Antenatal care is associated with adherence to iron supplementation among pregnant women in selected low-middle-income-countries of Asia, Africa, and Latin America & the Caribbean regions: Insights from Demographic and Health Surveys.

Anaemia is a global public health problem affecting 800 million women and children globally. Anaemia is associated with perinatal mortality, child morbidity and mortality, mental development, immune competence, susceptibility to lead poisoning and performance at work. The objective of this article is to identify whether antenatal care-seeking was associated with the uptake of iron supplementation among pregnant women, adjusting for a range of covariates. This article used data from the cross-sectional recent Demographic and Health Surveys (DHS) of 12 countries in Asia, Africa and Latin America & the Caribbean regions. The individual-level data from 273,144 women of reproductive age (15-49 years) were analysed from multi-country DHS. Multiple Logistic regression analyses were conducted using Predictive Analytics Software for Windows (PASW), Release 18.0. Receiving at least four antenatal care visits was significantly associated with the consumption of 90 or more iron-containing supplements in 12 low and middle income countries across three regions after adjusting for different household and respondent characteristics, while mass media exposure was found to be a significant predictor in India and Indonesia. Antenatal care seems to be the most important predictor of adherence to iron intake in the selected countries across Africa, Asia, Latin America and Caribbean regions.

Tanzanian men's engagement in household chores is associated with improved antenatal care seeking and maternal health.

BACKGROUND: Male support for partners' antenatal care (ANC) has the potential to improve women's care-seeking and maternal health outcomes. This study describes factors that are associated with men's involvement in household tasks and explores the relationship between men's help with tasks and women's ANC-seeking, diet and workload during pregnancy as well as other health behaviors. METHODS: This study was conducted in five Lake Zone regions of Tanzania. Cross-sectional surveys were carried out among approximately 10,000 households that had children under the age of 2 years. Surveys were administered to mothers of children less than 2 years and where available, their male partners. Data were collected between December 2015 and May 2020, in conjunction with a large-scale campaign aimed at reducing childhood stunting by changing the behavior of mothers, caregivers, and decision makers. Data analysis included bivariate analysis and logistic regression modeling. RESULTS: Men's engagement in household activities was significantly associated with living in an urban setting, being younger, having at least some formal schooling, early verbal interactions with their children, and male involvement in healthcare decisions. Additionally, mothers of male partners that were engaged in household activities were significantly older and more likely to have at least some secondary school education. Relative to households where men only infrequently helped out with chores or not at all, women from households where men frequently helped were significantly more likely to have taken iron tablets during pregnancy, report having eaten more than usual, lessening their household workload during their most recent pregnancy, and more likely to have played with their child in the week prior to the survey. CONCLUSION: Male's participation in household tasks is associated with a general improvement in mother's ANC behaviors. Implicit in these findings is that general primary education for both men and women has health benefits that transcend socioeconomic class and that future interventions aimed to engage males in household tasks may target older males with less education living in rural areas.

Engaging fathers to improve complementary feeding is acceptable and feasible in the Lake Zone, Tanzania.

In Tanzania, suboptimal complementary feeding practices contribute to high stunting rates. Fathers influence complementary feeding practices, and effective strategies are needed to engage them. The objectives of this research were to examine the acceptability and feasibility of (1) tailored complementary feeding recommendations and (2) engaging fathers in complementary feeding. We conducted trials of improved practices with 50 mothers and 40 fathers with children 6-18 months. At visit 1, mothers reported current feeding practices and fathers participated in focus group discussions. At visit 2, mothers and fathers received individual, tailored counselling and chose new practices to try. After 2 weeks, at visit 3, parents were interviewed individually about their experiences. Interview transcripts were analysed thematically. The most frequent feeding issues at visit 1 were the need to thicken porridge, increase dietary diversity, replace sugary snacks and drinks and feed responsively. After counselling, most mothers agreed to try practices to improve diets and fathers agreed to provide informational and instrumental support for complementary feeding, but few agreed to try feeding the child. At follow-up, mothers reported improved child feeding and confirmed fathers' reports of increased involvement. Most fathers purchased or provided funds for recommended foods; some helped with domestic tasks or fed children. Many participants reported improved spousal communication and cooperation. Families were able to practice recommendations to feed family foods, but high food costs and seasonal unavailability were challenges. It was feasible and acceptable to engage fathers in complementary feeding, but additional strategies are needed to address economic and environmental barriers.

