Correlating Caretakers' Knowledge, Attitudes and Practices of Hygiene and Continued Breastfeeding with Infants' Gross Motor Development Delay
Y Zeng, J He, M Hao, W Han, T Yamauchi
Background: Gross motor development delay is related to lower physical activity and higher adiposity risk for children. As the factor of this issue remains unclear, this study investigated the factors contributing to motor development delay. Methods: We recruited 132 children and their caretakers in a suburban area of China. The sociodemographic characteristics, child feeding practice, knowledge, attitudes, and practices of hygiene were investigated using a questionnaire. Child's nutritional status and gross motor milestones were assessed using the WHO Multicentre Growth Reference Study. Results: Approximately 20% of children experienced delayed achievement of certain milestones. Children from high-income families were more likely to experience developmental delay than those from middle-income. Continued breastfeeding at one year and superior hygiene potentially improved motor development. Conclusions: This study suggests providing telework support can improve mothers continued breastfeeding rates and broader hygiene education for both mothers and grandmothers in suburban areas of China.
Keyword : Child development; Continued breastfeeding; Gross motor milestones; Hygiene
Motor development is a major developmental pathway during early childhood. Motor skills are involved in the movement and coordination of the muscles. However, it is estimated that nearly 250,000,000 children under five years do not achieve their developmental potential in low- and middle-income countries.1 The delayed achievement of motor milestones have both short- and long-term negative effects on a child's development. Delayed accomplishment of actions like rolling over, sitting, and crawling is associated with the delayed execution of walking autonomously.2 Moreover, the delayed attainment of motor milestones is also related to lower physical activity,3 and a higher risk of adiposity later in life.4 Many of them are exposed to multiple risks, such as poverty, malnutrition, and unstimulating home environments.5
The researches concerning children's early development has extensively documented the growth-related issues in low- and middle-income countries.6,7 A cross-country comparative study that examined Cambodia, Chile, Ghana, Guatemala, Lebanon, Pakistan, the Philippines, and the USA with a focus on socioeconomic status consistently found that the motor scores of children from low-income families were lower than those of children from the middle- and high-income families.8 Impoverished children were more likely to experience less stimulation and demonstrated a higher prevalence of infectious diseases and other health-related issues.8,9 However, a high prevalence of motor developmental delay among children under the age of three was reported in China in 2015,10 whereas China has experienced rapid economic growth in the past decade. In addition to poverty, other risk factors associated with child gross motor development need to be clarified.
The evidence concerning child nutrition showed that child-feeding practices such as breastfeeding has a protective effect on children's motor achievement.11,12 A study conducted in Greece found a significant positive correlation between breastfeeding duration and cognitive, language, and motor development at the age of 18 months.13 The WHO recommends exclusively breastfeeding children for the first six months and continued breastfeeding for up to one year or beyond.14 However, about half of the children did not receive continued breastfeeding in their first year of life in China.15 Therefore, we hypothesised that the short duration of continued breastfeeding would be a risk factor associated with gross motor development delay in China.
In addition to nutritional factors, gross motor development is also influenced by environmental factors. Mothers' educational level,16-18 having siblings,19,20 and attending pre-school21,22 were found to be the environmental factors for motor development. Moreover, recent studies that focused on children's domestic environment have highlighted the importance of water, sanitation, and hygiene (WASH) for their development. The first three years of a child's life are critical for the consolidation of their gut health and linear growth. Early child development could be affected by the inflammation, stunting, and environmental enteropathy that can occur due to poor WASH.23 However, there is limited evidence focused on hygiene, which is a non-negligible environmental factor for children.
This study assessed the nutritional status and gross motor development of the children and investigated the child-feeding practices and the hygiene knowledge, attitudes, and practices (KAPs) of their caretakers living in a suburban area of China. The specific objective of this study was to investigate the factors contributing to motor development delay in terms of social-economic status, child nutrition and hygiene.
Anthropometric Z-scores were calculated using the WHO Anthro software (version 3.2.2). Based on the nutritional indices of the WHO Child Growth Standard, malnutrition (stunting, underweight, and wasting) was defined as length/height-for-age Z-scores (L/HAZ), weight-for-age Z-scores (WAZ), and weight-for-length/height Z-scores (WL/HZ) of <–2 SD, respectively. Overweight in children was defined as WL/HZ >+2 SD.24
Characteristics of the Participants
Child Feeding Practice
WASH Service Level and Caretaker's KAPs of Hygiene
Gross Motor Development
The differences in the month age at which children of different family monthly income achieved certain gross motor milestones are shown in Figure 1. For sitting alone, children in the 'mid-income' group attained milestone earlier than the 'low-income' group (P=0.032). For standing alone, children in the 'mid-income' group attained milestone earlier than the 'low-income' group (P=0.001). For walking alone, children in the 'mid-income' group attained milestone earlier both than the 'low-income' group and the 'high-income' group (P=0.004 and P=0.037, respectively).
Table 5 shows the risk factors associated with walk delay in multivariate logistic regression analysis. Continued breastfeeding at one year (adjusted odds ratio [OR]=0.14, 95% confidence interval [CI]: 0.04-0.49), a senior high school (adjusted OR=0.16, 95% CI: 0.03-0.71) or college-level (adjusted OR=0.24, 95% CI: 0.06-0.99) educational attainment among the mothers were associated with lower odds of child motor development delay. Child's mother worked outside the local area (adjusted OR=12.76, 95% CI: 1.54-105.97), low hygiene KAPs scores (adjusted OR=5.52, 95% CI: 1.26-24.21) significantly predicted the delayed achievement of walking with assistance.
