Structured early childhood education exposure and childhood cognition - Evidence from an Indian birth cohort.

Experiences in early childhood form the bedrock of future human potential. In impoverished settings, structured early childhood education (ECE) in preschool years can augment overall childhood and later human abilities. The current study evaluates preschool learning exposure and childhood cognition, using longitudinal follow-up of a community-based birth cohort in Vellore, south India. The birth cohort study site in Vellore recruited 251 newborns between 2010 and 2012 from dense urban settlements and further followed up into childhood. Preschool enrolment details were obtained from parents. Childhood cognition was assessed by Weschler's preschool primary scale of intelligence (WPPSI) and Malin's intelligence scale for Indian Children (MISIC) at 5 and 9 years of age respectively. Bivariate and multivariate regression analyses were performed with adjustments for socio-economic status (SES), maternal education, stunting status and home environment. Out of 251 new-borns recruited into the MAL-ED birth cohort, 212 (84.46%) and 205 (81.7%) children were available for the 5 year and 9 year follow-up respectively. At 5 years, structured ECE of 18 to 24 months duration was significantly associated with higher cognition scores, with the highest increase in processing speed [ß: 19.55 (11.26-27.77)], followed by full-scale intelligence [ß: 6.75 (2.96-10.550)], even after adjustments for SES, maternal cognition, home factors and early childhood stunting status. Similarly adjusted analysis at 9 years showed that children who attended 1.5-2 years of structured ECE persisted to have higher cognition, especially in the performance domain [ß: 8.82 (2.60-15.03)], followed by the full-scale intelligence [ß: 7.24 (2.52-11.90)]. Follow-up of an Indian birth cohort showed that structured ECE exposure was associated with better school entry cognition as well as mid-childhood cognition. Strengthening ECE through a multi-pronged approach could facilitate to maximize cognitive potential of human capital.

Early Childhood Stimulating Environment Predicts Later Childhood Resilience in an Indian Longitudinal Birth Cohort Study.

BACKGROUND: Human resilience is dynamic and generated through myriad interactions starting from early childhood. Resilience can improve quality of life and longevity. OBJECTIVE: The current analysis evaluates childhood resilience at 9 years of age and its associations with concurrent cognition and early childhood factors, using longitudinal follow-up of a community birth cohort in Vellore, south India. METHODS: Resilience was assessed using the Child and Youth Resilience Measure and cognition utilizing the Malin's Intelligence Scale for Indian Children. Early childhood variables included growth stunting, maternal depression scores, home environment scores, and socio-economic status (SES) at 2 years of age. Statistical evaluation included bivariate analysis with further multi-variate regression for each resilience domain and the total resilience score. FINDINGS: Out of 251 newborns recruited into the original birth cohort, 205 (81.7%) children were available for the 9-year follow-up. Mean (SD) scores in individual, caregiving, and context domains of resilience were 26.34 (3.2), 19.52 (1.6), and 20 (1.8) respectively. Individual resilience domain was associated with verbal cognition scores at 9 years of age (0.07, p = 0.019) and total home environment scores (0.16, p = 0.027) at 2 years of age, when adjusted for stunting, maternal depression, and SES. The total resilience score was associated only with concurrent verbal intelligence (0.08, p = 0.026) after adjustment with early childhood factors. Analysis of individual home environment factors showed that daily stimulation was associated with the individual domain of resilience. CONCLUSIONS: Follow-up of an Indian birth cohort showed that in addition to concurrent cognitive abilities, childhood resilience was related to early childhood stimulating home environment. Promoting optimal stimulating home environments in low-resource settings to nurture holistic childhood development including mental health is essential.

Knowledge, Attitude and Practices of Contraceptives Among Married Women of Rural Vellore.

Introduction: Ensuring reproductive health is central to the process of developing and improving the health of women and children and is linked to the issues such as sexually transmitted diseases, poverty, education, gender equality, and human rights. This community-based cross-sectional study was conducted to assess the knowledge, attitude, and practices of contraceptives of married women aged 18-49 years in rural Vellore, Tamil Nadu. Methods: This study was conducted in Kaniyambadi block in Vellore, Tamil Nadu. Two-stage cluster sampling was used. A total of 200 households were selected. From each household, one eligible woman was selected. Results: Two hundred women participated in the study. Nine percent had good knowledge, 52.5% had a good attitude and 67.5% had good practices as defined by this study. Education, belonging to non-scheduled caste, age, type of family, and the number of living children were significantly associated with knowledge, attitude, and practices in both bivariate analysis and multivariate analysis. The main reasons for not using contraception were the desire to have a child and the fear of side effects of contraceptives. Conclusion: Despite poor knowledge levels and moderate levels of good attitude, modern contraceptive usage in this study population was high. Women thought traditional methods were more effective than modern contraceptives. Permanent sterilization in women was the widely practiced modern contraceptive method. Strategies and methods to improve knowledge, and adoption of modern contraceptive usage among women and men need to be designed, implemented and studied.

