Published by Oxford University Press on behalf of the International Epidemiological Association International Journal of Epidemiology 2011;40:1215–1226

ß The Author 2011; all rights reserved. Advance Access publication 15 July 2011 doi:10.1093/ije/dyr094

Pre-natal and post-natal growth

trajectories and childhood cognitive
ability and mental health
Seungmi Yang,1* Kate Tilling,2 Richard Martin,2,3 Neil Davies,2,3 Yoav Ben-Shlomo2,3 and
Michael S Kramer1,4
1
Department of Paediatrics, McGill University, Montreal, Canada, 2Department of Social Medicine, University of Bristol, Bristol,
UK, 3Department of Social Medicine, MRC Centre for Causal Analyses in Translational Epidemiology, University of Bristol, Bristol,

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UK and 4Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
*Corresponding author. The Research Institute of McGill University Health Centre, 4060 Ste-Catherine West (Place Toulon),
Montreal, Quebec H3Z 2Z3, Canada. E-mail: seungmi.yang@mail.mcgill.ca

Accepted 17 May 2011

Background Most studies of the associations between pre-natal or post-natal
growth and cognitive ability have been based on children with
pathologically slow growth measured between two time points
only, rather than children with normal growth trajectories esti-
mated from multiple measures of growth.
Methods We investigated the associations of pre-natal and post-natal trajec-
tories in both weight and length/height through the first 5 years of
life with cognitive ability and mental health at 6.5 years of age
among healthy children. Our study is based on 11 899 children
who were born healthy at 537 completed weeks with birth
weight 52500 g and had up to 13 measures of weight and
length/height from birth to age 5 years and cognitive ability and be-
haviour measured at 6.5 years. Using a linear spline random-effects
model with 2 knots at 3 and 12 months, we estimated growth trajec-
tories for each child from birth to age 5 years in weight and length/
height in four periods: gestational age-specific birth weight and
length (pre-natal ‘growth’), early infancy (0–3 months), late infancy
(3–12 months) and early childhood (1–5 years). We used generalized
estimating equations to estimate mean differences in IQ and mental
health according to pre-natal and post-natal growth trajectory.
IQ was measured using the Wechsler Abbreviated Scales of
Intelligence, and mental health was assessed using the Strengths
and Difficulties Questionnaire.
Results A 1 standard deviation (SD) in birth weight was positively associated
with cognitive ability (0.82 IQ points, 95% CI: 0.54–1.10) after ad-
justing for confounders. For post-natal weight gain trajectories, a 1
SD faster weight gain was associated with an increase of 0.77 (95%
CI: 0.42–1.11) IQ points for early infancy, 0.30 (95% CI: 0.02–0.58)
points for late infancy, and 0.40 (95% CI: 0.04–0.76) for early child-
hood after adjusting for confounders and for earlier growth. For
length/height trajectories, the magnitudes of increase in cognitive
ability were similar to each other (0.6 points) across the four per-
iods. Pre-natal and infancy growth, but not early childhood growth,
were associated with reduced externalising behaviours.

1215
1216 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Conclusions Although the effect sizes are small and residual confounding cannot
be excluded, our results suggest that among healthy children, faster
growth from the pre-natal period through age 5 years is positively
associated with cognitive ability, whereas faster growth in the
pre-natal period and infancy is positively associated with mental
health at early school age.
Keywords Term birth, pre-natal growth, post-natal growth, growth trajectory,
cognitive ability, child behaviour, child mental health

