Effectiveness of locally produced ready-to-use supplementary foods on the prevention of stunting in children aged 6-23 months: a community-based trial from Pakistan.

Undernutrition is a major public health problem in developing countries. Around 40·2 % of children are stunted in Pakistan. This longitudinal study aimed to assess the effectiveness of locally produced ready-to-use supplementary foods in the prevention of stunting by detecting change in of children in intervention v. control arm against the 2006 WHO growth reference. A community-based non-randomised cluster-controlled trial was conducted from January 2018 to December 2020 in the district of Kurram, Khyber Pakhtunkhwa, Pakistan. A total of 80 clusters (each cluster comprising ≈ 250-300 households) were defined in the catchment population of twelve health facilities. Children aged 6-18 months were recruited n 1680. The intervention included a daily ration of 50 g - locally produced ready-to-use-supplementary food (Wawa-Mum). The main outcome of this study was a change in length for age z-score (LAZ) v. WHO growth standards. Comparison between the interventions was by t test and ANOVA. Cox proportional hazard models were used to assess the association between stunting occurrence and the utilisation of locally produced supplement. Out of the total 1680, fifty-one out of the total 1680, 51·1 out of the total 1680 and 51·1 % (n 859) were male. Mean age 13·9 months (sd + 859) were male. Mean age 13·9 months (sd + -4·4). At baseline, 36·9 % (n 618) were stunted. In the intervention group, mean LAZ score significantly increased from -1·13(2·2 sd) at baseline to -0·93(1·8 sd) at 6-month follow-up (P value 0·01) compared with the control group. The incidence rate of stunting in the intervention arm was 1·3 v. 3·4 per person year in the control arm. The control group had a significantly increased likelihood of stunting (Hazard Ratio (HR) 1·7, 95 % CI 1·46, 2·05, P value < 0·001) v. the intervention group. Locally produced ready-to-use supplementary food is an effective intervention for reducing stunting in children below 2 years of age. This can be provided as part of a malnutrition prevention package to overcome the alarming rates of stunting in Pakistan.

Linear growth beyond 24 months and child neurodevelopment in low- and middle-income countries: a systematic review and meta-analysis.

AIM: To synthesize available evidence on the association between change in linear growth (height for age z score, HAZ) beyond the first two years of life with later child neurodevelopment outcomes in Low- and middle-income countries (LMICs). METHODS: We searched PubMed, Web of Science, and EMBASE for cohort studies on the association between change in HAZ after age two and neurodevelopment outcomes in middle or late childhood. Data extraction was done independently by two reviewers. RESULTS: A total of 21 studies, that included 64,562 children from 13 LMICs were identified. Each unit increase in change in HAZ above two years is associated with a + 0.01 increase (N = 8 studies, 27,393 children) in the cognitive scores at 3.5 to 12 years of age and a + 0.05-standard deviation (SD) increase (95% CI 0.02 to 0.08, N = 3 studies, 17,830 children) in the language score at 5 to 15 years of age. No significant association of change in HAZ with motor (standardized mean difference (SMD) 0.04; 95% CI: -0.10, 0.18, N = 1 study, 966 children) or socio-emotional scores (SMD 0.00; 95% CI: -0.02, 0.01, N = 4 studies, 14,616 participants) was observed. CONCLUSION: Changes in HAZ after the first two years of life appear to have a small or no association with child neurodevelopment outcomes in LMICs.

Growth patterns of infants with in- utero HIV and ARV exposure in Cape Town, South Africa and Lusaka, Zambia.