Secular Growth Trends in Early Childhood-Evidence from Two Low-Income Birth Cohorts Recruited over a Decade in Vellore, India.

Stunting and extreme poverty are considered significant risk factors impacting child development in low-and-middle-income countries. We used two birth cohorts recruited 8-9 years apart in urban low-income (slum) settings in Vellore, south India and analyzed secular growth trends and their predictors. In the rotavirus cohort recruited between 2002 and 2003, 373 children completed the 3-year follow-up. "The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development" (MAL-ED) cohort recruited between 2010 and 2012 had 215 children completing follow-up. The MAL-ED cohort had better socio-economic status (SES) markers and mothers were better educated compared with the previous cohort. Children in the MAL-ED cohort had less stunting at 1, 2, and 3 years of age. The linear mixed effects model evaluating linear growth during the first 3 years of age showed that low birth weight and being a female child were associated with stunting in both cohorts. There was no association between SES and stunting in the rotavirus cohort, whereas SES was associated with linear growth in the MAL-ED cohort. Future studies could incorporate nutritional and nonnutritional interventions in vulnerable populations to evaluate their effect on birth weight as well as early childhood stunting.

Are early childhood stunting and catch-up growth associated with school age cognition?-Evidence from an Indian birth cohort.

BACKGROUND: Millions of children worldwide especially in the Asian subcontinent are vulnerable to early childhood stunting. There are contradictory reports of the association between catch-up growth in childhood and school age cognition. METHODS: A community-based birth cohort recruited between 2010 and 2012 from urban slums in Vellore, India was followed up until 9 years of age. From regular anthropometric measurements, stunting status for each individual child was calculated at 2, 5 and 9 years. Cognition was assessed at 9 years of age using the Malin's Intelligence Scale for Indian Children (MISIC). Children were divided into groups based on stunting at each time point as well as catch-up growth, and a regression model was utilised to evaluate their association with cognition at 9 years. RESULTS: Among 203 children included in this analysis, 94/203 (46.31%) children were stunted at 2 years of age, of whom 39.36% had a catch-up growth at 5 years of age, and 38.30% at 9 years. Around 10% of the cohort remained stunted at all time points. In the multivariable analysis, children who were stunted at 2, 5 and 9 years had a significantly lower verbal and total intelligence quotient (IQ) scores by 4.6 points compared to those who were never stunted. Children with catch up growth following stunting at 2 years had higher cognition scores than those who were persistently stunted throughout the childhood. CONCLUSIONS: This study showed persistent stunting in childhood was associated with lowering of 4-5 IQ points in childhood cognition at 9 years of age. Recovery from early life stunting in children with catch up growth prevented further lowering of cognition scores in these children compared to persistently stunted children. Nutritional supplementation during late infancy and early toddlerhood in addition to continuing nutritional supplementation programmes for preschool and school children can improve childhood stunting and cognitive abilities in vulnerable populations.

Implementing FCTC Article 17 Through Participatory Research With Bidi Workers in Tamil Nadu, India.