Importance of authorship and inappropriate authorship assignment in paediatric research in low- and middle-income countries.

OBJECTIVE: To understand the importance of authorship and authorship position, and gauge perceptions of inappropriate authorship assignment, among authors publishing paediatric research conducted in low- and middle-income countries (LMICs). METHODS: We conducted a cross-sectional, mixed-methods study using an online survey of both corresponding and randomly selected, non-corresponding authors who published research conducted in LMICs from 2006 to 2015 in the top four paediatric journals by Eigenfactor score. We used chi-square tests to compare responses by authors living in LMICs to authors living in high-income countries (HICs). We analysed qualitative responses using thematic analysis. RESULTS: Of 1420 potential respondents, 19.6% (n = 279) completed the survey. 57% (n = 159) lived in LMICs and 43% (n = 120) in HICs. LMIC authors more commonly perceived first authorship as most important for their academic advancement than HIC authors (74.2% vs. 60.8%, P = 0.017), while HIC authors reported last authorship as most important (25.1% vs. 38.3%, P = 0.018). 65% (n = 181) of respondents believed that their collaborators had been inappropriately assigned authorship positions (no difference in LMIC and HIC responses) and 32.6% (n = 91) reported personally accepting inappropriate authorship positions (more common in HIC respondents, P = 0.005). In qualitative data, respondents questioned the applicability of standard authorship guidelines for collaborative research conducted in LMICs. CONCLUSIONS: LMIC and HIC authors held different perceptions about the importance of authorship position. Reported inappropriate authorship assignment was common among both LMIC and HIC respondents. Alternatives to standard authorship criteria for research conducted in LMICs merit further studies.

OBJECTIF: Comprendre l'importance de la paternité d'auteur et de la position de l'auteur, et évaluer les perceptions de l'attribution inappropriée de la paternité d'auteur parmi les auteurs qui publient des recherches pédiatriques menées dans des pays à revenu faible ou intermédiaire (PRFI). MÉTHODES: Nous avons mené une étude transversale à méthodes mixtes avec un sondage en ligne auprès d'auteurs de correspondance et sélectionnés au hasard, d'auteurs not de correspondance, ayant publié des recherches menées dans des PRFIde 2006 à 2015 dans les quatre revues pédiatriques les mieux classées par le score d'Eigenfactor. Nous avons utilisé des tests de chi carré pour comparer les réponses des auteurs des PRFI à ceux des aux auteurs des pays à revenu élevé (PRE). Nous avons analysé les réponses qualitatives à l'aide d'une analyse thématique. RÉSULTATS: Sur 1.420 répondants potentiels, 19,6% (n = 279) ont répondu au sondage. 57% (n = 159) vivaient dans des PRFI et 43% (n = 120) dans des PRE. Les auteurs des PRFI estimaient plus souvent que la position de premier auteur était le plus important pour leur avancement universitaire que les auteurs des PRE (74,2% contre 60,8%, P = 0,017), tandis que les auteurs desPRE ont déclaré que le dernier auteur était le plus important (25,1% contre 38,3%, P = 0,018). 65% (n = 181) des répondants estimaient que des positions d'auteur avaient été attribués de manière inappropriée à leurs collaborateurs (aucune différence entre les réponses des PRFI et des PRE) et 32,6% (n = 91) ont déclaré avoir personnellement accepté des positions d'auteurs inappropriées (plus fréquents chez les répondants desPRE, P = 0,005). En ce qui concerne les données qualitatives, les répondants se sont interrogés sur l'applicabilité des directives standards en matière de paternité d'auteur pour la recherche collaborative menée dans les PRFI. CONCLUSIONS: Les auteurs des PRFI et desPREont des perceptions différentes sur l'importance de la position de l'auteur. L'attribution inappropriée de laposition d'auteur signalée était fréquente chez les répondants des PRFI et des PRE. Les alternatives aux critères standards de la paternité d'auteur pour les recherches menées dans les PRFI méritent d'être approfondies.

Authorship in paediatric research conducted in low- and middle-income countries: parity or parasitism?

