Perinatal care and breastfeeding education during the COVID-19 pandemic: Perspectives from Kenyan mothers and healthcare workers.

The impact of the COVID-19 pandemic on breastfeeding (BF) practices in low- and middle-income countries (LMICs) is not well understood. Modifications in BF guidelines and delivery platforms for breastfeeding education during the COVID-19 pandemic are hypothesised to have affected BF practices. We aimed to understand the experiences with perinatal care, BF education and practice among Kenyan mothers who delivered infants during the COVID-19 pandemic. We conducted in-depth key informant interviews with 45 mothers who delivered infants between March 2020 and December 2021, and 26 health care workers (HCW) from four health facilities in Naivasha, Kenya. While mothers noted that HCWs provided quality care and BF counselling, individual BF counselling was cited to be less frequent than before the pandemic due to altered conditions in health facilities and COVID-19 safety protocols. Mothers stated that some HCW messages emphasised the immunologic importance of BF. However, knowledge among mothers about the safety of BF in the context of COVID-19 was limited, with few participants reporting specific counselling or educational materials on topics such as COVID-19 transmission through human milk and the safety of nursing during a COVID-19 infection. Mothers described COVID-19-related income loss and lack of support from family and friends as the major challenge to practising exclusive breastfeeding (EBF) as they wished or planned. COVID-19 restrictions limited or prevented mothers' access to familial support at facilities and at home, causing them stress and fatigue. In some cases, mothers reported job loss, time spent seeking new means of employment and food insecurity as causes for milk insufficiency, which contributed to mixed feeding before 6 months. The COVID-19 pandemic created changes to the perinatal experience for mothers. While messages about the importance of practising EBF were provided, altered HCW education delivery methods, reduced social support and food insecurity limit EBF practices for mothers in this context.

Enteric Permeability, Systemic Inflammation, and Post-Discharge Growth Among a Cohort of Hospitalized Children in Kenya and Pakistan.

OBJECTIVES: To determine whether gut permeability is associated with post-discharge growth and systemic inflammation among hospitalized children in low- and middle-income countries. METHODS: Children aged 2-23 months being discharged from Civil Hospital Karachi (Pakistan) and Migori County Referral Hospital (Kenya) underwent lactulose-rhamnose ratio (LRR) permeability testing and were compared to age-matched children from their home communities. Linear mixed effect models estimated the associations between LRR among discharged children with change in length-for-age (LAZ) and weight-for-age z score (WAZ) at 45, 90, and 180 days after discharge. Linear regression tested if relationships between LRR, systemic inflammation [C-reative protein (CRP), Cluster of Differentiation 14 (CD14), Tumour Necrosis Factor Alpha (TNFα), Interleukin-6 (IL-6)], and enterocyte damage [Intestinal Fatty-Acid Binding protein (I-FABP)] differed between the hospitalized and community groups. RESULTS: One hundred thirty-seven hospitalized and 84 community participants were included. The hospitalized group had higher log-LRR [0.43, 95% confidence interval (CI): 0.15-0.71, P = 0.003] than the community children. Adjustment for weight-for-length z score at discharge attenuated this association (0.31, 95% CI: 0.00-0.62, P = 0.049). LRR was not associated with changes in WAZ or LAZ in the post-discharge period. Associations between LRR and CRP (interaction P = 0.036), TNFα ( P = 0.017), CD14 ( P = 0.078), and IL-6 ( P = 0.243) differed between community and hospitalized groups. LRR was associated with TNFα ( P = 0.004) and approached significance with CD14 ( P = 0.078) and IL-6 ( P = 0.062) in community children, but there was no evidence of these associations among hospitalized children. CONCLUSIONS: Although increased enteric permeability is more prevalent among children being discharged from hospital compared to children in the community, it does not appear to be an important determinant of systemic inflammation or post-discharge growth among hospitalized children.

Guidance for Systematic Integration of Undernutrition in Attributing Cause of Death in Children.

