Malawi Developmental Assessment Tool Research Articles

Comparing motor development in children with hydrocephalus after treatment with ventriculoperitoneal shunt and endoscopic third ventriculostomy: a cross-sectional study

Introduction Ventriculoperitoneal shunt insertion (VPSI) and endoscopic third ventriculostomy (ETV) are the major procedures for treating pediatric hydrocephalus. However, studies comparing motor development following the two treatments are limited.Objective We aimed to determine motor development outcomes in children with hydrocephalus up to 2 years of age after undergoing VPSI or ETV, to identify which surgical approach yields better motor outcomes and may be more effective for Malawian children.Methods This was a cross-sectional study where we recruited two groups of participants: one group consisted of children with hydrocephalus treated with VP shunt whilst the other group were treated with ETV, at least 6 months prior to this study. Participants were identified from the hospital records and were called to come for neurodevelopmental assessment using the Malawi Development Assessment Tool (MDAT).ResultsA total 152 children treated for hydrocephalus within an 18-month period met the inclusion criteria. Upon follow up and tracing, we recruited 25 children who had been treated: 12 had VPSI and 13 had ETV. MDAT revealed delays in both assessed motor domains: 19 out of the 25 children had delayed gross motor whilst 16 of 25 had delayed fine motor development. There was no significant difference between the shunted and the ETV groups. Conclusion Children with hydrocephalus demonstrate delays in motor development six to 18 months after treatment with either VPSI or ETV. This may necessitate early and prolonged intensive rehabilitation to restore motor function after surgery. Long-term follow-up studies with bigger sample sizes are required to detect the effect of the two treatment approaches.

Developmental and Nutritional Changes in Children with Severe Acute Malnutrition Provided with n-3 Fatty Acids Improved Ready-to-Use Therapeutic Food and Psychosocial Support: A Pilot Study in Tanzania.

Children with severe acute malnutrition (SAM) are at high risk of impaired development. Contributing causes include the inadequate intake of specific nutrients such as polyunsaturated fatty acids (PUFAs) and a lack of adequate stimulation. We conducted a pilot study assessing developmental and nutritional changes in children with SAM provided with a modified ready-to-use therapeutic food and context-specific psychosocial intervention in Mwanza, Tanzania. We recruited 82 children with SAM (6-36 months) and 88 sex- and age-matched non-malnourished children. We measured child development, using the Malawi Development Assessment Tool (MDAT), measures of family and maternal care for children, and whole-blood PUFA levels. At baseline, the mean total MDAT z-score of children with SAM was lower than non-malnourished children; -2.37 (95% confidence interval: -2.92; -1.82), as were their total n-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) levels. After 8 weeks of intervention, MDAT z-scores improved in all domains, especially fine motor, among children with SAM. Total n-3 and EPA levels increased, total n-6 fatty acids decreased, and DHA remained unchanged. Family and maternal care also improved. The suggested benefits of the combined interventions on the developmental and nutritional status of children with SAM will be tested in a future trial.

Correlates of early child development among children with stunting: A cross-sectional study in Uganda.

Many children in low- and middle-income countries are not attaining their developmental potential. Stunting is associated with poor child development, but it is not known which correlates of stunting are impairing child development. We explored potential socioeconomic, nutritional, clinical, and household correlates of early child development among 12-59-month-old children with stunting in a cross-sectional study in Uganda. Development was assessed using the Malawi Development Assessment Tool (MDAT) across four domains of gross and fine motor, language, and social skills. Linear regression analysis was used to assess correlates of development in the four domains and total MDAT score. Of 750 children included, the median [interquartile range] age was 30 [23-41] months, 55% of the children resided in rural settings with 21% from female-headed households and 47% of mothers had no schooling. The mean ± standard deviation height-for-age z-score (HAZ) was -3.02 ± 0.74, 40% of the children had a positive malaria test and 65% were anaemic (haemoglobin < 110 g/L). One-third had children's books at home, majority (96%) used household objects to play with and most of them (70%) used toys as pretence items like those to mimic cooking. After age, sex, and site adjustments, HAZ (0.24, 95% confidence interval [CI]: 0.14-0.33) and head circumference (0.07, 95%CI: 0.02-0.12) were positive correlates of total MDAT score, whereas weight-for-height z-score (WHZ) was not. Current breastfeeding was associated with 0.41 (95%CI: 0.17-0.65) lower total MDAT score. Children from households with a single income earner had 0.22 (95%CI: 0.06-0.37) lower total MDAT score. Furthermore, severe food insecurity, inflammation and positive malaria test were associated with lower scores for motor development. All family care indicator subscales (FCIs) positively correlated with the total MDAT score and this association was independent of household's socioeconomic status. In conclusion, stunting degree, head circumference, number of household income earners and stimulation by improved FCIs correlate with early child development among stunted children. The negative association with prolonged breastfeeding is likely due to reverse causality. Identified correlates may inform initiatives to support children with stunting attain their development potential.