BACKGROUND: Infants born HIV-exposed yet remain uninfected (HEU) are at increased risk of poorer growth and health compared to infants born HIV-unexposed (HU). Whether maternal antiretroviral treatment (ART) in pregnancy ameliorates this risk of poorer growth is not well understood. Furthermore, whether risks are similar across high burden HIV settings has not been extensively explored. METHODS: We harmonized data from two prospective observational studies conducted in Cape Town, South Africa, and Lusaka, Zambia, to compare weight-for-age (WAZ), length-for-age (LAZ) and weight-for-length (WLZ) Z-scores between infants who were HEU and HU, converting infant anthropometric measures using World Health Organisation Growth Standards adjusted for age and sex. Linear mixed effects models were fit to identify risk factors for differences in anthropometrics at 6-10 weeks and 6 months by infant HIV exposures status and by timing of exposure to maternal ART, either from conception or later in gestation. RESULTS: Overall 773 mother-infant pairs were included across two countries: women living with HIV (WLHIV), 51% (n = 395) with 65% on ART at conception and 35% initiating treatment in pregnancy. In linear mixed effects models, WAZ and WLZ at 6-10 weeks were lower among infants who were HEU vs HU [ß = - 0.29 (95% CI: - 0.46, - 0.12) and [ß = - 0.42 (95% CI: - 0.68, - 0.16)] respectively after adjusting for maternal characteristics and infant feeding with a random intercept for country. At 6 months, LAZ was lower [ß = - 0.28 CI: - 0.50, - 0.06)] among infants who were HEU, adjusting for the same variables, with no differences in WAZ and WLZ. Within cohort evaluations identified different results with higher LAZ among infants who were HEU from Zambia at 6-10 weeks, [ß = + 0.34 CI: + 0.01, + 0.68)] and lower LAZ among infants who were HEU from South Africa [ß = - 0.30 CI: - 0.59, - 0.01)] at 6 months, without other anthropometric differences at either site. CONCLUSION: Infant growth trajectories differed by country, highlighting the importance of studying contextual influences on outcomes of infants who were HEU.

Lower birth weight-for-age and length-for-age z-scores in infants with in-utero HIV and ART exposure: a prospective study in Cape Town, South Africa.

BACKGROUND: Successful scale-up of antiretroviral therapy (ART) during pregnancy has minimized infant HIV acquisition, and over 1 million infants are born HIV-exposed but uninfected (HEU), with an increasing proportion also exposed in utero to maternal ART. While benefits of ART in pregnancy outweigh risks, some studies have reported associations between in utero ART exposure and impaired fetal growth, highlighting the need to identify the safest ART regimens for use in pregnancy. METHODS: We compared birth anthropometrics of infants who were HEU with those HIV-unexposed (HU) in Cape Town, South Africa. Pregnant women had gestational age assessed by ultrasound at enrolment. Women living with HIV were on ART (predominately tenofovir-emtricitabine-efavirenz) either prior to conception or initiated during pregnancy. Birth weights and lengths were converted to weight-for-age (WAZ) and length-for-age (LAZ) z-scores using Intergrowth-21st software. Linear regression was used to compare mean z-scores adjusting for maternal and pregnancy characteristics. RESULTS: Among 888 infants, 49% (n = 431) were HEU and 51% (n = 457) HU. Of 431 HEU infants, 62% (n = 268) were exposed to HIV and antiretrovirals (ARVs) from conception and 38% (n = 163) were exposed to ARVs during gestation but after conception (median fetal ARV exposure of 21 weeks [IQR; 17-26]). In univariable analysis, infants who were HEU had lower mean WAZ compared with HU [ß = - 0.15 (95% Confidence Interval (CI): - 0.28, - 0.020)]. After adjustment for maternal age, gravidity, alcohol use, marital and employment status the effect remained [adjusted ß - 0.14 (95%CI: - 0.28, - 0.01]. Similar differences were noted for mean LAZ in univariable [ß - 0.20 (95%CI: - 0.42, - 0.01] but not multivariable analyses [adjusted ß - 0.18 (95%CI: - 0.41, + 0.04] after adjusting for the same variables. Mean WAZ and LAZ did not vary by in utero ARV exposure duration among infants who were HEU. CONCLUSION: In a cohort with high prevalence of ART exposure in pregnancy, infants who were HEU had lower birth WAZ compared with those HU. Studies designed to identify the mechanisms and clinical significance of these disparities, and to establish the safest ART for use in pregnancy are urgently needed.

Diagnostic measures for severe acute malnutrition in Indian infants under 6 months of age: a secondary data analysis.