Introduction trial of a breastfeeding promotion intervention mod-

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The pre-natal period (particularly the third trimester
of pregnancy) and the first few years of life are crucial
for brain development.1,2 During this period, the brain
develops rapidly through the processes of neurogen-
esis, axonal and dendritic growth, synaptogenesis, cell
death, synaptic pruning, myelination and gliogenesis.3
These processes occur sequentially and depend on
each other. Although cognitive ability has a heritable
component, environmental insults during the early
months and years of life are likely to have long-
lasting adverse effects on cognitive development.2
Insults with demonstrated adverse effects include pre-
term birth4–6 and failure to thrive in infancy.7
Relatively few studies, however, have examined as-
sociations of pre- and post-natal growth with cogni-
tive ability in healthy children born at term without
pathological growth restriction.8–13 Whereas most
have reported a positive association of weight gain
in infancy and early childhood with later cognitive
ability,8–10,12 some have found no association.11,13
Not only is the empirical evidence inconclusive, but
also most studies have estimated differences in
cognitive ability associated with a change in weight
between two time points only, rather than with tra-
jectories estimated from multiple measures of growth.
Finally, although cognitive ability is closely related to
mental health problems and poor pre-natal growth
has been associated with later behavioural prob-
lems,14 behavioural sequelae of post-natal growth
have rarely been studied. The aim of our study, there-
fore, was to examine the extent to which pre-natal
and post-natal trajectories in both weight and
length/height through the first 5 years of life are asso-
ciated with cognitive ability and mental health at
6.5 years of age among children who had been born
at or after term.
Methods
Study participants
Study children were participants in the Promotion of
Breastfeeding Intervention Trial (PROBIT). A full de-
scription of PROBIT has been published elsewhere.15
In brief, PROBIT is a cluster-randomized controlled
elled on the WHO/UNICEF Baby-Friendly Hospital
Initiative. A total of 17 046 mothers and their healthy
infants in the Republic of Belarus born at 537 com-
pleted weeks of gestation and with birth weight
52500 g were recruited from 31 maternity hospitals
and affiliated polyclinics during their postpartum stay
between June 1996 and December 1997. They had
scheduled follow-up study visits at 1, 2, 3, 6, 9 and
12 months in the first year and at age 6.5 years.
Follow-up thorough the first year was achieved in
16 491 infants (97%); 13 889 (81.5%) children were
seen and examined at the 6.5-year follow-up. Our
study is based on 11 899 (86%) of the children who
had cognitive ability and behaviour scores measured
at the 6.5-year visit. The study received approval from
the Institutional Review Board of the Montreal
Children’s Hospital, and participating mothers signed
the consent in Russian.
Measures
Exposures (growth)
Infant weight (grams) and length (centimetres) at
birth and gestational age in completed weeks were
obtained from obstetric records during the postpar-
tum hospital stay. Weight and length during the
first year of life were measured by paediatricians at
the scheduled PROBIT visits at 1, 2, 3, 6, 9 and
12 months. Weights and lengths/heights between
12 months and 5 years were abstracted from the poly-
clinic records of routine check-ups. A total of 2095
(15%) children had no routine check-up visits, and
on average 4 (range 1–6) measures of weight and
height per child were abstracted from the clinic
records.
Outcomes
At the 6.5-year follow-up, cognitive ability was mea-
sured by the Wechsler Abbreviated Scales of
Intelligence (WASI).16 The WASI consists of four
subtests of vocabulary and similarities to measure
verbal IQ and block designs and matrices to measure
performance IQ. The WASI was translated from
English to Russian and back-translated to ensure
comparability of the Russian version. It was adminis-
tered by the polyclinic paediatricians after extensive
 PRE-NATAL OR POST-NATAL GROWTH AND CHILD DEVELOPMENT
training and follow-up monitoring by child psycholo-
gists and psychiatrists in Minsk, Belarus.
Interpaediatrician agreement was high, with Pearson
correlation coefficients (95% confidence intervals) of
0.80 (0.67–0.89) for vocabulary, 0.72 (0.54–0.83) for
similarities, 0.80 (0.67–0.89) for block designs and
0.79 (0.66–0.88) for matrices in a convenience
sample of 45 children during a 1-week training work-
shop.17 The present study used the full-scale IQ from
the WASI for the primary measure of general cogni-
tive ability of children. We also assessed the associ-
ations with verbal and performance IQ. Additionally,
at the 6.5-year follow-up visit, parents provided teach-
ers’ names if the child had started formal schooling
by the time of his/her follow-up visit, and the teachers
were asked to evaluate the child’s performance in
mathematics, reading, writing and other subjects ac-
cording to a 5-point Likert scale as far below (1),
somewhat below, at, somewhat above, or far above
(5) his or her grade level, based on items in the
Teacher Report Form of the Child Behaviour
Checklist.18
Child mental health was measured using the
Strengths and Difficulties Questionnaire (SDQ).19
The SDQ is a brief behavioural screening question-
naire for mental illness in children and adolescents
from ages 4 to 16 years and consists of five subscales
(hyperactivity, conduct problems, emotional symp-
toms, peer problems and prosocial behaviour), each
with five items. Each item is rated as not true (0),
somewhat true (1) or certainly true (2). The score for
each of the five scales is generated by summing the
scores for the five items, each ranging from 0 to 10.
Scores for hyperactivity, conduct problems, emotional
symptoms and peer problems are summed to generate
a total difficulties score. A recent study20 has shown
that although the four ‘difficulties’ subscales tap dis-
tinct dimensions of behavioural problems, summariz-
ing them into externalising behaviour (sum of
hyperactivity and conduct problem scores) and inter-
nalizing behaviour (sum of emotional symptoms and
peer problems) is more parsimonious and better able
to reduce measurement errors in a general population.
Thus, our behaviour measures of the SDQ are pre-
sented as total difficulties, externalizing behaviours,
internalizing behaviours and prosocial behaviour.
The SDQ has been validated not only against other
measures of child behaviour problems, including the
Child Behaviour Checklist (CBCL)21 but also clinical
diagnostic measures of mental disorder in children.22
The SDQ has been shown to compare favourably with
other measures for identifying hyperactivity and at-
tention problems.23–25 Several studies have demon-
strated the cross-cultural validity of the SDQ in
European and developing countries.23,26–28 The
Russian version of the SDQ has previously been
used in clinical and research settings.29
The parent accompanying the child (usually the
mother) at the 6.5-year follow-up completed the
1217
SDQ in the polyclinic waiting room. Of the total of
13 889 children, parents of 13 868 children completed
the SDQ. The teachers of those who had begun school
also completed the teacher version of the SDQ distrib-
uted by the polyclinic paediatricians. The SDQ items
are identical in the parent and the teacher versions.
Of all children seen at the follow-up, the teacher SDQ
was obtained in 87% (n ¼ 12 016); most of the re-
mainder had not yet begun formal schooling at the
time of the follow-up. As previously reported,30 in-
ternal consistency and test–retest reliability of the
parent and teacher SDQ were high in our study;
Cronbach’s for total difficulties, for example, was
0.82 and 0.73 in the teacher and parent SDQ, respect-
