Subnational estimates of vitamin A supplementation coverage in children: a geospatial analysis of 45 low- and middle-income countries.

OBJECTIVES: Vitamin A supplementation (VAS) can protect children from the adverse health consequences of vitamin A deficiency. Granular data on VAS coverage can guide global and national efforts to achieve universal VAS coverage. To provide geographically precise targeting of VAS programs and to monitor progress in reducing geographic disparities, we aimed to create high-resolution (5 × 5 km2) maps of VAS coverage in children under 5 years across VAS priority countries. STUDY DESIGN: We used cross-sectional data from the Demographic and Health Surveys (DHS) program. METHODS: We used data from the DHS program for United Nations Children's Fund -designated VAS priority countries between 2000 and 2017 with data available from 2005 or later. The outcome variable was the proportion of children under 5 years who received a vitamin A dose in each sampled cluster. We applied a Bayesian geostatistical approach incorporating geographic, climatic, and nutritional covariates to estimate VAS coverage for each cell. We estimated and mapped absolute VAS coverage, Bayesian uncertainty intervals, and exceedance probabilities. RESULTS: Our sample included countries from Latin America and the Caribbean, Asia, and Africa. Most countries had estimated VAS coverage levels <70%, and our exceedance probabilities indicated high certainty that our estimates fell below this threshold in most grid cells. International variations were most notable in the Latin America and the Caribbean region and Africa. Intranational variations were greatest in some South Asian and West and Central African countries. CONCLUSIONS: These prevalence and exceedance maps, especially used with data on indicators of VAS need, could help to improve equity.

The association of preterm birth and small birthweight for gestational age on childhood disability screening using the Ten Questions Plus tool in rural Sarlahi district, southern Nepal.

CONTEXT: The Ten Questions tool was developed in 1984 as a low-cost, simple screen for childhood disability and referral for diagnosis in low-resource settings, and its use in Nepal has not been previously evaluated. Preterm birth and intrauterine growth restriction are potential risk factors for child disability and loss of developmental potential, but there are few studies examining this relationship from developing settings. OBJECTIVE: To examine the associations of small for gestational age and preterm birth as predictors of Ten Questions Plus positivity. DESIGN, SETTING AND PARTICIPANTS: The Ten Questions Plus questionnaire was administered to caregivers of 680 children between 2 and 5 years of age from August 2007 to March 2008 in rural Sarlahi, southern Nepal. Participants had previously been enrolled in a randomized trial of chlorhexidine cleansing at birth. At 1 month of age, children were then enrolled into a randomized 2 × 2 factorial trial of daily iron and zinc supplementation between October 2001 and January 2006. INTERVENTION: None. MAIN OUTCOME MEASURE: Positive screen on the Ten Questions Plus tool defined as a positive response to one or more questions. RESULTS: Of preterm children, 37 (33.6%) had a positive response to at least one question on the Ten Questions Plus and were considered at risk for disability. One hundred and seventy term children (29.8%) were at risk for disability. CONCLUSIONS: The Ten Questions Plus tool can be used in this rural Nepali setting to identify children at increased risk for mental and physical disability to be targeted for further examination. The prevalence of parent-reported disabilities is high in this population (almost one-third of children); children who are both preterm and small-for-gestational age are at increased risk for motor milestone delay, reported learning difficulty, speech and behavioural problems. Intrauterine growth restriction may affect child development and result in disabilities later in childhood.

Impact of clean delivery kit use on clean delivery practices in Beni Suef Governorate, Egypt.

OBJECTIVE: A major factor contributing to neonatal and maternal infections is unhygienic delivery practices. This study explores the impact of clean delivery kit (CDK) use on clean delivery practices during home and facility deliveries. DESIGN: Kits were distributed from primary care facilities and mothers and birth attendants received training on kit importance and use. The study was designed as a cross-sectional cohort study. Raedat (community health workers) visited 349 women during the postpartum period to administer a structured questionnaire. SETTING: The study was conducted from mid-March through mid-July 2001 in two rural areas of Ihnasia district in Beni Suef Governorate (Upper Egypt). RESULT: In bivariate analysis, CDK users in the home were more likely to report that the birth attendant had clean hands (P<0.001), washed/wiped the mother's perineum (P<0.001), used a sterile cord tie (P=0.001), applied antiseptic to the cord after cutting (P<0.001), and used a sterile cord cover (P<0.001) as compared with non-CDK users. CDK users at the facility were more likely to report that the birth attendant washed/wiped the mothers perineum (P=0.049) and used a sterile cord cover (P=0.030) as compared with non-CDK users. CONCLUSION: In settings in which unhygienic practices during home as well as facility deliveries are prevalent, use of inexpensive CDKs can promote clean delivery practices.