BACKGROUND: Weight for length z-score (WLZ) < - 3 is currently used to define severe acute malnutrition (SAM) among infants. However, this approach has important limitations for infants younger than 6 months of age as WLZ cannot be calculated using WHO growth standards if infant length is < 45 cm. Moreover, length for age z-score (LAZ) and weight for length z-score (WLZ) are least reliable measures, with high chances of variation, and less chances of detecting undernutrition in under 6 months infants. The objective of the current analysis was to compare WLZ with WAZ and LAZ in a cohort of Indian infants in predicting the deaths between 6 weeks and 6 months of age. METHODS: The data was from an individually randomized trial conducted in slums of Delhi, India in which infants' weight and length were measured at 6 weeks of age (at the time of the first immunization visit). Vital status of the infants was documented from 6 weeks to 6 months of age. The sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios were calculated for WAZ < -3, WLZ < -3, and LAZ < -3 for deaths between 6 weeks and 6 months of age. The receiver operating characteristics curve was calculated for each of the above anthropometric indicators. RESULTS: For deaths occurring between 6 weeks to 6 months of age, the specificity ranged between 85.9-95.9% for all three anthropometric indicators. However, the sensitivity was considerably higher for WAZ; it was 64.6% for WAZ < -3, 39.1% for LAZ < -3, and 25.0% for WLZ < -3. WAZ < -3 had higher area under curve (0.75; 95% CI: 0.68, 0.82) and hence, better discriminated deaths between 6 weeks and 6 months of age than WLZ < -3. The adjusted relative risk (RR 10.6, 95% CI 5.9, 18.9) and the population attributable fraction (PAF 57.9, 95% CI 38.8, 71.0%) of mortality was highest for WAZ < -3. CONCLUSIONS: We found WAZ < -3 at 6 weeks of age to be a better predictor of death in the 6 weeks to 6 months of life in comparison to WLZ < -3 and LAZ < -3 and propose that it should be considered to diagnose SAM in this age group.

Growth patterns and their contributing factors among HIV-exposed uninfected infants.

With expanded HIV treatment and prevention programmes, most infants born to HIV-positive women are uninfected, but the patterns and determinants of their growth are not well described. This study aimed to assess growth patterns in a cohort of HIV-exposed uninfected (HEU) infants who participated in an experimental HIV vaccine trial and to test for associations with maternal and infant factors, including in-utero exposure to antiretroviral therapy (ART), mode of delivery, exclusive breastfeeding, mother's education and receipt of the vaccine. Infants in the trial were seen at regular clinic visits from birth to 48 weeks of age. From the anthropometric measurements at these visits, weight-for-age z-scores (WAZ), weight-for-length z-scores (WLZ) and length-for-age z-scores (LAZ) were computed using World Health Organization (WHO) software and reference tables. Growth patterns were investigated with respect to maternal and infant factors, using linear mixed regression models. From 94 infants included at birth, growth data were available for 75.5% at 48 weeks. The determinants of infant growth in this population are multifactorial: infant LAZ during the first year was significantly lower among infants delivered by caesarean section (p = 0.043); both WAZ and LAZ were depressed among infants with longer exposure to maternal ART (WAZ: p = 0.015; LAZ: p < 0.0001) and among infants of mothers with lower educational level (WAZ: p = 0.038; LAZ: p < 0.0001); the effect of maternal education was modified by breastfeeding practice, with no differences seen in exclusively breastfed infants. These findings inform intervention strategies to preserve growth in this vulnerable infant population.

Factors associated with dietary diversity and length-for-age z-score in rural Ethiopian children aged 6-23 months: A novel approach to the analysis of baseline data from the Sustainable Undernutrition Reduction in Ethiopia evaluation.

Infants and young children need diets high in nutrient density and diversity to meet the requirements of rapid growth and development. Our aim was to evaluate sociodemographic, agricultural diversity, and women's empowerment factors associated with child dietary diversity and length-for-age z-score (LAZ) in children 6-23 months using data collected as part of the Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study baseline survey in May-June 2016. We here present a novel analysis using directed acyclic graphs (DAGs) to represent our assumptions about the causal influences between the factors of interest and the outcomes. The causal diagrams enabled the identification of variables to be included in multivariable analysis to estimate the total effects of factors of interest using ordinal logistic/linear regression models. We found that child dietary diversity was positively associated with LAZ with children consuming 4 or more food groups having on average an LAZ score 0.42 (95% CI [0.08, 0.77]) higher than those consuming no complementary foods. Household production of fruits and vegetables was associated with both increased child dietary diversity (adjusted OR 1.16; 95% CI [1.09, 1.24]) and LAZ (adjusted mean difference 0.05; 95% CI [0.005, 0.10]). Other factors positively associated with child dietary diversity included age in months, socio-economic status, maternal education, women's empowerment and dietary diversity, paternal childcare support, household food security, fruit and vegetable cultivation, and land ownership. LAZ was positively associated with age, socio-economic status, maternal education, fruit and vegetable production, and land ownership.

Stunting, wasting and breast-feeding as correlates of body composition in Cambodian children at 6 and 15 months of age.

