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Developmental trends in early on childhood and their predictors from an Indian birth accomplice

  • Manikandan Srinivasan2,
  • Anuradha Bose3,
  • Sushil John4,
  • Venkata Raghava Mohan3,
  • Reeba Roshan1,
  • Karthikeyan Ramanujam2 &
  • Gagandeep Kangii

BMC Public Health volume 21, Article number:1083 (2021) Cite this article

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Abstract

Background

Early on childhood developmental pattern analyses not only projection time to come knowledge potential, but also identify potential risks for possible intervention. The electric current report evaluates developmental trends in the start 3 years of life and their predictors in a low and centre income country setting.

Methods

Trends of early childhood development at 6, 15, 24 and 36 months of age and their predictors were explored in a longitudinal community-based nativity cohort study in an urban slum in Vellore, S Bharat. Development was assessed using the Bayley Scales of Baby and Toddler Evolution-III (BSID-Three).

Results

The birth cohort enrolled 251 children with 94, 91, 91 and 87% follow-up at half dozen, 15, 24 and 36 months respectively. Child development domains of cognition, language, motor and social skills showed a significant decline in scores between 6 and 36 months of age. College socioeconomic position (SEP) and nurturing domicile environment contributed to increase in knowledge scores by i.nine and 0.9 units respectively. However, stunting acquired a refuse in cognition scores by ane.7 units. Higher maternal cognition, higher SEP, and caregiver responsivity positively contributed to linguistic communication alter over time, while higher maternal depression contributed negatively. An enriching home surround, growth parameters and blood iron status had positive association with alter in motor skills.

Conclusions

A triple intervention plan to enhance domicile environment and nurturance, early on childhood food supplementation, and maternal educational activity and well-being might forestall kid developmental decline in high take chances settings.

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Background

It is estimated that around 250 one thousand thousand young children living in the depression and middle income countries (LMIC) gamble poor development and sub-optimal livelihood potential [ane, 2] considering of exposure to twin risks of farthermost poverty and stunting [3]. Describing developmental trajectory patterns in the LMIC non merely helps in understanding developmental variations unlike from conventional standards, only also aids in identifying sensitive periods and specific risk factors including agin childhood experiences. Region-specific analysis of developmental trajectory patterns tin in addition help to custom-make specific developmental intervention, which tin be later incorporated into public health policy.

Sensitive periods for optimal childhood development include the fourth dimension period from formulation to 2 years of age considered the first-thousand days of life [4] and from two to 5 years of age, the 2d-1000 days of life [5, 6]. Large multi-national nascence cohort studies accept shown complex interactions among early on babyhood infections, nutritional intake, family socio-economic position and habitation environment, affecting cognition at 2 years [7] as well as 5 years of age [eight]. Risk factors including foetal growth restriction manifesting as low nascency weight [9], absolute poverty [2], early on childhood stunting [2, 5], micronutrient deficiency [ten], poor sanitation [xi], diarrhoea [12, 13], maternal depression [14] and sub-optimal home environment [15, 16] can adversely impact early child development with persisting effects on subsequently school cognition, learning and behaviour [1, two, 5].

Early childhood developmental trajectory analyses accept been predominantly restricted to cognition [9, 17, xviii], with a few evaluating other developmental domains such as social skills [xix]. Group based trajectory modelling of a large Chinese birth cohort showed four different patterns of cognition paths in the first 24 months of life [9], while longitudinal social profiles of Japanese children between two and 5 years of age showed three different trajectories [19]. Development of neuropsychological functions in Indian children was described equally "non-linear, heterogeneous and protracted" in a cross-sectional report [20]. Indian nativity cohort follow-upwardly studies, every bit office of large multinational projects, have predominantly evaluated early childhood infection/growth in relation to later on historic period knowledge [12, 21, 22] disallowment a few evaluating early childhood growth-development linkage [23]. There have been few studies exploring evolution of all domains of evolution over fourth dimension in the early years, especially in a LMIC setting. The electric current study was planned to evaluate the trends of child developmental domains of cognition, language, social and motor skills in the first 3 years of life and analyse their predictors. Information technology is hypothesized that socio-economical position, dwelling environs, maternal cognition and micronutrient status volition influence developmental domains.

