Beena Koshy

Background: Children with disabilities experience lower school enrolment rates and may be systematically excluded from school-based deworming programmes. The DeWorm3 trial provided an opportunity to evaluate whether community-wide mass drug administration (cMDA) could reduce these disparities by reaching children outside the education system. Methods: We conducted a secondary analysis of the data from the DeWorm3 trial in Tamil Nadu, India. Children aged 5–17 years (n=82 417) who participated in at least one of the six rounds of cMDA were included. Disability was assessed using the UNICEF/Washington Group’s Child Functioning Module. Mixed-effects logistic regression models examined associations between disability status and treatment coverage, adjusting for sociodemographic factors. Results: Children with disabilities (1.1% of the population) had higher unadjusted odds of not receiving deworming treatment compared with children without disabilities (OR=1.49, 95% CI 1.19 to 1.84), though this association was attenuated after adjustment (adjusted OR=1.10, 95% CI 0.86 to 1.37). Among school-attending children who received treatment, those with disabilities had significantly lower odds of receiving school-based treatment (adjusted OR=0.57, 95% CI 0.44 to 0.73). Subgroup analyses revealed that age, school attendance, parental marital status, geographical location and the COVID-19 pandemic significantly modified these associations. Conclusion: While cMDA reduced some disparities in deworming coverage, children with disabilities remained less likely to receive school-based treatment. Public health programmes should combine school-based approaches with targeted community outreach strategies to ensure equitable inclusion of children with disabilities, particularly those experiencing multiple vulnerabilities.

Early childhood stunting (ECS) affects millions of children globally and conjectured to result in suboptimal brain and cognitive development later in life. Charting out the trajectory of brain network development and most importantly how the compensation of function can be achieved gives windows of intervention to clinicians, educators and policy makers. In this study, advanced network neuroscience tools, graph theoretical methods applied on diffusion weighted MR-imaging (DWI) revealed the effects of ECS on white matter (WM) organization in a community-based birth cohort of 170 children (mean age = 9.18 years, SD = 0.28) from Vellore, India. Based on stunting status at ages two, five, and nine years, children were categorised into four groups: always stunted (AS; n =21), stunted until five with catch-up at nine (S5C9; n =31), stunted until two with catch-up at five (S2C5; n =28), and never stunted or typically developing (TD; n =90). The catch-up groups showed strikingly similar anthropometric measures compared to TD. However, all stunted groups (AS, S5C9, S2C5) showed significantly lower performance and verbal IQ scores compared to TD children. DWI data revealed AS children exhibited shorter tract lengths across select cortico-cortical connections, an increased number and strength of short- and medium-range connections, and a corresponding reduction in long-range connections and strength. Network analyses further revealed that AS and S5C9 groups displayed higher local clustering and local efficiency relative to TD, reflecting greater local segregation of brain networks. Hub-like modules was broadly conserved across groups, although both catch-up groups (S2C5 and S5C9) showed additional hubs, suggesting compensatory network reorganization via a more modular architecture. Together, these findings provide novel evidence that ECS is linked to altered structural reorganization of brain networks and reduced cognitive performance in later childhood. While persistent stunting (AS) is associated with the most pronounced alterations, partial catch-up (S2C5 and S5C9) is accompanied by compensatory adaptations, such as increased short-range connectivity and recruitment of additional hubs. These results underscore the critical importance of early nutritional interventions to support optimal brain network development.

Background and objectives: Structured early childhood education (ECE) can enhance human potential by improving academic performance, particularly in impoverished settings. This study evaluated the association between ECE and cognition at age 12 years in the longitudinal malnutrition and enteric diseases (MAL-ED) cohort follow-up study in Vellore, South India. Methods: The MAL-ED Vellore cohort enrolled 251 newborns between 2010–2012 from urban low- and middle-income (LMIC) settings and followed them at multiple timepoints. Parents reported ECE details, including duration of enrollment. At 12 years, cognition was assessed using Malin’s Intelligence Scale for Indian Children (MISIC). Bivariate and multivariate regression analyses were conducted with adjustments for socioeconomic position (SEP), sex, maternal education, and stunting status. Results: Of the original cohort, 212 (84.46%), 205 (81.67%), and 191 (76.09%) children were available at 5, 9, and 12 years, respectively. By age 5 years, 54.25% (115/212) had attended structured ECE. Exposure for 18–24 months was positively associated with verbal IQ [β: 4.36 (1.85–6.86)], performance IQ [β: 4.96 (1.25–8.68)], and total IQ [β: 4.66 (1.96–7.36)] at age 12 years, compared to those without exposure, after adjustment for SEP, sex, stunting at 2 and 5 years, and maternal cognition. Conclusions: Twelve-year follow-up of an Indian birth cohort demonstrated that structured ECE continued to show positive associations with pre-adolescent cognition, extending evidence previously reported at 5 and 9 years. Structured ECE and its effective implementation may optimize human capital in India.