INTRODUCTION: The exploitation, poor conditions, and precarity in the bidi (hand-rolled leaf cigarette) industry in India make it ripe for the application of the FCTC's Article 17, "Provision of support for economically viable alternative activities". "Bottom-up", participatory approaches give scope to explore bidi rollers' own circumstances, experiences, and aspirations. METHODS: A team of six community health volunteers using a participatory research orientation developed a questionnaire-based semi-structured interview tool. Forty-six bidi rolling women were interviewed by pairs of volunteers in two northern Tamil Nadu cities. Two follow-up focus groups were also held. A panel of 11 bidi rollers attended a workshop at which the findings from the interviews and focus groups were presented, further significant points were made and possible alternatives to bidi rolling were discussed. RESULTS: Bidi workers are aware of the adverse impact of their occupation on them and their families, as well as the major risks posed by the product itself for the health of consumers. However, they need alternative livelihoods that offer equivalent remuneration, convenience, and (in some cases) dignity. Alternative livelihoods, and campaigns for better rights for bidi workers while they remain in the industry, serve to undercut industry arguments against tobacco control. Responses need to be diverse and specific to local situations, i.e. "bottom-up" as much as "top-down", which can make the issue of scaling up problematic. CONCLUSION: Participatory approaches involving bidi workers themselves in discussions about their circumstances and aspirations have opened up new possibilities for alternative livelihoods to tobacco. IMPLICATIONS: Progress with the FCTC's Article 17 has generally been slow and has focussed on tobacco cultivation rather than later stages in the production process. The bidi industry in India is ripe for the application of an alternative livelihoods approach. This study is one of the first to use participatory methods to investigate the circumstances, experiences, and aspirations of bidi workers themselves.

Impact of the COVID-19 National Lockdown on a Rural and Tribal Population of Tamil Nadu, Southern India: A Mixed-Methods Survey.

We assessed the impact of the national lockdown on a rural and tribal population in Tamil Nadu, southern India. A mixed-methods approach with a pilot-tested, semi-structured questionnaire and focus group discussions were used. The impact of the lockdown on health, finances, and livelihood was studied using descriptive statistics. Multivariable logistic regression was carried out to identify factors associated with households that borrowed loans or sold assets during the lockdown, and unemployment during the lockdown. Of the 607 rural and tribal households surveyed, households from comparatively higher socioeconomic quintiles (adjusted odds ratio [aOR], 1.84; 95% CI, 1.01-3.34), with no financial savings (aOR, 2.91; 95% CI, 1.17-7.22), and with larger families (aOR, 1.76; 95% CI, 1.22-2.53), took loans or sold assets during the lockdown. Previously employed individuals from rural households (aOR, 5.07; 95% CI, 3.30-7.78), lower socioeconomic households (aOR, 3.08; 95% CI, 1.74, 5.45), and households with no savings (aOR, 1.78; 95% CI, 1.30-2.44) became predominantly unemployed during the lockdown. Existing government schemes for the elderly, differently abled, and widows were shown to be accessible to 89% of the individuals requiring these schemes in our survey. During the focus group discussions, the limited reach of online classes for schoolchildren was noted and attributed to the lack of smartphones and poor Internet connectivity. Although the sudden, unannounced national lockdown was imposed to flatten the COVID-19 curve, aspects related to livelihood and financial security were affected for both the rural and tribal populations.

Risk Factors and Hazards in the Household Environment for Elevated Blood Lead Levels in Urban Preschool Children of Vellore: A Case-Control Approach in the MAL-ED Birth Cohort.

OBJECTIVES: To study the household environmental risk factors and hazards associated with elevated blood lead levels (EBLLs) in preschool children in an urban setting of Vellore, South India. METHODS: A case-control study within the MAL-ED (Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development) birth cohort was conducted between January 2014 and January 2015. The study included 153 pre-school children: 87 cases and 66 controls with elevated and normal BLLs, respectively. A structured questionnaire was used to assess the sociodemographic profile, household environment, breastfeeding practices, children's habits, and the use of cosmetics in them. Household environmental samples of wall and door paint, floor dust, drinking water, and cosmetics were estimated for lead levels using gas flame atomic absorption spectrometry (FAAS). RESULTS: Children born with low birth weight, those living in houses painted at least once in the last five years and those residing in houses older than ten years had a higher odds of EBLLs [OR (95% CI) = 3.79 (1.24-11.1); 4.84 (1.42-16.53); 5.07 (2.06-12.46), and 2.58 (0.99-6.69)], respectively. Drinking water samples from both cases (88%) and controls (95%) had lead levels more than the Environmental Protection Agency (EPA), USA recommendation of 0.015 ppm. CONCLUSIONS: Low birth weight and the household environment pose important risk factors/hazards for elevated blood lead levels in urban preschool children. Multipronged interventions that include government legislations, household environmental modification, safe water supply, and community education are pivotal in reducing lead exposure in young children.

Primary care for the urban poor in India during the pandemic: Uninterrupted management of non-communicable diseases and home-based care of patients with COVID-19 infection.