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ively. Correlations between the parent and the teacher
SDQ scores were modest: 0.28 for total difficulties,
0.39 for externalizing behaviours and 0.21 for inter-
nalizing behaviours.
Potential confounders
Potentially confounding maternal and family charac-
teristics included maternal and paternal age at the
time of the child’s birth, maternal smoking and alco-
hol consumption during pregnancy, breastfeeding,
marital status, number of other children in the house-
hold, parental education and occupation (all based on
maternal report at enrolment), and maternal and pa-
ternal height and body mass index (based on mater-
nal report at the 6.5-year follow-up).
Statistical analysis
We examined the association of growth trajectories
during the first 5 years to allow a time lag before
the outcome ascertainment (at 6.5 years). We esti-
mated growth trajectories for each child from birth
to age 5 years in weight and length/height using a
linear spline random-effects model31 with MLwiN
version 2.1 (www.cmm.bristol.ac.uk/MLwiN/index.
shtml).32 Such models estimate mean growth trajec-
tories based on the repeated measures of weight and
length/height over time and allow individual growth
trajectories to randomly vary around the mean. This
approach allows for changes in scale and variance of
growth measures over time and uses all available data
for each individual.
We used fractional polynomials to find the
best-fitting growth trajectory for weight and length/
height, and identified the best-fitting spline knots at 3
and 12 months for each sex. The model fits the data
well; 95% limits of agreement between observed and
expected growth measures were within 10% of the
mean values at each planned visit in the first year
and at the 6.5-year follow-up. Thus, for both boys
and girls, linear random-effects models were fitted
for weight and length/height growth trajectory for
four periods: pre-natal ‘growth’ (birth weight and
length standardized by gestational age for each sex)
and growth between 0–3 months (‘early infancy’),
3–12 months (‘late infancy’) and 1–5 years (‘early
1218 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
childhood’). For instance, weight for child i at age j
was modelled as:
yij ¼ 0 þ u0i þ ð 1 þu1i Þsi1 þð 2 þu2i Þsi2 þð 3 þu3i Þsi3
þ eij j
where 0 is the population average birth weight
(intercept) and 1, 2 and b3 are the population aver-
age velocities (slopes) of weight gain between 0–3
months, 3–12 months and 12–60 months, respectively
(the fixed effects). u0i, u1i, u2i and u3i represent
individual-level random effects. u0i is the deviation
from the average intercept for child i, and u1i, u2i
and u3i are the deviations for child i from the average
velocities of weight gain between 0–3 months, 3–12
months and 12–60 months, respectively. si1, si2 and si3
are the amount of time spent in each period for child i
at age j. Finally, eij is the deviation from the predicted
weight for child i at age j (the occasion-level random
effects) and is related to age to allow for the increase
in weight (and therefore the increase in the size of
the measurement error of weight) with age. The
individual-level random effects correlation matrix
was unstructured, i.e. each random effect was allowed
to be correlated with all other random effects. The
occasion-level random effects were independent;
thus we assumed that measurement error at one
age was unrelated to measurement error for that in-
dividual at another age. Occasion- and individual-
level random effects were independent.
From these models, individual-specific estimates of
growth trajectory (i.e. each child’s deviation from the
mean) in weight and length/height for the four peri-
ods were obtained for each child.33 These weight and
length/height trajectory parameters were then stan-
dardized (z-scored) for sex, and additionally for ges-
tational age for pre-natal growth.
Mean differences in IQ and SDQ scores by pre-natal
and post-natal growth trajectory in weight and
length/height were estimated by generalized estimat-
ing equations (GEE) regression analysis using STATA
10. We used the GEE approach to account for cluster-
ing in the data by hospitals and associated polyclinics
and thereby correctly estimate standard errors of the
regression coefficients. Associations with each growth
parameter were examined in three models: (i) un-
adjusted; (ii) adjusted for potential confounding fac-
tors (‘adjusted 1’); and (iii) adjusted for potential
confounders and for earlier growth (‘adjusted 2’)
models.
Results
Table 1 shows the baseline characteristics of the
PROBIT children in our study, their growth measures
from birth to age 5 years, and the mean IQ, teachers’
ratings of the children’s academic performance, and
parent and teacher SDQ scores. Only minimal differ-
ences were observed between our analytic sample and
those excluded from the original sample of the
PROBIT due to loss to follow-up or missing informa-
tion on exposures or outcomes. Compared with those
excluded, children included in our study were similar
with respect to birth weight, gestational age, parental
age or parental size. Those excluded were slightly
more likely to have fathers with university education
(16% vs 12%) and non-manual occupation (30% vs
28%) and to be first-born children (61% vs 56%),
but slightly less likely to have mothers with
non-manual occupation (40% vs 43%).
Table 2 shows the association between the growth
trajectories and IQ at age 6.5 years. The patterns of
association did not vary by sex (all P-values for
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sex-interaction 40.10), and thus we present
sex-adjusted results. For weight gain trajectory, the
unadjusted associations show that a 1 SD greater
birth weight for gestational age (e.g. 447 g in boys
and 434 g in girls at 40 weeks) was associated with
a 0.94-point (95% CI: 0.62–1.25) increase in full-scale
IQ. A 1 SD faster weight gain during early infancy
was associated with a 1.25-point (95% CI: 0.88–
1.62) increase; the corresponding increases were 0.68
(95% CI: 0.44–0.93) points for late infancy and 0.99
(95% CI: 0.70–1.29) points for early childhood growth.
After adjusting for potential confounders (adjusted 1),
the associations were attenuated by 15–50%, with
greater attenuation for associations with weight gain
during late infancy and early childhood. Of the con-
founding factors included, parental socioeconomic
position and size, education and height in particular,
most attenuated the associations and were responsible
for 30% of the attenuation. Further adjustment for
earlier growth (adjusted 2) did not substantially
change the patterns of association. Stronger associ-
ations with birth weight and early infancy weight
gain were also observed when verbal and performance
IQ scores were analysed separately.
For length/height gain trajectories, faster growth
was positively associated with full-scale IQ scores in
all four periods, with the largest association observed
for height gain during early childhood in unadjusted
associations. After adjustment for potential confoun-
ders and earlier growth (adjusted 2), the positive as-
sociations in the unadjusted model were attenuated
by 30–50%, especially for early childhood height gain.
As seen with weight gain trajectories, parental educa-
tion and height were mainly responsible for the at-
tenuation. The attenuated associations between
infancy length gain and IQ in adjusted 1 were
strengthened with adjustment for earlier growth (ad-
justed 2), because infancy length gain was negatively
correlated with birth length (r ¼ 0.31 for early in-
fancy and r ¼ 0.49 for late infancy). The patterns
of association between length/height trajectories and
verbal and performance IQ were essentially the same
as observed for full-scale IQ.
Whereas growth measures in all four periods were
positively associated with school performance,
 PRE-NATAL OR POST-NATAL GROWTH AND CHILD DEVELOPMENT 1219