Background: Children with disabilities experience lower school enrollment rates and may be systematically excluded from school-based deworming programs. The DeWorm3 trial provided an opportunity to evaluate whether community-wide mass drug administration (cMDA) could reduce these disparities by reaching children outside the education system. Methods: We conducted a secondary analysis of the data from the DeWorm3 trial in Tamil Nadu, India. Children aged 5-17 years (n=82,417) who participated in at least one of the six rounds of cMDA were included. Disability was assessed using the UNICEF/Washington Group’s Child Functioning Module. Mixed-effects logistic regression models examined associations between disability status and treatment coverage, adjusting for sociodemographic factors. Results: Children with disabilities (1.1% of the population) had higher unadjusted odds of not receiving deworming treatment compared to children without disabilities (OR=1.49, 95% CI: 1.19-1.84), though this association was attenuated after adjustment (adjusted OR=1.10, 95% CI: 0.86-1.37). Among school-attending children who received treatment, those with disabilities had significantly lower odds of receiving school-based treatment (adjusted OR=0.57, 95% CI: 0.44-0.73). Subgroup analyses revealed that age, school attendance, parental marital status, geographic location, and the COVID-19 pandemic significantly modified these associations. Conclusion: While community-wide mass drug administration reduced some disparities in deworming coverage, children with disabilities remained less likely to receive school-based treatment. Public health programs should combine school-based approaches with targeted community outreach strategies to ensure equitable inclusion of children with disabilities, particularly those experiencing multiple vulnerabilities.

Early childhood stunting can result in sub-optimal executive functions (EF), affecting academic achievements and economic potential in later life. This study hypothesized that children always stunted (AS) at ages 2, 5 and 9 years had lower EF than those who were never stunted (NS). A birth-cohort in Vellore, India was followed up with periodic anthropometric and development/cognitive measures over 2, 5 and 9 years of age. Based on stunting status at these time points, children were classified as NS, stunted at 2 years and caught up by 5 years (S2N5), stunted at 2 and 5 years but caught up later (S5N9), and AS. At 9th year, children underwent neuroimaging using 3T MRI scanner and EF assessment using FAS phonemic fluency test, colour cancellation test and colour trials tests (CTT). From the original birth-cohort of 251, 205 children were reviewed at 9 years. FAS phonemic fluency test showed NS group had significantly higher test scores compared to AS (11.52 vs. 7.4, p = 0.02). In CTT, a significant difference in near misses score was observed between NS and AS groups (0.12 vs. 0.38, p = 0.03). Upon evaluating unimodal brain association areas, volumes of right occipital fusiform gyrus (9991 mm³ vs. 9313 mm³; p = 0.04; η² = 0.11), and left lateral occipital cortex (13458 mm³ vs. 12559 mm³; p = 0.03; η² = 0.07) were significantly higher among NS compared to AS group. Considering higher order association areas, only left pars triangularis was found to be significantly reduced among AS children compared to NS group (4284 mm³ vs. 3291 mm³; p = 0.01; η² = 0.07). Similarly, there were also significance visible in the basal ganglia regions and the cerebellum. Current study demonstrated EF dysfunction in verbal fluency and inhibitory control in a dose response fashion in groups AS-to-NS with corresponding EF-related brain volumetric changes, highlighting the need for focused nutritional and nurturing approaches in early childhood for gain in human capital.

Background: Early childhood stunting affects around 150 million young children worldwide and leads to suboptimal human potential in later life. However, there is limited data on the effects of early childhood stunting and catch-up growth on brain morphometry. Methods: We evaluated childhood brain volumes at nine years of age in a community-based birth-cohort follow-up study in Vellore, south India among four groups based on anthropometric assessments at two, five, and nine years namely ‘Never Stunted’ (NS), ‘Stunted at two years and caught up by five years’ (S2N5), ‘Stunted at two and five years and caught up by nine years’ (S2N9), and ‘Always Stunted’ (AS). T1-weighted magnetic resonance imaging (MRI) images were acquired using a 3T MRI scanner, and brain volumes were quantified using FreeSurfer software. Analysis of Variance (ANOVA) was used to determine the differences in brain volumetry between the stunting groups, with age and sex as covariates. The effect size ANOVA models was evaluated using Eta squared. Findings: Amongst 251 children from the initial cohort, 178 children with a mean age of 9.54 underwent neuroimaging and considered for further analysis. The total brain volume, subcortical volume, bilateral cerebellar white matter, and posterior corpus callosum showed a declining trend from NS to AS. Regional cortical brain analysis showed significant lower bilateral lateral occipital volumes, right pallidum, bilateral caudate, and right thalamus volumes between NS and AS. Interpretation: To the best of our knowledge, this first neuroimaging analysis to investigate the effects of persistent childhood stunting and catch-up growth on brain volumetry indicates impairment at different brain levels involving total brain and subcortical volumes, networking/connecting centres (thalamus, basal ganglia, callosum, cerebellum) and visual processing area of lateral occipital cortex.

