Evaluating preschool linear growth velocities: an interim reference illustrated in Nepal.

OBJECTIVE: An annualised linear growth velocity (LGV) reference can identify groups of children at risk of growing poorly. As a single velocity reference for all preschool ages does not exist, we present an interim tool, derived from published, normative growth studies, for detecting growth faltering, illustrating its use in Nepali preschoolers. DESIGN: The WHO Child Growth Velocity Standard was adapted to derive 12-month increments and conjoined to the Tanner-Whitehouse Height Velocity Reference data yielding contiguous preschool linear growth annualised velocities. Linear restricted cubic spline regressions were fit to generate sex-specific median and standard normal deviate velocities for ages 0 through 59 months. LGV Z-scores (LGVZ) were constructed, and growth faltering was defined as LGVZ < ­2. SETTING: Use of the reference was illustrated with data from Nepal's Tarai region. PARTICIPANTS: Children contributing the existing growth references and a cohort of 4276 Nepali children assessed from 2013 to 2016. RESULTS: Fitted, smoothed LGV reference curves displayed monotonically decreasing 12-month LGV, exemplified by male/female annual medians of 26·4/25·3, 12·1/12·7, 9·1/9·4, 7·7/7·8 and 7/7 cm/years, starting at 0, 12, 24, 36 and 48 months, respectively. Applying the referent, 31·1 %, 28·6 % and 29·3 % of Nepali children <6, 6­11 and 12­23 months of age, and ∼6 % of children 24­59 months, exhibited growth faltering. Under 24 months, faltering velocities were more prevalent in girls (34·4 %) than boys (25·3 %) (P < 0·05) but comparable (∼6 %) in older preschoolers. CONCLUSIONS: A LGV reference, concatenated from extant data, can identify preschool groups at-risk of growth faltering. Application and limitations are discussed.

Season of Data Collection of Child Dietary Diversity Indicators May Affect Conclusions About Longer-Term Trends in Peru, Senegal, and Nepal.

BACKGROUND: The WHO-UNICEF minimum dietary diversity (MDD) indicator for children aged 6-23 mo is a global monitoring indicator used to track multi-year population-level changes in dietary quality, but the influence of seasonality on MDD estimates remains unclear. OBJECTIVES: To examine how seasonality of data collection may influence population-level MDD estimates and inferences about MDD changes over multiple survey years. METHODS: We selected countries with 3 or more consecutive years of MDD data collection, including continuous national Demographic Health Surveys in Senegal (2012-2017; n = 12,183) and Peru (2005-2016; n = 35,272) and the Policy and Science for Health, Agriculture, and Nutrition sentinel site seasonal surveys (covering 3 seasons/y) in Nepal (2013-2016; n  = 1309). The MDD prevalence (≥5 of 8 food groups) and an 8-item continuous Food Group Score (FGS) and 95% CIs were estimated by month and compared for lean and non-lean seasons using ordinary least squares regression with dummy variables for year. RESULTS: The national prevalence of MDD was higher in Peru (75.4%) than in Nepal (39.1%) or in Senegal (15.7%). Children in Peru were 1.8% (coefficient, -0.0179; 95% CI, -0.033 to -0.002) less likely to achieve MDD during the lean season. Similar seasonal magnitudes were observed in Senegal (coefficient, -0.0347; 95% CI, -0.058 to -0.011) and Nepal (coefficient, -0.0133; 95% CI, -0.107 to 0.081). The FGS was about 0.1 item lower during the lean season in all 3 countries. In comparison, MDD increased by an average rate of only 4.2 and 4.4 percentage points per 5 y in Peru and Senegal, respectively. Intakes of specific food groups were stable across months in all countries, with the provitamin A-rich food group exhibiting the most seasonality. CONCLUSIONS: The magnitude of seasonal variation in MDD prevalence was smaller than expected but large relative to longer-term changes. If large-scale surveys are not conducted in the same season, biased conclusions about trends are possible.

The Risk Factors for Child Anemia Are Consistent across 3 National Surveys in Nepal.