Table 1 Means (standard deviation) of growth measures, outcomes and covariates in the study sample

Growth measures
Weight (kg)
Birth weight 3.44 (0.42)
3 months 6.11 (0.67)
12 months 10.58 (1.01)
6.5 years 22.81 (3.61)
Length/height (cm)
Birth length 51.9 (2.13)
3 months 60.9 (2.4)
12 months 75.9 (2.7)

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6.5 years 120.7 (5.2)
Estimated growth velocity
Weight (kg/year)
0–3 months 10.82 (1.58)
3–12 months 6.38 (0.87)
1–5 years 1.89 (0.36)
Length/height (cm/year)
0–3 months 36.0 (6.21)
3–12 months 21.54 (1.95)
1–5 years 8.88 (0.80)
IQ
Full-scale IQ 105.2 (15.8)
Verbal IQ 103.2 (16.9)
Performance IQ 106.2 (15.1)
School performance [1 (far below) – 5 (far above) the grade level]
Mathematics 3.2 (0.8)
Reading 3.2 (0.8)
Writing 3.2 (0.8)
Other 3.3 (0.6)
Average 3.2 (0.7)
Parental SDQ
Total difficulties 11.5 (5.0)
Externalizing behaviours 6.3 (3.2)
Internalizing behaviours 5.2 (3.0)
Prosocial behaviour 8.3 (1.6)
Teacher SDQ
Total difficulties 9.6 (5.8)
Externalizing behaviours 5.3 (4.0)
Internalizing behaviours 4.3 (3.0)
Prosocial behaviour 7.5 (2.2)
Gestational age (weeks) 39.4 (1.0)
Mother’s pregnancy behaviour [n (%)]
Smoking (yes) 249 (2.1)
Drinking (yes) 281 (2.4)
Mother’s age (years) 24.5 (4.9)
Father’s age (years) 27.4 (5.1)
(continued)
1220 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Table 1 Continued
Parental body size
Mother’s weight (kg) 66.2 (12.5)
Mother’s height (cm) 164.4 (5.7)
Father’s weight (kg) 80.2 (11.7)
Father’s height (cm) 176.1 (6.6)
Mother’s marital status [n (%)]
Married 10,618 (89.2)
Cohabitating 814 (6.8)
Unmarried 467 (3.9)
No. of children

