Hb A1c in relation to intrauterine growth among male adolescents in southern Brazil.

The fetal origins hypothesis states that nutritional deprivation in utero affects fetal development and contributes to the incidence of diseases associated with the metabolic syndrome in later life. This study investigated whether haemoglobin (Hb) A(1c), an indicator of blood glucose, varied among healthy male adolescents according to their fetal growth rate, in a middle-income setting. Participants were men aged 18 years, belonging to the 1982 Pelotas birth cohort. Complete data, including gestational age and Hb A(1c) at age 18 years, were available for 197 individuals. There was an inverse association between mean Hb A(1c) and birthweight for the gestational age, but not birthweight alone. The association remained significant after adjustment for family income and mother's education, as well as for body mass index at 18 years (P for trend=0.01 and 0.03, respectively).

Growth, morbidity, and mortality of children in Dhaka after treatment for severe malnutrition: a prospective study.

Over 1300 severely malnourished children (< 60% of US National Center for Health Statistics weight-for-height, with edema, or both) are admitted each year to the Children's Nutrition Unit in Dhaka. Fatality during treatment is low and recovery is rapid. Our aim was to determine whether this initial success is sustained when children return home. A previous attempt to address this question was frustrated by the difficulty in tracing children after discharge because most are from slum settlements and families move frequently. This prospective study with fortnightly monitoring was therefore undertaken. The main outcomes of interest were anthropometric status, relapse, morbidity, and mortality. Children (n = 437) who had been treated for severe malnutrition when aged 12-59 mo and had reached the discharge criterion of 80% of weight-for-height, were followed for the next 12 mo. During follow-up, 7.5% were lost without trace, 0.6% relapsed, and 2.3% died. Morbidity was high, with a mean of seven episodes of diarrhea during the year. Outpatient visits for diarrhea occurred for 67% of children, and 58% had pneumonia (10% had pneumonia three times). After 12 mo, mean weight-for-height was 91% (-0.92 z score) but mean height-for-age remained at 84% (-4.14 z score). Weight gain, but not height gain, tended to be lower in children who experienced more diarrhea. Fever and cough were not associated with either weight or height gain. The high prevalence of illness highlights the need for continued accessible health care and for interventions to reduce disease acquisition.

Birth spacing and child health in urban Brazilian children.

The associations between birth interval and a range of child health outcomes were examined in a population-based cohort of approximately 3500 urban Brazilian children. The effects of several socioeconomic and maternal confounding factors were controlled for in the analyses. Children born after shorter birth intervals (less than 18 and 18 through 23 months) were disadvantaged with respect to most of the health outcomes when compared with children born after intermediate birth intervals (24 through 35, 36 through 47, and 48 through 71 months). Effects were particularly marked for birth weight, postneonatal mortality, and anthropometric status at mean age 19 months. Children born after a long birth interval (greater than 71 months) also showed some disadvantage for birth weight, perinatal mortality, and infant mortality. However, this group experienced lower risks of hospitalizations during the first 19 months of life and better anthropometric status at mean age 19 months. This study provides data that are scarce from such settings and contributes to the quantification of associations between birth spacing and child health. This information is important in the planning of appropriate intervention strategies.

Comparison of the causes and consequences of prematurity and intrauterine growth retardation: a longitudinal study in southern Brazil.

A cohort of 5914 liveborns (99% of the city births) was followed up to the age of 4 years in Pelotas, southern Brazil. Besides the perinatal evaluation, the cohort children were examined again at mean ages of 11, 23, and 47 months. During each visit the children were weighed and measured and information on morbidity was collected. Also, multiple sources of information were used for monitoring mortality throughout the study. Of the babies with known gestational age, 9.0% were classified as intrauterine growth-retarded and 6.3% as preterm. Excluding those of unknown gestational age, 62% of low birth weight babies were intrauterine growth-retarded and 36% were preterm. Intrauterine growth retardation was statistically associated with maternal height, prepregnancy weight, birth interval, and smoking, whereas preterm births were associated with maternal prepregnancy weight and maternal age. Preterm babies had a perinatal mortality rate 13 times higher than that of babies of appropriate birth weight and gestational age and 2 times higher than that of intrauterine growth-retarded babies. Infant mortality rates presented a similar pattern, with the differentials being more pronounced during the neonatal than in the postneonatal period. In the first 2 years of life intrauterine growth-retarded children were at almost twice the risk of being hospitalized for diarrhea compared with appropriate birth weight, term children, while preterm children experienced only a slightly greater risk. For pneumonia, however, both groups of children were hospitalized significantly more than appropriate birth weight, term children. In terms of growth, despite their earlier disadvantage, preterm children gradually caught up with their appropriate birth weight, term counterparts.(ABSTRACT TRUNCATED AT 250 WORDS)

Measurement of the frequency and severity of childhood acute respiratory infections through household surveys in northern Ghana.

