A Randomized Multiple Micronutrient Powder Point-of-Use Fortification Trial Implemented in Indian Preschools Increases Expressive Language and Reduces Anemia and Iron Deficiency.

BACKGROUND: Anemia is a global public health problem that undermines childhood development. India provides government-sponsored integrated nutrition/child development preschools. OBJECTIVES: This double-masked, cluster-randomized controlled trial examines whether point-of-use multiple micronutrient powder (MNP) compared with placebo fortification of preschool meals impacts child development and whether effects vary by preschool quality (primary outcome) and biomarkers of anemia and micronutrients (secondary outcomes). We also measured growth and morbidity. METHODS: We randomly assigned 22 preschools in rural India to receive MNP/placebo fortification. We administered baseline and endline blood sampling and measures of childhood development (Mullen Scales of Early Learning, inhibitory control, social-emotional), anthropometry, and morbidity to preschoolers (aged 29-49 mo). Preschools added MNP/placebo to meals 6 d/wk for 8 mo. We conducted linear mixed-effects regression models accounting for preschool clustering and repeated measures. We evaluated child development, examining effects in high- compared with low-quality preschools using the Early Childhood Environment Rating Scale-Revised and the Home Observation for the Measurement of the Environment Inventory, modified for preschools. RESULTS: At baseline, mean age ± SD was 36.6 ± 5.7 mo, with 47.8% anemic, 41.9% stunted, and 20.0% wasted. Baseline expressive/receptive language scores were higher in high-quality compared with low-quality preschools (P = 0.02 and P = 0.03, respectively). At endline (91% retention, n = 293/321), we found MNP compared with placebo effects in expressive language (Cohen's standardized effect d = 0.4), inhibitory control (d = 0.2), and social-emotional (d = 0.3) in low-quality, not high-quality, preschools. MNP had significantly greater reduction of anemia and iron deficiency compared with placebo (37% compared with 13.5% and 41% compared with 1.2%, respectively). There were no effects on growth or morbidity. CONCLUSIONS: Providing multiple micronutrient-fortified meals in government-sponsored preschools is feasible; reduced anemia and iron deficiency; and, in low-quality preschools, increased preschoolers' expressive language and inhibitory control and reduced developmental disparities. Improving overall preschool quality by incorporating multiple components of nurturing care (responsive care, learning, and nutrition) may be necessary to enhance preschoolers' development. This trial was registered at clinicaltrials.gov as NCT01660958.

Mechanisms linking height to early child development among infants and preschoolers in rural India.

Stunting has been negatively associated with children's development. We examined the range of height by testing hypotheses: (a) height is positively associated with children's development, with associations moderated by inflammation and (b) home environments characterized by nurturance and early learning opportunities is positively associated with children's development over time and attenuate associations with height. Data included 513 infants (mean age 8.6 months) and 316 preschoolers (mean age 36.6 months) in rural India from a randomized controlled trial of multiple micronutrient powders (MNPs). Measures included height (height-for-age z-scores based on WHO standards), inflammation (C-reactive protein concentration >5 mg/L), nurturance (HOME Inventory), child development (Mullens Scales of Early Learning), and inhibitory control (preschoolers). Linear mixed effects models accounting for repeated measures, clustering, and confounders were used to assess associations between height and child development over time (infants: enrollment, 6 and 12 months; preschoolers: enrollment and 8 months). Moderating effects of inflammation and nurturance were tested with interaction terms. Among infants and preschoolers, height and nurturance were positively associated with all domains of child development over time, with the exception of inhibitory control. Among preschoolers, in the presence of inflammation, height was not associated with child development. Among infants, but not preschoolers, a nurturant home environment attenuated significant associations between height with fine motor and receptive language development. The mechanisms associated with children's development over time are multifactorial and include direct and indirect associations among nutrition, health, and the home environment, as supported by the Nurturing Care Framework.

Teaching to varied disciplines and educational levels simultaneously: An innovative approach in a neonatal follow-up clinic.

