Multiple factors influence infant and child neurodevelopment in low resource settings. In offspring of participants in the preconception maternal nutrition trial, Women First (WF), we examined the impact of providing a preconception (Arm 1) or prenatal (Arm 2) nutrient supplement (compared to controls, Arm 3) on neurodevelopmental outcomes at 24 months; predictors of neurodevelopment scores; and associations of infant anthropometrics with neurodevelopmental scores. Follow-up visits for anthropometry were conducted at 6-, 12-, 18- and 24-month of age. At 24-months, in a randomized subset, the Bayley Scales of Infant Development, 3rd edition (BSID-III), including cognitive, motor and social-emotional subscales, and the Family Care Indicators (FCI) questionnaire, assessing family and home environment, were completed. Multiple covariates (intervention arm, site, maternal sociodemographic characteristics, FCI subscales, birthweight and 6-24 months\' change in anthropometry z-scores, (e.g., ΔLAZ6-2 4) were evaluated by linear regression to predict BSID-III outcomes and to assess associations of anthropometric changes with BSID-III scores. The analysis consisted of 1386 infants (n = 441, 486, 459 for Arms 1, 2 and 3, respectively). None of the domain-specific BSID-III subscale scores differed by maternal intervention arm. Four covariates significantly predicted (p ≤ 0.01) all 3 BSID-III subscales: secondary maternal education, ΔLAZ6 - 24, birthweight >2500 g, and FCI play materials. Linear growth was associated with all domains of neurodevelopment. The results underscore the multi-dimensional aspects of child development represented by the nurturing care framework, including prenatal maternal nutrition, post-natal growth, maternal education for responsive caregiving and opportunities for early learning.

BACKGROUND: Providing nurturing care for young children is essential for promoting early child development (ECD). However, there is limited knowledge about how mothers and fathers across diverse contexts in sub-Saharan Africa care for their children and from whom they receive guidance and support in their caregiving roles. We aimed to examine caregivers\' nurturing care practices and sources of parenting knowledge in rural Mozambique.
METHODS: This is a secondary analysis using data from a qualitative evaluation of a pilot intervention to improve nurturing care for early child health and development within existing health systems. The evaluation was conducted across three primary care health facilities and their catchment areas in Nampula province, Mozambique. For this study, we analyzed data from in-depth interviews conducted with 36 caregivers (32 mothers and 4 fathers) to investigate mothers\' and fathers\' daily caregiving experiences. Data were analyzed using thematic content analysis.
RESULTS: Caregivers described various caregiving roles relating to general caregiving of young children (e.g., feeding, bathing, caring for child\'s health) and stimulation (e.g., play and communication) activities. Mothers more commonly engaged in general caregiving activities than fathers, whereas both mothers and fathers engaged in stimulation activities. Other family members, including siblings, grandparents, and aunts/uncles, were also actively engaged in general caregiving activities. With respect to sources of parenting knowledge, caregivers received parenting guidance and support primarily from their own mothers/parents and facility-based health providers.
CONCLUSIONS: These findings highlight the importance of adopting a holistic approach involving caregivers and their context and reveal potential strategies to promote caregiving and ECD in rural Mozambique and similar contexts.

OBJECTIVE: To compare the difference between the growth and developmental status of the children who were residing in the area where Inclusive Early Childhood Development (IECD) project was being implemented and who had received interventions through trained Anganwadi workers (Frontline workers) under Integrated Child Development Services (ICDS) scheme with the children who had not received the Inclusive ECD project interventions.
METHODS: It was a mixed method cohort study, nested in an ongoing project in a medical college in which Inclusive ECD was used as an intervention through International Guide for Monitoring Child Development (GMCD) which is a tool for both monitoring and assessment with the help of existing government structures and personnel such as Anganwadi workers, Anganwadi supervisors and their contact points with communities. A sample of 200 children was selected; 100 each from intervention group (IECD cohort) and comparison group (Usual care cohort) and were followed till the child became 2 y of age.
RESULTS: IECD intervention showed statistically significant effect on weight (p = 0.04) and height (p = 0.03) of the IECD cohort. Overall developmental assessment showed that the identified developmental issues (Concerns + Delays) were approximately half in IECD cohort (9.67% + 5.37% = 15.04%) as compared to usual care cohort (17.20% + 11.82% = 29.02%). The results from binomial logistic regression performed for developmental outcomes were statistically significant (p = 0.04) suggesting that children with IECD intervention have lower odds of developing developmental issues.
CONCLUSIONS: The study indicates that it is possible to implement IECD interventions through frontline workers, which significantly improves the growth and development of the children.