Minimally invasive tissue sampling (MITS) is increasingly being used to better understand causes of death in low-resource settings. Undernutrition (eg, wasting, stunting) is prevalent among children globally and yet not consistently coded or uniformly included on death certificates in MITS studies when present. Consistent and accurate attribution of undernutrition is fundamental to understanding its contribution to child deaths. In May 2020, members of the MITS Alliance Cause of Death Technical Working Group convened a panel of experts in public health, child health, nutrition, infectious diseases, and MITS to develop guidance for systematic integration of undernutrition, as assessed by anthropometry, in cause of death coding, including as part of the causal chain or as a contributing condition, in children <5 years of age. The guidance presented here will support MITS and other researchers, public health practitioners, and clinicians with a systematic approach to assigning and interpreting undernutrition in death certification.

Minimally Invasive Postmortem Intestinal Tissue Sampling in Malnourished and Acutely Ill Children Is Feasible and Informative.

BACKGROUND: Intestinal disorders such as environmental enteric dysfunction (EED) are prevalent in low- and middle-income countries (LMICs) and important contributors to childhood undernutrition and mortality. Autopsies are rarely performed in LMICs but minimally invasive tissue sampling is increasingly deployed as a more feasible and acceptable procedure, although protocols have been devoid of intestinal sampling to date. We sought to determine (1) the feasibility of postmortem intestinal sampling, (2) whether autolysis precludes enteric biopsies' utility, and (3) histopathologic features among children who died during hospitalization with acute illness or undernutrition. METHODS: Transabdominal needle and endoscopic forceps upper and lower intestinal sampling were conducted among children aged 1 week to 59 months who died while hospitalized in Blantyre, Malawi. Autolysis ratings were determined for each hematoxylin and eosin slide, and upper and lower intestinal scoring systems were adapted to assess histopathologic features and their severity. RESULTS: Endoscopic and transabdominal sampling procedures were attempted in 28 and 14 cases, respectively, with >90% success obtaining targeted tissue. Varying degrees of autolysis were present in all samples and precluded histopathologic scoring of 6% of 122 biopsies. Greater autolysis in duodenal samples was seen with longer postmortem interval (Beta = 0.06, 95% confidence interval, 0.02-0.11). Histopathologic features identified included duodenal Paneth and goblet cell depletion. Acute inflammation was absent but chronic inflammation was prevalent in both upper and lower enteric samples. Severe chronic rectal inflammation was identified in children as young as 5.5 weeks. CONCLUSIONS: Minimally invasive postmortem intestinal sampling is feasible and identifies histopathology that can inform mortality contributors.

Exclusive breastfeeding among working mothers in Kenya: Perspectives from women, families and employers.

Exclusive breastfeeding (EBF) for the first 6 months of life improves survival, growth and development. In Kenya, recent legislation and policies advocate for maternity leave and workplace support for breastfeeding and breast milk expression. We conducted a qualitative study to describe factors influencing EBF for 6 months among mothers employed in commercial agriculture and tourism. We interviewed employed mothers (n = 42), alternate caregivers and employed mothers' husbands (n = 20), healthcare providers (n = 21), daycare directors (n = 22) and commercial flower farm and hotel managers (n = 16) in Naivasha, Kenya. Despite recognizing the recommended duration for EBF, employed mothers describe the early cessation of EBF in preparation for their return to work. Managers reported supporting mothers through flexible work hours and duties. Yet, few workplaces have lactation spaces, and most considered adjusting schedules more feasible than breastfeeding during work. Managers and healthcare providers believed milk expression could prolong EBF but thought mothers lack experience with pumping. The most frequently suggested interventions for improving EBF duration were to expand schedule flexibility (100% of groups), provide on-site daycare (80% of groups) and workplace lactation rooms (60% of groups), improve milk expression education and increase maternity leave length (60% of groups). Returning to work corresponds with numerous challenges including lack of proximate or on-site childcare and low support for and experience with milk expression. These factors currently make EBF for 6 months unattainable for most mothers in these industries. Interventions and supports to improve breastfeeding upon return to work are recommended to strengthen employed mothers' opportunity for EBF.

Septic Systems and Rainfall Influence Human Fecal Marker and Indicator Organism Occurrence in Private Wells in Southeastern Pennsylvania.