Methods

Settings and subjects

The present study was done as an independent sub-assay of a large prospective, multinational longitudinal nativity accomplice written report conducted across viii different nations beyond the world -'The Etiology, Gamble Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Evolution (MAL-ED) Network' [24]. The Indian report site was a densely populated urban slum in Vellore, South India and covered a population of 12,000 [25]. Children were enrolled at birth past consecutive sampling and details of enrollment, exclusion criteria, follow up and details are available in previously published articles from the same nascence cohort [26,27,28]. The original nascence cohort enrollment and consistent follow-ups were approved by the Institutional Review Board of Christian Medical College, Vellore and children were recruited at each stage after informed parental consent.

Measures

Bayley scales of baby and toddler evolution-Iii (BSID-III)

The Bayley Scales of Babe and Toddler Development-III (BSID-3) assesses development in the domains of motor, language, cognition and social skills betwixt ane and 42 months of age [29], and details of administration are available with proposed methodology [30], as well as customs level conduct already published [27, 28]. BSID-III was administered at 6, xv, 24 and 36 months of age. Private domain caliber was calculated from the raw score using child's chronological age.

The WAMI measure for socio-economical position

The WAMI mensurate with components of access to improved water and sanitation, assets, maternal pedagogy and full household income is a simplified mensurate of socio-economical position (SEP) developed during the MAL-ED report, [31] and details are provided in other published articles from the same cohort [26,27,28].

The HOME scale

The Abode Observation for the Measurement of the Environment (HOME) calibration (Babe/Toddler version) analyses the abode environment of the child including stimulation and support and is considered the gold standard with good psychometrics [32, 33]. Both physical and interactive home environment are observed and scored in this measure, specifically female parent-kid interactions including responsiveness.

The modified version has six subscales consisting of total 48 items with subscales of advisable play materials, avoidance of restriction and punishment, organization of the environment, parental interest, responsiveness to parent, and diverseness in daily stimulation [34]. The HOME scale was administered by a trained social worker, who observed the habitation environment for 45–60 min at 6, 24 and 36 months of child's historic period. Supplementary information was obtained using a mother/caregiver interview as per the MAL-ED study protocol [35]. Further details about this measure is provided in another published commodity from the same nativity cohort [26].

Maternal noesis was assessed past Raven's progressive matrices, a scale of non-verbal reasoning at vi–8 months of child's age [36]. The Self Reporting Questionnaire-20 (SRQ-20), developed by the World Health Organisation to appraise depressive symptoms in low-resource settings, was used to assess maternal psychological disturbances at 1,6, fifteen, 24 and 36 months of child age [37]. The full SRQ score was calculated using 16 items, which yielded one cistron structure [38].

Claret drove

Blood samples were collected at 7, 15, 24, 36 and threescore months; and details of collection, testing mechanisms and methods are published [28]. Samples were tested for hemoglobin (vii, 15, 24, and 36 months); ferritin assays (at 7, fifteen and 24 months) and blood lead levels (at 15, 24 and 36 months). As inflammation can influence serum ferritin levels, both transferrin (R) and ferritin (F) levels were utilized to find total trunk atomic number 26 levels using the formula, where positive values indicated iron reserves [39]:

$$ \mathrm{Body}\ \mathrm{Fe}\ \left(\mathrm{mg}/\mathrm{kg}\correct)=\left(\frac{-\left(\log \left(\frac{R}{F} ratio\correct)-2.8229\right)}{0.1207}\right) $$

Data entry

Data entry was made in the double entry database system managed by Information Coordinating Middle (DCC) of the MAL-ED study. Data collection forms filled by the field workers were authenticated by the field supervisor before inbound into the database [24].

Statistical assay

The outcome variable, BSID scores, assessed at vi, 15, 24 and 36 months of age was summarized using mean and standard deviation (SD) nether specific domains namely - noesis, linguistic communication, motor and socio-emotional domain. Independent predictors such equally maternal depression score, maternal knowledge and various domains of HOME inventory scale were summarized every bit hateful and SD. Height-for-age and weight-for historic period scores below − 2 SD were categorized equally stunted and underweight respectively. Values of claret iron measured at 7, 15 and 24 months were considered for assay and the missing values were replaced with the average of measurements available at the other time points. Blood lead levels measured at xv, 24 and 36 months were averaged to obtain hateful lead level. Domain-wise score of cognitive evolution was compared across the time points using repeated measures ANOVA examination. Factors predicting cerebral development scores across the iv time points were measured using the generalized estimating equations (GEE) – population averaged model based on the post-obit equation,