The study aimed at assessing stunting, wasting and breast-feeding as correlates of body composition in Cambodian children. As part of a nutrition trial (ISRCTN19918531), fat mass (FM) and fat-free mass (FFM) were measured using 2H dilution at 6 and 15 months of age. Of 419 infants enrolled, 98 % were breastfed, 15 % stunted and 4 % wasted at 6 months. At 15 months, 78 % were breastfed, 24 % stunted and 11 % wasted. Those not breastfed had lower FMI at 6 months but not at 15 months. Stunted children had lower FM at 6 months and lower FFM at 6 and 15 months compared with children with length-for-age z ≥0. Stunting was not associated with height-adjusted indexes fat mass index (FMI) or fat-free mass index (FFMI). Wasted children had lower FM, FFM, FMI and FFMI at 6 and 15 months compared with children with weight-for-length z (WLZ) ≥0. Generally, FFM and FFMI deficits increased with age, whereas FM and FMI deficits decreased, reflecting interactions between age and WLZ. For example, the FFM deficits were -0·99 (95 % CI -1·26, -0·72) kg at 6 months and -1·44 (95 % CI -1·69; -1·19) kg at 15 months (interaction, P<0·05), while the FMI deficits were -2·12 (95 % CI -2·53, -1·72) kg/m2 at 6 months and -1·32 (95 % CI -1·77, -0·87) kg/m2 at 15 months (interaction, P<0·05). This indicates that undernourished children preserve body fat at the detriment of fat-free tissue, which may have long-term consequences for health and working capacity.

Study protocol to assess the impact of an integrated nutrition intervention on the growth and development of children under two in rural Bangladesh.

BACKGROUND: The period from birth to two years is the "critical window" for achieving optimal growth and development. An inadequate quality and quantities of complementary foods, poor child-feeding practices and infection negatively impact the growth of under-twos. Approximately one-third of under-fives in developing countries are stunted; many are also micronutrient deficient. An estimated 6% of mortalities among under-fives can be prevented by ensuring optimal complementary feeding. The objective of the study was to assess the ability of a 12-month integrated nutrition intervention to improve the nutritional status (length-for-age Z-score) of 6 to 12-month-old children in rural Bangladesh. METHODS: In this community-based randomized controlled trial, the intervention group received a package of interventions that includes, food vouchers; to prepare egg-based nutritious snacks (suji firni for < 1-year-olds, suji halwa for > 1-year-olds), micronutrient powder to fortify children's food at home, child feeding counselling and water, sanitation and hygiene (WASH), behaviour change communication. The control group received routine health messages provided by the government. Baseline and endline surveys were conducted; Data collection was performed monthly on children's growth, food voucher utilization, child feeding and morbidity. In addition, we assessed the cognitive development of the children after 12 months of intervention. CONCLUSION: This trial aims to explore whether an integrated nutrition intervention can mitigate childhood stunting during the critical window of opportunity in rural Bangladesh. The results may provide robust evidence to improve the linear growth of children in developing countries. TRIAL REGISTRATION: The study was retrospectively registered on August 17, 2018 and is available online at ClinicalTrials.gov (ID: NCT02768181).

Factors associated with catch-up growth in early infancy in rural Pakistan: A longitudinal analysis of the women's work and nutrition study.

The adverse health impacts of early infant stunting can be partially ameliorated by early catch-up growth. Few studies have examined predictors of and barriers to catch-up growth to identify intervention points for improving linear growth during infancy. This study aimed to estimate the prevalence of, and factors associated with, catch-up growth among infants in Pakistan. A longitudinal study of mother-infant dyads (n = 1,161) was conducted in rural Sindh province, with enrolment between December 2015 and February 2016 (infants aged 0.5-3 months), and follow-up (n = 1035) between November 2016 and January 2017 (infants aged 9-15 months). The outcome was catch-up growth (change in conditional length-for-age z-scores >0.67 between baseline and endline). Associated factors were examined using multivariable logistic regression analyses. The prevalence of stunting was 45.3% at baseline and 60.7% at follow-up. 22.8% of infants exhibited catch-up growth over this period. Factors positively associated with catch-up growth included maternal height (odds ratio (OR) = 1.08 [1.05-1.11]), household wealth (OR = 3.61 [1.90-6.84]), maternal (OR = 2.43 [1.30-4.56]) or paternal (OR = 1.46 [1.05-2.03]) education, and households with two or more adult females (OR = 1.91 [1.26-2.88]). Factors negatively associated with catch-up growth were two (OR = 0.64 [0.45-0.89]) or three or more (OR = 0.44 [0.29-0.66]) preschool children in the household and the infant being currently breastfed (OR = 0.59 [0.41-0.88]). Catch-up growth was exhibited among approximately a quarter of infants despite living in challenging environments associated with extremely high rates of early infant stunting. Several modifiable factors were identified that might represent suitable programme intervention points to off-set early infant stunting in rural Pakistan.