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0 6741 (56.6)
1 4128 (34.7)
2þ 1030 (8.7)
Mother’s education [n (%)]
University degree 1579 (13.3)
Partial university 6075 (51.1)
Secondary education 3800 (31.9)
<Secondary education 445 (3.7)
Mother’s occupation [n (%)]
Non-manual 5134 (43.1)
Manual 4041 (34.0)
Unemployed 2724 (22.9)
Father’s education (n (%))
University degree 1467 (12.3)
Partial university 5460 (45.9)
Secondary education 4297 (36.1)
<Secondary education 277 (2.3)
Missing 398 (3.3)
Father’s occupation [n (%)]
Non-manual 3294 (27.7)
Manual 6506 (54.7)
Unemployed 1617 (13.6)
Unknown 482 (4.0)

associations between pre-natal and infant growth
were larger than those for early childhood growth
(data not shown). For example, a 1 SD greater birth
weight for gestational age was associated with a
0.03-point (95% CI: 0.02–0.05) higher teacher rating
in mathematics after adjusting for potential confoun-
ders. A 1 SD faster weight gain in early infancy, late
infancy and early childhood was associated with
increased mathematics ratings by 0.02 (95% CI:
0.01–0.04), 0.03 (95% CI: 0.02–0.05) and 0.01 (95%
CI: 0.01 to 0.03) points, respectively, after adjusting
for confounders and earlier growth. The corres-
ponding figures for length/height gain were 0.01
(95% CI: 0.00–0.03), 0.04 (95% CI: 0.02–0.06), 0.04
(95% CI: 0.02–0.06) and 0.02 (95% CI: 0.00–0.04)
points, respectively, in fully adjusted models.
Table 3 summarizes the associations between
growth trajectories and teacher SDQ scores. In un-
adjusted analyses, a 1 SD increase in birth weight
for gestational age was negatively associated with
total difficulties, externalizing behaviours and inter-
nalizing behaviours and positively associated with
prosocial behaviour. After adjustment for potential
confounders, inverse associations between birth
weight and total difficulties (0.28, 95% CI: 0.40
to 0.15), externalizing behaviours (0.16,
 PRE-NATAL OR POST-NATAL GROWTH AND CHILD DEVELOPMENT 1221

Table 2 Associations between pre-natal and post-natal growth trajectories (z-scores) through 5 years of age and IQ at age
6.5 years

Unadjusted Adjusted 1 Adjusted 2

Weight trajectory
Full-scale IQ
Birth weight 0.94 (0.62, 1.25) 0.82 (0.54, 1.10) –
Weight gain from 0 to 3 months 1.25 (0.88, 1.62) 0.87 (0.52, 1.21) 0.77 (0.42, 1.11)
Weight gain from 3 to 12 months 0.68 (0.44, 0.93) 0.32 (0.06, 0.56) 0.29 (0.01, 0.58)
Weight gain from 1 to 5 years 0.99 (0.70, 1.29) 0.54 (0.27, 0.81) 0.40 (0.04, 0.76)
Verbal IQ
Birth weight 0.89 (0.54, 1.24) 0.81 (0.50, 1.12) –

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Weight gain from 0 to 3 months 1.26 (0.86, 1.66) 0.80 (0.44, 1.65) 0.70 (0.34, 1.05)
Weight gain from 3 to 12 months 0.68 (0.41, 0.95) 0.28 (0.001, 0.56) 0.27 (-0.03, 0.58)
Weight gain from 1 to 5 years 1.07 (0.76, 1.38) 0.63 (0.31, 0.95) 0.52 (0.08, 0.95)
Performance IQ
Birth weight 0.77 (0.50, 1.04) 0.65 (0.37, 0.93) –
Weight gain from 0 to 3 months 0.96 (0.65, 1.27) 0.75 (-0.04, 1.30) 0.67 (0.34, 1.00)
Weight gain from 3 to 12 months 0.53 (0.29, 0.76) 0.26 (0.01, 0.51) 0.23 (-0.06, 0.53)
Weight gain from 1 to 5 years 0.69 (0.41, 0.98) 0.34 (0.06, 0.63) 0.22 (-0.13, 0.56)
Length/Height trajectory
Full-scale IQ
Birth length 0.89 (0.61, 1.18) 0.62 (0.32, 0.92) –
Length gain from 0 to 3 months 0.86 (0.48, 1.23) 0.42 (0.04, 0.81) 0.65 (0.24, 1.05)
Length gain from 3 to 12 months 0.68 (0.27, 1.09) 0.23 (-0.15, 0.61) 0.68 (0.28, 1.08)
Height gain from 1 to 5 years 1.38 (0.94, 1.82) 0.77 (0.39, 1.16) 0.64 (0.16, 1.13)
Verbal IQ
Birth length 0.80 (0.53, 1.06) 0.53 (0.25, 0.81) –
Length gain from 0 to 3 months 0.89 (0.51, 1.27) 0.38 (0.02, 0.74) 0.57 (0.17, 0.97)
Length gain from 3 to 12 months 0.83 (0.36, 1.30) 0.39 (-0.06, 0.84) 0.84 (0.33, 1.33)
Height gain from 1 to 5 years 1.44 (0.97, 1.91) 0.82 (0.40, 1.24) 0.62 (0.10, 1.14)
Performance IQ
Birth length 0.81 (0.51, 1.11) 0.59 (0.27, 0.91) –
Length gain from 0 to 3 months 0.62 (0.25, 0.99) 0.35 (-0.01, 0.72) 0.56 (0.18, 0.94)
Length gain from 3 to 12 months 0.38 (0.07, 0.69) 0.01 (-0.30, 0.31) 0.37 (0.05, 0.70)
Height gain from 1 to 5 years 1.03 (0.67, 1.39) 0.57 (0.23, 0.91) 0.55 (0.14, 0.97)
Adjusted 1: adjusted for sex, term status (early term/term/post-term), maternal smoking and drinking during pregnancy, duration
of breastfeeding, number of older children, parental marital status, parental education and occupation, and parental height and
BMI.
Adjusted 2: adjusted for all variables in Adjusted 1 plus earlier growth trajectory.