Traditional birth attendants in rural Nepal: knowledge, attitudes and practices about maternal and newborn health.

Efforts to formalise the role of traditional birth attendants (TBAs) in maternal and neonatal health programmes have had limited success. TBAs' continued attendance at home deliveries suggests the potential to influence maternal and neonatal outcomes. The objective of this qualitative study was to identify and understand the knowledge, attitudes and practices of TBAs in rural Nepal. Twenty-one trained and untrained TBAs participated in focus groups and in-depth interviews about antenatal care, delivery practices, maternal complications and newborn care. Antenatal care included advice about nutrition and tetanus toxoid (TT) immunisation, but did not include planning ahead for transport in cases of complications. Clean delivery practices were observed by most TBAs, though hand-washing practices differed by training status. There was no standard practice to identify maternal complications, such as excessive bleeding, prolonged labour, or retained placenta, and most referred outside in the event of such complications. Newborn care practices included breastfeeding with supplemental feeds, thermal care after bathing, and mustard seed oil massage. TBAs reported high job satisfaction and desire to improve their skills. Despite uncertainty regarding the role of TBAs to manage maternal complications, TBAs may be strategically placed to make potential contributions to newborn survival.

The effect of maternal micronutrient supplementation on early neonatal morbidity in rural Nepal: a randomised, controlled, community trial.

OBJECTIVE: Micronutrient deficiencies during pregnancy may be linked to poor newborn health and poor host defences against infection. We assessed newborn morbidity to determine the effect of four combinations of antenatal micronutrient supplements. DESIGN: Cluster-randomised, double-masked, controlled trial. SETTING: Rural community in Nepal. INTERVENTIONS: Women received daily supplements from early pregnancy through to 3 months postpartum of vitamin A alone (control) or vitamin A with folic acid, folic acid plus iron, folic acid plus iron plus zinc or a multiple micronutrient supplement containing these and 11 other nutrients. MAIN OUTCOME MEASURES: Infants were visited in their home at birth (n = 3927) and for each of 9 days thereafter to elicit a 24-h history of nine infant morbidity symptoms, measure infant respiratory rate and axial temperature, and assess the infant for chest indrawing. At 6 weeks of age, infants were visited again in their homes to elicit a 30-day and 7-day history of 10 morbidity symptoms using parental recall. RESULTS: Maternal micronutrient supplementation had no effect on 10-day morbidity or morbidity 30-day and 7-day morbidity assessed at 6 weeks of age all relative risks were close to 1. Symptoms of birth asphyxia increased by about 60% (p<0.05) in infants of women who received the multiple micronutrient supplement compared with the control. Symptoms of combinations of sepsis, preterm and birth asphyxia were associated with 8- to 14-fold increased odds of 6-month infant mortality. CONCLUSIONS: None of the combinations of antenatal micronutrient supplements tested improved symptoms of neonatal morbidity in the first 10 days of life or at 6 weeks of age. Further research is needed to elucidate the association and mechanism of increased risk of birth asphyxia following maternal multiple micronutrient supplementation. TRIAL REGISTRATION NUMBERS: NCT00115271.

Household knowledge and practices of newborn and maternal health in Haripur district, Pakistan.

OBJECTIVE: To learn about household maternal and newborn health knowledge and practices to aid the design of newborn programming within Save the Children's Haripur Program. STUDY DESIGN: In April, we conducted 43 semi-structured interviews (SSIs) and 34 focus group discussions among men, women of reproductive age and health service providers; in September, we added 21 SSIs among new mothers, new fathers and dais. Two investigators analyzed the findings according to themes within six care types: antenatal, delivery, immediate newborn, routine postpartum, special maternal and special newborn. RESULT: Findings indicated poor maternal diet and antenatal care-seeking. Home delivery with an untrained dai was the norm. Respondents knew about benefits of clean delivery, but rarely put knowledge into practice. Knowledge and practices for maintaining the newborn's warmth were good. Delayed initiation of breastfeeding, avoidance of colostrum and prelacteal feeding were almost universal. Unhygienic cord care, including an unclean cut and application of ghee on the cord-stump, was the norm. After delivery, mothers often maintained low fluid intake but otherwise reported healthy nutritional practices. Knowledge of some danger signs in newborns was common, but timely action upon recognition was not. CONCLUSION: Although the findings illustrate some beneficial practices, many reported practices are harmful to the newborn. These findings, consistent with the sparse existing data in Pakistan, inform program interventions for household-level behavioral change.

Impact of topical oils on the skin barrier: possible implications for neonatal health in developing countries.