Cognition development ij  = αi + βi Gender + β2 Stunted ij  + βthree Underweight ij  + β4 Mother's knowledge scores+ β5 SEP ij  + β6 Body fe ij  + β7 Mean blood lead + β8 Female parent's depression scores ij  + β9–fourteen Domains of Abode Inventory scale + ε ij .

where 'i' and 'j' refers to children and time points of measurements respectively, and, εij representing the random error. Multicollinearity of the covariates included in the model was tested using variance inflation factor and none of the variables were observed to exist collinear. GEE model was used to adjust for clustering at the subject level, considering of repeated measurements on children. Subject ID of written report children was used as the clustering variable in the model. We specified exchangeable correlation construction in the model, based on the quasi Information Criteria (QIC) and robust standard errors were estimated [40]. Beta co-efficients along with 95% confidence interval take been reported for the independent predictors. Model fit was assessed using Wald statistics and p less than 0.05 was considered equally statistical significance. Information assay was done using Stata version 13 (StataCorp. 2013. Stata Statistical Software. Release 13. College station, TX: StataCorp LP).

Results

In the original birth-cohort, 251 newborns were enrolled subsequently registering 301 pregnant mothers. 50 children were excluded every bit per the exclusion criteria: another sibling registered in the MAL-ED written report (northward = eight), medical comorbidities in children (north = 7), multiple pregnancy (n = 1), pre-existing plan to drift (northward = 5), mother non bachelor for consent (n = 9), combination of two or more of the to a higher place mentioned reasons (due north = 10) and mothers/parents refused participation (n = 10). Subsequent follow ups at 6, 15, 24 and 36 months had 235, 229, 228 and 218 children respectively. Migration was the main cause for the loss to follow-up, equally illustrated in other published articles from the same cohort [28].

The Vellore birth-cohort had a mean birth weight (SD) of two.89 (0.44) kg and 17% of newborns weighed less than 2.v kg. More than 80% of families had monthly income less than 5000 Indian rupees (70 USD). The cohort had girl predominance at birth (56%) likewise as subsequent follow-ups. Cohort characteristics at 6 and 36 months are summarized in Table i, with details of 6, 15, 24 and 36 months in Supplementary Table ane.

Tabular array i Baseline characteristics of the birth accomplice established in Vellore in 2010

Full size table

Developmental domain quotients of cognition, language, motor and social skills significantly differed between 6 and 36 months of age (Table ii) with both cognition and social domains showing decline of more than 15 points (Fig. 1).

Table 2 Mean (SD) domain caliber scores of Bayley Scales of Infant Development -III represented domain-wise beyond 6, 15, 24 and 36 months in MAL-ED children (N = 216)

Total size table

Fig. i
figure 1

Domain wise scores obtained in Bayley scales of infant development assessed betwixt 6 and 36 months of historic period in children of MAL-ED accomplice, Vellore

Full size image

Analysing factors responsible for the alter in cognition scores between six and 36 months, higher SEP, body iron levels and Abode factors of parental responsivity and provision of appropriate play materials positively predicted cognition (Table 3). The maximum positive association was with SEP followed past HOME factors, while stunting had the maximum negative impact. Higher maternal knowledge, higher SEP, and caregiver responsivity positively contributed to language change over time, while higher maternal depression contributed negatively. Maximum consequence size on linguistic communication modify was seen with SEP.

Table iii Factors associated with kid development scores measured at 6, 15, 24 and 36 months in Vellore cohort of MAL-ED report (N = 216)

Full size table

Factors positively contributing to change in motor scores included higher maternal knowledge, college weight and height for age scores, college body iron levels and positive abode factors of abstention of brake and punishment, and availability of advisable play materials. Both Home factors and growth parameters had high association with change in motor skills. Body fe levels positively influenced social domain change over fourth dimension with beta-coefficient (95% CI) of 0.xx (0.05–0.34), while claret lead levels had a negative influence with beta-coefficient (95% CI) of − 0.22 (− 0.34- -0.09) in univariate analyses. There were no significant associations in multivariate assay, thus non reported in Table 3.