OBJECTIVES: Interest in global health has increased greatly in the past two decades. Concomitantly, the number and complexity of research partnerships between high-income (HIC) and low- and middle-income countries (LMICs) has grown. We aimed to determine whether there is authorship parity (equitable representation and author order) or parasitism (no authors from study countries) in paediatric research conducted in LMICs. METHODS: We reviewed all articles published from 2006 to 2015 in the four paediatric journals with the highest Eigenfactor scores. We limited our review to articles from LMICs and abstracted information on author affiliation and order, funding source and study design. We calculated Student's t-tests and chi-square using Fisher's exact test with Monte Carlo estimates. RESULTS: There were 24 169 articles published during the study period, and 1243 met inclusion criteria. Of those, 95.9% (n = 1,192) included at least one author affiliated with a LMIC. Among multicountry studies (n = 165), 40.4% did not include authors from every LMIC involved. Of the 9876 authors, most were affiliated with institutions from upper-middle-income countries (41.7%) and HICs (32.7%), with far fewer affiliated with lower middle-income (15.5%) and low-income countries (5.4%) (P < 0.001). In articles from low-income countries, first and last authors from HICs were more common than authors with low-income country affiliations (P < 0.001). CONCLUSIONS: Authorship parasitism was rare overall but common in multicountry studies. In studies conducted in low-income countries, HIC authors more commonly occupied first and last author positions than authors from the study countries. Where LMIC authors make substantial contributions, researchers should strive for authorship parity.

Children with access to improved sanitation but not improved water are at lower risk of stunting compared to children without access: a cohort study in Ethiopia, India, Peru, and Vietnam.

BACKGROUND: This study's purpose was to understand associations between water, sanitation, and child growth. METHODS: We estimated stunting (height-for-age Z score <-2 SD) and thinness (BMI-Z <-2 SD) risk ratios using data from 7,715 Ethiopian, Indian, Peruvian, and Vietnamese children from the Young Lives study. RESULTS: In unadjusted models, household access to improved water and toilets was often associated with reduced stunting risk. After adjusting for child, household, parent, and community variables, access to improved water was usually not associated with stunting nor thinness except in Ethiopia where access to improved water was associated with reduced stunting and thinness at 1y and 5y. In contrast, in both unadjusted and adjusted models, stunting at 1y was less common among children with good toilet access than among those without access and this difference persisted when children were 5y and 8y. For example, in adjusted estimates, Vietnamese 5y olds with access to improved toilets had relative stunting risk at 8y 0.62-0.68 that of 5y olds with no access to improved toilets. Water and toilets were rarely associated with thinness. CONCLUSIONS: Results from our study indicate that access to improved sanitation is more frequently associated with reduced stunting risk than access to improved water. However, additional studies are needed before drawing definitive conclusions about the impact of toilets relative to water. This study is the first to our knowledge to demonstrate the robust and persistent importance of access to improved toilets in infancy, not only during the first year but continuing into childhood. Additional longitudinal investigations are needed to determine concurrent and long-term associations of WASH with stunting and thinness.

Stunting in Infancy Is Associated with Decreased Risk of High Body Mass Index for Age at 8 and 12 Years of Age.

BACKGROUND: Effects of early-life stunting on adiposity development later in childhood are not well understood, specifically with respect to age in the onset of overweight and obesity. OBJECTIVES: We analyzed associations of infant stunting with prevalence of, incidence of, and reversion from high body mass index-for-age z score (BMIZ) later in life. We then estimated whether associations of infant stunting with BMIZ varied by sex, indigenous status, and rural or urban residence. METHODS: Data were collected from 1942 Peruvian children in the Young Lives cohort study at ages 1, 5, 8, and 12 y. Multivariable generalized linear models estimated associations of stunting (height-for-age z score <-2) at age 1 y with risk of BMIZ > 1 and BMIZ > 2 prevalence, incidence (moving above a BMIZ threshold between ages), and reversion (moving below a BMIZ threshold between ages) at later ages. RESULTS: After adjustment for covariates, stunting at age 1 y was associated with a lower prevalence of BMIZ > 1 at age 8 y (RR: 0.81; 95% CI: 0.66, 1.00; P = 0.049) and 12 y (RR: 0.75; 95% CI: 0.61, 0.91; P = 0.004), as well as a lower prevalence of BMIZ > 2 at age 8 y. Stunting was not associated with incident risk of BMIZ > 1 or BMIZ > 2. Stunting was positively associated at age 5 y with risk of reversion from BMIZ > 1 (RR: 1.22; 95% CI: 1.05, 1.42; P = 0.008) and BMIZ > 2. We found evidence that the association of stunting with prevalent and incident BMIZ > 1 was stronger for urban children at ages 5 and 8 y, and for nonindigenous children at age 8 y. CONCLUSIONS: Stunting predicted a lower risk of prevalent BMIZ > 1 and BMIZ > 2, even after controlling for potential confounders. This finding may be driven in part by a higher risk of reversion from BMIZ > 1 by age 5 y. Our results contribute to an understanding of how nutritional stunting in infancy is associated with BMIZ later in life.