BACKGROUND: Methodological issues in the design and interpretation of cross-sectional interview surveys of the prevalence of acute respiratory infections (ARI) were assessed among young children. METHODS: A cross-sectional survey was conducted in approximately 20,000 children in the north of Ghana. Approximately half were administered a questionnaire in which the initial questions about recent illnesses were direct questions about the presence or absence of three specific ARI-related symptoms (cough, rapid breathing, difficulty breathing), while the other half were administered a questionnaire which started with an open-ended question on whether the child was ill, designed to elicit spontaneous responses. A 2-week recall period was used in addition to point prevalence questions for half of the children in each group, while 4 weeks was used for the other half. The results were compared with those from a longitudinal morbidity surveillance system in an adjacent population of children. The repeatability of the responses to each of the symptoms/conditions was assessed in a subsample of the children. RESULTS AND CONCLUSIONS: The point and period prevalence rates of ARI symptoms or conditions based on spontaneously elicited responses were more likely to be valid than those based on prompted responses. Furthermore, using a 2-week recall period appeared to give more valid period prevalence rates than a 4-week recall period. The repeatability of the various ARI questions was not high (kappas 0.14 to 0.49), irrespective of the questionnaire design. Whether these findings will also be true in other populations needs to be assessed.

The role of conceptual frameworks in epidemiological analysis: a hierarchical approach.

BACKGROUND: This paper discusses appropriate strategies for multivariate data analysis in epidemiological studies. METHODS: In studies where determinants of disease are sought, it is suggested that the complex hierarchical inter-relationships between these determinants are best managed through the use of conceptual frameworks. Failure to take these aspects into consideration is common in the epidemiological literature and leads to underestimation of the effects of distal determinants. RESULTS: An example of this analytical approach, which is not based purely on statistical associations, is given for assessing determinants of mortality due to diarrhoea in children. CONCLUSIONS: Conceptual frameworks provide guidance for the use of multivariate techniques and aid the interpretation of their results in the light of social and biological knowledge.

Early childhood mortality in a Brazilian cohort: the roles of birthweight and socioeconomic status.

The deaths of children aged 1-4 years were studied in a cohort of 5914 Brazilian liveborns. A total of 29 early childhood deaths were recorded (cumulative mortality risk of approximately 6 per 1000), 17 of which (59%) were due to infectious diseases. The death rate was highest in the second year. Deaths were highly concentrated in children from low income (< US $50/month) families, where the cumulative risk of early childhood death was about 10 per 1000; on the other hand, there were no deaths among the 616 children from families with a monthly income of US $300 or more. Birthweight was also associated with mortality: the cumulative risk of children weighing less than 2000 g at birth was 21 per 1000, compared to 4 per 1000 among those with birthweights of 3500 g or more. Simultaneous adjustment for income and birthweight did not substantially change these differentials. These findings confirm the strong association between early childhood mortality and socioeconomic conditions, but also make evident the long-term effects of low birthweight.

PIP: Mortality was studied among a cohort of 5914 Brazilian live-borns aged 1-4 years. 29 early childhood deaths were recorded, 17 of which were due to infectious diseases. The highest death rate was observed in the 2nd year. Deaths were highly concentrated among children of families with income US$50/month, with a 10/1000 cumulative risk of early childhood death. No deaths, however, occurred among the 616 children from families with monthly income or= US$300. As for birth weight, the cumulative risk of death among children weighing 2000 gm at birth was 21/1000, compared with 4/1000 among those with birth weights of 3500 gm or more. Simultaneous adjustments for both income and birth weight failed to substantially change mortality differentials. Study results therefore confirm the strong association between early childhood mortality, income, and low birth weight.

Risk factors for clinical marasmus: a case-control study of Bangladeshi children.