95% CI: 0.24 to 0.07), internalizing behaviours
(0.12, 95% CI: 0.18 to 0.05) remained (although
were considerably attenuated), but the positive asso-
ciation with prosocial behaviour attenuated towards
the null. When potential confounders and (for the
post-natal period) earlier growth were adjusted for,
weight gain in late infancy was negatively associated
with externalising behaviours and positively with pro-
social behaviour. Similar patterns of association were
observed for length/height gain trajectories. Birth
length was negatively associated with total difficulties
(0.21, 95% CI: 0.33 to 0.08) and externalizing
behaviours (0.15, 95% CI: 0.23 to 0.06) after ad-
justing for potential confounders. Length/height gain
in later periods (particularly in infancy) was also
negatively associated with problem behaviours, show-
ing very similar effect sizes observed in weight gain
but with wider confidence intervals after adjusting
1222 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY

Table 3 Associations between pre-natal and post-natal growth trajectories (z-scores) through 5 years of age and teacher
SDQ scores at age 6.5 years

Weight trajectory Length/Height trajectory

a
Unadjusted Adjusted Unadjusted Adjusteda
Total difficulties
At birth 0.38 (0.48, 0.27) 0.28 (0.40, 0.15) 0.29 (0.40, 0.17) 0.21 (0.33, 0.08)
Gain from 0 to 3 months 0.15 (0.26, 0.04) 0.07 (0.19, 0.05) 0.05 (0.17, 0.07) 0.07 (0.21, 0.06)
Gain from 3 to 12 months 0.09 (0.20, 0.02) 0.13 (0.26, 0.01) 0.01 (0.10, 0.12) 0.11 (0.25, 0.03)
Gain from 1 to 5 years 0.07 (0.17, 0.03) 0.05 (0.07, 0.18) 0.10 (0.20, 0.002) 0.01 (0.12, 0.15)
Externalizing behaviours
At birth 0.23 (0.31, 0.16) 0.16 (0.24, 0.07) 0.20 (0.28, 0.12) 0.15 (0.23, 0.06)

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Gain from 0 to 3 months 0.09 (0.17, 0.01) 0.03 (0.12, 0.06) 0.04 (0.12, 0.04) 0.06 (0.16, 0.03)
Gain from 3 to 12 months 0.05 (0.13, 0.02) 0.09 (0.18, 0.01) 0.01 (0.07, 0.08) 0.08 (0.18, 0.01)
Gain from 1 to 5 years 0.003 (0.07, 0.07) 0.07 (0.01, 0.16) 0.06 (0.13, 0.02) 0.02 (0.07, 0.11)
Internalizing behaviours
At birth 0.14 (0.20, 0.08) 0.12 (0.18, 0.05) 0.08 (0.14, 0.02) 0.05 (0.13, 0.01)
Gain from 0 to 3 months 0.06 (0.12, 0.004) 0.04 (0.10, 0.03) 0.01 (0.07, 0.05) 0.02 (0.09, 0.05)
Gain from 3 to 12 months 0.04 (0.09, 0.02) 0.04 (0.11, 0.02) 0.003 (0.05, 0.06) 0.03 (0.11, 0.05)
Gain from 1 to 5 years 0.07 (0.12, 0.02) 0.02 (0.08, 0.05) 0.04 (0.09, 0.01) 0.00 (0.07, 0.07)
Prosocial behavior
At birth 0.07 (0.03, 0.11) 0.03 (0.01, 0.08) 0.04 (0.002, 0.09) 0.01 (0.04, 0.06)
Gain from 0 to 3 months 0.02 (0.02, 0.07) 0.02 (0.07, 0.02) 0.01 (0.04, 0.05) 0.02 (0.07, 0.04)
Gain from 3 to 12 months 0.04 (0.01, 0.08) 0.06 (0.01, 0.11) 0.01 (0.03, 0.05) 0.02 (0.04, 0.07)
Gain from 1 to 5 years 0.02 (0.02, 0.05) 0.02 (0.06, 0.03) 0.03 (0.01, 0.07) 0.01 (0.04, 0.07)
a
Adjusted models include all potential confounding factors and earlier growth trajectory estimates for post-natal growth.