Impact evaluation of a maternal and child cash transfer intervention, integrated with nutrition, early childhood development, and agriculture messaging (MAZIKO-IE): a study protocol for a cluster-randomised controlled trial

BackgroundChildren in Malawi face high rates of malnutrition and are at risk of not reaching their developmental potential. Community-based childcare centres (CBCCs) can be cost-effective platforms for scaling-up early childhood development (ECD) and nutrition social behaviour change (SBC) interventions. However, evidence also suggests potential synergies from coupling nutrition SBC with cash transfers (CT), given that rural households in Malawi face high levels of poverty and recurring extreme lean season food-security shocks. The Maziko trial is aimed at evaluating the effectiveness and cost-effectiveness of using CBCCs and parenting care groups as platforms to improve maternal diets and child nutrition and development by providing nutrition-sensitive SBC and CT intervention packages in communities already receiving a standard of care Government SBC program.MethodsWe designed a 3-year cluster-randomised controlled trial in two districts of Malawi, including 156 communities randomised to one of four treatment arms: (1) standard of care (SoC) arm: receiving the standard Government SBC program; (2) SBC arm: receiving the SoC intervention with additional nutrition-sensitive SBC activities to improve nutritious food production, diets, and care practices for young children; (3) low CT arm: SoC plus SBC plus a maternal and child cash transfer ~ 17 USD per month; and (4) high CT arm: SoC plus SBC plus a maternal and child CT ~ 43 USD per month. The trial will enrol pregnant women and children < 2 years of age. The primary outcomes are maternal diet assessed using the mean probability of adequacy and child development assessed using the Malawi Developmental Assessment Tool. Intermediate outcomes along the programme impact pathways will also be measured, including maternal mental health, maternal empowerment, child feeding practices, and child nutritional status.DiscussionThis is the first study to examine the impact and synergies of combining ECD SBC with nutrition-sensitive SBC and CTs on maternal and child outcomes during the first 1000 days. The findings from this evaluation will inform national ECD and nutrition programmes.Trial registrationISRCTN ISRCTN53055824. Registered on 7 March 2022.

Effect of fatty acid profiles in varying recipes of ready-to-use therapeutic foods on neurodevelopmental and clinical outcomes of children (6-59 months) with severe wasting: a systematic review.

In 2020, 13.6 million children under 5 years suffered from severe acute malnutrition (SAM)/wasting. Standard ready-to-use therapeutic foods (RUTFs) improve polyunsaturated fatty acid (PUFA) status but contain suboptimal amounts of omega-3 (n-3) PUFAs with unbalanced n-6-to-n-3 PUFA ratios. The aim was to compare the effects of RUTFs with different essential fatty acid contents on PUFA status, neurodevelopmental, and clinical outcomes (mortality, comorbidities, and recovery) of children with severe wasting. Twelve databases, trial repositories, and article references with no publication limitations. Ten studies from randomized, quasi, and cluster-randomized controlled trials providing RUTFs as home treatment to children 6-59 months with SAM/wasting were included. Plasma phospholipid eicosapentaenoic acid content was higher in children receiving RUTF with altered essential fatty acid contents compared with standard RUTF (0.20 [0.15-0.25], P < 0.00001). Docosahexaenoic acid (DHA) status only improved in children receiving RUTF with added fish oil (0.33 [0.15-0.50], P = 0.0003). The Malawi Developmental Assessment tool (MDAT) global development and problem-solving assessment scores were higher in global assessment and gross motor domains in children receiving added fish oil compared with standard formulation (0.19 [0.0-0.38] and 0.29 [0.03-0.55], respectively). Children receiving high-oleic-acid RUTF (lowering the n-6:n-3 PUFA ratio of the RUTF) with or without fish oil had significantly higher scores in social domains compared with those receiving the standard formulation (0.16 [0.00-0.31] and 0.24 [0.09-0.40]). Significantly higher mortality risk was found in children receiving a standard formulation compared with RUTF with a lower n-6:n-3 PUFA ratio (0.79 [0.67-0.94], P = 0.008). Although lowering n-6:n-3 PUFA ratios did not increase plasma DHA, it improved specific neurodevelopmental scores and mortality due to lower linoleic acid (high-oleic-acid peanuts), higher alpha-linolenic acid (altered oil), or both. Additional preformed n-3 long-chain PUFAs (fish oil) with RUTF improved the children's DHA status, neurodevelopmental outcomes, and weight-for-height z score. More research is needed regarding cost, availability, stability, acceptability, and the appropriate amount of n-3 long-chain PUFAs required in RUTFs for the best clinical outcomes. PROSPERO registration no. CRD42022303694.