A case-control study of risk factors of clinical marasmus was undertaken to guide intervention efforts in rural Bangladesh. Cases were children whose mid-upper arm circumference measured < 110 mm and controls were children matched for age and sex with arm circumference > 120 mm. Between June 1988 and June 1989, 164 such pairs of children aged 1-4 years were studied. The effects of various demographic, socioeconomic, environmental, and health factors, reported by mothers, were investigated in a multivariate analysis using conditional logistic regression. Results showed an increased risk of marasmus among children from families with other children under 5 years of age (odds ratio [OR] = 2.51; 95% confidence interval [CI]: 1.33-4.74), and children who consumed formula foods (OR = 16.41, 95% CI: 3.39-79.36). Higher maternal education was associated with reduced risk of marasmus, compared with no education, the OR for < 5 years of schooling = 0.57, 95% CI: 0.23-1.41; OR for > or = 5 years of schooling = 0.34, 95% CI: 0.15-0.76. The strong association of childhood marasmus with mother's education and child spacing supports the notion that non-nutritional factors should be essential components of efforts to reduce severe malnutrition in Bangladesh.

Persistent diarrhoea in a rural area of Bangladesh: a community-based longitudinal study.

As part of a health impact evaluation of a water supply and sanitation project in a rural area of Bangladesh, diarrhoeal morbidity was recorded in children 0-4 years of age using weekly recall in household interviews, during the period March 1984 to December 1987. During the baseline year, 1984, the incidence rate of all diarrhoea episodes (3.8 episodes per child per year), and those defined as persistent, duration greater than 14 days (0.6 episodes per child per year), showed a similar age distribution, peaking in the 12-23 month age group. Sixteen per cent of all episodes were classified as persistent, and this proportion was greatest in the 0-5 month age group (25%). Children suffering at least one episode of persistent diarrhoea in 1984 also experienced a higher incidence of acute diarrhoea (less than = 14 days duration) than those suffering acute diarrhoea only (4.2 versus 3.7 episodes per child per year). Persistent diarrhoea showed a similar seasonal pattern to that of all episodes. Rates of abdominal pain, isolation of Shigella spp and a diagnosis of dysentery were significantly higher in persistent episodes than in acute episodes. Closer follow-up of children during 1986 and 1987, through the recording of all periods of absence of the child from the home, showed that overall diarrhoea incidence rates were little affected when absence was taken into account, but that the incidence of persistent diarrhoea and the proportion of episodes classified as persistent were significantly reduced. The implications of this methodological problem are discussed.

The epidemiology of acute diarrhoea in a rural community in Imo State, Nigeria.

As part of an evaluation of a water supply and sanitation project, a baseline cross-sectional study of diarrhoea, and its putative risk factors, was conducted in 5 villages in Imo State, Nigeria. Data were collected from 4641 and 5920 persons during surveys in the dry and wet seasons, respectively. 8 d period prevalence rates for diarrhoea ranged from 5 to 50%, with the highest rates occurring in the 6 to 23 month age group. Diarrhoea was associated with up to 75% of all illnesses in young children and with about 20% in adults. Risk factors included lower socio-economic status, an unclean domestic environment, use of non-purified water, absence of soap, and feeding methods other than exclusive breast-feeding in the early months of infancy. These results suggest that the education component of water supply and sanitation projects should emphasize personal and domestic hygiene and infant feeding.

Reduction in diarrhoeal diseases in children in rural Bangladesh by environmental and behavioural modifications.

The impact of a water, sanitation and hygiene education intervention project on diarrhoeal morbidity in children under 5 years old was evaluated in a rural area of Bangladesh. Data were collected throughout 1984-1987, covering both pre- and post-intervention periods, from an intervention and a control area. The 2 areas were similar with respect to most socio-economic characteristics and baseline levels of diarrhoeal morbidity. The project showed a striking impact on the incidence of all cases of diarrhoea, including dysentery and persistent diarrhoea. By the end of the study period, children in the intervention area were experiencing 25% fewer episodes of diarrhoea than those in the control area. This impact was evident throughout the year, but particularly in the monsoon season, and in all age groups except those less than 6 months old. Within the intervention area, children from households living closer to handpumps or where better sanitation habits were practised experienced lower rates of diarrhoea. These results suggest that an integrated approach to environmental interventions can have a significant impact on diarrhoeal morbidity.

The Imo State (Nigeria) Drinking Water Supply and Sanitation Project, 2. Impact on dracunculiasis, diarrhoea and nutritional status.