Cross-Sectional and Longitudinal Associations between Household Food Security and Child Anthropometry at Ages 5 and 8 Years in Ethiopia, India, Peru, and Vietnam.

BACKGROUND: Poor childhood nutritional status has lifetime effects and food insecurity is associated with dietary practices that can impair nutritional status. OBJECTIVES: We assessed concurrent and subsequent associations between food insecurity and height-for-age z scores (HAZs) and body mass index-for-age z scores (BMI-Zs); evaluated associations with transitory and chronic food insecurity; and tested whether dietary diversity mediates associations between food insecurity and nutritional status. METHODS: We used data from the Young Lives younger cohort composed of children in Ethiopia (n = 1757), India (n = 1825), Peru (n = 1844), and Vietnam (n = 1828) recruited in 2002 (round 1) at ∼1 y old, with subsequent data collection at 5 y in 2006 (round 2) and 8 y in 2009 (round 3). RESULTS: Children from food-insecure households had significantly lower HAZs in all countries at 5 y (Ethiopia, -0.33; India, -0.53; Peru, -0.31; and Vietnam, -0.68 HAZ; all P < 0.001), although results were attenuated after controlling for potential confounders (Ethiopia, -0.21; India, -0.32; Peru, -0.14; and Vietnam, -0.27 HAZ; P < 0.01). Age 5 y food insecurity predicted the age 8 y HAZ, but did not add predictive power beyond HAZ at age 5 y in Ethiopia, India, or Peru. Age 5 y food insecurity predicted the age 8 y BMI-Z even after controlling for the 5 y BMI-Z, although associations were not significant after the inclusion of additional confounding variables (Ethiopia, P = 0.12; India, P = 0.29; Peru, P = 0.16; and Vietnam, P = 0.51). Chronically food-insecure households had significantly lower HAZs than households that were consistently food-secure, although BMI-Zs did not differ by chronic food-insecurity status. Dietary diversity mediated 18.8-30.5% of the association between food security and anthropometry in Vietnam, but mediated to a lesser degree (8.4-19.3%) in other countries. CONCLUSIONS: In 4 countries, food insecurity at 5 y of age was associated with both HAZ and BMI-Z at age 8 y, although the association was attenuated after adjusting for other household factors and anthropometry at age 5 y, and remained significant only for the HAZ in Vietnam.

Participation in the Juntos Conditional Cash Transfer Program in Peru Is Associated with Changes in Child Anthropometric Status but Not Language Development or School Achievement.

BACKGROUND: It is unclear what effects a conditional cash transfer (CCT) program would have on child anthropometry, language development, or school achievement in the context of the nutrition transition experienced by many low- and middle-income countries. OBJECTIVE: We estimated the association of participation in Peru's Juntos CCT with anthropometry, language development, and school achievement among children aged 7-8 y. METHODS: We used data from the Young Lives Study of a cohort born between 2001 and 2002. We estimated associations of the Juntos program with height-for-age z score (HAZ), body mass index-for-age z score (BAZ), stunting, and overweight at age 7-8 y separately for children participating in the program for ≥2 y (n = 169) and children participating for <2 y (n = 188). We then estimated associations with receptive vocabulary and grade achievement among children who had been assessed at age 4-6 y before enrollment in Juntos (n = 243). We identified control subjects using propensity score matching and conducted difference-in-differences comparisons. RESULTS: Juntos participation was associated with increases in HAZ among boys participating for ≥2 y [average effect of treatment among the treated (ATT): 0.43; 95% CI: 0.09, 0.77; P = 0.01] and for boys participating for <2 y (ATT: 0.52; 95% CI: 0.23, 0.80; P < 0.01). Among girls participating in the program for ≥2 y, BAZ declined (ATT: -0.60; 95% CI: -1.00, -0.21; P < 0.01) as did the prevalence of overweight (ATT: -22.0 percentage points; 95% CI: -42.5, -2.7 percentage points; P = 0.03). We observed no significant associations of Juntos participation with receptive vocabulary or grade attainment. CONCLUSIONS: CCT program participation in Peru was associated with better linear growth among boys and decreased BAZ among girls, highlighting that a large-scale poverty-alleviation intervention may influence anthropometric outcomes in the context of the nutrition transition.