additionally for earlier growth. Most of the attenu-
ation from the unadjusted to the fully adjusted asso-
ciations was due to adjustment for confounding
factors rather than for earlier growth.
Similar results were observed for parental SDQ
scores. Birth weight and early infancy weight gain
were negatively associated with total difficulties and
externalizing behaviours in unadjusted analyses (data
not shown). The associations were small in magni-
tude, however, and were not observed after adjusting
for potential confounding factors, except for the asso-
ciation between birth weight and externalizing behav-
iours (0.07, 95% CI: 0.13 to 0.01). Similar
patterns were observed with length/height gain trajec-
tories (data not shown).
Discussion
In this cohort of healthy children born at or after
term, we found small, positive associations of
growth trajectories from the pre-natal period through
the first 5 years of life with both cognitive ability and
mental health at age 6.5 years. However, the pattern
of associations across the four periods defined in our
study differed somewhat for weight and length/height
gain trajectories, in particular for cognitive ability. For
weight gain trajectory, mean IQ differences associated
with growth during the pre-natal period and early
infancy (0–3 months) were larger than with later
growth, whereas the contributions of length/height
gain trajectories to mean IQ differences across the
four periods were similar to one another. These pat-
terns were observed not only with full-scale IQ scores,
but also for verbal and performance IQ. Nevertheless,
we found that irrespective of earlier growth, faster
growth at later ages was associated with increased
full-scale IQ scores. For child behaviour, pre-natal
growth showed larger associations than did post-natal
growth.
The large sample size, prospective cohort design and
large number of growth measures from birth to age
5 years (up to 13) are strengths of study. Our frac-
tional linear spline random-effects model is an im-
provement on the approaches used in previous
studies. It allowed us to identify important time
points at which the rate of growth differs in the
first 5 years of life, rather than using arbitrary time
points limited by availability of data, as was often the
case in previous studies. The time points identified by
our linear spline approach were based solely on
growth measures to represent distinct biological
 PRE-NATAL OR POST-NATAL GROWTH AND CHILD DEVELOPMENT
growth patterns over the 5 years and were not influ-
enced by the choice of our outcome measures. Our
analytical approach also enabled us to estimate indi-
vidual trajectories by allowing random variation
across individuals and their associations with differ-
ences in cognitive ability and behaviour scores.
The associations observed in our study are probably
generalizable to other developed country settings.
First, our findings are not based on children with
growth problems but rather on normal, healthy chil-
dren. Second, Belarus resembles Western developed
countries with respect to readily accessible basic
health care services, high levels of sanitation, high
immunization rates, low incidence of infection and
low rates of infant and child mortality.
Some limitations in our study also require discus-
sion, however. First, although we adjusted for a wide
range of maternal and paternal characteristics,
residual confounding by family characteristics (both
genetic and environmental factors) cannot be
excluded. All coefficients were attenuated (by up to
50%) with adjustment for the confounders included
here, and it seems likely that other confounders exist
(not measured here) which would attenuate these re-
lationships further. Parental cognitive ability, a strong
predictor of cognitive ability of offspring,34 for ex-
ample, may also affect growth trajectory via parenting
behaviours such as feeding practices and physical ac-
tivity. The lack of maternal psychological distress data
in our data may also explain the observed association
for behaviour. However, Alati et al.35 showed that the
association between birth weight and behavioural
problems is not affected by the adjustment for mater-
nal anxiety and depression in a relatively large birth
cohort. Second, although we deliberately chose a min-
imum of 1.5 years between the growth and outcome
measures, reverse causation could theoretically
explain our findings; children with higher cognitive
ability and/or better mental health might grow
faster via better eating practices.36 Third, weight and
length/height measures in our study were not stan-
dardized across hospitals and polyclinics, which is
likely to increase measurement errors. These measure-
ment errors are unlikely to vary systematically by
child cognitive ability and behaviour across study
sites, however, and would therefore tend to attenuate
associations toward the null.
Measurement errors for IQ and behaviour are also a
potential source of bias. Despite our efforts to stand-
ardize measurements across paediatricians at 31 poly-
clinics, mean IQ scores across polyclinics were highly
clustered, as indicated by the intra-class coefficient of
0.31. Since a single paediatrician measured IQ at 24 of
the 31 polyclinics (two paediatricians shared the work
at the seven busiest polyclinics), this clustering prob-
ably reflects differences in strictness or leniency in
scoring or timing of responses among paediatricians,
rather than true geographic differences in IQ across
polyclinics. The clustering of growth measures (which
1223
were also measured by the paediatricians) was not as
strong, however, as reflected by intra-class coefficients
of 0.01 to 0.19. The clustering of IQ thus does not
confound the association but widens CIs of the esti-
mates of the association when statistically accounted
for in our analysis.37 In regard to behaviour measures,
having multiple informants—both the parent and the
teacher—is likely to have reduced potential reporting
bias of child behaviour. The parent and teacher SDQ
scores have been observed to provide complementary
information; teachers appear better able to assess
externalising behavioural problems, whereas parents
appear better at assessing internalizing behaviours.25
Despite larger effect sizes for the teacher SDQ scores,
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the direction of associations observed with the parent
and the teacher SDQs in our study were consistent
with each other. Finally, the Russian version of the
WASI has never been formally validated. Nonetheless,
WASI scores in PROBIT children were associated
strongly with parental education and other family
characteristics in the expected directions and were