In this cross-sectional study, we investigated the nutritional status and motor development of children and determined the factors contributing to motor development delay. Approximately 20% of children had delayed achievement in at least one gross motor milestones. Children in this study achieved gross motor milestones earlier than the children from Vietnam and India, and obtained a similar result to the children from the USA (Table 4).27-29 To our surprise, children who lived in the study area faced developmental problems in spite of their household's financial status. The multiple comparison analysis showed that the children in the high-income group attained the walking alone milestone later than those in the middle-income group (Figure 1). Previous studies reported that better financial conditions were correlated with higher maternal education and mental health, less family stress and child illness, and consequently had a positive effect on children's early development.22,30,31 However, this finding was contrary to previous research. Further analysis was needed to explain this unexpected finding.
Poor Hygiene KAPs of Caretaker
Nevertheless, grandmothers had significantly lower hygiene KAPs scores compared to mothers. In this study, grandmothers were the primary caretakers of children from families that had a higher monthly income. Intergenerational parenting is common (50-70%) among many families in China.33 Leaving children with grandparents allowed both mother and father to work and receive a better family monthly income. However, as demonstrated earlier, poor KAPs of hygiene was associated with gross motor development delay. Compared to mothers, grandmothers may pose a higher risk of motor development delay to the child due to their poor hygiene KAPs. Therefore, considering the intergenerational parenting situation in China, it is important to include not only mothers but also grandmothers in the promotion of hygiene KAPs.
Low Prevalence of Continued Breastfeeding
However, the practice of continued breastfeeding in China is poor. Only about half of the children in this study continued breastfeeding. The prevalence of continued breastfeeding at one year (57%) was consistent with the 2017 national data (51%).15 The continued breastfeeding rate was low in China compared to Bangladesh (95%), Vietnam (81%), and Indonesia (80%).39 A global study reported a strong inverse correlation between the duration of breastfeeding and gross domestic product per capita after utilising the national data of 153 countries.40 These results suggested that the prevalence of continued breastfeeding in the study site, as well as in China, needs to be improved. Further research on how economic growth reduces continued breastfeeding rates in China may help develop relevant countermeasures.
In the current study, families with employed mothers were likely to have a higher family monthly income than those with unemployed mothers. However, when the child's mother worked outside the local vicinity, it significantly predicted the delayed achievement of walking with assistance (Table 5). This separation of mother and child leads to inadequate child-feeding practice. Previous studies highlighted that maternal occupational status was the main barrier to continued breastfeeding in high-income regions. The mothers who had full-time employment,41,42 longer working hours,43 and shorter maternity leave44,45 were less likely to breastfeed their children for a longer duration. Such associations may support employment outside the local vicinity as a plausible cause for mothers' shorter breastfeeding duration. Furthermore, the childcare tasks shifted to the grandmother when mothers worked outside the local vicinity. The lower KAPs and educational status of grandmothers thus become risk factors for gross motor development delay among children. Adequate legal policies, sufficient social and family support, and sound strategies for telework may help working mothers continue breastfeeding their children.
The discussion above further consolidates the unexpected result that high household income is a predictor of gross motor development delay in the examined suburban area of China. Families in which the grandmother is the primary caretaker and the mother works away from home tend to get a higher income. However, these factors lead to children a shorter period of continued breastfeeding and subsequent nutrition, and less protection in terms of hygiene.
There were several limitations to this study. First, the site of our study was a single suburban area of China, and thus there is a need to obtain more data from other cities to confirm the accuracy of the results. The population of this study demonstrated socioeconomic and gender diversity, and therefore may be reflective of other suburban areas of China. Moreover, we assessed the child's gross motor development based on the WHO Multicentre Growth Reference Study. The WHO standard included children from six geographically diverse countries: Brazil, Ghana, India, Norway, Oman, and the USA. Although we found a similar developmental outcome in children from the USA, more evidence is needed to verify the feasibility of this standard to measure Chinese children. Finally, a correlation was found between the hygiene KAPs of caretakers and gross motor development. Although the specific mechanism of this topic remains unclear, our findings provide evidence for the correlation between hygiene and child early development.
The children's nutritional status was generally good, whereas 20% of them experienced gross motor development delay in this study. Factors associating lower risks of gross motor developmental delay were continued breastfeeding at one year and caretaker's hygiene KAPs. Children from high monthly income families were less likely to receive continued breastfeeding for their mothers working status, and most of their primary caretaker was the grandmother who had relatively lower hygiene KAPs, which could explain the reason why high income associated with gross motor development delay. These findings suggest several courses of action to provide friendlier telework support for mothers to improve continued breastfeeding rates and conduct a broader hygiene education that includes both mothers and grandmothers in the examined suburban area of China.
The study was financed by the JSPS KAKENHI (Grant/Award Number: 18H00992). The authors wish to thank the study participants and hospital staffs for the contribution and support to the research.
Declaration of Interest
The authors declare that they have no conflict of interests.
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