In the United States, approximately 48 million people are served by private wells. Unlike public water systems, private well water quality is not monitored, and there are few studies on the extent and sources of contamination of private wells. We extensively investigated five private wells to understand the variability in microbial contamination, the role of septic systems as sources of contamination, and the effect of rainfall on well water quality. From 2016 to 2017, weekly or biweekly samples (n = 105) were collected from five private wells in rural Pennsylvania. Samples were tested for general water quality parameters, conventional and sewage-associated microbial indicators, and human pathogens. Total coliforms, human Bacteroides (HF183), and pepper mild mottle virus were detected at least once in all wells. Regression revealed significant relationships between HF183 and rainfall 8-14 days prior to sampling and between total coliforms and rainfall 8-14 or 0-14 days prior to sampling. Dye tracer studies at three wells confirmed the impact of household septic systems on well contamination. Microbiological measurements, chemical water quality data, and dye tracer tests provide evidence of human fecal contamination in the private wells studied, suggesting that household septic systems are the source of this contamination.

Development and validation of a tool to assess appetite of children in low income settings.

Reliable and validated tools for measuring appetite of children in South Asia are not available. This study aimed to develop and validate a tool for assessing appetite level of under-five children. Based on literature review and findings from focus group discussions (FGDs), an initial 27-item interview-based tool, the "Early Childhood Appetite and Satiety Tool (ECAST)" was developed in Bangladesh. Fourteen FGDs were carried out in rural and urban settings and constructs for inclusion were derived from the themes and coding of FGDs and appetite assessment tools used in Western contexts. For structural validation, the ECAST-27-was administered on 150 mothers/primary caregivers of children aged 6-59 months, living in urban and rural areas. To validate the association with other variables, the ECAST was administered on mothers of children aged 12-24 months in the community (N = 50), and two groups of wasted, hospitalized children (Weight-for-length, Z score <-2SD) [group1: twenty acutely ill children aged 6-59 months; group 2: twenty children in nutritional rehabilitation aged 18-24 months]. Reliability of ECAST was estimated using Cronbach's alpha and Pearson's correlation coefficient. Kaiser-Meyer-Olkin = 0.73 and the Bartlett's test of sphericity, χ2(253) = 755.791, p < 0.001 indicated that the raw data were suitable. Given the convergence of the Scree plot, Kaiser's criterion and dropping of cross loading items, a 16-item ECAST was produced with three sub scales: Appetite cue; Food responsiveness and Emotion and preference, which were internally valid and had good test-retest reliability (Cronbach's alpha 0.6 and test-retest reliability 0.797). Total ECAST scores of wasted children with good appetite were significantly higher from those with poor appetite (p = 0.004 and 0.001 for two wasted groups respectively). Results suggest that ECAST may provide a useful measure to assess the appetite level of under-five children.

"Our girls need to see a path to the future" --perspectives on sexual and reproductive health information among adolescent girls, guardians, and initiation counselors in Mulanje district, Malawi.

BACKGROUND: Malawi has one of the highest adolescent pregnancy rates worldwide; at 141 births/1000 girls it is 3-fold higher than the global average. Adolescent pregnancy contributes to poor maternal and neonatal outcomes, school dropout, and poverty. In preparation for an information, education, and communication (IEC) intervention to reduce unintended pregnancy among adolescent girls, formative research was conducted to understand how and what sexual and reproductive health (SRH) information is shared with girls in southern, rural Malawi, and perceptions of such information among key informants. METHODS: Forty semi-structured interviews were conducted with three participant groups: adolescent girls (n = 18), mothers/female guardians (M/FGs) of adolescent girls (n = 12), and leaders of initiation rites (n = 10). Interviews were conducted in 15 villages. Data were analyzed and coded using Dedoose 7.5. RESULTS: Participants widely acknowledged both the health risks and the general social unacceptability of early childbearing, yet adolescent pregnancy is common in the region. Respondents also acknowledged the importance of female school completion and the norm that pregnancy usually marks the end of a girl's education. Unprotected transactional sex was reported to be common and driven by poverty. Initiation rites were described as prevalent and often encourage girls to practice sex at puberty. Contraceptives, and even condoms, were reportedly discouraged for adolescents due to concerns about inappropriateness for nulliparous and young girls and misconceptions about side effects. Adolescent respondents also noted barriers to accessing condoms and contraceptives. M/FGs were described as gatekeepers to SRH information and services, and many parents reported delaying SRH discussions until after sexual debut due to concerns about encouraging sexual activity. Adolescent and M/FG participants expressed a desire for role models or "outside experts" to provide SRH education and to promote an alternate vision to adolescent motherhood. CONCLUSION: To improve SRH outcomes for adolescent girls, it is critical to engage key stakeholders and create an enabling environment so that girls can effectively act on the IEC they receive. Initiation counselors remain entrenched information sources; efforts to provide them with training on accurate SRH messaging could leverage an existing channel. Engaging parents, especially mothers, is crucial to encourage earlier SRH education and to gain their acceptance of adolescent access to SRH services. Also important is mobilizing the broader community of influencers in support of girls' SRH and vision for a healthier future. Sensitization messages focusing on the health, educational and economic benefits of preventing early pregnancy may overcome misconceptions about and barriers to contraceptive use. Finally, fostering girls' aspirations for school completion and jobs and other income generating opportunities via role models can encourage an alternative to adolescent motherhood. Ultimately, poverty and gender inequity reduction is critical for long-lasting impact on the SRH of adolescent girls in the region.