Growth faltering and recovery in children aged 1-8 years in four low- and middle-income countries: Young Lives.

OBJECTIVE: We characterized post-infancy child growth patterns and determined the incidence of becoming stunted and of recovery from stunting. DESIGN: Data came from Young Lives, a longitudinal study of childhood poverty in four low- and middle-income countries. SETTING: We analysed length/height measurements for children at ages 1, 5 and 8 years. SUBJECTS: Children (n 7171) in Ethiopia, India, Peru and Vietnam. RESULTS: Mean height-for-age Z-score (HAZ) at age 1 year ranged from -1·51 (Ethiopia) to -1·08 (Vietnam). From age 1 to 5 years, mean HAZ increased by 0·27 in Ethiopia (P < 0·001) and decreased among the other cohorts (range: -0·19 (Peru) to -0·32 (India); all P < 0·001). From 5 to 8 years, mean HAZ increased in all cohorts (range: 0·19 (India) to 0·38 (Peru); all P < 0·001). Prevalence of stunting (HAZ<-2·0) at 1 year ranged from 21 % (Vietnam) to 46 % (Ethiopia). From age 1 to 5 years, stunting prevalence decreased by 15·1 percentage points in Ethiopia (P < 0·001) and increased in the other cohorts (range: 3·0 percentage points (Vietnam) to 5·3 percentage points (India); all P ≤ 0·001). From 5 to 8 years, stunting prevalence decreased in all cohorts (range: 5·0 percentage points (Vietnam) to 12·7 percentage points (Peru); all P < 0·001). The incidence of becoming stunted between ages 1 to 5 years ranged from 11 % (Vietnam) to 22 % (India); between ages 5 to 8 years, it ranged from 3 % (Peru) to 6 % (India and Ethiopia). The incidence of recovery from stunting between ages 1 and 5 years ranged from 27 % (Vietnam) to 53 % (Ethiopia); between ages 5 and 8 years, it ranged from 30 % (India) to 47 % (Ethiopia). CONCLUSIONS: We found substantial recovery from early stunting among children in four low- and middle-income countries.

Promoting Caregiver Early Childhood Development Behaviors through Social and Behavioral Change Communication Program in Tanzania.

Objectives: Stunting remains a prevalent issue in Tanzania. The consequences of stunting include reduced height, greater susceptibility to disease, and diminished cognitive ability throughout the lifespan. Lack of psychosocial stimulation is associated with increased stunting, particularly in terms of its cognitive impact. The Addressing Stunting in Tanzania Early (ASTUTE) program was a large social and behavior change communication (SBCC) intervention that aimed to reduce childhood stunting in the region by targeting early childhood development (ECD) behaviors. The purpose of this study is to report on the extent to which exposure to ASTUTE might be related to ECD behaviors. Methods: ASTUTE disseminated program messages via a mass media campaign and interpersonal communication (IPC). Logistic regression models were used to explore the relationship between exposure to TV, radio, IPC messages, and key ECD behaviors of female primary caregivers and male heads of household. Results: Among primary caregivers, IPC was positively associated with all ECD behaviors measured. Radio was associated with all behaviors except drawing with their child. TV was associated with all behaviors except playing with their child. Among heads of household, only the radio was positively associated with the ECD behaviors measured. Conclusions for practice: Findings indicate that SBCC interventions that include mass media and IPC components may be effective at promoting parental engagement in ECD behaviors. Significance: We know that ECD is important for a child's development. We know that parents play a critical role in promoting ECD behaviors. We are still exploring ways to influence parents so that they are more involved in ECD behaviors. The results presented here provide evidence for successful mass media and IPC efforts to improve parents' ECD behaviors. We hope this study will add more evidence for large interventions such as these to the literature, and we are very hopeful that governments and large international NGOs will prioritize SBCC approaches in the future, especially in locations where face-to-face interventions may be challenging.