PURPOSE: Across various health conditions and geographic regions, there remains a dearth of clinicians with the expertise and confidence to identify and manage children with disabilities. At the front line of this crisis are clinician-educators, who are tasked with caring for these unique patients and with training the future workforce. Balancing patient care and clinical instruction responsibilities is particularly challenging when trainees of varied educational levels and specialties report simultaneously. The lack of a standard curriculum further compounds the clinician-educator's teaching demands and threatens the consistency of trainees' learning. Recognizing these challenges in their work in a neonatal follow-up clinic, the authors sought a solution through an established curriculum development process. MATERIALS AND METHODS: A needs assessment survey was conducted to gauge medical trainees' knowledge, skills, and experiences. Applying needs assessment findings, the authors developed a curriculum, which was administered online to several trainee cohorts just prior to rotations in the neonatal follow-up clinic. RESULTS: After completing the curriculum, trainees scored significantly higher on neonatal follow-up knowledge tests. CONCLUSIONS: Providing advance exposure helped to ensure that trainees arrived with comparable basal knowledge, which served as a foundation for more advanced instruction. This curricular approach may be useful across teaching venues, especially those with multi-level or multi-discipline learners.

Civil Unrest in the Context of Chronic Community Violence: Impact on Maternal Depressive Symptoms.

OBJECTIVES: To examine changes in maternal-child health surrounding the April 2015 civil unrest in Baltimore, Maryland, following Freddie Gray's death while in police custody. METHODS: We conducted cross-sectional Children's HealthWatch surveys January 2014 through December 2015 in pediatric emergency departments and primary care clinics on maternal-child health and June 2015 through October 2015 on daily and community routines. We used trend analysis and piecewise logistic regression to examine effects of time, residential proximity moderation, and mediation analysis to assess proximity and maternal-child health relations via maternal concerns. RESULTS: Participants comprised 1095 mothers, 93% of whom were African American and 100% of whom had public or no insurance; 73% of participants' children were younger than 24 months. Following the unrest, prevalence of maternal depressive symptoms increased significantly in proximal, but not distal, neighborhoods (b = 0.41; 95% confidence interval [CI] = 0.03, 0.79; P = .03). Maternal concerns were elevated in proximal neighborhoods and associated with depressive symptoms; mediation through maternal concern was not significant. Five months after the unrest, depressive symptoms returned to previous levels. CONCLUSIONS: Civil unrest has an acute effect on maternal depressive symptoms in neighborhoods proximal to unrest. Public Health Implications. To mitigate depressive symptoms associated with civil unrest, maintain stability of community routines, screen for maternal depressive symptoms, and provide parent-child nurturing programs.

Population Attributable Fraction of Anemia Associated with Plasmodium falciparum Infection in Children in Southern Malawi.

Anemia is a leading cause of morbidity in sub-Saharan Africa. The etiologies of anemia are multifactorial, and it is unclear what proportion of anemia is attributable to malaria in children of different ages in Malawi. We evaluated the population attributable fraction (PAF) of anemia due to malaria using multiple cross-sectional surveys in southern Malawi. We found a high prevalence of anemia, with the greatest proportion attributable to malaria among school-age children (5-15 years) in the rainy season (PAF = 18.8% [95% CI: 16.3, 21.0], compared with PAF = 5.2% [95% CI: 4.0, 6.2] among young children pooled across season [< 5 years] and PAF = 9.7% [95% CI: 6.5, 12.4] among school-age children in the dry season). Malaria control interventions will likely lead to decreases in anemia, especially among school-age children.

Effect of Extended Prophylactic Antibiotic Duration in the Treatment of Open Fracture Wounds Differs by Level of Contamination.

OBJECTIVE: To determine the association between prophylactic antibiotic duration after the definitive wound closure of an open fracture and deep surgical site infection (SSI). DESIGN: Retrospective cohort study. SETTING: 41 clinical sites in the United States, Canada, Australia, Norway, and India. PARTICIPANTS: Patients (N = 2400) with open fractures of the extremities who participated in the Fluid Lavage of Open Wounds (FLOW) trial. INTERVENTION: Extended antibiotic prophylaxis, defined as more than 72 hours of continuous antibiotic use after definitive wound closure. MAIN OUTCOME MEASUREMENT: Deep SSI diagnosed within 1 year of enrollment. RESULTS: Forty-two percent of participants received extended antibiotic prophylaxis. Deep SSI prevalence was 5%, 8%, and 23% for wounds with mild, moderate, and severe contamination, respectively. In open fractures with mild contamination, extended antibiotic use showed a trend toward increased odds [adjusted odds ratio (aOR) = 1.39; 95% confidence interval (CI), 0.92-2.11] of deep SSI compared with shorter use. No association was found among patients with moderate contamination (aOR = 1.09; 95% CI, 0.53-2.27). By contrast, extended antibiotic prophylaxis was strongly protective (aOR = 0.20; 95% CI, 0.07-0.60) against deep SSI in patients with severe contamination. Propensity score sensitivity analysis results were consistent with these findings. CONCLUSIONS: The evidence suggests differential effects of extended postclosure antibiotic duration on SSI odds contingent on the degree of contamination in open fracture wounds. Although extended antibiotic duration resulted in lower odds of SSI among patients with severely contaminated wounds, we observed a trend toward higher odds of SSI in mildly contaminated wounds. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Angiotensin converting enzyme inhibitors and interstage failure in infants with hypoplastic left heart syndrome.