The Precise-DYAD Neurodevelopmental substudy protocol: neurodevelopmental risk in children of mothers with placental complications

Background: Over 250 million children are not reaching their developmental potential globally. The impact of prenatal factors then influenced by postnatal environmental factors on child neurodevelopment, is still unclear—particularly in low- and middle-income settings. This study aims to understand the impact of placental complications as well as environmental, psychosocial, and biological predictors on neurodevelopmental trajectories. Methods: This is an observational cohort study of female and male children (≈3,950) born to women (≈4,200) with and without placental disorders (pregnancy-induced hypertension, foetal growth restriction, and premature birth) previously recruited into PREgnancy Care Integrating Translational Science, Everywhere study with detailed biological data collected in intrapartum and post-partum periods. Children will be assessed at six weeks to 6 months, 11-13 months, 23-25 months and 35-37 months in rural and semi-urban Gambia (Farafenni, Illiasa, and Ngayen Sanjal) and Kenya (Mariakani and Rabai). We will assess children's neurodevelopment using Prechtls General Movement Assessment, the Malawi Development Assessment Tool (primary outcome), Observation of Maternal-Child Interaction, the Neurodevelopmental Disorder Screening Tool, and the Epilepsy Screening tool. Children screening positive will be assessed with Cardiff cards (vision), Modified Checklist for Autism in Toddlers Revised, and Pediatric Quality of Life Inventory Family Impact. We will use multivariate logistic regression analysis to investigate the impact of placental complications on neurodevelopment and conduct structural equation modelling using latent class growth to study trajectories and relationships between biological, environmental, and psychosocial factors on child development. Conclusions: We aim to provide information regarding the neurodevelopment of infants and children born to women with and without placental complications at multiple time points during the first three years of life in two low-resource African communities. A detailed evaluation of developmental trajectories and their predictors will provide information on the most strategic points of intervention to prevent and reduce the incidence of neurodevelopmental impairments.

Neurodevelopment of children who are HIV-exposed and uninfected in Kenya.

Predictors of neurodevelopment among children who are HIV-exposed uninfected (CHEU) are poorly understood. Mothers with and without HIV and their children were enrolled during 6-week postnatal care visits across seven sites in Kenya between March 2021 and June 2022. Infant neurodevelopment was assessed using the Malawi Developmental Assessment Tool, including social, language, fine motor and gross motor domains. We used multivariate linear mixed effects models to identify associations between 1-year neurodevelopment scores, HIV and antiretroviral therapy (ART) exposures, and household factors, adjusted for potential confounders and clustered by the site. At 1-year evaluation, CHEU (n = 709) and children who are HIV-unexposed uninfected (CHUU) (n = 715) had comparable median age (52 weeks) and sex distribution (49% vs. 52% female). Mothers living with HIV were older (31 vs. 27 years), had lower education (50% vs. 26% primary) and were more likely to be report moderate-to-severe food insecurity (26% vs. 9%) (p < 0.01 for all). Compared to CHUU, CHEU had higher language scores (adjusted coeff: 0.23, 95% CI: 0.06, 0.39) and comparable social, fine and gross motor scores. Among all children, preterm birth was associated with lower gross motor scores (adjusted coeff: -1.38, 95% CI: -2.05, -0.71), food insecurity was associated with lower social scores (adjusted coeff: -0.37, 95% CI: -0.73, -0.01) and maternal report of intimate partner violence (IPV) was associated with lower fine motor (adjusted coeff: -0.76, 95% CI: -1.40, -0.13) and gross motor scores (adjusted coeff: -1.07, 95% CI: -1.81, -0.33). Among CHEU, in utero efavirenz (EFV) exposure during pregnancy was associated with lower gross motor scores compared to dolutegravir (DTG) exposure (adjusted coeff: -0.51, 95% CI: -1.01, -0.03). Lower fine and gross motor scores were also associated with having a single or widowed mother (adjusted coeff: -0.45, 95% CI: -0.87, -0.03) or a deceased or absent father (adjusted coeff: -0.81, 95% CI: -1.58, -0.05), respectively. Biologic and social factors were associated with child neurodevelopment. Despite socio-demographic differences between CHEU and CHUU, 1-year neurodevelopment was similar. Addressing IPV and food insecurity may provide benefits regardless of maternal HIV status. DTG use was associated with higher neurodevelopmental scores in CHEU, compared to EFV regimens, potentially contributing to a lack of neurodevelopmental difference between CHEU and CHUU.