Rapid urbanization and increased women\'s involvement in paid work have contributed to the upsurge of informal childcare centers, especially in low-income settings where quality is a major issue. However, there are limited data on the factors associated with the quality of childcare centers in informal settlements in Africa.
We conducted a quantitative observation and questionnaire survey of 66 childcare centers to identify the factors associated with the quality of childcare services in two informal settlements (Korogocho and Viwandani) in Nairobi. The quality of the centers (outcome variable) was assessed using a locally developed tool. Data on center characteristics including type, size, location, length of operation, charges, and number of staff were collected. Center providers\' knowledge, attitude, and practices (KAP) in childcare were assessed through a questionnaire, focusing on nurturing care and business management. Data were described using means and standard deviation or frequencies and percentages. Associations between quality center score (outcome variable) and other variables were examined using multivariable linear regression to identify potential predictors of the quality of the center environment.
A total of 129 childcare centers were identified and categorized as home-based (n = 45), center-based (n = 14), school-based (n = 61), and church-based (n = 9). The number of home-based centers was particularly high in Viwandani (n = 40; 52%). Only 9% of home-based centers reported any external support and 20% had any training on early childhood development. Of the 129 centers, 66 had complete detailed assessment of predictors of quality reported here. Unadjusted linear regressions revealed associations between quality of childcare center and center providers\' education level, type of center, support received, caregiver-child ratio, number of children in the center, and center providers\' KAP score (p < 0.05). However, in the multivariable regression, only higher levels of center provider KAP (β = 0.51; 95% CI: 0.18, 0.84; p = 0.003) and center type (β = 8.68; 95% CI: 2.32, 15.04; p = 0.008) were significantly associated with center quality score.
Our results show that center providers\' knowledge and practices are a major driver of the quality of childcare centers in informal settlements in Nairobi. Interventions for improving the quality of childcare services in such settings should invest in equipping center providers with the necessary knowledge and skills through training and supportive supervision.

Children who are HIV-exposed and uninfected (CHEU) are a growing population at potential risk of poor neurocognitive development. We tested a nurturing care intervention on children\'s neurocognitive development and maternal depressive symptoms (primary) with mediation through caregiving activities (secondary).
This study was conducted among six intervention and nine comparison antenatal-care/prevention of vertical transmission (ANC/PVT) HIV clinics in eSwatini. We enrolled pregnant women and measured infant development at 9 and 18 months. mothers2mothers (m2m) designed and implemented the clinic-home-community-based intervention. We measured infants\' neurodevelopment, maternal depressive symptoms and caregiving activities with the Mullen Scales of Early Learning (MSEL), Edinburgh Postnatal Depression Scale, HOME Inventory and Family Care Indicators. We fitted linear mixed effects regression models with clinic random effects to compare intervention versus comparison arms, and generalised structural equation models to evaluate mediation, adjusting for confounders.
Mother-infant pairs (n = 429) participated between January 2016 through May 2018. Socio-demographic characteristics were balanced between arms except for higher rates of peri-urban versus rural residence and single versus married mothers in the comparison group. The 18 month retention was 82% (180/220) intervention, 79% (166/209) comparison arm, with 25 infant deaths. Intervention MSEL scores were significantly, and modestly, higher in receptive language (55.7 [95% CI 54.6, 56.9] vs. 53.7 [95% CI 52.6, 54.8]), expressive language (42.5 [95% CI 41.6, 39.8] vs. 40.8 [95% CI 39.8, 41.7]) and composite MSEL (85.4 [95% CI 83.7, 84.5] vs. 82.7 [95% CI 81.0, 84.5]), with no difference in maternal depressive symptoms or in observations of mother-child interactions. Intervention book-sharing scores were higher (0.63 vs. 0.41) and mediated the effect on MSEL scores (indirect effect, p-values ≤ 0.024). The direct effects on visual reception and expressive language scores were significantly higher in the intervention compared to the comparison arm (coefficients 1.93 [95% CI 0.26, 3.60] and 1.66 [95% CI 0.51, 2.79, respectively]).
Nurturing care interventions can be integrated into ANC/PVT clinic-home-community programmes. The intervention, mediated through interactive caregiving activities, increased language development scores among CHEU. Partnering with a local team, m2m, to design and implement a culturally relevant intervention illustrates the ability to impact parent-child play and learning activities that are associated with children\'s neurodevelopment.