Morbidity due to dracunculiasis (guinea worm disease) and diarrhoea in persons of all ages, and nutritional status of young children, were used as health impact indicators in the evaluation of the Imo State Drinking Water Supply and Sanitation Project in south-eastern Nigeria. Data were collected using repeated cross-sectional surveys and longitudinal follow-up. The study area was found to have a low level of endemicity of dracunculiasis. While no impact could be demonstrated on overall period or point prevalence rates in the cross-sectional surveys, a prospective longitudinal survey showed a significant reduction in the percentage of person-fortnights positive for dracunculiasis in areas served by the project, while the control areas showed no such change. In the cross-sectional surveys it was found that, in the project villages, those persons drinking only borehole water had significantly lower period prevalence rates one year later than others. Moreover, those living further from the nearest borehole had higher rates of dracunculiasis. An impact of the project on diarrhoea morbidity was found only in limited sub-groups of the population. A greater association with water availability rather than quality was suggested for rates in young children. The prevalence of wasting (less than 80% weight-for-height) among children aged less than 3 years decreased significantly over time in all 3 intervention villages; there was no such decline in the control villages.

The Imo State (Nigeria) Drinking Water Supply and Sanitation Project, 1. Description of the project, evaluation methods, and impact on intervening variables.

A health impact evaluation was conducted in conjunction with the Imo State Drinking Water Supply and Sanitation Project in Nigeria. The project consisted of a package of water supply, sanitation, and health and hygiene education given by village-based workers. The evaluation was a quasi-experimental study covering pre-, peri- and post-intervention periods. Data were collected from 3 intervention and 2 control villages. Baseline surveys indicated that the intervention and control areas were similar with respect to most socio-demographic variables. Use of the improved water supply was high, although this was influenced by borehole-to-population ratios and household-to-borehole distances. Water collection time was consequently greatly reduced. Data from a small sample of households showed that borehole water became heavily contaminated during collection and storage, and that there was no significant change in consumption of water per person. Adults in 46% of household units in the intervention area were using ventilated improved pit latrines by the end of the study period. Use by young children (2-5 years old), however, was low. Limitations in the success of the health education component of the project were found. Although changes were found in knowledge, attitudes and practices related to water and sanitation, and in management of childhood diarrhoea, this occurred in both the intervention and control areas.

Designing educational messages to improve weaning food hygiene practices of families living in poverty.

This paper describes a methodology to design feasible interventions to improve weaning food hygiene practices of families living in extreme poverty. Educational messages to promote specific behavioural changes were defined and tested by utilizing a combination of ethnographic, survey and observational methods, and integrating viewpoints and suggestions of mothers and caretakers into the decision-making process. This new approach culminated in a household trial in which five groups, each of 15 non-practising mothers, were invited to adopt defined behaviours (handwashing before and after defined events, boiling water for reconstituting powdered milk, feeding gruel by spoon rather than bottlefeeding, not storing gruels and milks, and all four together). All initiated the advocated behaviours and most (53-80%) sustained the new behaviours and practised them every time during a one-month period. Of the four advocated behaviours, spoon-feeding was the most difficult to adopt wholly. The methodology was developed in response to the high priority given to reducing weaning food contamination for diarrhoeal disease control, and the lack of any existing methodology for defining appropriate educational interventions in resource-poor regions. This approach, with its combination of qualitative and quantitative methods and community focus, is recommended for future studies to design hygiene and other health education interventions in developing countries.

Maternal education in relation to early and late child health outcomes: findings from a Brazilian cohort study.

In a population-based cohort of approximately 6000 Brazilian children, the associations between maternal education and a number of child health outcomes were studied while controlling for potentially confounding variables such as family income and education of the husband. In the crude analyses, maternal education was associated with perinatal and infant mortality, hospital admissions in the first 20 months of life and the three nutritional indicators (length-for-age, weight-for-age and weight-for-length) at mean age 20 months. After adjustment for confounding, the apparent associations with outcomes in early infancy--birthweight and perinatal mortality--were no longer present, while that with infant mortality persisted despite being reduced. Strong associations remained with later outcomes including hospital admissions, length-for-age and weight-for-age at mean age 20 months. Among infants born to women with little or no schooling, deaths due to diarrhoea, pneumonia and other infectious diseases were particularly common. These findings support the hypothesis that maternal education has an effect on child health which is partly independent from that of other socioeconomic factors; they also suggest that maternal care is more important than the biological characteristics of the mothers since stronger effects were observed for the late (postneonatal mortality, hospital admissions and nutritional status) than for the early (birthweight, perinatal mortality) outcomes.

Defecation practices of young children in a Peruvian shanty town.