Problem: The two waves of COVID-19 severely affected the healthcare system in India. The government responded to the first wave with a strict nationwide lockdown which disrupted primary care, including the management of non-communicable diseases (NCDs). The second wave overwhelmed healthcare facilities leading to inadequate access to hospital services. Collectively, these issues required urgent responses, including the adaptation of primary care. Approach: The Low-Cost Effective Care Unit (LCECU) of Christian Medical College, Vellore (CMC) has a network of community volunteers, community health workers, an outreach nurse, social workers and doctors who operate clinics in six poorer areas of Vellore. The network adapted quickly, responding to the lockdown during the first wave and ensuring ongoing primary care for patients with non-communicable diseases. During the second wave, the team developed a system in collaboration with other CMC departments to provide home-based care for patients with COVID-19. Local setting: The LCECU is a 48-bed unit of the Department of Family Medicine, part of the 3,000-bed CMC. It originated in 1982, aiming to care for the poor populations of Vellore town. It has been actively working among urban communities since 2002, with a focus on delivering Community Oriented Primary Care (COPC), for six poor urban communities since 2016. Relevant changes: During the first wave of COVID the LCECU team ensured patients with NCDs had uninterrupted primary care and medications by visiting them in their homes. The team also addressed food insecurity by organizing a daily lunch service for 600 people for over 2 months. In the second wave, the team responded to community needs by organizing and delivering home-based care to monitor patients affected by COVID-19. Lessons learned: The COVID-19 pandemic raises many questions about the preparedness of health systems for disasters that disproportionately affect marginalized populations globally. COVID-19 is only one of the many potential disasters, including non-communicable diseases, mental health problems, pollution, climate change, and lifestyle illness. There is an urgent need to study models of care that support vulnerable communities in an accessible, cost-effective, and patient-oriented way, particularly in low- and middle-income countries. This paper outlines lessons on how the LCECU team addressed disaster management:1. The COVID-19 pandemic has highlighted the importance of primary care-based rapid response interventions in disaster management.2. The LCECU model demonstrated the effectiveness of a primary care intervention based on pre-existing networks and familiarity between primary care teams and the community.3. Establishing community-based health care via interdisciplinary teams, including community health workers, community volunteers, outreach nurses, and doctors, is key.4. Addressing other social determinants of health, such as food insecurity, is an important component of care delivery.

Developmental trends in early childhood and their predictors from an Indian birth cohort.

BACKGROUND: Early childhood developmental pattern analyses not only project future cognition potential, but also identify potential risks for possible intervention. The current study evaluates developmental trends in the first 3 years of life and their predictors in a low and middle income country setting. METHODS: Trends of early childhood development at 6, 15, 24 and 36 months of age and their predictors were explored in a longitudinal community-based birth cohort study in an urban slum in Vellore, South India. Development was assessed using the Bayley Scales of Infant and Toddler Development-III (BSID-III). RESULTS: The birth cohort enrolled 251 children with 94, 91, 91 and 87% follow-up at 6, 15, 24 and 36 months respectively. Child development domains of cognition, language, motor and social skills showed a significant decline in scores between 6 and 36 months of age. Higher socioeconomic position (SEP) and nurturing home environment contributed to increase in cognition scores by 1.9 and 0.9 units respectively. However, stunting caused a decline in cognition scores by 1.7 units. Higher maternal cognition, higher SEP, and caregiver responsivity positively contributed to language change over time, while higher maternal depression contributed negatively. An enriching home environment, growth parameters and blood iron status had positive association with change in motor skills. CONCLUSIONS: A triple intervention plan to enhance home environment and nurturance, early childhood nutrient supplementation, and maternal education and well-being might prevent child developmental decline in high risk settings.

A retrospective study on the microbial spectrum and antibiogram of uropathogens in children in a secondary care hospital in Rural Vellore, South India.