Optimal infant and young child feeding (IYCF) and nurturing care during the first years of children\'s lives are crucial for ensuring their growth and development. The IYCF and nurturing practices are associated with a multifaceted interplay of context-specific factors where fathers\' involvement is necessary. The aim of this study is to explore the current scenario of fathers\' involvement in IYCF practices in the urban slums of Bangladesh. A cross-sectional survey among the residents of the Sat Tola slum in Dhaka, the capital of Bangladesh was conducted. To avoid social desirability bias, 361 mothers of children aged <24 months were interviewed regarding fathers\' involvement. An operational definition of father\'s involvement was developed based on 11 criteria and then scoring was applied to classify \'Good Involvement\' and associated factors were identified using multivariable logistic regression. Fathers\' mean age was around 31 (SD ± 6.09) years and the majority of them (44.32%) completed primary education. Fathers had diversified occupations such as day laborer (32.41%), garment worker (22.71%), and business (14.96%). Factors that were significantly associated with the father\'s involvement in IYCF practices include educational status (aOR = 3.98, 95% CI = 1.91, 8.26, p < .00) and theiroccupational status (aOR = 0.34, 95% CI = 0.16, 0.70, p = .00). Fathers were more active for their first child (aOR: 1.99, 95% CI = 1.04, 3.79, p = .03). Having child in the age group of 14-20 months (aOR = 2.73, 95% CI = 1.32, 5.64, p = <.01) and wife in the age group of 21-30 years (aOR = 2.34, 95% CI = 1.20, 4.58, p = .01) were significantly associated. The study finding explored that fathers\' education and occupation as well as mothers\' age and education were significantly associated factors for fathers\' involvement in the IYCF practices. Further longitudinal studies are recommended to establish the causal relationship between fathers\' involvement with IYCF and their impact on child growth and development.