Nutritional status and human milk intake of exclusively breast-fed infants at high altitude in La Paz, Bolivia.

Breast-feeding habits are related to the nutritional status and the risk of illness and death in children under 2 years of age. For the first 6 months, infants should be exclusively breast-fed. This study aimed to evaluate the relationship between the infant's nutritional status and human milk intake by breast-fed infants at high altitude. A quantitative, descriptive, correlational study was conducted including mother/baby pairs of infants aged 2-6 months. The amount of human milk consumed by the infants was assessed by the deuterium oxide dose-to-mother technique. The lipid content of human milk was measured by creamatocrit, and anthropometric measurements were performed. A total of eighteen mother/baby pairs were assessed. The mean human milk intake was 888 (sd 149) g/d, and the intake of water from other sources was 24·3 (sd 29·8) g/d. The lipid content in human milk was 41 (sd 12) g/l. The infant's nutritional indicators were normal in all cases. A moderate positive correlation was found between milk volume and z scores weight-for-length r 0·58 (P=0·01), BMI-for-age r 0·56 (P=0·01) and weight-for-age r 0·45 (P=0·05). There was no correlation with length-for-age z score. The mean of breast milk intake in this study was similar to that found in other studies in the world. The lipid content is comparable to similar studies and was within the normal range. Children older than 3 months showed signs of stunting despite adequate volume and lipid content of breast milk.

Environmental enteric dysfunction and systemic inflammation predict reduced weight but not length gain in rural Bangladeshi children.

Environmental enteric dysfunction (EED) and systemic inflammation (SI) are common in developing countries and may cause stunting. In Bangladesh, >40 % of preschool children are stunted, but EED and SI contributions are unknown. We aimed to determine the impact of EED and SI (assessed with multiple indicators) on growth in children (n 539) enrolled in a community-based randomised food supplementation trial in rural Bangladesh. EED was defined with faecal myeloperoxidase, α-1 antitrypsin and neopterin and serum endotoxin core antibody and glucagon-like peptide-2, consolidated into gut inflammation (GI) and permeability (GP) scores, and urinary lactulose:mannitol α-1 acid glycoprotein (AGP) characterised SI. Biomarker associations with anthropometry (15-, 18- and 24-month length-for-age (LAZ), weight-for-length (WLZ) and weight-for-age (WAZ) z scores) were examined in pairwise correlations and adjusted mixed-effects regressions. Stunting, wasting and underweight prevalence at 18 months were 45, 15 and 37 %, respectively, with elevated EED and SI markers common. EED and SI were not associated with 15-24-month length trajectory. Elevated (worse) GI and GP scores predicted reduced 18-24-month WLZ change (ß -0·01 (se 0·00) z score/month for both). Elevated GP was also associated with reduced 15-18-month WLZ change (ß -0·03 (se 0·01) z score/month) and greater 15-month WLZ (ß 0·16 (se 0·05)). Higher AGP was associated with reduced prior and increased subsequent WLZ change (ß -0·04 (se 0·01) and ß 0·02 (se 0·00) z score/month for 15-18 and 18-24 months). The hypothesised link from EED to stunting was not observed in this sample of Bangladeshi 18-month-olds, but the effects of EED on constrained weight gain may have consequences for later linear growth or for other health and development outcomes.

An agriculture-nutrition intervention improved children's diet and growth in a randomized trial in Ghana.