BACKGROUND: Anemia is an etiologically heterogeneous condition affecting over half of preschool-aged children in South Asia. An urgent need exists to elucidate context-specific causes of anemia to effectively address this issue. OBJECTIVES: This study investigated national trends and stability in the prevalence of child anemia and associated risk factors from 2013 to 2016 in Nepal. METHODS: Same-season national surveys were administered in 2013, 2014, and 2016 in 63 sites across 21 districts, selected using multistage random sampling, representing the mountains, hills, and Tarai (plains). Among consenting households with children aged 6-59 mo, a random sample of capillary blood was selected each year for anemia assessment using an Hb 201+ hemoglobinometer, with n = 835, 807, and 881 children assessed, respectively. Prevalence of child anemia, defined as hemoglobin <11.0 g/dL with adjustment for altitude, was estimated each year and disaggregated by region and child age. Prevalence ratios were estimated using log-binomial regression models with robust SE or robust Poisson regression when models failed to converge. Interaction terms between each risk factor and year were created to test for consistencies in associations over time. RESULTS: The national prevalence of child anemia decreased from 63.3% (95% CI: 59.0%, 67.5%) in 2013 to 51.9% (95% CI: 46.5%, 57.2%) in 2014 and increased to 59.3% (95% CI: 54.7%, 63.8%) in 2016. Across years, prevalence was highest in the Tarai (58.4-70.2%), followed by the mountains (53.0-61.1%) and hills (37.5-51.4%). Nationally and across time, child age and maternal anemia were significantly associated with child anemia. Child diarrhea and stunting, maternal thinness, and poor water and sanitation conditions also showed consistent trends toward higher anemia prevalence. CONCLUSIONS: Anemia affects more than half of Nepalese children aged 6-59 mo. Although prevalence varies year to year, the stability of observed risk factors suggests the need to focus on reducing gastrointestinal infection, promoting adequate household sanitation, and improving maternal and child health.

The new 2017 ACC/AHA guideline for classification of hypertension: changes in prevalence of hypertension among adults in Bangladesh.

We analyzed the Bangladesh Demographic and Health Survey 2011 data to examine absolute differences in hypertension prevalence according to the hypertension definition of the "2017 American College of Cardiology/American Heart Association (2017 ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults" and "Seventh Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC7)" 2003 guidelines. Among 7839 participants ≥35 years, the JNC7 and 2017 ACC/AHA classified 25.7% (95% confidence interval (CI): 24.5-27.0%) and 48.0% (95% CI: 46.4-49.7%) people hypertensive, respectively. The JNC7 prevalence was 19.4% (95% CI: 18.0-21.0%) among males and 31.9% (95% CI: 30.1-33.6%) among females. The prevalence was 41.4% (95% CI: 39.4-43.5%) among males and 54.5% (95% CI: 52.4-56.4%) among females as per the 2017 ACC/AHA guideline. From JNC7 to 2017 ACC/AHA, the overall difference in prevalence was 22.3% (95% CI: 19.8-24.8%). Males and females had similar differences, 22.0% (95% CI: 18.3-25.7%) and 22.6% (95% CI: 19.4-26.0%), respectively. As per the 2017 ACC/AHA guideline, >50% prevalence was observed among people with body mass index ≥25 kg/m2, college-level education, co-morbid diabetes, richest wealth quintile, females, age ≥55 years, urban residence, or living in Khulna, Rangpur or Dhaka divisions; the absolute difference was >20% in most categories. We found a substantial increase in the prevalence of hypertension due to change in blood pressure thresholds as per the 2017 ACC/AHA guideline. We recommend conducting more comprehensive population-based studies to estimate the recent burden of hypertension in Bangladesh. Future studies should estimate similar prevalence in other countries.

Determinants of early neonatal mortality in Afghanistan: an analysis of the Demographic and Health Survey 2015.

BACKGROUND: Neonatal mortality is declining slowly compared to under-five mortality in many developing countries including Afghanistan. About three-fourths of these deaths occur in the early neonatal period (i.e., the first week of life). Although a number of studies investigated determinants of early neonatal mortality in other countries, there is a lack of evidence regarding this in Afghanistan. This study investigated determinants of early neonatal mortality in Afghanistan. METHODS: Data from the Afghanistan Demographic and Health Survey 2015 (AfDHS 2015) were analyzed. After reporting the weighted frequency distributions of selected factors, a multilevel logistic regression model revealed adjusted associations of factors with early neonatal mortality. RESULTS: A total of 19,801 weighted live-births were included in our analysis; 266 (1.4%) of the newborns died in this period. Multivariable analysis found that multiple gestations (adjusted odds ratio (AOR): 9.3; 95% confidence interval (CI): 5.7-15.0), larger (AOR: 2.9; 95% CI: 2.2-3.8) and smaller (AOR: 1.8; 95% CI: 1.2-2.6) than average birth size, maternal age ≤ 18 years (AOR: 1.8; 95% CI: 1.1-3.2) and ≥ 35 years (AOR: 1.7; 95% CI: 1.3-2.3), and birth interval of < 2 years (AOR: 2.6; 95% CI: 1.4-4.9) had higher odds of early neonatal mortality. On the other hand, antenatal care by a skilled provider (AOR: 0.7; 95% CI: 0.5-0.9), facility delivery (AOR: 0.7; 955 CI: 0.5-0.9), paternal higher education level (AOR: 0.7; 95% CI: 0.5-1.0), living in north-western (AOR: 0.3; 95% CI: 0.1-0.6), central-western regions (AOR: 0.5; 95% CI: 0.3-0.9) and in a community with higher maternal education level (AOR: 0.4; 95% CI: 0.2-0.9) had negative association. CONCLUSIONS: Several individual, maternal and community level factors influence early neonatal deaths in Afghanistan; significance of the elements of multiple levels indicates that neonatal survival programs should follow a multifaceted approach to incorporate these associated factors. Programs should focus on birth interval prolongation with the promotion of family planning services, utilization of antenatal care and institutional delivery services along with management of preterm and sick infants to prevent this large number of deaths in this period.