BACKGROUND: In sub-Saharan Africa, one-quarter of all pregnancies occur in adolescents. Children born to adolescent mothers have poorer physical and socio-cognitive development. One reason may be inadequate knowledge on childcare and psychosocial support during pregnancy and post partum, since adolescent mothers have less antenatal care attendance and overall interaction with the health care system. Mobile health technology has been used to relay health information to special groups; however, psychosocial support commonly requires physical interaction.
OBJECTIVE: We aimed to assess the efficacy of an interactive mobile text messaging platform and support groups in improving adolescent mothers\' knowledge and practices as well as infant growth and development.
METHODS: This was a quasi-experimental study, conducted among adolescent mothers with infants younger than 3 months, in Homa Bay County, Kenya. Five of the 8 subcounties in Homa Bay County were purposively selected as study clusters. Four subcounties were assigned as intervention clusters and 1 as a control cluster. Adolescent mothers from 2 intervention subcounties received interactive text messaging only (limited package), whereas those from the other 2 subcounties received text messaging and weekly support groups, moderated by a community health extension worker and a counselor (full package); the control cluster only received the end-line evaluation (posttest-only control). The follow-up period was 9 months. Key outcomes were maternal knowledge on childcare and infant development milestones assessed using the Developmental Milestones Checklist (DMC III). Knowledge and DMC III scores were compared between the intervention and control groups, as well as between the 2 intervention groups.
RESULTS: We recruited 791 mother-infant pairs into the intervention groups (full package: n=375; limited package: n=416) at baseline and 220 controls at end line. Attrition from the intervention groups was 15.8% (125/791). Compared with the control group, adolescent mothers receiving the full package had a higher knowledge score on infant care and development (9.02 vs 8.01; P<.001) and higher exclusive breastfeeding rates (238/375, 63.5% vs 112/220, 50.9%; P=.004), and their infants had higher average DMC III scores (53.09 vs 48.59; P=.01). The limited package group also had higher knowledge score than the control group (8.73 vs 8.01; P<.001); this group performed better than the full package group on exclusive breastfeeding (297/416, 71.4% vs 112/220, 50.9%; P<.001) and DMC III scores (58.29 vs 48.59; P<.001) when compared with the control group. We found a marginal difference in knowledge scores between full and limited package groups (9.02 vs 8.73; P=.048) but no difference in DMC III scores between the 2 groups (53.09 vs 58.29; P>.99).
CONCLUSIONS: An interactive text messaging platform improved adolescent mothers\' knowledge on nurturing infant care and the development of their children, even without physical support groups. Such platforms offer a convenient avenue for providing reproductive health information to adolescents.
BACKGROUND: Pan African Clinical Trials Registry PACTR201806003369302; https://tinyurl.com/kkxvzjse.

UNASSIGNED: This study aims to identify the contexts, environments, and nurturing care predictors that determine whether a child is developmentally on track in Ceará, Brazil.
UNASSIGNED: We analysed data from a cross-sectional study conducted with caregivers of 6,447 children aged 0-59 months during a vaccination campaign in Ceará in October 2019. The validated Child Development Assessment Questionnaire was used to assess early childhood development (ECD) and children with a z-score ≥ -1 SD were considered developmentally on track. We conducted logistic regression models to understand the effects of contexts, environments, and nurturing care domains on ECD.
UNASSIGNED: Children in the early years (< 36 months) were more likely to meet the ECD milestones if they were not born with low birth weight (AOR: 0·64; 95% CI: 0·42-0·97), were exposed to manufactured toys in their house (2·68; 1·97-3·66), their heads of household were employed (1·61; 1·16-2·23), and their caregivers had read the Child Health Handbook (1·42; 1·13-1·77) and engaged them in stimulating activities (1·71; 1·26-2·32). Children aged 36-59 months were more likely to meet the ECD milestones if they were breastfed (never: ref. / < 3 months: 3·72; 1·91-7·26 / 3-5 months: 3·21; 1·74-5·93 / 6-11 months: 3·73; 1·95-7·16 / ≥ 12 months: 3·89; 2·25-6·72), had books at home (0: ref / 1-3: 1·71; 1·22-2·40 / 4-6: 2·24; 1·27-3·94 / 7+: 2·71; 1·05-7·00), and their caregivers received information about ECD (1·49; 1·11-2·01) and engaged them in stimulating activities (1·80; 1·27-2·56). Children aged 36-59 months were less likely to meet developmental milestones if they watched TV or used tablets/smartphones for more than two hours per day (0·61; 0·44-0·84), played with household objects (0·62; 0·41-0·92), participated in governmental early childhood programmes aimed at vulnerable families (0·62; 0·45-0·86), had families that participated in income transfer programmes (0·68; 0·47-0·99) (families living in poverty or extreme poverty), and their caregivers considered slapping (0·67; 0·48-0·94) a necessary disciplinary method.
UNASSIGNED: Having favourable socioeconomic conditions, breastfeeding, the absence of harsh discipline, caregivers who provide responsive care, and the provision of opportunities for early learning are the key factors that increase the likelihood of a child achieving their full developmental potential in Ceará, Brazil.
UNASSIGNED: This study was supported by the Maria Cecília Souto Vidigal Foundation (F0245), Brazil. The funder had no role in the design, analysis, or writing of this article.