also positively correlated with children’s academic
performances (correlation coefficients 0.3).38
Research on long-term effects of post-natal growth
has focused mostly on children with very slow growth
characterized as ‘growth faltering’ or ‘failure to
thrive’. Only recently have researchers directed atten-
tion to child growth and its association with cognitive
development in general, healthy populations. Wide
variations in the growth period examined, growth
measures used and ages at which cognitive ability
was assessed characterize these studies; most have
reported small but positive associations,8,10,12,39–41
consistent with our results. One exception is the
study by Belfort et al.,11 which reported no association
between weight gain in the first 6 months and cog-
nitive ability measured at age 3 years. The authors
argue that among healthy, term-born children,
post-natal growth is not related to cognitive develop-
ment, but the relatively small sample size (n ¼ 872) is
likely to have been underpowered to detect a modest
effect.
Studies have reported that early infancy is a ‘sensi-
tive’ period for cognitive development, but most such
studies were largely based on children with failure to
thrive.9,42,43 The term ‘sensitive period’ denotes an age
range during which exposure effects are increased,
although such effects can be modified or even re-
versed over time.44 Among studies from generally
healthy populations, the existence of a sensitive
period in post-natal growth for later cognitive devel-
opment remains unclear, mainly owing to limitations
in their analytical approach, usually based on avail-
able growth data collected at arbitrary limited time
points. Our approach to examining growth trajectories
suggests that effects may vary somewhat by growth
measure and by outcome. Birth weight and early in-
fancy weight gain seem more important for cognitive
ability, whereas growth in length/height seem equally
1224 INTERNATIONAL JOURNAL OF EPIDEMIOLOGY
important across all periods. It is not clear why the
patterns of association with cognitive ability differ
across weight and length/height trajectories. The
different patterns observed in our study suggest that
growth throughout the first 5 years contributes to
later cognitive ability but does not provide strong
evidence for a true sensitive period of cognitive devel-
opment. The different patterns may merely reflect
greater errors in measuring length than weight,
especially for infants.
We conceptualized family socioeconomic character-
istics as potentially confounding the association be-
tween growth trajectory and IQ. This view is
supported by the substantial attenuation of the
observed associations with adjustment for parental
socioeconomic position and height, which is also
closely related to socioeconomic position.45 However,
it could be hypothesised that the effects of family
background on child cognitive ability are mediated
by child growth. In an attempt to test this hypoth-
esized pathway, we examined associations of parental
education and occupation with IQ and the degree of
attenuation after adjustment for child growth.
Although the socioeconomic factors were positively
associated with IQ independently of growth trajectory,
the associations were only trivially attenuated by ad-
justment for child growth (data not shown).
To our knowledge, no previous study has examined
the association between post-natal growth and child
behaviour in healthy children. Children with experi-
ences of extreme malnutrition and stunting have been
reported to show problem behaviours, including
aggressiveness, attention deficits, peer problems, de-
pressive symptoms and hyperactivity.46–49 Our results
are consistent in direction, although smaller in mag-
nitude, with those observed in children with severe
growth restriction in infancy or early childhood.
Given the linear relationship between total difficulties
scores of the SDQ and the likelihood of having mental
disorder observed in a recent study,22 our results sug-
gest that faster post-natal growth may also have
beneficial effects in mental health among healthy
children.
KEY MESSAGES
 Most studies of the associations between pre-natal or post-natal growth and cognitive and behav-
ioural development have been based on children with pathologically slow growth or with growth
measured between two time points only.
 In this large cohort of healthy children who were born at term or later with birth weight of at least
2500 g, children with faster growth from the pre-natal period through the first 5 years of life showed
higher scores in IQ at age 6.5 years.
 For behavioural development, it seems that faster growth in the pre-natal period and infancy but not
in early childhood is associated with lower scores in problem behaviours, suggestive of better mental
health.
A possible biological mechanism underlying the
positive association observed in our study is the
growth hormone (GH)/insulin-like growth factor
(IGF)-I system. GH/IGF-I system plays a key role in
somatic growth regulation, particularly for longitudin-
al growth at pre-pubertal ages.50 A recent trial has
shown that children born small for gestational age
who underwent GH treatment showed not only
catch-up growth in height, but also improvements
in IQ and problem behaviour scores.51 In addition,
serum IGF-I level has been positively associated
with cognitive ability in healthy children with
normal growth.52
Concerns and debate have arisen about the adverse
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effects of rapid weight gain in infancy, including
increased long-term risk of obesity,53,54 high blood
pressure55–57 and insulin resistance.58 Although the
magnitudes of association are small, we have also
observed positive associations of pre-natal and
post-natal growth and blood pressure at 6.5 years of
age in our study sample.33 In the present study, how-
ever, our results suggest that rapid growth in infancy
and early childhood is positively associated with the
development of cognition and mental health.
Increased susceptibility to infection,59 smaller adult
stature60 and mental illness61 are among other ad-
verse health consequences associated with slower
infant growth. The overall evidence suggests that
the long-term consequences of rapid infant weight
gain may vary according to outcome,62 and clinical
and public health practice therefore needs to consider
both the risks and benefits of potential interventions.
Funding
This research was supported by a grant from the
Canadian Institutes of Health Research (MOP-53155).
Conflict of interest: None declared.
 PRE-NATAL OR POST-NATAL GROWTH AND CHILD DEVELOPMENT
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