Little is known about feces disposal practices, their determinants and feasibility for change, despite their importance in the control of diarrheal diseases. We report here the results of formative research for the development of an intervention to promote sanitary disposal of feces of young children. The study was conducted in a densely populated shanty town area of Lima, where water and sanitation systems are scarce. In-depth interviews were undertaken with mothers, husbands and community leaders. Group discussions were held with mothers in order to validate findings from the interviews, investigate particular topics further and explore reactions to possible intervention strategies. The principal defecation sites for young children were diapers, potties, the ground in or near the home, the hill, latrines and flush toilets. The main determinants found were the age of the child, the effort required by the method, perceptions of dirtiness and the availability of resources. Almost all children under one year of age use diapers but the high resource cost of diaper washing is a strong motivation for mothers to move their children on as early as possible. Potties were considered the most socially acceptable and 'hygienic' defecation method for children between one and three years of age. Nevertheless, defecation directly onto the ground is common at this age. Potty training is deemed to be quite difficult and the long term achievements are determined by the initial training success. In most cases, the training process is authoritative and inconsistent. The use of latrines and flush toilets is not considered appropriate for children until they are three to four years old. Based on these initial findings, a micro-trial was conducted to assess the feasibility and acceptability of promoting greater use of potties and associated practices. The results of the trial were very encouraging and provided valuable information for the design of a community-wide intervention. Our findings help explain why the emphasis given in most sanitation projects, where efforts have been concentrated on the promotion of latrines, has failed to induce their utilization by small children. Sanitation projects should incorporate interventions that will promote hygienic defecation and stool clearance practices for infants and small children.

The timing of nutritional status determination: implications for interventions and growth monitoring.

A population-based birth cohort of 1226 urban Brazilian children underwent anthropometric examinations at, on average, ages 11, 23 and 47 months. Multiple regression analyses showed that while birth weight was the single most important factor in predicting nutritional status at age 11 months, a wide range of other social, biological and morbidity factors also appeared to play a significant role. Environmental and dietary factors, however, showed no significant association. Nutritional status at age 11 months was a very strong predictor of nutritional status at ages 23 and 47 months and the other explanatory factors made a minimal additional contribution to the regression models. These results suggest that, in this population, childhood nutritional status is primarily determined before the end of the first year of life. These findings have implications for the timing and nature of nutritional interventions and for mechanisms for identifying those children who will suffer from poor nutritional status later in childhood.

Lack of impact of a water and sanitation intervention on the nutritional status of children in rural Bangladesh.

The nutritional impact of a water and sanitation intervention in a rural community of Bangladesh, comprising the provision of handpumps, construction of latrines and hygiene education was assessed. During 3 years, the quarterly anthropometric measures of about 200 children aged 12-35 months from the intervention community were compared with those of a similar number of children from a control area. The interventions reduced the incidence of diarrhoea by 25 per cent among the children less than 5 years of age. There was no significant difference in nutritional status, however, between the two groups of children. Moreover, within the intervention area, indicators of water and latrine use were not significantly related to the children's nutritional status. This suggests that either the obtained reduction of diarrhoea was not large enough to have an impact on nutritional status or that diarrhoea is not an important cause of malnutrition in this community.

Institutional maternal mortality in Mali.

OBJECTIVES: To measure the institutional maternal mortality ratio (MMR) in Mali and suggest ways to reduce it. METHODS: Routinely recorded data from 24 health institutions in three regions were reviewed for 1988 to 1992. RESULTS: The overall MMR in the institutions was 201 maternal deaths per 100,000 live births. Hemorrhage, toxemia and infections accounted for 80% of the 360 recorded maternal deaths, almost all of which were preventable. The main reasons why these conditions result in death lie in poor quality and maldistribution of health services, lack of transport and late use of allopathic services. CONCLUSIONS: Maternal mortality is still a major public health problem in Mali, even among the small proportion of women who reach health facilities. Substantial new initiatives are urgently needed to reduce this major cause of preventable adult female mortality.

Deaths due to dysentery, acute and persistent diarrhoea among Brazilian infants.

In a population-based study, all infant deaths occurring in a one-year period in the metropolitan areas of Porto Alegre and Pelotas, in southern Brazil, were studied. There were 227 infants who presented diarrhoea during the fatal illness, and in 75% of these diarrhoea was considered to be the underlying cause of death. Acute diarrhoea (< 14 days' duration) accounted for 28% of the deaths, persistent diarrhoea for 62% and dysentery for a further 10%. Approximately one-half of the children with persistent diarrhoea were admitted to a hospital in the first two weeks of the episode. Hospital-acquired infections were likely to have contributed to one- to two-thirds of deaths due to dysentery and persistent diarrhoea. A comparison with neighbourhood controls showed that breast milk provided substantial protection against deaths due to either acute or persistent diarrhoea.