UNLABELLED: Topical therapy to enhance skin barrier function may be a simple, low-cost, effective strategy to improve outcome of preterm infants with a developmentally compromised epidermal barrier, as lipid constituents of topical products may act as a mechanical barrier and augment synthesis of barrier lipids. Natural oils are applied topically as part of a traditional oil massage to neonates in many developing countries. We sought to identify inexpensive, safe, vegetable oils available in developing countries that improved epidermal barrier function. The impact of oils on mouse epidermal barrier function (rate of transepidermal water loss over time following acute barrier disruption by tape-stripping) and ultrastructure was determined. A single application of sunflower seed oil significantly accelerated skin barrier recovery within 1 h; the effect was sustained 5 h after application. In contrast, the other vegetable oils tested (mustard, olive and soybean oils) all significantly delayed recovery of barrier function compared with control- or Aquaphor-treated skin. Twice-daily applications of mustard oil for 7 d resulted in sustained delay of barrier recovery. Moreover, adverse ultrastructural changes were seen under transmission electron microscopy in keratin intermediate filament, mitochondrial, nuclear, and nuclear envelope structure following a single application of mustard oil. CONCLUSION: Our data suggest that topical application of linoleate-enriched oil such as sunflower seed oil might enhance skin barrier function and improve outcome in neonates with compromised barrier function. Mustard oil, used routinely in newborn care throughout South Asia, has toxic effects on the epidermal barrier that warrant further investigation.

Rapid identification and antibiotic susceptibility testing of Salmonella enterica serovar Typhi isolated from blood: implications for therapy.

The turnaround time (TAT) for Salmonella enterica serovar Typhi identification and reporting of the antibiotic susceptibility profile was determined for 391 cases of typhoid fever, using the lysis direct plating or lysis centrifugation method of blood culture along with rapid antimicrobial susceptibility testing. The TAT was more rapid (TAT for 90% of the patients [TAT(90)] = 30 h; TAT(100)

Zinc supplementation during pregnancy and effects on growth and morbidity in low birthweight infants: a randomised placebo controlled trial.

BACKGROUND: Infant malnutrition and mortality rates are high in less-developed countries especially in low-birthweight infants. Zinc deficiency is also widely prevalent in these circumstances. We aimed to assess the effect of daily zinc supplements given to pregnant mothers on their infants' growth and morbidity. METHODS: We did a double-blind, placebo controlled, randomised trial in 199 and 221 Bangladeshi infants whose mothers took 30 mg daily elemental zinc or placebo, respectively, from 12 to 16 weeks' gestation until delivery. Infants were followed up until 6 months of age. We obtained data for morbidity every week by mothers' recall. Infants' anthropometric measurements were done every month, and their serum zinc was assessed at 1 and 6 months of age. FINDINGS: Infants of mothers who received zinc during pregnancy had at age 6 months reduced risks compared with those in the placebo group for acute diarrhoea (risk ratio 0.84; 95% CI 0.72-0.98), dysentery (0.36; 0.25-0.84), and impetigo (0.53; 0.34-0.82). These reductions were seen in low-birthweight infants but not in those with normal birthweight. There were no differences in infant growth or serum zinc concentrations between treatment groups. INTERPRETATION: Maternal zinc supplementation during pregnancy resulted in a reduction of the health risks in Bangladeshi low-birthweight infants, although this intervention did not improve birthweight. Whether zinc should be added to usual antenatal supplements in regions with high rates of low birthweight should be reviewed.

Dermatitis as a presenting sign of cystic fibrosis.

BACKGROUND: Three percent to 13% of patients with cystic fibrosis present with protein-energy malnutrition that is characterized by hypoproteinemia, edema, and anemia and is associated with high morbidity and mortality. Cutaneous manifestations of malnutrition are rare in patients with cystic fibrosis and have been attributed to deficiencies of protein, zinc, and essential fatty acids. OBSERVATIONS: We describe five patients who presented with failure to thrive, hypoproteinemia, edema, and a cutaneous eruption before the onset of pulmonary symptoms and before the diagnosis of cystic fibrosis was made. The rash had a predilection for the extremities (lower > upper), perineum, and periorificial surfaces. In most cases, erythematous, scaling papules developed by 4 months of age and progressed within 1 to 3 months to extensive, desquamating plaques. Alopecia was variable, and mucous membrane or nail involvement was not observed. The rash was associated with malnutrition and resolved in all survivors within 10 days of providing pancreatic enzyme and nutritional supplementation. The pathogenesis of the rash is unclear, but it appears to stem from deficiencies of zinc, protein, and essential fatty acids and may be mediated by alterations in prostaglandin metabolism. CONCLUSIONS: Cystic fibrosis should be included in the differential diagnosis of the red, scaly infant, particularly when failure to thrive, hypoproteinemia, and edema are also present. Recognition of rash as a sign of cystic fibrosis complicated by protein-energy malnutrition will allow earlier diagnosis and treatment of these patients and may improve their outcome.