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Similarities and differences in child development from birth to age 3 years by sex and across four countries: a cross-sectional, observational study

We studied a large sample of healthy children in four countries with different cultural and linguistic characteristics to examine the development of children in the first 3 years of life. Our study provides information on developmental milestones that might be used across populations to assess development and also on those that require further investigation or elimination from international instruments.

The aim of most research comparing early childhood development across populations has been to describe cultural and ethnic variations and their association with contextual differences.20x20Fernald, LCH, Kariger, P, Engle, P, and Raikes, A. Examining early childhood development in low-income countries: a toolkit for the assessment of children in the first five years of life. World Bank,
Washington DC; 2009http://siteresources.worldbank.org/INTCY/Resources/395766-1187899515414/Examining_ECD_Toolkit_FULL.pdf. ()
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Most studies have included children from high-income countries, ethnic minorities, and small samples from LMICs. By contrast, our objective was to describe the variability in the ages of attainment of milestones and to establish whether enough similarities exist to guide the development of universal instruments, to avoid the costly restandardisation and revalidation of instruments. We therefore used definitions of equivalence to interpret our data rather than statistical significance alone.

In a cross-sectional study9x9Lansdown, RG, Goldstein, H, Shah, PM et al. Culturally appropriate measures for monitoring child development at family and community level: a WHO collaborative study. Bull World Health Organ. 1996;
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Our study advances the understanding of early childhood development by showing that many milestones in numerous domains are similarly attained across sexes and countries. We found that the attainment of almost all milestones is similar in the first year when environmental and cultural influences might have the smallest effect. The similarity of play across our country samples parallels earlier studies.26x26Cote, LR and Bornstein, MH. Child and mother play in three US cultural groups: comparisons and associations. J Fam Psychol. 2009;
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A large proportion of the differences in ages of attainment of milestones was associated with timing of children’s exposure to experiences. For example, South African children could drink from a cup at a median age of 8 months compared with Argentinian children who reached this milestone at a median age of 16 months. In South Africa, where early independence is encouraged,28x28Roman, NV. Maternal parenting in single and two-parent families in South Africa from a child’s perspective. Soc Behav and Personal. 2011;
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The differences between countries in language milestones must be interpreted with caution. Receptive language is known to be difficult to assess because it is dependent on what caregivers expect and think children understand.30x30Tomasello, M and Mervis, CB. The instrument is great, but measuring comprehension is still a problem. Monographs of the Society for Research in Child Development. 1994;
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Our study has important strengths. First, the cross-sectional design avoids potential biases of repeated questioning and retention of compliant families. Second, the countries included are from diverse geographical areas of the world with ethnic, cultural, and language differences. Third, the sample of almost 5000 children is one of the largest to date, providing information on multiple domains of development of healthy children younger than 3 years. Fourth, our criteria for a healthy sample were more stringent than criteria used in previous research.31x31Wijnhoven, TM, de Onis, M, Onyango, AW et al. Assessment of gross motor development in the WHO Multicentre Growth Reference Study. Food Nutr Bull. 2004;
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,32x32Gladstone, M, Lancaster, GA, Umar, E et al. The Malawi Developmental Assessment Tool (MDAT): the creation, validation, and reliability of a tool to assess child development in rural African settings. PLoS Med. 2010;
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We excluded children with health conditions associated with potential adverse developmental outcomes.34x34Walker, SP, Wachs, TD, Gardner, JM…, and International Child Development Steering Group. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;
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Our study has important limitations. We did not include a large number of LMICs, particularly those with lower incomes. We chose four countries that were culturally distinct and had collaborating teams with the capacity to do rigorous research and to provide services for children identified with risk factors. Another limitation is that the sample did not include rural sites. Thus, the applicability of our results to rural populations needs to be established. The small sample size—particularly the small number of older children (aged 25–42 months) enrolled in South Africa—is a limitation that is reflected in the larger confidence intervals in South Africa for some of the milestones attained at an older age, and might require repetition in larger samples. The number of children who were excluded because of health problems was more than we expected in all countries, but particularly in South Africa, where we could not change our recruitment strategy as we did in India, because the sociodemographic characteristics of children attending private paediatric clinics would have been substantially different. We recruited children from health clinics and not from homes to enable application of health criteria. This approach might decrease generalisability because our sample might have included more children with health problems using the clinics than children with health problems in the general population, or an increased number of healthy children that access primary care. Bias in either direction should not affect the results of the healthy sample. Direct measurements of undernutrition and anaemia, detailed questioning of caregivers about birthweight, perinatal and chronic illness, and a health checklist provided by clinicians were the most rigorous health criteria we could apply. Nevertheless, we might have erroneously included some children with unknown health conditions. We did not exclude children with psychosocial risk factors such as poverty, a low level of caregiver education, or depression.34x34Walker, SP, Wachs, TD, Gardner, JM…, and International Child Development Steering Group. Child development: risk factors for adverse outcomes in developing countries. Lancet. 2007;
13: 145–157
Summary | Full Text | Full Text PDF | Scopus (760)
| Google ScholarSee all References

Our study has identified the median age at which healthy children of both sexes and from four countries attain milestones in multiple developmental domains. These findings might contribute to the construction of internationally applicable tools to assess children’s development to guide policy, service delivery, and intervention research that might help narrow the gap between high-income countries and LMICs in addressing early childhood development.


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