Background: The World Health Organization and others promote responsive caregiving to support all children to thrive, particularly in low- and middle-income countries. The 14-item Mother\'s Object Relations Scales - Short Form (MORS-SF) may be of use in research and public health programmes because of its basis in attachment theory and ability to capture parental feelings towards their child. Methods: We culturally adapted the MORS-SF for use with mothers in the SPRING home visits trial when their infants were 12 months old. The same dyads were assessed using the HOME inventory concurrently and Bayley Scales of Infant Development III (BSID-III) at 18 months of age. Mixed effects linear regression was used to examine associations between MORS-SF (explanatory variable) and HOME-IT, and the cognitive, language and motor domains of BSID-III (outcome variables). Results: 1273 dyads completed all assessments. For the motor and language BSID-III scales and for HOME-IT there were strong and positive associations with the MORS-SF warmth sub-scale, and strong and negative associations with the invasion sub-scale. Important but less strong associations were seen with the BSID-III cognitive scale. Evidence of interaction suggested that both are individually important for child development. Conclusions: This is the first time MORS-SF has been used in India where optimising responsive caregiving is of importance in supporting all children to reach their potential. It is also the first time that the tool has been used in relation to child development. MORS-SF could be a valuable addition to evaluation in early childhood development.

Early initiation of breastfeeding after birth and exclusive breastfeeding for the first six months improves child survival, nutrition and health outcomes. However, only 42% of newborns worldwide are breastfed within the first hour of life. Small and sick newborns are at greater risk of not receiving breastmilk and often require additional support for feeding. This study compares breastfeeding practices in Rwandan neonatal care units (NCUs) before and after the implementation of a package of interventions aimed to improve breastfeeding.
This pre-post intervention study was conducted at two district hospital NCUs in rural Rwanda from October-December 2017 (pre-intervention) and September 2018-March 2019 (post-intervention). Only newborns admitted before their second day of life (DOL) were included. Data were extracted from patient charts for clinical and demographic characteristics, feeding, and patient outcomes. Exclusive breastfeeding at discharge was based on last recorded infant feeding on the day of discharge. Logistic regression analysis was used to evaluate factors associated with exclusive breastfeeding at discharge.
Pre-intervention, 255 newborns were admitted in the NCUs and 793 were admitted in post-intervention. Exclusive breastfeeding on the day of birth (DOL0) increased from 5.4% (12/255) to 35.9% (249/793). At discharge, exclusive breastfeeding increased from 69.6% (149/214) to 87.0% (618/710). The mortality rate decreased from 16.1% (41/255) to 10.5% (83/793). Factors associated with greater odds of exclusive breastfeeding at discharge included admission during the post-intervention period (aOR 4.91; 95% CI 1.99, 12.11), and admission for infection (aOR 2.99; 95% CI 1.13, 7.93). Home deliveries (aOR 0.15; 95% CI 0.05, 0.47), preterm delivery (aOR 0.36; 95% CI 0.15, 0.87) and delayed first breastmilk feed (aOR 0.04 for DOL3 vs. DOL0; 95% CI 0.01, 0.35) reduced odds of exclusive breastfeeding at discharge.
Expansion and adoption of evidenced-based guidelines, using innovative approaches, aimed at the unique needs of small and sick newborns may help to improve earlier initiation of breastfeeding, decrease mortality, and improve exclusive breastfeeding on discharge from hospital among small and sick newborns. These interventions should be replicated in similar settings to determine their effectiveness.