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al. Association of infants exposed to prenatal Zika virus infection with their clinical, neurologic, and developmental status evaluated via the general movement assessment tool. JAMA Netw Open 2019; 2: e187235. 3 Nielsen-Saines K, Brasil P, Kerin T, et al. Delayed childhood neurodevelopment and neurosensory alterations in the second year of life in a prospective cohort of ZIKV-exposed children. Nat Med 2019; 25: 1213-17. 4 Faiçal AV, de Oliveira JC, Oliveira JVV, et al. Neurodevelopmental delay in normocephalic children with in utero exposure to Zika virus. BMJ Paediatr Open 2019; 5: e000486. 5 Carvalho AL, Ventura P, Taguchi T, et al. Cerebral palsy in children with congenital Zika syndrome: a 2-year neurodevelopmental follow-up.

Background Both young and advanced maternal age is associated with adverse birth and child outcomes. Few studies have examined these associations in low- and middle-income countries (LMICs) and none have studied adult outcomes in the offspring. Methods Pooled data from five birth cohorts (total N=19,403) in Brazil, Guatemala, India, the Philippines and South Africa were used to examine associations of maternal age with offspring birth weight, gestational age, height-for-age and weight-for-height Z-scores in childhood, attained schooling, and adult height, body composition (BMI, waist circumference, fat and lean mass) and cardiometabolic risk factors (blood pressure and fasting plasma glucose concentration), along with binary variables derived from these. Analyses were unadjusted and adjusted for maternal socio-economic status, height and parity, and breastfeeding duration. Findings In unadjusted analyses, younger (≤19 years) and older (≥35 years) maternal age was associated with lower birth weight, gestational age, child nutritional status and schooling. Associations with younger maternal age remained after adjustment; odds ratios (OR) for low birth weight, pre-term birth, 2-year stunting and failure to complete secondary schooling were 1·18 (95% CI: 1·02,1·36), 1·26 (1·03,1·53), 1·46 (1·25,1·70) and 1·38 (1·18,1·62) respectively compared with mothers aged 20-24 years. After adjustment, older maternal age remained associated with increased risk of pre-term birth (OR=1·33 (1·05,1·67)) but children of older mothers had less 2-year stunting (OR=0·64 (0·54,0·77)) and failure to complete secondary schooling (OR=0·59 (0·48,0·71)). Offspring of both younger and older mothers had higher adult fasting glucose concentrations (~0·05 mmol/l). Interpretation Children of young mothers in LMICs are disadvantaged at birth and in childhood nutrition and schooling. Efforts to prevent early childbearing should be strengthened. After adjusting for confounders, children of older mothers have advantages in nutritional status and schooling. Extremes of maternal age may be associated with disturbed offspring glucose metabolism. Funding Wellcome Trust, Bill and Melinda Gates Foundation

Objective To assess the efficacy of an intervention designed to improve the mother-infant relationship and security of infant attachment in a South African peri-urban settlement with marked adverse socioeconomic circumstances. Design Randomised controlled trial. Setting Khayelitsha, a peri-urban settlement in South Africa. Participants 449 pregnant women. Interventions The intervention was delivered from late pregnancy and for six months postpartum. Women were visited in their homes by previously untrained lay community workers who provided support and guidance in parenting. The purpose of the intervention was to promote sensitive and responsive parenting and secure infant attachment to the mother. Women in the control group received no therapeutic input from the research team. Main outcome measures Primary outcomes: quality of mother-infant interactions at six and 12 months postpartum; infant attachment security at 18 months. Secondary outcome: maternal depression at six and 12 months. Results The intervention was associated with significant benefit to the mother-infant relationship. At both six and 12 months, compared with control mothers, mothers in the intervention group were significantly more sensitive (6 months: mean difference=0.77 (SD 0.37), t=2.10, P<0.05, d=0.24; 12 months: mean difference=0.42 (0.18), t=−2.04 , P<0.05, d=0.26) and less intrusive (6 months: mean difference=0.68 (0.36), t=2.28, P<0.05, d=0.26; 12 months: mean difference=−1.76 (0.86), t=2.28 , P<0.05, d=0.24) in their interactions with their infants. The intervention was also associated with a higher rate of secure infant attachments at 18 months (116/156 (74%) v 102/162 (63%); Wald=4.74, odds ratio=1.70, P<0.05). Although the prevalence of maternal depressive disorder was not significantly reduced, the intervention had a benefit in terms of maternal depressed mood at six months (z=2.05, P=0.04) on the Edinburgh postnatal depression scale). Conclusions The intervention, delivered by local lay women, had a significant positive impact on the quality of the mother-infant relationship and on security of infant attachment, factors known to predict favourable child development. If these effects persist, and if they are replicated, this intervention holds considerable promise for use in the developing world. Trial registration Current Controlled Trials ISRCTN25664149.

Key PointsQuestionWhat is the association of differing levels of persistence and severity of postnatal depression with long-term child outcomes?FindingsThis observational study of 9848 women with varying levels of postnatal depression and 8287 children found that, compared with children of women with postnatal depression that did not persist, of either moderate or severe intensity, children of women with persistent and severe depression are at an increased risk for behavioral problems by age 3.5 years as well as lower mathematics grades and depression during adolescence. Furthermore, women with persistent postnatal depression are likely to experience significant depressive symptoms until at least 11 years after childbirth.MeaningWomen with persistent and severe postnatal depression should be prioritized for treatment because they are likely to continue to experience high levels of depressive symptoms and because of the high risk of adverse child development.