Caregiver perceptions of children's linear growth in Bangladesh: a qualitative analysis.

OBJECTIVE: To understand caregivers' perceptions of children's linear growth and to identify the cultural meanings and perceptions of risk associated with poor height attainment. DESIGN: Three investigators from Bangladesh conducted twelve focus group discussions. SETTING: The study was conducted in rural and slum settings in Bangladesh. SUBJECTS: Participants included mothers and alternative caregivers (n 81) who were recruited by household screening. No eligible, recruited subjects refused participation. RESULTS: Caregivers reported limited experience with growth monitoring services from the health system. Caregivers mainly use visual cues and developmental milestones to understand if children are growing properly, and recognize that children normally experience both weight gain and linear growth with age. Mothers expressed concern over children's malnutrition and short stature, but did not discuss children's failure to attain a 'growth potential' or distinguish inherited short stature from stunting. Caregivers interpret the consequences of poor height attainment as primarily social and economic and cite few health risks. CONCLUSIONS: Linear growth interpretation is determined more by community norms than by guidance from nutrition programming or the health system. Interventions to prevent or reduce linear growth failure may be perceived to have limited value where appropriate linear growth in children is determined by comparison to peers and siblings. Such perceptions may be significant barriers to programmes addressing stunting prevention in settings where many children are stunted. Efforts to raise awareness about the risks of linear growth faltering may need to consider delivering messages to caregivers that emphasize the social and economic consequences of stunting.

Interventions to reduce post-acute consequences of diarrheal disease in children: a systematic review.

BACKGROUND: Although acute diarrhea often leads to acute dehydration and electrolyte imbalance, children with diarrhea also suffer long term morbidity, including recurrent or prolonged diarrhea, loss of weight, and linear growth faltering. They are also at increased risk of post-acute mortality. The objective of this systematic review was to identify interventions that address these longer term consequences of diarrhea. METHODS: We searched Medline for randomized controlled trials (RCTs) of interventions conducted in low- and middle-income countries, published between 1980 and 2016 that included children under 15 years of age with diarrhea and follow-up of at least 7 days. Effect measures were summarized by intervention. PRISMA guidelines were followed. RESULTS: Among 314 otherwise eligible RCTs, 65% were excluded because follow-up did not extend beyond 7 days. Forty-six trials were included, the majority of which (59%) were conducted in Southeast Asia (41% in Bangladesh alone). Most studies were small, 76% included less than 200 participants. Interventions included: therapeutic zinc alone (28.3%) or in combination with vitamin A (4.3%), high protein diets (19.6%), probiotics (10.9%), lactose free diets (10.9%), oral rehydration solution (ORS) formulations (8.7%), dietary supplements (6.5%), other dietary interventions (6.5%), and antimicrobials (4.3%). Prolonged or recurrent diarrhea was the most commonly reported outcome, and was assessed in ORS, probiotic, vitamin A, and zinc trials with no consistent benefit observed. Seven trials evaluated mortality, with follow-up times ranging from 8 days to 2 years. Only a single trial found a mortality benefit (therapeutic zinc). There were mixed results for dietary interventions affecting growth and diarrhea outcomes in the post-acute period. CONCLUSION: Despite the significant post-acute mortality and morbidity associated with diarrheal episodes, there is sparse evidence evaluating the effects of interventions to decrease these sequelae. Adequately powered trials with extended follow-up are needed to identify effective interventions to prevent post-acute diarrhea outcomes.