BACKGROUND: Urinary tract infection (UTI) is common among children. Empiric antibiotics have to be started as early as possible or it may lead to an irreversible renal parenchymal damage and renal scarring in children. The objectives were to determine the prevalence and microbial profile of paediatric UTI and to determine the antimicrobial susceptibility pattern. METHODOLOGY: This is a retrospective study which looked at urine cultures of children below 15 years that were sent during the study period. RESULTS: Among the total urine cultures sent only 21.2% showed significant growth of organisms. The most common organism isolated was E. coli (75.5%). E. coli was least sensitive to cefpodoxime and co-trimoxazole, whereas highly sensitive to nitrofurantoin. Of the total children who had significant growth, 46% had ESBL. DISCUSSION: The prevalence of culture-proven UTI among children was found to be 21.2%. The most common organism isolated among the study population was E. coli (75.5%) followed by Enterococcus species (19.0%) and Klebsiella species (14.5%). It was also found that E. coli was least sensitive to cefpodoxime (31.6%) and co-trimoxazole (26.3%), moderately to amoxicillin-clavulanate (52.4%), whereas highly sensitive to nitrofurantoin (82.9%). This was similar with the studies done at other secondary care hospitals, in Oman and Oddanchathram, South India. CONCLUSIONS: With the increasing resistance, cephalosporins should not be used in treating paediatric UTI, whereas nitrofurantoin can be started as an empiric antibiotic, which can later be changed according to the susceptibility pattern.

Association between head circumference at two years and second and fifth year cognition.

BACKGROUND: Head circumference (HC) measurement is routinely not performed in early childhood and there is conflicting information about its utility in literature. The current study analyses the association between HC at two years of age and cognition at two and five years of age. METHODS: A community based birth-cohort recruited between 2010 and 2012 was followed up till five years of age in an urban slum in Vellore, India. Children were recruited at birth after informed parental consent by consecutive sampling using eligibility criteria of healthy new-born, singleton pregnancy and family's availability in the study area during follow-up. HC measured at two years of age was used as the exposure variable to calculate association with cognition at both two and five years of age. Cognitive domain of Bayley scale of infant development was used at two years of age and Wechsler Preschool Primary Scales of Intelligence at five years. RESULTS: Of the 251 enrolled children, 138 (55%) were girls and 71 (30%) belonged to lower socioeconomic status. At 2 years, 8.81% of children had HC < - 3SD. Compared to children with HC z-scores ≥ - 2 SD, those with measurements < - 3 SD had a lower cognition scores by - 2.21 [95% CI: - 3.87 - -0.56] at 2 years. Also, children with HC < - 3 SD at two years scored significantly lower scores in cognitive domains of verbal, - 7.35 [95% CI: - 11.78 - -2.92] and performance, - 7.07 [95% CI: - 11.77 - -2.36] intelligence at five years. CONCLUSIONS: This study showed that smaller HC at 2 years of age was negatively associated with cognition at both 2 and 5 years of age. Early childhood HC measurements can be utilised as a cheaper screening tool to identify children at risk in LMIC settings. Further studies can confirm these findings in diverse settings.

Home environment: Short-term trends and predictors in early childhood from an Indian community birth cohort.

BACKGROUND: Early childhood home environment is intricately linked to child development and later cognitive and academic skills. There is limited literature evaluating home environmental trends and predictors in the low- and middle-income country settings. AIMS: Determine the trends of early childhood home environment changes between 6 and 36 months of age, and the factors associated with these changes. STUDY DESIGN: Longitudinal community-based birth cohort follow-up study in a semi-urban slum in Vellore, South India. SUBJECTS: Consecutive sampling of a birth cohort between March 2010 and February 2012. OUTCOME MEASURES: Home environment was objectively assessed using the 'Home Observation for the Measurement of the Environment' (HOME) scale. Predictors of change in the home environment over time also were analyzed. Multivariable linear regression models and linear mixed effect models were used to identify the factors associated with HOME score at individual time points and over-a-time period, respectively. RESULTS: The birth cohort enrolled 251 children with a follow-up of 235, 228 and 218 children at 6, 24 and 36 months, respectively. The socio-economic status (SES) was the single biggest predictor for the HOME score at each time point, with increasing strength over time. Maternal education predicted home environment at 24 months, while maternal depression was negatively associated at 6 and 24 months of age. SES and maternal factors contributed to the overall change in the HOME score. Maternal factors predicted relational home environmental change over time. CONCLUSION: SES and maternal factors consistently predicted early childhood home environment at 6, 24 and 36 months of age and its change over time. It is important to support maternal education and wellbeing along with socio-economic measures to optimize early childhood environment.

Screening practices for breast and cervical cancer and associated factors, among rural women in Vellore, Tamil Nadu.