Word

This prospective longitudinal nascency accomplice follow-up analysis from urban Vellore evaluated developmental trends in the domains of knowledge, language, motor and social skills; and predictors for private domain change over fourth dimension. All developmental domain quotients showed a decreasing trend over time with cognition and language domains dropping more than than xv points betwixt vi and 36 months of age. Children in the highest tertile of SEP had better knowledge and linguistic communication scores over time. Stunted children had poorer knowledge and motor scores over time. Home environmental factors of parental responsivity affected changes in knowledge and language scores, while punishment avoidance and toy availability influenced the motor score change. Higher maternal knowledge afflicted changes in both linguistic communication and motor domains, while maternal depression adversely afflicted language scores over time. Hateful body iron levels was associated with changes in both cognition and motor skills. In that location was a good level of follow-up in the electric current study with 94% at 6 months, 91% at 24 months and 87% at 36 months.

Kid evolution evolves over fourth dimension and developmental measures such as BSID-3 have shown weak predictability of school age cognition [41], motor skills [42], and behaviour [43]. Despite this, BSID is the most common developmental tool used across the earth, as it is a sensitive measure of child development [29]. Though child developmental process and sequence are compatible beyond the world, there tin be differences in the rate of achievement between populations. Trends of all developmental domains in an urban low-income setting as shown in this study can exist useful for clinical do in such settings, academic agreement, and analysis of risks contributing to whatsoever setback. Though the current assay has not done a consummate trajectory exploration, the nascency accomplice showed a decreasing trend in all developmental domains' quotients. This is in discordance with some other large rural birth cohort written report reported from China, where more than xc% showed an increasing trend in cognitive evolution between 6 and 24 months of age [9]. The Vellore nascency cohort is predominantly a low-income urban slum setting with boosted ecology and nutritional challenges, which take been explored in the electric current analysis. Similar results were reported from some other study conducted in rural Republic of india, where recruited infants showed a refuse in scores in fine motor, receptive and expressive language skills and visual reception over a 6-month follow-up menstruation [23]. A previous nascency cohort follow upward done in other urban slums of Ramnaickanpalayam, Chinnallapuram and Kaspa in Vellore had too revealed decline in cognition scores betwixt three and vii years of age [44].

The SEP including household wealth affects linear growth [45, 46], development [2] and knowledge [15, 47] in children. Childhood SEP is shown to influence neural evolution particularly of the language and executive part areas in the brain [48]. Better SEP tin can issue in improved nutrition, better sanitation, less infection and enhanced interactive experiences, all of which can meliorate child evolution especially language as shown in the current study.

Stunting had independent associations with cognition and motor scores despite correction with SEP, Home status and micronutrient levels in the current report. Stunting has been shown to impact development and cognition; thus integrated interventions have been suggested to improve both linear growth and kid development [2, v]. A rural study conducted in Telangana, Southward India found like results where summit z-scores at enrollment had a positive association with all child development domains, the event of which was attenuated past a nurturing abode environs [23].

In the electric current report, positive home ecology factors influenced developmental gains over time, despite correction with SEP. Home surround tin can mediate the relationship between SEP and early childhood evolution [15, 16] also every bit betwixt linear growth and development [23]. The two components of home environs – physical and relational modulate each other, with the sensitive and interactive relational cistron overriding the negative effects of a sub-optimal habitation milieu. The issue of physical overcrowding on childhood development and cognition can be mediated by maternal responsiveness [49].

Maternal factors can influence kid development, noesis and behaviour direct and indirectly through better home environmental factors. The effect of maternal depression can even start in the dues-natal catamenia not merely through altered placental functions, only also past causing foetal epigenetic changes and stress reactivity [14]. Maternal depression equally well every bit lack of breastfeeding practices can lead to adverse paediatric development [50]. Maternal cognition also affects babyhood development and cognition through genetic factors as well as enriching interacting experiences [8, fifteen, 49].

Iron deficiency in early childhood, when there is an increased iron need to optimize neuronal maturation, neurotransmitter synthesis, mitochondrial function and other iron dependent enzymes [51], can be detrimental equally shown in the electric current assay. This early babyhood fe deficiency can take persisting furnishings on noesis in afterwards life every bit evidenced by another analysis on the aforementioned cohort showing cumulative iron deficiency negatively impacting verbal, operation and processing speed domains of cognition at 5 years of age [28]. That assessment had shown that more than than xl% of children had atomic number 26 deficiency at xv and 24 months of age. Subsequently babyhood iron supplementation improves body fe stores, but not the persisting effect of early onset atomic number 26 deficiency on cognition [51, 52].