Growth and neurodevelopmental outcomes of preterm and low birth weight infants in rural Kenya: a cross-sectional study

ObjectiveData on long-term outcomes of preterm (PT) and low birth weight (LBW) infants in countries with high rates of neonatal mortality and childhood stunting are limited, especially from community settings....

Neurodevelopmental Outcome at 6 Months Following Neonatal Resuscitation in Rural Tanzania.

Early bag-mask ventilation (BMV) administered to non-breathing neonates at birth in the presence of birth asphyxia (interruption of placental blood flow) has reduced neonatal mortality by up to 50% in low- and middle-income countries. The neurodevelopmental outcome of neonates receiving BMV remains unknown. Using the Malawi Developmental Assessment Tool (MDAT), infants who received BMV at birth were assessed at 6 months, evaluating gross motor, fine motor, language and social skills. A healthy cohort with no birth complications was assessed with the same tool for comparison. Mean age-adjusted MDAT z-scores were not significantly different between the groups. The number of children having developmental delay defined as a z-score ≤ -2 was significantly higher in the resuscitated cohort for the fine motor and language domain and overall MDAT z-score. The prevalence of clinical seizures post discharge was significantly higher in the resuscitated group and was associated with neurodevelopmental delay. Infants with developmental delay or seizures were more likely to have a 5 min Apgar < 7 and a longer duration of BMV. Most children receiving BMV at birth are developing normally at 6 months. Still, there are some children with impaired development among resuscitated children, representing a subgroup of children who may have suffered more severe asphyxia.

Association of Circulating Biomarkers with Growth and Cognitive Development in Rural Tanzania: A Secondary Analysis of the Early Life Interventions in Childhood Growth and Development In Tanzania (ELICIT) Study

BackgroundChildren in low-resource areas experience nutritional and infection challenges delaying growth and cognitive development. ObjectivesOur goal was to assess for associations of circulating biomarkers related to nutrition and inflammation, with growth and developmental outcomes among children in a birth cohort in a resource-poor area in rural Tanzania. MethodsWe assessed data from 1,120 children participating in the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) study. At age 12 and 18 mo, participants had blood tests performed for hemoglobin, collagen-X, insulin-like growth factor-1 (IGF-1), fibroblast growth factor-21 (FGF21), thyroglobulin, ferritin, soluble transferrin receptor (sTFR), retinol binding protein-4 (RBP4), C-reactive protein (CRP), α1-acid glycoprotein (AGP), and CD14. At 18 mo, participants had anthropometry measured and converted to z-scores for length-for-age (LAZ), weight-for-age (WAZ) and head-circumference-for-age (HCZ) and had the Malawi Developmental Assessment Tool (MDAT) performed to evaluate cognitive development. We performed linear regression assessing biomarkers (predictor variable) on anthropometry and MDAT scores (dependent variables), adjusted for sex, socioeconomic status, and baseline values. ResultsThere was a high degree of intrafactor correlation between 12 and 18 mo and interfactor correlation between biomarkers. IGF-1 and sTFR were positively and FGF21 and ferritin negatively associated with LAZ at 18 mo, whereas collagen-X and CD14 were additionally associated with recent linear growth. Only markers predominantly related to nutrition were consistently linked with WAZ at 18 mo, while RBP4 and AGP were additionally associated with recent change in WAZ. IGF-1 was positively and thyroglobulin, RBP4, and CD14 negatively linked to MDAT scores. IGF-1 was the only factor linked to both 18-mo LAZ and MDAT. ConclusionsIndividual biomarkers were consistently linked to growth and cognitive outcomes, providing support for relationships between nutrition and inflammation in early child development. Further research is needed to assess overlaps in how biomarker-related processes interact with both growth and learning. Registered at clinicaltrials.govNCT03268902.