Impact of early and concurrent stunting on cognition.

Undernutrition is associated with poor cognitive development, late entry into school, decreased years of schooling, reduced productivity and smaller adult stature. We use longitudinal data from 1674 Peruvian children participating in the Young Lives study to assess the relative impact of early stunting (stunted at 6-18 months of age) and concurrent stunting (stunted at 4.5-6 years of age) on cognitive ability. Anthropometric data were longitudinally collected for children at 6-18 months of age and 4.5-6 years of age at which time verbal and quantitative ability were also assessed. We estimate that an increase in concurrent height-for-age z-scores (HAZ) by one standard deviation was associated with an increase in a child's score on the Peabody Picture Vocabulary Test (PPVT) by 2.35 points [confidence interval (CI): 1.55-3.15] and a 0.16 point increase on the cognitive development assessment (CDA) (CI: 0.05-0.27). Furthermore, we report that the estimate for concurrent HAZ and PPVT is significantly higher than the estimate for early stunting and PPVT. We found no significant difference between early and concurrent estimates for HAZ and CDA. Children from older mothers, children whose mothers had higher education levels, children living in urban areas, children who attended pre-school, children with fewer siblings and children from wealthier backgrounds scored higher on both assessments. Cognitive skills of children entering school were associated with early stunting but the strongest association was found with concurrent stunting suggesting that interventions preventing linear growth faltering should not only focus on the under 2s but include children up to 5 years of age.

Health facility-based counselling and community outreach are associated with maternal dietary practices in a cross-sectional study from Tanzania.

BACKGROUND: Anemia and underweight among women are major public health challenges. Access to health services can improve dietary behaviors and women's nutritional status. We examined whether exposure to health services is associated with women's dietary practices in Tanzania. METHODS: Data come from a cross-sectional baseline survey among 5000 female primary caregivers who were randomly selected via two-stage sampling, prior to implementing a maternal and child nutrition program. We ran frequencies on women's exposure to existing health facility-based counselling, community health worker visits, and attendance at women's support groups. We examined associations between exposure to these interventions and maternal diets and adjusted for sociodemographic covariates using ordinary least squares regression and ordered logistic regression. RESULTS: A third of the sample (34.1%) had received any antenatal care (ANC) during their most recent pregnancy or had been advised by anyone about nutrition (37.0%). 68.0% had never had a community health worker (CHW) speak to them about their children's health and 9.4% had participated in a women's group. Only 8.0% of mothers ate more than usual during pregnancy and 7.1% ate more types of foods. After adjusting for mother's age, education and household assets, women who received nutrition advice were 1.3 times (95% CI: 1.1, 1.7) more likely than mothers who did not to eat more during pregnancy. Receiving antenatal care (ANC) and advice on nutrition before, during, and after pregnancy and delivery were highly associated with the mother eating more types of foods. Hearing from a CHW about children's health but not support group attendance was often associated with various dietary practices. Almost all measures of access to health services were significantly associated with mothers' frequency of eating in the previous 24 h. Receiving advice on nutrition during pregnancy and after giving birth and CHW contact were associated with mothers' dietary diversity in the previous 24 h. CONCLUSIONS: Several program exposure variables-especially being counselled about nutrition-were associated with improved dietary practices. Improving service delivery at scale may contribute to improved dietary behaviors in larger populations, given the associations we describe, along with findings from the existing literature.

Children who recover from early stunting and children who are not stunted demonstrate similar levels of cognition.

Stunting is associated with adverse cognitive development in childhood and adolescence, fewer years of schooling, decreased productivity, and reduced adult stature. Recovery from early stunting is possible; however, few studies explore whether those who demonstrate linear catch-up growth experience long-term cognitive deficits. Using longitudinal data on 1674 Peruvian children from the Young Lives study, we identified factors associated with catch-up growth and assessed whether children who displayed catch-up growth have significantly lower cognition than children who were not stunted during infancy and childhood. Based on anthropometric data for children 6-18 mo of age and again for the same children when they were 4.5-6 y of age, we categorized participants as not stunted, stunted in infancy but not childhood (catch-up), stunted in childhood, and stunted in infancy and childhood. Children who had grandparents in the home, had less severe stunting in infancy, and had taller mothers were more likely to demonstrate catch-up growth by round 2. Children who experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted (P = 0.6 and P = 0.7, respectively). Those stunted in childhood as well as those stunted in infancy and childhood scored significantly lower on both assessments than children who were not stunted. Based on findings from this study, policy makers and program planners should consider redoubling efforts to prevent stunting and promote catch-up growth over the first few years of life as a way of improving children's physical and intellectual development.