There are limitations for the current study including a comparatively small sample size. Though BSID-III is a sensitive and adapted measure, there can be variations (inside normal limits) in developmental achievements. Nonetheless the depression-income urban slum setting of the accomplice, its high early babyhood iron deficiency and a pregnant decline in developmental quotients over time warrant an assessment every bit in the current study. Strengths of the written report include good follow-up of a longitudinal nascence cohort, strong data granularity during early childhood period, standardized developmental, domicile environment and SEP assessments, claret results from a national reference laboratory and rigorous quality control measures internally and externally.

Conclusions

This longitudinal nativity cohort follow-upward study has shown a significant decline in developmental scores in cognition, language, motor and social domains betwixt half-dozen and 36 months of age in a LMIC urban slum setting. Positive domicile ecology factors in addition to SEP enhanced developmental outcomes. Both maternal components of cognition and depression showed effects on progress of kid development. Linear growth as well as iron deficiency independently influenced development.

Findings of the current report tin be relevant for other loftier risk settings worldwide. The written report confirms 3 big domains associated with childhood development - nurturing environment and SEP nether ecology factors, maternal factors of instruction and low, and nutritional factors of iron deficiency and appropriate linear growth. Information nearly advisable early childhood diet and nurturing activities can exist provided in both antenatal and immunization clinics to empower mothers. Community level support groups for new mothers tin help and back up mothers in the post-partum period, while iron supplementation and fortification can optimize early childhood iron deficiency. A triple intervention plan to enhance home environment and nurturance, maternal education and well-existence, and early childhood nutrient supplementation might prevent child developmental decline in high run a risk settings.

Availability of data and materials

MAL-ED data from all sites are deposited in the https://clinepidb.org website, which take public access afterwards advisable permissions.

Abbreviations

BSID-III:

Bayley Scales of Infant and Toddler Evolution-III

Home:

Home Observation for the Measurement of the Environment scale

LMIC:

Low and middle income countries

MAL-ED:

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development

SEP:

Socio-economic position

SRQ-20:

Self Reporting Questionnaire-20

WAMI:

Water and sanitation, avails, maternal education and total household income

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Acknowledgements

The authors give thanks the participants, their families and staff of the MAL-ED Network project.

Funding

The Etiology, Gamble Factors and Interactions of Enteric Infections and Malnutrition and the Consequence for Child Health and Evolution Project (MAL-ED) is carried out as a collaborative project supported by the Bill and Melinda Gates Foundation, the Foundation for the NIH and the National Institutes of Health/Fogarty International Center. The funding torso did non play whatever role in the blueprint of the study and collection, analysis, and interpretation of data and in writing the manuscript.

Writer data

Affiliations

  1. Developmental Paediatrics Unit, Christian Medical Higher, Vellore, 632004, India

    Beena Koshy & Reeba Roshan

  2. Wellcome enquiry Unit of measurement, Christian Medical Higher, Vellore, 632004, India

    Manikandan Srinivasan, Karthikeyan Ramanujam & Gagandeep Kang

  3. Customs Health, Christian Medical College, Vellore, 632004, India

    Anuradha Bose & Venkata Raghava Mohan

  4. Depression Price Effective Intendance Unit, Christian Medical College, Vellore, 632004, India

    Sushil John

Contributions

Drs. GK, SJ, AB, VRM, RR and BK are involved in the nativity cohort study planning, recruitment and follow-upwards besides as in the planning, assay, write-upwardly and correction of the electric current study. Drs. MS is involved in the data analysis, write-up and corrections. Mr. KR is the data co-ordinator, who entered and analysed data and is involved in the study write-up and corrections. All authors canonical the final manuscript.

Corresponding author

Correspondence to Beena Koshy.

Ethics declarations

Ethics approval and consent to participate

This study was conducted co-ordinate to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects/patients were approved by the Institutional Review Board, Christian Medical Higher, Vellore (IRB min no. 6789 dated 24.02.2009). Written informed consent was obtained from all participants' parents.

Consent for publication

Not applicable as there is no identifying data.

Competing interests

None

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Koshy, B., Srinivasan, One thousand., Bose, A. et al. Developmental trends in early childhood and their predictors from an Indian nativity cohort. BMC Public Health 21, 1083 (2021). https://doi.org/10.1186/s12889-021-11147-3

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  • DOI : https://doi.org/ten.1186/s12889-021-11147-iii

Keywords

  • Early on childhood
  • Developmental trends
  • Socio-economical position
  • Domicile surround
  • Maternal factors

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