High Burden of Neurodevelopmental Delay among Children Born to Women with Obstructed Labour in Eastern Uganda: A Cohort Study.

Over 250 million infants in low and middle-income countries do not fulfill their neurodevelopment potential. In this study, we assessed the incidence and risk factors for neurodevelopmental delay (NDD) among children born following obstructed labor in Eastern Uganda. Between October 2021 and April 2022, we conducted a cohort study of 155 children (aged 25 to 44 months), born at term and assessed their neurodevelopment using the Malawi Developmental Assessment Tool. We assessed the gross motor, fine motor, language and social domains of neurodevelopment. The incidence of neurodevelopmental delay by 25 to 44 months was 67.7% (105/155) (95% CI: 59.8-75.0). Children belonging to the poorest wealth quintile had 83% higher risk of NDD compared to children belonging to the richest quintile (ARR (Adjusted Risk Ratio): 1.83; 95% CI (Confidence Interval): [1.13, 2.94]). Children fed the recommended meal diversity had 25% lower risk of neurodevelopmental delay compared to children who did not (ARR: 0.75; 95% CI: [0.60, 0.94]). Children who were exclusively breastfed for the first 6 months had 27% lower risk of neurodevelopmental delay compared to children who were not (ARR: 0.73; 95% CI: [0.56, 0.96]). We recommend that infants born following obstructed labor undergo neurodevelopmental delay screening.

The Association among Malaria in Pregnancy, Neonatal inflammation, and Neurocognitive Development in a Cohort of Malawian Infants.

Malaria in pregnancy (MIP) causes poor birth outcomes, but its impact on neurocognitive development has not been well characterized. Between 2012 and 2014, we enrolled 307 mother-infant pairs and monitored 286 infants for neurocognitive development using the Malawi Developmental Assessment Tool at 6, 12, and 24 months of age. MIP was diagnosed from peripheral blood and placental specimens. Cord blood cytokine levels were assessed for a subset of neonates. Predictors of neurodevelopment were examined using mixed-effect logistic regression for developmental delay. Among the participants, 78 mothers (25.4%) had MIP, and 45 infants (15.7%) experienced severe neurocognitive delay. MIP was not associated with differences in cord blood cytokine levels or neurocognitive development. Preterm birth, low birthweight, increasing maternal education level, and increasing interleukin 6 levels were associated significantly with delay. The results highlight the prevalence of severe delay and a need for broad access to early childhood support in this setting.

Neurodevelopment assessment of small for gestational age children in a community-based cohort from Pakistan

BackgroundChildren born small for gestational age (SGA) may experience more long-term neurodevelopmental issues than those born appropriate for gestational age (AGA). This study aimed to assess differences in the neurodevelopment...

Performance of the UNICEF/UN Washington Group tool for identifying functional difficulty in rural Zimbabwean children.