Stunting in Ghana is associated with rural communities, poverty, and low education; integrated agricultural interventions can address the problem. This cluster randomized controlled trial tested the effect of a 12-month intervention (inputs and training for poultry farming and home gardening, and nutrition and health education) on child diet and nutritional status. Sixteen clusters were identified and randomly assigned to intervention or control; communities within clusters were randomly chosen, and all interested, eligible mother-child pairs were enrolled (intervention: 8 clusters, 19 communities, and 287 households; control: 8 clusters, 20 communities, and 213 households). Intention-to-treat analyses were used to estimate the effect of the intervention on endline minimum diet diversity (≥4 food groups), consumption of eggs, and length-for-age (LAZ)/height-for-age (HAZ), weight-for-age (WAZ), and weight-for-length (WLZ)/weight-for-height (WHZ) z-scores; standard errors were corrected for clustering. Children were 10.5 ± 5.2 months (range: 0-32) at baseline and 29.8 ± 5.4 months (range: 13-48) at endline. Compared with children in the control group, children in the intervention group met minimum diet diversity (adjusted odds ratio = 1.65, 95% CI [1.02, 2.69]) and a higher LAZ/HAZ (ß = 0.22, 95% CI [0.09, 0.34]) and WAZ (ß = 0.15, 95% CI [0.00, 0.30]). Sensitivity analyses with random-effects and mixed-effects models and as-treated analysis were consistent with the findings. There was no group difference in WLZ/WHZ. Integrated interventions that increase access to high-quality foods and nutrition education improve child nutrition.

A community-based cluster randomised controlled trial to evaluate the effectiveness of different bundles of nutrition-specific interventions in improving mean length-for-age z score among children at 24 months of age in rural Bangladesh: study protocol.

BACKGROUND: Prevalence of stunting among under-five children in Bangladesh is 36%, varying with geographic and socio-economic characteristics. Previously, research groups statistically modelled the effect of 10 individual nutrition-specific interventions targeting the critical first 1000 days of life from conception, on lives saved and costs incurred in countries with the highest burden of stunted children. However, primary research on the combined effects of these interventions is limited. Our study directly addresses this gap by examining the effect of combinations of 5 preventive interventions on length-for-age z-scores (LAZ) among 2-years old children. METHODS: This community-based cluster randomised trial (c-RCT) compares 4 intervention combinations against one comparison arm. Intervention combinations are: 1) Behaviour change communication (BCC) on maternal nutrition during pregnancy, exclusive breastfeeding, and complementary feeding, along with prenatal nutritional supplement (PNS) and complementary food supplement (CFS); 2) BCC with PNS; 3) BCC with CFS; and 4) BCC alone. The comparison arm receives only routine health and nutrition services. From a rural district, 125 clusters were selected and randomly assigned to any one of the five study arms by block randomisation. A bespoke automated tab-based system was developed linking data collection, intervention delivery and project supervision. Total sample size is 1500 pregnant women, with minimum 1050 resultant children expected to be retained, powered to detect a difference of at least 0.4 in the mean LAZ score of children at 24 months, the main outcome variable, between the comparison arm and each intervention arm. Length and other anthropometric measurements, nutritional intake and other relevant data on mother and children are being collected during enrolment, twice during pregnancy, postpartum monthly till 6 months, and every third month thereafter till 24 months. DISCUSSION: This c-RCT explores the effectiveness of bundles of preventive nutrition intervention approaches addressing the critical window of opportunity to mitigate childhood stunting. The results will provide robust evidence as to which bundle(s) can have significant effect on linear growth of children. Our study also will have policy-level implications for prioritising intervention(s) tackling stunting. TRIAL REGISTRATION: The study was retrospectively registered on May 2, 2016 and is available online at ClinicalTrials.gov (ID: NCT02768181 ).

Association between malaria immunity and pregnancy outcomes among Malawian pregnant women receiving nutrient supplementation.

BACKGROUND: Malaria antibody responses measured at delivery have been associated with protection from maternal anaemia and low birth weight deliveries. Whether malarial antibodies present in the first half of pregnancy may protect from these or other poor birth outcomes is unclear. To determine whether malaria antibodies in the first half of pregnancy predict pregnancy outcomes, antibodies were measured to a range of merozoite antigens and to antigens expressed on the surface of parasitized red blood cells (pRBCs) in plasma samples collected at 14-20 weeks of gestation from Malawian women. The latter antibodies were measured as total IgG to pRBCs, and antibodies promoting opsonic phagocytosis of pRBCs. Associations between antibodies and maternal haemoglobin in late pregnancy or newborn size were investigated, after adjusting for potential covariates. RESULTS: Antibodies to pRBC surface antigens were associated with higher haemoglobin concentration at 36 weeks. Total IgG to pRBCs was associated with 0.4 g/l [(95% confidence interval (0.04, 0.8)] increase in haemoglobin, and opsonizing antibody with 0.5 (0.05, 0.9) increase in haemoglobin for each 10% increase in antibody. These antibodies were not associated with birthweight, placental malaria, or newborn anthropometrics. Antibodies to merozoite antigens and non-placental-binding IEs were not associated with decreased risk of any of these outcomes. In some instances, they were negatively associated with outcomes of interest. CONCLUSION: Antibodies to placental-binding infected erythrocytes may be associated with higher haemoglobin levels in pregnancy, whereas antibodies to other malaria antigens may instead be markers of malaria exposure. Trial registration clinicaltrials.gov NCT01239693. Registered Nov 10, 2010.