Promoting Father Involvement for Child and Family Health.

Paternal involvement in children's lives is associated with a variety of child outcomes, including improved cognition, improved mental health, reduced obesity rates, and asthma exacerbation. Given this evidence, the American Academy of Pediatrics has promoted actions by pediatricians to engage fathers in pediatric care. Despite these recommendations, the mother-child dyad, rather than the mother-father-child triad, remains a frequent focus of care. Furthermore, pediatric care is often leveraged to improve maternal health, such as screening for maternal depression, but paternal health is infrequently addressed even as men tend to exhibit riskier behaviors, poorer primary care utilization, and lower life expectancy. Therefore, increasing efforts by pediatric clinicians to engage fathers may affect the health of both father and child. These efforts to engage fathers are informed by currently used definitions and measures of father involvement, which are discussed here. Factors described in the literature that affect father involvement are also summarized, including culture and context; interpersonal factors; logistics; knowledge and self-efficacy; and attitudes, beliefs, and incentives. Innovative ways to reach fathers both in the clinic and in other settings are currently under investigation, including use of behavior change models, motivational interviewing, mobile technologies, peer support groups, and policy advocacy efforts. These modalities show promise in effectively engaging fathers and improving family health.

Estimated Change in Prevalence of Hypertension in Nepal Following Application of the 2017 ACC/AHA Guideline.

Importance: The 2017 American College of Cardiology/American Heart Association (ACC/AHA) Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults lowered the systolic and diastolic blood pressure thresholds for hypertension to 130 and 80 mm Hg, respectively. This represents a reduction of 10 mm Hg in both systolic and diastolic blood pressure levels used to define hypertension compared with previous guidelines, such as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Objectives: To estimate the prevalence of hypertension among adults aged 18 years or older in Nepal per the 2017 ACC/AHA guideline and to determine the absolute difference in hypertension prevalence comparing the 2017 ACC/AHA and JNC 7 guidelines. Design, Setting, and Participants: The cross-sectional analysis used data from the population-based 2016 Nepal Demographic and Health Survey. Data were collected from June 2016 to January 2017 using a multistage stratified sampling procedure that was applied in urban and rural areas, using wards as the primary sampling units. Individuals aged 15 years or older from selected households were interviewed. The survey had an overall response rate of approximately 97%. Main Outcomes and Measures: The primary outcome was the prevalence of hypertension. Blood pressure was measured 3 times for each participant with 5-minute intervals between. Hypertension was present if blood pressure was greater than or equal to 130/80 mm Hg for the 2017 ACC/AHA guideline, and greater than or equal to 140/90 mm Hg for the JNC 7 guideline. Results: Among 13 519 participants (median [interquartile range] age, 38 [26-53] years; 7821 [57.9%] female), 44.2% (95% CI, 43.4%-45.0%; n = 5977) had hypertension according to the 2017 ACC/AHA guideline compared with 21.2% (95% CI, 20.5%-21.9%; n = 2869) by the JNC 7 guideline. The new prevalence was associated with an absolute increase of 23.0% (95% CI, 22.3%-23.7%) from the JNC 7 guideline. When estimating the proportion of hypertension by background characteristics, the new 2017 ACC/AHA guideline definition increased the prevalence to 50% or greater for some categories, with the highest prevalence among those with a body mass index (calculated as weight in kilograms divided by height in meters squared) greater than or equal to 30 (71.6%; 95% CI, 67.7%-75.3%) and between 25 and 29.9 (62.1%; 95% CI, 60.1%-64.1%). Conclusions and Relevance: For adults in Nepal, the new 2017 ACC/AHA guideline reveals a greater estimated prevalence of hypertension compared with the JNC 7 guideline. Because of the public health significance of hypertension, higher prevalence rates confirm the importance of developing effective prevention and control methods in this country.