"Those who care much, understand much." Maternal perceptions of children's appetite: Perspectives from urban and rural caregivers of diverse parenting experience in Bangladesh.

Appetite in children is an important determinant of nutritional intake and growth. The information used by caregivers to understand children's appetite can help inform infant and young child feeding promotion and appetite assessment. We conducted a qualitative study to (a) explore maternal perceptions and responses to children's appetite and (b) to identify how these factors differ by type of caregiver, level of maternal experience, and urban versus rural context. We used purposive sampling to recruit mothers and alternate caregivers into 14 total focus group discussions (six to eight participants in each group; N = 95) in both urban and rural settings in Bangladesh. To understand children's appetite, caregivers monitor children's dietary patterns, emotional signs, and physical and verbal cues. Healthy appetite was observed by willingness to eat diverse foods, finish offered portions, and by acceptance of foods without excessive prompting. Child illness was cited for a cause of low appetite, which was manifested through fussiness, and avoiding commonly consumed foods. Mothers described a limited set of feeding practices (offering diverse foods, playing, and cheering children with videos) to encourage consumption when children lacked appetite. Mothers' stress related to work was noted as a barrier to identifying appetite cues. Urban mothers described a lower access to instrumental social support for child feeding but informational support than mothers in the rural setting. Understanding caregivers' perceptions of children's appetite may inform strategies to improve responsive feeding and tool development to assess changes in appetite as early indicators of change in health or nutrition status among high-risk children.

Global burden of diseases, injuries, and risk factors for young people's health during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013.

BACKGROUND: Young people's health has emerged as a neglected yet pressing issue in global development. Changing patterns of young people's health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10-24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors. METHODS: The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories. FINDINGS: The leading causes of death in 2013 for young people aged 10-14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15-19 years (14·2%) and 20-24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20-24 years (17·1%) and the fourth highest for girls aged 15-19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15-19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20-24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20-24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20-24 years. Alcohol and drug use in those aged 10-24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs. INTERPRETATION: Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young people's health risk factors and their determinants in health information systems. FUNDING: Bill & Melinda Gates Foundation.

Inpatient management of children with severe acute malnutrition: a review of WHO guidelines.

OBJECTIVE: To understand how the World Health Organization's (WHO's) guidelines on the inpatient care of children with complicated severe acute malnutrition may be strengthened to improve outcomes. METHODS: In December 2015, we searched Google scholar and WHO's website for WHO recommendations on severe acute malnutrition management and evaluated the history and cited evidence behind these recommendations. We systematically searched WHO International Clinical Trials Registry Platform, clinicaltrials.gov and the Controlled Trials metaRegister until 10 August 2015 for recently completed, ongoing, or pending trials. FINDINGS: WHO's guidelines provide 33 recommendations on the topic. However, 16 (48.5%) of these recommendations were based solely on expert opinion - unsupported by published evidence. Another 11 (33.3%) of the recommendations were supported by the results of directly relevant research - i.e. either randomized trials (8) or observational studies (3). The other six recommendations (18.2%) were based on studies that were not conducted among children with complicated severe malnutrition or studies of treatment that were not identical to the recommended intervention. Trials registries included 20 studies related to the topic, including nine trials of alternative feeding regimens. Acute medical management and follow-up care studies were minimally represented. CONCLUSION: WHO's guidelines on the topic have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with severe malnutrition is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.

Use of the lactulose to mannitol ratio to evaluate childhood environmental enteric dysfunction: a systematic review.