BACKGROUND: Population-based screening coverage for breast and cervical cancer screening in the community is inadequately reported in India. This study assessed screening rates, awareness, and other factors affecting screening, among rural women aged 25-60 years in Vellore, Tamil Nadu. METHODS: Women aged 25-60 years, from five randomly selected villages of a rural block were included in this cross-sectional study in Vellore, Tamil Nadu. Households were selected by systematic random sampling, followed by simple random sampling of eligible women in the house. A semi-structured questionnaire was used to assess screening practices, awareness, and other factors related to cervical and breast cancer. RESULTS: Although 43.8% and 57.9% were aware of the availability of screening for cervical and breast cancer respectively, screening rates were only 23.4% (95% confidence interval [CI]: 18.4-28.4%) and 16.2% (95% CI: 11.9-20.5%), respectively. Adequate knowledge (score of ≥50%) on breast cancer was only 5.9%, with 27.2% for cervical cancer. Only 16.6% of women had ever attended any health education program on cancer. Exposure to health education (breast screening odds ratio [OR]: 6.89, 95% CI: 3.34-14.21; cervical screening OR: 6.92, 95% CI: 3.42-14.00); and adequate knowledge (breast OR: 4.69, 95% CI: 1.55-14.22; cervix OR: 3.01, 95% CI: 1.59-5.68) were independently associated with cancer screening. CONCLUSION: Awareness and screening rates for breast and cervical cancer are low among rural women in Tamil Nadu, a south Indian state with comparatively good health indices, with health education being an important factor associated with screening practices.

Accuracy of Trained Community-based Rehabilitation Volunteers in Identification and Appropriate Referral of Adults with Perceived Visual Disability in an Urban-slum Setting in Southern India.

PURPOSE: The integration of primary eyecare into existing primary healthcare systems requires simple yet effective tools that do not overburden the grass-root level worker. The objective of this study was to test the accuracy of a questionnaire-based tool administered by trained community-based rehabilitation volunteers (CBRVs) in identifying persons with visual disability, proportions accessing referral pathway and barriers to uptake of eyecare services. METHODS: CBRVs working in the urban-slum service area of a teaching hospital were trained in administering a questionnaire-based tool derived from the World Health Organization (WHO) "Training in the community for people with disabilities" to a responsible adult member of the household. Post-training, they screened and referred adults with perceived visual problems. This tool was tested against two reference standards: (i) history of visual disability elicited by ophthalmologist; (ii) pre-set visual acuity and diagnosis criteria. RESULTS: Ten CBRVs screened 950 individuals of whom 805 (84.7%) were examined by an optometrist and ophthalmologist. Sensitivity and specificity of this method were 75% (95% CI 72-78%), 95.8% (95% CI 94-98%) respectively, using history and 60.2% (95% CI 57-63%), 91.8% (95% CI 90-94%) using clinical criteria as reference standard. Referral pathway was used by 91/221 (41.2%) referred individuals. The commonest barriers to accessing eye care were 'did not feel the need' (32.2%) and 'busy with work/household responsibilities' (30.2%). CONCLUSIONS: This questionnaire-based tool administered by grass-root level health workers to a responsible adult member of the family may be a promising screening method for identification and appropriate referral of persons with visual disability in the community.

Body iron and lead status in early childhood and its effects on development and cognition: a longitudinal study from urban Vellore.

OBJECTIVE: Early childhood factors can have persisting effects on development and cognition in children. We propose to explore the trends of Fe deficiency and Pb toxicity in early childhood and their association with child development at 2 years of age and cognition at 5 years. DESIGN: Longitudinal birth cohort study. SETTING: Urban slum, Vellore, India. PARTICIPANTS: Children enrolled at birth were followed up regularly in the first 2 years with developmental and cognitive assessments at 2 and 5 years of age, respectively. RESULTS: The birth cohort enrolled 251 children with 228 children followed up at 2 years and 212 at 5 years of age. Fe deficiency (ID) was highest at 15 months of age and improved subsequently at 24 months. Blood Pb levels (BLL) remained high at all age groups with an increasing trend with age; 97 % at 36 months having high BLL. Persistent high mean BLL at 15 and 24 months had negative association with both cognition and expressive language raw scores of 24 months, while high mean BLL at 15, 24 and 36 months had no significant association with any of the domains of cognition at 5 years of age. Early childhood cumulative body Fe status at 7, 15 and 24 months did not show any association with child development at 2 years, but was associated with verbal, performance and processing speed components of cognition at 5 years. CONCLUSIONS: Optimising body Fe status and limiting Pb exposure in early childhood can augment child development and school entry cognition.