Over one billion people live with disability worldwide, of whom 80% are in developing countries. Robust childhood disability data are limited, particularly as tools for identifying disability function poorly at young ages. A subgroup of children enrolled in the Sanitation Hygiene Infant Nutrition Efficacy (SHINE) trial (a cluster-randomised, community-based, 2x2 factorial trial in two rural districts in Zimbabwe) had neurodevelopmental assessments at 2 years of age. We evaluated functional difficulty prevalence in HIV-exposed and HIV-unexposed children using the Washington Group Child Functioning Module (WGCFM), comparing absolute difference using chi-squared or Fisher's exact tests. Concurrent validity with the Malawi Developmental Assessment Tool (MDAT) was assessed using logistic regression with cohort MDAT score quartiles, linear regression for unit-increase in raw scores and a Generalised Estimating Equation approach (to adjust for clusters) to compare MDAT scores of those with and without functional difficulty. A 3-step, cluster-adjusted multivariable regression model was then carried out to examine risk factors for functional difficulty. Functional Difficulty prevalence was 4.2% (95%CI: 3.2%, 5.2%) in HIV-unexposed children (n = 1606) versus 6.1% (95%CI: 3.5%, 8.9%) in HIV-exposed children (n = 314) (absolute difference 1.9%, 95%CI: -0.93%, 4.69%; p = 0.14). Functional difficulty score correlated negatively with MDAT: for each unit increase in WGCFM score, children completed 2.6 (95%CI: 2.2, 3.1) fewer MDAT items (p = 0.001). Children from families with food insecurity and poorer housing were more at risk of functional difficulty. Functional difficulty was identified in approximately 1-in-20 children in rural Zimbabwe, which is comparable to prevalence in previous studies. WGCFM showed concurrent validity with the MDAT, supporting its use in early childhood.

Low linoleic acid foods with added DHA given to Malawian children with severe acute malnutrition improve cognition: a randomized, triple-blinded, controlled clinical trial

ABSTRACTBackgroundThere is concern that the PUFA composition of ready-to-use therapeutic food (RUTF) for the treatment of severe acute malnutrition (SAM) is suboptimal for neurocognitive recovery.ObjectivesWe tested the hypothesis that RUTF made with reduced amounts of linoleic acid, achieved using high-oleic (HO) peanuts without added DHA (HO-RUTF) or with added DHA (DHA-HO-RUTF), improves cognition when compared with standard RUTF (S-RUTF).MethodsA triple-blind, randomized, controlled clinical feeding trial was conducted among children with uncomplicated SAM in Malawi with 3 types of RUTF: DHA-HO-RUTF, HO-RUTF, and S-RUTF. The primary outcomes, measured in a subset of subjects, were the Malawi Developmental Assessment Tool (MDAT) global z-score and a modified Willatts problem-solving assessment (PSA) intention score for 3 standardized problems, measured 6 mo and immediately after completing RUTF therapy, respectively. MDAT domain z-scores, plasma fatty acid content, anthropometry, and eye tracking were secondary outcomes. Comparisons were made between the novel PUFA RUTFs and S-RUTF.ResultsAmong the 2565 SAM children enrolled, mean global MDAT z-scores were –0.69 ± 1.19 and –0.88 ± 1.27 for children receiving DHA-HO-RUTF and S-RUTF, respectively (difference 0.19, 95% CI: 0.01, 0.38). Children receiving DHA-HO-RUTF had higher gross motor and social domain z-scores than those receiving S-RUTF. The PSA problem 3 scores did not differ by dietary group (OR: 0.92, 95% CI: 0.67, 1.26 for DHA-HO-RUTF). After 4 wk of treatment, plasma phospholipid EPA and α-linolenic acid were greater in children consuming DHA-HO-RUTF or HO-RUTF when compared with S-RUTF (for all 4 comparisons P values < 0.001), but only plasma DHA was greater in DHA-HO-RUTF than S-RUTF (P < 0.001).ConclusionsTreatment of uncomplicated SAM with DHA-HO-RUTF resulted in an improved MDAT score, conferring a cognitive benefit 6 mo after completing diet therapy. This treatment should be explored in operational settings. This trial was registered at clinicaltrials.gov as NCT03094247.

Measuring the impact of a training intervention for early childhood centre staff on child development outcomes: Findings from a cluster randomized control field trial in rural Malawi.