The association of maternal vitamin D status with infant birth outcomes, postnatal growth and adiposity in the first 2 years of life in a multi-ethnic Asian population: the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort study.

Maternal vitamin D status during pregnancy has been associated with infant birth and postnatal growth outcomes, but reported findings have been inconsistent, especially in relation to postnatal growth and adiposity outcomes. In a mother-offspring cohort in Singapore, maternal plasma vitamin D was measured between 26 and 28 weeks of gestation, and anthropometric measurements were obtained from singleton offspring during the first 2 years of life with 3-month follow-up intervals to examine birth, growth and adiposity outcomes. Associations were analysed using multivariable linear regression. Of a total of 910 mothers, 13·2 % were vitamin D deficient (<50 nmol/l) and 26·5 % were insufficient (50-75 nmol/l). After adjustment for potential confounders and multiple testing, no statistically significant associations were observed between maternal vitamin D status and any of the birth outcomes - small for gestational age (OR 1·00; 95 % CI 0·56, 1·79) and pre-term birth (OR 1·16; 95 % CI 0·64, 2·11) - growth outcomes - weight-for-age z-scores, length-for-age z-scores, circumferences of the head, abdomen and mid-arm at birth or postnatally - and adiposity outcomes - BMI, and skinfold thickness (triceps, biceps and subscapular) at birth or postnatally. Maternal vitamin D status in pregnancy did not influence infant birth outcomes, postnatal growth and adiposity outcomes in this cohort, perhaps due to the low prevalence (1·6 % of the cohort) of severe maternal vitamin D deficiency (defined as of <30·0 nmol/l) in our population.

Stunting at birth: recognition of early-life linear growth failure in the western highlands of Guatemala.

OBJECTIVE: Measurements of length at birth, or in the neonatal period, are challenging to obtain and often discounted for lack of validity. Hence, classical 'under-5' stunting rates have been derived from surveys on children from 6 to 59 months of age. Guatemala has a high prevalence of stunting (49.8%), but the age of onset of growth failure is not clearly defined. The objective of the study was to assess length-for-age within the first 1.5 months of life among Guatemalan infants. DESIGN: As part of a cross-sectional observational study, supine length was measured in young infants. Mothers' height was measured. Length-for-age Z-scores (HAZ) were generated and stunting was defined as HAZ <-2 using WHO growth standards. SETTING: Eight rural, indigenous Mam-Mayan villages (n 200, 100% of Mayan indigenous origin) and an urban clinic of Quetzaltenango (n 106, 27% of Mayan indigenous origin), Guatemala. SUBJECTS: Three hundred and six newborns with a median age of 19 d. RESULTS: The median rural HAZ was -1.56 and prevalence of stunting was 38%; the respective urban values were -1.41 and 25%. Linear regression revealed no relationship between infant age and HAZ (r = 0.101, r(2) = 0.010, P = 0.077). Maternal height explained 3% of the variability in HAZ (r = 0.171, r(2) = 0.029, P = 0.003). CONCLUSIONS: Stunting must be carried over from in utero growth retardation in short-stature Guatemalan mothers. As linear growth failure in this setting begins in utero, its prevention must be linked to maternal care strategies during gestation, or even before. A focus on maternal nutrition and health in an intergenerational dimension is needed to reduce its prevalence.

The interactive association of dietary diversity scores and breast-feeding status with weight and length in Filipino infants aged 6-24 months.