Childhood gut dysfunction (enteropathy) is common in resource-poor environments. Stunting is its presumed major consequence. Identification of biomarkers of gut dysfunction could identify the presence of, and, ideally, assess interventions for, enteropathy. Classically, enteropathy has been identified histopathologically. However, less invasive assays may be more sensitive for detecting earlier perturbations reflecting specific functional derangements. The most commonly used test has been the urinary lactulose to mannitol ratio (L:M), which primarily assesses gut leakiness, and which also measures absorption. We systematically reviewed the L:M literature published from 2000 to 2010 pertinent to children in developing country settings, and identified 25 relevant publications representing heterogeneous studies. We conclude that the L:M test has many attributes, including reflecting 2 physiologic processes (absorption and permeability) and likely correlation with growth failure consequent to child gut dysfunction. However, improved test technical performance, data reporting, and correlation with host phenotypes are needed to maximize the utility of this test.

Environmental enteric dysfunction: pathogenesis, diagnosis, and clinical consequences.

Stunting is common in young children in developing countries, and is associated with increased morbidity, developmental delays, and mortality. Its complex pathogenesis likely involves poor intrauterine and postnatal nutrition, exposure to microbes, and the metabolic consequences of repeated infections. Acquired enteropathy affecting both gut structure and function likely plays a significant role in this outcome, especially in the first few months of life, and serve as a precursor to later interactions of infection and malnutrition. However, the lack of validated clinical diagnostic criteria has limited the ability to study its role, identify causative factors, and determine cost-effective interventions. This review addresses these issues through a historical approach, and provides recommendations to define and validate a working clinical diagnosis and to guide critical research in this area to effectively proceed. Prevention of early gut functional changes and inflammation may preclude or mitigate the later adverse vicious cycle of malnutrition and infection.

Pediatric anemia in rural Ghana: a cross-sectional study of prevalence and risk factors.

OBJECTIVE: To assess anemia prevalence and identify associated parameters in children <3 years of age in a rural area of Ghana. METHOD: Univariate and multivariate logistic regression of cross-sectional survey results from 861 children aged <3 years attending routine immunization services in Berekum district. RESULTS: Anemia prevalence was 73.1%; most were either mildly (31.2%) or moderately (38.7%) affected. Risk factors for anemia (hemoglobin < 11.0 g/dl) in multivariate analysis were malaria parasitemia and male sex; these factors and younger age were associated with anemia severity. A partial defect in glucose-6-phosphate dehydrogenase was associated with decreased severity. Height-for-age, but not weight-for-age, was associated with anemia and its severity. CONCLUSIONS: Malaria parasitemia was strongly associated with anemia and its severity, suggesting that malaria control may be the most effective way to reduce the burden of anemia in rural Ghanaian children.

Prevalence and Correlates of Stunting among a High-Risk Population of Kenyan Children Recently Hospitalized for Acute Illnesses.

Stunting (length/height-for-age z-score < -2) is associated with significant morbidity and mortality among children under 5 years of age in sub-Saharan Africa. Children who are stunted and recently hospitalized for acute illness may be at particularly elevated risk for post-discharge mortality. In this cross-sectional analysis, we measured the prevalence of stunting at hospital discharge and identified host, caregiver, and environmental correlates of stunting among children aged 1-59 months in Western Kenya enrolled in the Toto Bora Trial. Child age- and site-adjusted prevalence ratios were estimated using Poisson regression. Of the 1,394 children included in this analysis, 23% were stunted at hospital discharge. Older children (12-23 months and 24-59 months versus 0-5 months) had a higher prevalence of stunting (adjusted prevalence ratio [aPR]: 1.58; 95% CI: 1.04-2.36 and aPR: 1.59; 95% CI: 1.08-2.34, respectively). HIV-exposed, uninfected children (aPR: 1.94; 95% CI: 1.39-2.70), children with HIV infection (aPR: 2.73; 95% CI: 1.45-5.15), and those who were never exclusively breastfed in early life (aPR 2.51; 95% CI: 1.35-4.67) were more likely to be stunted. Caregiver education (primary school or less) and unimproved sanitation (pit latrine without slab floor or open defecation) were associated with increased risk of stunting (aPR: 1.94; 95% CI: 1.54-2.44; aPR: 1.99; 95% CI: 1.20-3.31; aPR: 3.57; 95% CI: 1.77-7.21, respectively). Hospital discharge represents an important opportunity for both identifying and delivering targeted interventions for nutrition-associated poor outcomes among a high-risk population of children.