BackgroundEvidence from low‐income settings around early education interventions that can improve young children's development is sparse, particularly with regard to the most marginalized children. This study used a two‐arm parallel cluster randomized control design to evaluate the impact of an adapted staff training programme on the developmental outcomes of children attending community‐based early learning centres in Thyolo district, rural Malawi.MethodsAt baseline we randomly selected 48 centres, from each of which 20 children were randomly selected, although data from one centre was incomplete resulting in 932 children from 47 centres. Centres were randomly allocated to either the intervention or control arm. Twelve months later, follow‐up data were collected from 44 centres. At baseline and endline, community‐based childcare centre (CBCC) managers provided information about the centre, and parents/guardians provided information on the children, including the primary outcomes of age‐standardized development scores in the language and social domains, measured using the Malawi Developmental Assessment Tool. Children in the bottom 2.5 percentile of either domain were considered to have a delay; a third outcome variable, Any Delay, was developed to indicate children with a delay in either or both domains. Centre‐level mean scores were calculated, and linear regression models were constructed to assess differences between baseline and endline and between allocation groups.ResultsAnalysis of the difference between baseline and endline measures in the allocation groups shows a non‐significant reduction in delay associated with the study intervention across all domains. Adjustment for baseline characteristics within the CBCCs showed little impact on the magnitude of the observed effect, and the difference remained non‐significant.ConclusionsDespite no observed differences between allocation groups, the data did indicate a positive change in the intervention groups in both domains, particularly language. Community‐based early learning in Malawi holds tremendous potential for promoting inclusive development and learning.

Assessing neurodevelopmental outcome in children with hydrocephalus in Malawi. A pilot study

IntroductionCongenital and infantile hydrocephalus are assumed to be major contributors to pediatric morbidity, mortality and functional disability in low-income countries. Despite this, epidemiologic data and the overview of neurodevelopmental outcomes in these regions is very limited. We aimed to pilot the use of a wide range of more locally suitable tools to assess neurodevelopment to understand whether they were feasible for use and could provide estimates of developmental delay and poor functioning in a population of children with hydrocephalus in Malawi. MethodsWe conducted a prospective observational cohort study, at the tertiary neurosurgery clinic in Blantyre, Malawi in 2018, recruiting consecutive children with congenital and infantile hydrocephalus who were previously treated with ventriculoperitoneal shunts and endoscopic third ventriculostomy (ETV) in the neurosurgery unit of the hospital. We assessed demographic details, and gained information on children’s functioning using the Liverpool Outcome Score (LOS), and the Eating and Drinking Ability Classification System as well as full anthropometric assessment and child development with the Malawi Developmental Assessment Tool (MDAT). ResultsAll tools were feasible for use, easy to train on, could be used for assessing children with hydrocephalus and were suitable to adapt for our environment. We evaluated 41 children, aged 2–60 months with a mean age of 22.6 months (interquartile range [IQR] = 8.3 months −36.5 months). Functional assessment using the Liverpool Outcome Score showed the majority of children 92.7% (CI 80.1–98.5, n = 38) had severe sequelae from the hydrocephalus and were dependent on their parents or caregivers. Only 27 children (65.9%, CI 49.4, 80.0) had full or expected control of their bowel and bladder and 6 children (14.6%, CI 5.6, 29.2), had a recent history of seizures. About two thirds (63.4% CI 45.0–77.9, n = 26/41) of children were able to eat and to drink safely and efficiently. Over two thirds of the children (70.7%, CI 56.8, 84.6, n = 29) were stunted and almost half of the cohort underweight (43.9%,(CI 28.5, 60.3, n = 18). Almost half 48.8% (CI 32.9, 64.9, n = 20/41) had developmental delay on MDAT with 41.5% (CI 26.4, 56.6, n = 17/41) graded as severely delayed (-<2sd on developmental age z score). We found significant associations between dependence identified by the LOS and developmental delay according to the MDAT (p = 0.014, Pearson’s chi-squared test). ConclusionThis pilot study demonstrates that the assessment tools we used identified a high proportion of children with hydrocephalus as having functional difficulties, stunted growth and developmental delay, in Malawi. Use of these tools can now be scaled up and will be helpful to support research in understanding what factors contribute to poor functioning, growth and development in these cohorts and help us to investigate what strategies may prevent and support children with hydrocephalus in African settings.

Cognitive Outcomes at 18 Months: Findings from the Early Life Interventions for Childhood Growth and Development in Tanzania (ELICIT) Trial.

ABSTRACT.Micronutrient deficiencies and enteric infections negatively impact child growth and development. We enrolled children shortly after birth in a randomized, placebo-controlled, 2 × 2 factorial interventional trial in Haydom, Tanzania, to assess nicotinamide and/or antimicrobials (azithromycin and nitazoxanide) effect on length at 18 months of age. Cognitive score at 18 months using the Malawi Developmental Assessment Tool (MDAT), which includes gross motor, fine motor, language, and social assessments, was a secondary outcome. Here, we present the MDAT results of 1,032 children. There was no effect of nicotinamide (change in development-for-age Z score [DAZ] −0.08; 95% CI: −0.16, 0) or antimicrobials (change in DAZ 0.04; 95% CI: −0.06, 0.13) on overall MDAT score. The interventions had no effect on cognitive outcomes in subgroups defined by gender, socioeconomic status, birthweight, and birth season or on MDAT subscores. Further analyses are needed to identify targetable risk factors for impaired cognitive development in these settings.