INTRODUCTION: Angiotensin converting enzyme inhibitors are commonly prescribed medications after the Norwood procedure. There are little data that can be used to determine if angiotensin converting enzyme inhibitors improve interstage outcomes in children with single ventricle defects. The objective of this study was to investigate the relationship between angiotensin converting enzyme inhibitors and interstage failure among infants born with hypoplastic left heart syndrome. METHODS: We conducted a retrospective cohort study using data from the National Pediatric Cardiology Quality Improvement Collaborative database (collected between 2008 and 2015). We used logistic regression models to assess the exposure-outcome associations and propensity score matching to account for differences in baseline patient characteristics associated with use of angiotensin converting enzyme inhibitors. RESULTS: A total of 1 487 neonates participated in the study. Thirty-nine percent of patients were prescribed angiotensin converting enzyme inhibitors after the Norwood procedure; 11% experienced interstage failure (death, heart transplantation, and not being a candidate for the second-stage surgery). Before propensity score matching, patients receiving angiotensin converting enzyme inhibitors were significantly more likely to experience interstage failure, compared to patients not on angiotensin converting enzyme inhibitors (OR = 1.44; 95% CI: 1.04, 1.99; P = 0.03). Although there was an increased odds of interstage failure among patients receiving angiotensin converting enzyme inhibitors compared to patients not receiving angiotensin converting enzyme inhibitors in the propensity score-matched cohort, this association was not significantly different (adjusted OR = 1.29; 95% CI: 0.88, 1.95; P = 0.18). CONCLUSION: Angiotensin converting enzyme inhibitor therapy did not demonstrate a beneficial effect on interstage failure among infants with hypoplastic left heart syndrome, even when patient characteristics associated with the use of angiotensin converting enzyme inhibitors were considered.

Do Parental Concerns Predict Developmental and Behavioral Diagnoses in a Developmental Clinic?

Parental concerns are useful tools to help pediatric care providers identify the presence of developmental and behavioral problems. This study sought to learn whether specific parental concerns helped predict diagnoses in a tertiary developmental clinic. Parents of preschoolers who attended a preschool developmental clinic (n = 101) were surveyed about behavioral and developmental concerns and their concerns about possible diagnoses. Clinical diagnoses were subsequently obtained on all children and compared with parents' primary concerns. In our sample, approximately 50% of concerns were about language development and 21% about behavior. The most common diagnoses were communication disorder (41%) and developmental delay (42%). Only 30% of children whose parents had concerns about an autism spectrum diagnosis had actually received that diagnosis. Neither parental concerns about development and behavior nor their concerns about specific diagnosis predict clinical diagnosis in our tertiary developmental setting.

Health outcomes of neonates with osteogenesis imperfecta: a cross-sectional study.

OBJECTIVE: To assess at-birth health outcomes of neonates with osteogenesis imperfecta (OI). STUDY DESIGN: A total of 53 women who self-reported having had at least one child with OI completed the survey. We evaluated pregnancy length, neonatal intensive care unit (NICU) usage, at-birth complications, and the child's clinical information including OI type, height and weight. RESULTS: Information was gathered on a total of 77 children (60 type I, 4 type III and 13 type IV). Health conditions reported at birth included breech presentation (24%), prematurity (27%), fracture (18%), bone deformity (18%) and respiratory problems (22%). Approximately 31% (n = 24) received NICU care. There was a significant association between younger maternal age, preterm delivery and NICU admission. CONCLUSION: Our findings suggest that newborns with OI appear to be at high risk of skeletal disorders, preterm delivery and breech presentation. Younger maternal age and preterm delivery seem to be strong predictors of the need for NICU care. Our data suggest that pregnant women with OI younger than 20 years of age may benefit from added clinical supervision in anticipation of adverse effects on their child.