Prevalence and correlates of paediatric guideline non-adherence for initial empirical care in six low and middle-income settings: a hospital-based cross-sectional study.

OBJECTIVES: This study evaluated the prevalence and correlates of guideline non-adherence for common childhood illnesses in low-resource settings. DESIGN AND SETTING: We used secondary cross-sectional data from eight healthcare facilities in six Asian and African countries. PARTICIPANTS: A total of 2796 children aged 2-23 months hospitalised between November 2016 and January 2019 with pneumonia, diarrhoea or severe malnutrition (SM) and without HIV infection were included in this study. PRIMARY OUTCOME MEASURES: We identified children treated with full, partial or non-adherent initial inpatient care according to site-specific standard-of-care guidelines for pneumonia, diarrhoea and SM within the first 24 hours of admission. Correlates of guideline non-adherence were identified using generalised estimating equations. RESULTS: Fully adherent care was delivered to 32% of children admitted with diarrhoea, 34% of children with pneumonia and 28% of children with SM when a strict definition of adherence was applied. Non-adherence to recommendations was most common for oxygen and antibiotics for pneumonia; fluid, zinc and antibiotics for diarrhoea; and vitamin A and zinc for SM. Non-adherence varied by site. Pneumonia guideline non-adherence was more likely among patients with severe disease (OR 1.82; 95% CI 1.38, 2.34) compared with non-severe disease. Diarrhoea guideline non-adherence was more likely among lower asset quintile groups (OR 1.16; 95% CI 1.01, 1.35), older children (OR 1.10; 95% CI 1.06, 1.13) and children presenting with wasting (OR 6.44; 95% CI 4.33, 9.57) compared with those with higher assets, younger age and not wasted. CONCLUSIONS: Non-adherence to paediatric guidelines was common and associated with older age, disease severity, and comorbidities, and lower household economic status. These findings highlight opportunities to improve guidelines by adding clarity to specific recommendations.

Duodenal quantitative mucosal morphometry in children with environmental enteric dysfunction: a cross-sectional multi-country analysis.

BACKGROUND: Environmental enteric dysfunction (EED), a chronic inflammatory condition of the small intestine, is an important driver of childhood malnutrition globally. Quantifying intestinal morphology in EED allows for exploration of its association with functional and disease outcomes. OBJECTIVE: We sought to define morphometric characteristics of childhood EED and determine whether morphology features were associated with disease pathophysiology. METHODS: Morphometric measurements and histology were assessed on duodenal biopsy slides for this cross-sectional study from children with EED in Bangladesh, Pakistan, and Zambia (n=69), and those with no pathologic abnormality (NPA; n=8) or celiac disease (n=18) in North America. Immunohistochemistry was also conducted on 46, 8, and 18 biopsy slides, respectively. Linear mixed-effects regression models were used to reveal morphometric differences between EED compared to NPA or celiac disease, and identify associations between morphometry and histology or immunohistochemistry amongst children with EED. RESULTS: In duodenal biopsies, median EED villus height (248 µm), crypt depth (299 µm), and villus:crypt (V:C) ratio (0.9) values ranged between those of NPA (396 µm villus height; 246 µm crypt depth; 1.6 V:C ratio) and celiac disease (208 µm villus height; 365 µm crypt depth; 0.5 V:C ratio). Among EED biopsy slides, morphometric assessments were not associated with histologic parameters or immunohistochemical markers, other than pathologist determined subjective semi-quantitative villus architecture. CONCLUSIONS: Morphometric analysis of duodenal biopsy slides across geographies identified morphologic features of EED, specifically short villi, elongated crypts, and a smaller V:C ratio relative to NPA slides; although not as severe as in celiac slides. Morphometry did not explain other EED features, suggesting that EED histopathologic processes may be operating independently of morphology. While acknowledging the challenges with obtaining relevant tissue, these data form the basis for further assessments of the role of morphometry in EED.