Objectives: There is limited information about the stability and predictability of Bayley Scales of Infant and Toddler Development (BSID) assessing child development in low- and middle-income settings. The objective of the present study was to analyse stability and predictive validity of BSID using an existing birth cohort. Design: Prospective birth cohort follow-up study. Setting and participants: A community-based birth cohort of 251 newborns was recruited and followed-up in urban Vellore, South India, until 9 years of age. Using BSID-III, child development was measured at 6, 15, 24 and 36 months. Cognition was assessed using the Wechsler Preschool Primary Scales of Intelligence at 5 years, and the Malin’s Intelligence Scale for Indian Children scale at 7 and 9 years of age. The stability of BSID measurements across time points was expressed by intraclass correlation (ICC) and concordance correlation coefficients. Linear regression was used to describe the predictability of BSID-III of cognition at 5, 7 and 9 years. Results: The ICC for domain-wise BSID scores between time points of measurement suggested a weak correlation. The BSID scores at 36 months correlated best with Full-Scale Intelligence Quotient (FSIQ) at 5 years (r: 0.40–0.49), 7 years (r: 0.35–0.48) and 9 years (r: 0.36–0.38). BSID scores at 36 months predicted FSIQ better at 5, 7 and 9 years with R ² ranging from 23.3% to 28.6%, when compared with 24 months BSID scores (R ² - 16.0% to 25.9%). Conclusion: Poor stability and predictability of BSID warrant caution in the predictive projection of early childhood assessments. Better predictability of future cognition of 36 months’ BSID scores highlights its advantage over the 24 months’ assessment.

Background Early childhood stunting affects around 150 million young children worldwide and leads to suboptimal human potential in later life. However, there is limited data on the effects of early childhood stunting and catch-up growth on brain morphometry. Methods We evaluated childhood brain volumes at nine years of age in a community-based birth-cohort follow-up study in Vellore, south India among four groups based on anthropometric assessments at two, five, and nine years namely ‘Never Stunted’ (NS), ‘Stunted at two years and caught up by five years’ (S2N5), ‘Stunted at two and five years and caught up by nine years’ (S2N9), and ‘Always Stunted’ (AS). T1-weighted magnetic resonance imaging (MRI) images were acquired using a 3T MRI scanner, and brain volumes were quantified using FreeSurfer software. Findings Amongst 251 children from the overall cohort, 178 children with a mean age of 9.54 were considered for further analysis. The total brain volume, subcortical volume, bilateral cerebellar white matter, and posterior corpus callosum showed a declining trend from NS to AS. Regional cortical brain analysis showed significant lower bilateral lateral occipital volumes, right pallidum, bilateral caudate, and right thalamus volumes between NS and AS. Interpretation To the best of our knowledge, this first neuroimaging analysis to investigate the effects of persistent childhood stunting and catch-up growth on brain volumetry indicates impairment at different brain levels involving total brain and subcortical volumes, networking/connecting centres (thalamus, basal ganglia, callosum, cerebellum) and visual processing area of lateral occipital cortex.

Experiences in early childhood form the bedrock of future human potential. In impoverished settings, structured early childhood education (ECE) in preschool years can augment overall childhood and later human abilities. The current study evaluates preschool learning exposure and childhood cognition, using longitudinal follow-up of a community-based birth cohort in Vellore, south India. The birth cohort study site in Vellore recruited 251 newborns between 2010 and 2012 from dense urban settlements and further followed up into childhood. Preschool enrolment details were obtained from parents. Childhood cognition was assessed by Weschler’s preschool primary scale of intelligence (WPPSI) and Malin’s intelligence scale for Indian Children (MISIC) at 5 and 9 years of age respectively. Bivariate and multivariate regression analyses were performed with adjustments for socio-economic status (SES), maternal education, stunting status and home environment. Out of 251 new-borns recruited into the MAL-ED birth cohort, 212 (84.46%) and 205 (81.7%) children were available for the 5 year and 9 year follow-up respectively. At 5 years, structured ECE of 18 to 24 months duration was significantly associated with higher cognition scores, with the highest increase in processing speed [β: 19.55 (11.26–27.77)], followed by full-scale intelligence [β: 6.75 (2.96–10.550)], even after adjustments for SES, maternal cognition, home factors and early childhood stunting status. Similarly adjusted analysis at 9 years showed that children who attended 1.5–2 years of structured ECE persisted to have higher cognition, especially in the performance domain [β: 8.82 (2.60–15.03)], followed by the full-scale intelligence [β: 7.24 (2.52–11.90)]. Follow-up of an Indian birth cohort showed that structured ECE exposure was associated with better school entry cognition as well as mid-childhood cognition. Strengthening ECE through a multi-pronged approach could facilitate to maximize cognitive potential of human capital.