Exploring the relationship between chronic undernutrition and asymptomatic malaria in Ghanaian children.

BACKGROUND: A moderate association has been found between asymptomatic parasitaemia and undernutrition. However, additional investigation using the gold standard for asymptomatic parasitaemia confirmation, polymerase chain reaction (PCR), is needed to validate this association. Anthropometric measurements and blood samples from children less than five years of age in a rural Ghanaian community were used to determine if an association exists between chronic undernutrition and PCR-confirmed cases of asymptomatic malaria. METHODS: This was a descriptive cross-sectional study of 214 children less than five years of age from a community near Kumasi, Ghana. Blood samples and anthropometric measurements from these children were collected during physical examinations conducted in January 2007 by partners of the Barekuma Collaborative Community Development Programme. RESULTS: Findings from the logistic model predicting the odds of asymptomatic malaria indicate that children who experienced mild, moderate or severe stunting were not more likely to have asymptomatic malaria than children who were not stunted. Children experiencing anaemia had an increased likelihood (OR = 4.15; 95% CI: 1.92, 8.98) of asymptomatic malaria. Similarly, increased spleen size, which was measured by ultrasound, was also associated with asymptomatic malaria (OR = 2.17; 95% CI: 1.44, 3.28). Fast breathing, sex of the child, and age of the child were not significantly associated with the asymptomatic malaria. CONCLUSIONS: No significant association between chronic undernutrition and presence of asymptomatic malaria was found. Children who experience anaemia and children who have splenomegaly are more likely to present asymptomatic malaria. Programmes aimed at addressing malaria should continue to include nutritional components, especially components that address anaemia.

Are Household Expenditures on Food Groups Associated with Children's Future Heights in Ethiopia, India, Peru, and Vietnam?

Household expenditure surveys, routinely conducted in low-and middle-income countries (LMICs), usually include questions pertaining to recent household expenditures on key food groups. When child anthropometrics are also available, such expenditure data can provide insights into household food purchasing patterns that are associated with subsequent child growth measures. We used data from 6993 children, born around 2001, from Ethiopia, India, Peru, and Vietnam, from the Young Lives younger cohort. We compared associations between two weeks of household food expenditures (in PPP-Purchasing Power Parity adjusted dollars) on food groups and child height-for-age-Z score (HAZ) at subsequent time points to assess longitudinal associations. Total food expenditures, rural/urban residence, maternal and paternal schooling, and child sex were included in our adjusted models because they may affect the relations between household food group expenditures and future child HAZ. In Ethiopia, India, and Peru every extra PPP$ spent on fats was associated with 0.02-0.07 higher future HAZ. In Vietnam every extra PPP$ spent on starches, was significantly associated with a 0.01 lower future HAZ. Across countries, different patterns of food expenditure and procurement may be differentially critical for predicting child HAZ. Our results demonstrate how expenditures on specific food groups can be associated with children's linear growth. This study provides additional evidence of the utility of longitudinal household food expenditure data in understanding child nutritional status.

Improving Pediatric Academic Global Health Collaborative Research and Agenda Setting: A Mixed-Methods Study.

Academic global health collaborations have the potential to improve joint understanding of health issues in low- and middle-income countries (LMICs). Our objective was to elucidate perceptions of benefits and challenges of academic global health collaborations as well as areas for improving collaborative research conducted in LMICs. This cross-sectional, mixed-methods study surveyed investigators' perceptions of benefits and challenges of pediatric academic global health collaborations. Authors of articles from four pediatric journals reporting pediatric research conducted in LMICs published between 2006 and 2015 were surveyed. Responses of LMIC investigators were compared with those of investigators in high-income countries (HICs). Responses to open-ended questions were analyzed using a combined thematic and content analysis approach. Of 1,420 potential respondents, 252 (17.7%) responded to the survey. Collaborative research with investigators from other countries was perceived as beneficial by 88.5% of respondents (n = 223), although this perception was more common among HIC respondents (n = 110, 94.0%) than LMIC respondents (n = 113, 83.7%) (p = 0.014). Sixty-seven percent (n = 170) of respondents perceived that HIC investigators had set the research agenda in work conducted in a LMIC. Respondents identified several critical factors to improve academic global health collaborations, including research capacity building, communication, and early involvement of LMIC investigators with shared decision-making during study conception and grant writing. Pediatric academic global health collaboration was widely perceived as positive. However, despite calls for capacity building and locally generated research ideas, many respondents felt that HIC investigators set the research agenda for work conducted in LMICs. This study provides suggestions for improving collaboration among pediatric academicians globally.