Neurocognitive outcomes in Malawian children exposed to malaria during pregnancy: An observational birth cohort study.

BackgroundAnnually 125 million pregnancies are at risk of malaria infection. However, the impact of exposure to malaria in pregnancy on neurodevelopment in children is not well understood. We hypothesized that malaria in pregnancy and associated maternal immune activation result in neurodevelopmental delay in exposed offspring.Methods and findingsBetween April 2014 and April 2015, we followed 421 Malawian mother–baby dyads (median [IQR] maternal age: 21 [19, 28] years) who were previously enrolled (median [IQR] gestational age at enrollment: 19.7 [17.9, 22.1] weeks) in a randomized controlled malaria prevention trial with 5 or 6 scheduled assessments of antenatal malaria infection by PCR. Children were evaluated at 12, 18, and/or 24 months of age with cognitive tests previously validated in Malawi: the Malawi Developmental Assessment Tool (MDAT) and the MacArthur–Bates Communicative Development Inventories (MCAB-CDI). We assessed the impact of antenatal malaria (n [%] positive: 240 [57.3]), placental malaria (n [%] positive: 112 [29.6]), and maternal immune activation on neurocognitive development in children. Linear mixed-effects analysis showed that children exposed to antenatal malaria between 33 and 37 weeks gestation had delayed language development across the 2-year follow-up, as measured by MCAB-CDI (adjusted beta estimate [95% CI], −7.53 [−13.04, −2.02], p = 0.008). Maternal immune activation, characterized by increased maternal sTNFRII concentration, between 33 and 37 weeks was associated with lower MCAB-CDI language score (adjusted beta estimate [95% CI], −8.57 [−13.09, −4.06], p < 0.001). Main limitations of this study include a relatively short length of follow-up and a potential for residual confounding that is characteristic of observational studies.ConclusionsThis mother–baby cohort presents evidence of a relationship between malaria in pregnancy and neurodevelopmental delay in offspring. Malaria in pregnancy may be a modifiable risk factor for neurodevelopmental injury independent of birth weight or prematurity. Successful interventions to prevent malaria during pregnancy may reduce the risk of neurocognitive delay in children.

Pathways between caregiver body mass index, the home environment, child nutritional status, and development in children with severe acute malnutrition in Malawi.

Children with severe acute malnutrition (SAM) remain vulnerable after treatment at nutritional rehabilitation units (NRUs). The objective was to assess the concurrent pathways in a hypothesized model between caregiver body mass index (BMI), the home environment, and child nutritional status, and development (gross motor, fine motor, language, and social domains) in children with SAM following discharge from inpatient treatment. Structural equation modelling (SEM) was performed with data from a cluster-randomized controlled trial at the Moyo Nutritional Rehabilitation and Research Unit in Blantyre, Malawi. This approach was undertaken to explore simultaneous relationships between caregiver BMI, the home environment (Home Observation for Measurement of the Environment Inventory scores), child nutritional status (anthropometric indicators including weight-for-age z-scores [WAZ]), and child development (Malawi Developmental Assessment Tool (MDAT) z-scores as a latent variable) in children with SAM. These data were collected at participants’ homes six months after discharge from NRU treatment. This analysis included 85 children aged 6–59 months with SAM and their caregivers recruited to the trial at the NRU and followed up successfully six months after discharge. The model with WAZ as the nutritional indicator fit the data according to model fit indices (χ2 = 28.92, p = 0.42). Caregiver BMI was predictive of better home environment scores (β = 0.23, p = 0.03) and child WAZ (β = 0.30, p = 0.005). The home environment scores were positively correlated with MDAT z-scores (β = 0.32, p = 0.001). Child nutritional status based on WAZ was also correlated with MDAT z-scores (β = 0.37, p<0.001). This study demonstrates that caregiver BMI could ultimately relate to child development in children with SAM, through its links to the home environment and child nutritional status.