysis. Parental factors father s education mother s education mother s age mother s height mother s BMI hemoglobin level during pregnancy Birth spacing, malaria, maternal HIV, iron & zinc supplementation, and stimulation was not available in sufficient number of Child factors birth weight preterm birth small-for-gestational-age (SGA) birth exclusive breastfeeding till 6 months of age hemoglobin levels in infancy access to clean water access to sanitation diarrhea preceding the 6 months before development assessment
8 Methods: analyses Individual data set - Linear regression models to assess standardized mean differences (SMDs) in cognitive, motor, and language scores - Adjusted for: child s age and gender, maternal education and a measure of socioeconomic status income or household wealth and intervention assignment if RCT Meta-analysis - Estimates from 4 - Random effects modles using the DerSimonian and Larid method
9 Results: 20 cohorts, children Study Year Setting Primary study design Study population Asia 1 Black 2004 Bangladesh RCT cohort ± Tofail 2008 Bangladesh RCT cohort ± Tofail 2012 Bangladesh RCT cohort ± Taneja 2005 India RCT cohort ± Taneja 2015 India RCT cohort ± Yousafzai 2014 Pakistan randomized effectiveness trial cohort ± Duazo 2010 Philippines longitudinal program evaluation cohort ±0.88 Sub-Saharan Africa 8 Shapiro 2013 Botswana RCT cohort 224?±? 9 Alemtsehay 2009 Ethiopia cross-sectional, cohort cohort ± Gladstone 2011 Malawi cross-sectional, cohort cohort ± McDonald 2013 Tanzania RCT cohort ± Manji 2014 Tanzania RCT cohort ± Sudfeld 2015 Tanzania RCT cohort ± Locks 2016 Tanzania RCT cohort ±0.03 Latin America 15 Matijasevich 2010 Brazil longitudinal cohort cohort 3868?±? 16 Santos 2008 Brazil longitudinal cohort cohort ± Fernald 2011 Ecuador randomized effectiveness trial cohort ± Handal 2007 Ecuador prospective cohort study cohort ± Braun 2012 Mexico prospective cohort study cohort ±0.03 Europe 20 Akman 2004 Turkey RCT cohort ±0.59 N Child age in years at assessment (mean ± SD)
10 Parental education: positive dose-response relationship with cognitive, motor and language scores Cognitive Motor Language Risk Factor Mother's education No education (<1 years) (-0.24, ) (-0.13, -0.01) (-0.21, -0.09) Primary (1- <6 years) Reference Reference Reference Secondary (6- <10 years) (0.05, 0.24) < (0.06, 0.18) < (0.04, 0.21) Higher ( 10 years) (0.19, 0.48) < (0.14, 0.38) < (0.09, 0.33) Father's education No education (<1 years) (-0.08, 0.07) (-0.11, -0.04) < (-0.15, 0.20) Primary (1- <6 years) Reference Reference Reference Secondary (6- <10 years) (0.015, 0.11) (0.03, 0.13) < (0.02, 0.16) Higher ( 10 years) (0.08, 0.21) < (0.10, 0.26) < (0.11, 0.32)
11 Maternal age: no association Cognitive Motor Language Risk Factor Mother's age <15 years (-0.13, 0.25) (-0.06, 0.30) n/a n/a n/a 15-<20 years (-0.06, 0.05) (-0.11, 0.08) (-0.09, 0.11) years Reference Reference Reference 35 years (-0.06, 0.04) (-0.07, 0.05) (-0.05, 0.09)
12 Short maternal stature and low BMI: significantly lower motor scores Cognitive Motor Language Risk Factor Mother's height <145 cm (-0.20, ) (-0.19, -0.03) (-0.31, 0.09) <150 cm (-0.19, -0.02) (-0.16, 0.03) (-0.13, 0.06) <155 cm (-0.14, -0.04) < (-0.09, 0.009) (-0.12, 0.02) >155 cm Reference Reference Reference Mother's BMI (kg/m 2 ) < (-0.20, -0.02) (-0.11, 0.07) n/a n/a n/a <25 Reference Reference Reference 25-< (-0.04, 0.09) (-0.03, 0.11) (-0.21, 0.13) (-0.17, 0.14) (-0.14, 0.10) (-0.34, 0.06)
13 Maternal hemoglobin: no association Cognitive Motor Language Risk Factor Mother's hemoglobin level (g/l) Normal ( 110 g/l)) Reference Reference Reference Mild ( g/l) (-0.15, 0.03) (0.008, 0.11) n/a n/a n/a Moderate (70-99 g/l) (-0.19, 0.06) (-0.06, 0.04) n/a n/a n/a
14 Preterm birth: reduced cognitive & motor scores SGA: no effect Cognitive Motor Language Risk Factor Birth weight (g) Normal ( 2500 g) Reference Reference Reference Low (<2500 g) (-0.20, -0.07) < (-0.23, -0.06) < (-0.22, 0.00) Moderate low ( g) (-0.12, -0.03) < (-0.20, -0.02) (-0.10, 0.01) Very low (<2000 g) (-0.49, -0.07) (-0.40, -0.12) < (-0.60, 0.05) Gestational age (g) 2 Term ( 37 weeks) Reference Reference Reference Late preterm (34-37 weeks) (-0.39, -0.04) (-0.33, 0.04) (-0.23, 0.13) Early preterm (<34 weeks) (-0.34, 0.31) (-0.53, 0.006) (-0.55, 0.15) Size for gestational age 3 AGA ( 10 percentile) Reference Reference Reference Moderate SGA (3-<10 percentile) (-0.11, 0.12) (-0.10, 0.07) (-0.18, 0.06) Severe SGA (<3 percentile) (-0.24, 0.07) (-0.09, 0.12) (-0.13, 0.19)
15 Anemia in infancy: reduced cognitive and motor scores Cognitive Motor Language Risk Factor Child hemoglobin level (g/l) Normal ( 110 g/l) Reference Reference Reference Mild anemia ( g/l) (-0.13, 0.01) (-0.13, 0.07) n/a n/a n/a Moderate anemia (70-99 g/l) (-0.12, -0.10) < (-0.28, -0.09) < n/a n/a n/a
16 Lack of access to clean water and sanitation: reduced cognitive and motor scores Cognitive Motor Language Risk Factor Access to clean water Yes Reference Reference Reference No (-0.12, -0.09) < (-0.16, 0.01) (-0.35, -0.05) Access to sanitation Yes Reference Reference Reference No (-0.18, -0.07) < (-0.19, -0.01) (-0.27, 0.03)
17 Diarrhea and breastfeeding: no association Cognitive Motor Language Risk Factor Exclusive breastfeeding Yes Reference Reference Reference No (-0.08, 0.04) (-0.13, 0.04) ? n/a n/a n/a Diarrhoea Yes (-0.16, 0.13) (-0.14, 0.09) n/a n/a n/a No Reference Reference Reference
18 Summary: Parental factors
19 Summary: Child factors
20 Strengths and limitations Strengths: - global coverage of the cohorts - the large sample size - uniform classifications of early life exposures and statistical analyses across Limitations: - lack of data on child stimulation and education - observational data, causal relationship cannot be established - moderate to high level of heterogeneity
21 Implications Differential exposure to risk factors creates large disparities in children s development early in life. Intervention targeting these factors during pre-pregnancy through childhood is needed to improve the health and developmental potential of children.
22 Future research Estimate the effects of risk factors that co-occur Evaluate effectiveness and delivery strategies for comprehensive intervention packages
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