OBJECTIVE: To assess how breast-feeding and dietary diversity relate to infant length-for-age Z-score (LAZ) and weight-for-age Z-score (WAZ). DESIGN: Breast-feeding, dietary and anthropometric data from the Cebu Longitudinal Health and Nutrition Survey were analysed using sex-stratified fixed-effects longitudinal regression models. A dietary diversity score (DDS) based on seven food groups was classified as low (<4) or high (≥ 4). The complementary feeding patterns were: (i) non-breast-fed with low DDS (referent); (ii) breast-fed with low DDS; (iii) non-breast-fed with high DDS; and (iv) breast-fed with high DDS (optimal). Interactions between age, energy intake and complementary feeding patterns were included. SETTING: Philippines. SUBJECTS: Infants (n 2822) measured bimonthly from 6 to 24 months. RESULTS: Breast-feeding (regardless of DDS) was significantly associated with higher LAZ (until 24 months) and WAZ (until 20 months). For example, at 6 months, breast-fed boys with low DDS were 0.246 (95% CI 0.191, 0.302) sd longer and 0.523 (95% CI 0.451, 0.594) sd heavier than the referent group. There was no significant difference in size between breast-fed infants with high v. low DDS. Similarly, high DDS conferred no advantage in LAZ or WAZ among non-breast-fed infants. There were modest correlations between the 7-point DDS and nutrient intakes but these correlations were substantially attenuated after energy adjustment. We elucidated several interactions between sex, age, energy intake and complementary feeding patterns. CONCLUSIONS: These results demonstrate the importance of prolonged breast-feeding up to 24 months. The DDS provided qualitative information on infant diets but did not confer a significant advantage in LAZ or WAZ.

Significant differences in the length and weight measurements of Jordanian infants compared to the World Health Organization 2006 growth standards.

BACKGROUND: In 2006, the World Health Organization (WHO) introduced new growth standards based on data derived globally from optimally nourished breastfed infants. The aim of this study was to assess the effects of implementing WHO growth standards on the growth patterns of Jordanian infants. In addition, it was to ascertain the necessity of establishing country-specific growth standards and charts tailored to Jordanian infants. MATERIALS AND METHODS: The data of 102,846 infants (50.1% boys, 49.9% girls) aged 0-24 months, from 115 primary healthcare centers across the country were retrieved from a National E-health Program. Weight and length measurements were analyzed, and age- and sex-specific z-scores were calculated relative to the WHO growth standards. Data was analyzed using SPSS version 26. Mann-Whitney U test was performed to determine significant differences between the measurements for boys and girls in terms of age, length, and weight. RESULTS: Jordanian infants exhibited significantly shorter length-for-age measurements than WHO standards with mean z-scores of -0.56 and -0.38, for boys and girls, respectively. Weight-for-age measurements showed a good fit and were comparable to the WHO growth standards for boys (mean z score = -0.05) and girls (mean z score = 0.04). Notably, Jordanian infants displayed higher weight-for-length measurements, with mean z-scores of 0.51 for boys and 0.47 for girls. CONCLUSION: The availability of Jordanian-specific growth standards will improve the accuracy of assessing infant growth and enhance the monitoring and evaluation of their health and development.

Maternal vitamin D3 supplementation during the third trimester of pregnancy: effects on infant growth in a longitudinal follow-up study in Bangladesh.

OBJECTIVE: To estimate the effects of prenatal vitamin D supplementation on infant growth in Dhaka, Bangladesh. STUDY DESIGN: Longitudinal follow-up of infants born at term or late preterm (≥34 weeks) to participants in a randomized double-blind trial of maternal third-trimester vitamin D3 (35 000 IU/wk; vitamin D ) vs placebo. Anthropometry was performed at birth, 1, 2, 4, 6, 9, and 12 months of age. The primary analysis (n = 145 overall; n = 134 at 1 year) was a comparison of mean length-for-age z-score (LAZ) based on World Health Organization standards. RESULTS: LAZ was similar between groups at birth, but 0.44 (95% CI, 0.06-0.82) higher in vitamin D vs placebo at 1 year, corresponding to a sex-adjusted increase of 1.1 cm (95% CI, 0.06-2.0). Mean change in LAZ from birth to 1 month was significantly greater in vitamin D (0.53 per month) vs placebo (0.19 per month; P = .004); but there was no significant divergence thereafter. In longitudinal (repeated-measures) analysis, average LAZ during infancy was 0.41 higher in vitamin D vs placebo (95% CI, 0.11-0.71, P = .01). Stunting was less common in vitamin D (17% of infants were ever stunted) vs placebo (31%; P = .049). Other anthropometric indices were similar between groups. CONCLUSIONS: Maternal vitamin D3 supplementation (35 000 IU/wk) during the third trimester of pregnancy enhanced early postnatal linear growth in a cohort of infants in Bangladesh.