An interpersonal nutrition campaign and maternal knowledge and childhood feeding practices: a case study from mothers in rural Indonesia.

BACKGROUND: The purpose of this study was to examine the extent to which a national nutrition communication campaign (NNCC) intervention providing interpersonal communication (IPC) was associated with improved knowledge and behaviors related to feeding practices among mothers with children under two years of age in rural Indonesia. METHODS: Data came from a follow-up, cross-sectional survey of 1734 mothers. Key outcomes of interest were minimum meal frequency, minimum dietary diversity and minimum acceptable diet, as defined by the World Health Organization. Associations between exposure to the NNCC intervention and infant and young child feeding (IYCF) knowledge and behaviors were analyzed using adjusted linear and logistic regression, controlling for age, education, and income. RESULTS: A total of 525 mothers reported exposure to IPC interventions (30.3%). Participation in IPC was associated with increased knowledge of feeding practices (p < .0001). Separately, knowledge of feeding practices was related to achieving recommended behavioral practices of minimum meal frequency (p = 0.019), dietary diversity (p = 0.013), adequate diet (p < .001). CONCLUSION: These findings underscore the value of increasing maternal knowledge of IYCF practices through IPC interventions as a way to improve behavioral practices and address stunting in rural Indonesia.

Caregiver verbal encouragement increases food acceptance among Vietnamese toddlers.

Responsive feeding, defined as the positive environment and caregiving behaviors that encourage children to eat, is critical to their physical, mental, and social development. However, research and programs designed to foster responsive feeding have been limited. This research tested the hypothesis that caregiver encouragement, caregiver and child behaviors, and other feeding characteristics were associated with acceptance of food. A total of 91 mother/child pairs in rural, northern Vietnam were videotaped during 2 2-h feeding episodes. Children were 12 and 17 mo of age at the time of study. Caregiver and child behaviors were coded at the level of the "intended bite" (7135 bites total). Feeding episodes were marked by few physical actions and minimal verbal encouragement by caregivers. Results from generalized linear mixed models suggest that when caregivers provided children with positive comments, children were 2.4 times as likely to accept bites compared with when no comments were given. Twelve-mo-olds who were in the caregiver's arms [odds ratio (OR) = 0.5] or lap (OR = 0.5) were significantly less likely than those who stood to accept bites. The 17-mo-olds who played were less likely than those with no physical action to accept bites. Play appeared to distract boys more than girls. In Vietnam, programs should help caregivers provide positive verbal encouragement to eat. Program planners and implementers may want to encourage caregivers to avoid force feeding and other forms of physical pressure. Further, mealtime should be seen as an opportunity to develop long-term feeding skills and encourage a healthy appetite.

When is deliberate killing of young children justified? Indigenous interpretations of infanticide in Bolivia.

In the Andes, as elsewhere, infanticide is a difficult challenge that remains largely undocumented and misunderstood. From January to March 2004 we used community-based vital event surveillance systems, discussions with health staff, ethnographic interviews, and focus group discussions among Aymara men and women from two geographically distinct sites in the Andes of Bolivia to provide insights into the practice of infanticide. We noted elevated mortality at both sites. In one location, suspected causes of infanticide were especially high for girls. We also observed that community members maintain beliefs that justify infanticide under certain circumstances. Among the Aymara, justification for infanticide was both biological (deformities and twinship) and social (illegitimate birth, family size and poverty). Communities generally did not condemn killing when reasons for doing so were biological, but the taking of life for social reasons was rarely justified. In this cultural context, strategies to address the challenge of infanticide should include education of community members about alternatives to infanticide. At a program level, planners and implementers should target ethnic groups with high levels of infanticide and train health care workers to detect and address multiple warning signs for infanticide (for example, domestic violence and child maltreatment) as well as proxies for infant neglect and abuse such as mother/infant separation and bottle use.