The insulin sharps disposal study: Evaluation of a structured patient education initiative in an urban community health centre in India.

CONTEXT: India has witnessed an increase in people suffering from diabetes mellitus and also those on insulin. The issue of handling used sharps in the community is an area of concern. AIMS: Our study aimed to assess the change in knowledge and practise concerning the disposal of used insulin sharps in patients with diabetes, pre- and post-evaluation, a structured, health provider-initiated, patient-centred insulin-use health education (PIHE). SETTINGS AND DESIGN: A pre- and post-evaluation study of PIHE set in an urban health centre in south India. METHODS AND MATERIALS: A pre-evaluation study was done on a cross-sectional sample of type II diabetes patients, who visited the urban health centre and were on insulin for at least 1 year. A semi-structured pilot-tested questionnaire was used for the study. For 18 months, PIHE was provided to all insulin users at outpatient contact, after which a post-evaluation study among another cross-sectional sample of patients in the same centre, was done to assess change in knowledge and practise. STATISTICAL ANALYSIS USED: Univariate analysis followed by logistic regression. RESULTS: The participants in the pre- and post-evaluation studies had a mean (SD) age of 54.9 (11.33) years and 57.2 (11.01) years, respectively. The baseline characteristics of gender, socioeconomic status and diabetes duration were similar. There was a statistically significant (P < 0.001) difference in knowledge (19 [19%] to 81 [81%]) and practise (7 [7%] to 73 [73%]) of participants regarding the correct disposal method of used insulin syringes and sharps before and after PIHE. CONCLUSIONS: PIHE over an 18-month period for diabetic patients on insulin significantly improved knowledge and practises relating to insulin use and correct disposal of syringes and sharps.

Intestinal permeability and inflammation mediate the association between nutrient density of complementary foods and biochemical measures of micronutrient status in young children: results from the MAL-ED study.

BACKGROUND: Environmental enteric dysfunction (EED) is thought to increase the risk of micronutrient deficiencies, but few studies adjust for dietary intakes and systemic inflammation. OBJECTIVE: We tested whether EED is associated with micronutrient deficiency risk independent of diet and systemic inflammation, and whether it mediates the relation between intake and micronutrient status. METHODS: Using data from 1283 children in the MAL-ED (Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health) birth cohort we evaluated the risk of anemia, low retinol, zinc, and ferritin, and high transferrin receptor (TfR) at 15 mo. We characterized gut inflammation and permeability by myeloperoxidase (MPO), neopterin (NEO), and α-1-antitrypsin (AAT) concentrations from asymptomatic fecal samples averaged from 9 to 15 mo, and averaged the lactulose:mannitol ratio z-score (LMZ) at 9 and 15 mo. Nutrient intakes from complementary foods were quantified monthly from 9 to 15 mo and densities were averaged for analyses. α-1-Acid glycoprotein at 15 mo characterized systemic inflammation. Relations between variables were modeled using a Bayesian network. RESULTS: A greater risk of anemia was associated with LMZ [1.15 (95% CI: 1.01, 1.31)] and MPO [1.16 (1.01, 1.34)]. A greater risk of low ferritin was associated with AAT [1.19 (1.03, 1.37)] and NEO [1.22 (1.04, 1.44)]. A greater risk of low retinol was associated with LMZ [1.24 (1.08, 1.45)]. However, MPO was associated with a lower risk of high transferrin receptor [0.86 (0.74, 0.98)], NEO with a lower risk of low retinol [0.75 (0.62, 0.89)], and AAT with a lower risk of low plasma zinc [0.83 (0.70, 0.99)]. Greater nutrient intake densities (vitamins A and B6, calcium, protein, and zinc) were negatively associated with EED. Inverse associations between nutrient densities and micronutrient deficiency largely disappeared after adjustment for EED, suggesting that EED mediates these associations. CONCLUSIONS: EED is independently associated with an increased risk of low ferritin, low retinol, and anemia. Greater nutrient density from complementary foods may reduce EED, and the control of micronutrient deficiencies may require control of EED.

Low head circumference during early childhood and its predictors in a semi-urban settlement of Vellore, Southern India.

BACKGROUND: Stunting in developing countries continues to be a major public health problem. Measuring head circumference (HC) during clinical anthropometric assessment can help predict stunting. The aim of this study was to assess burden and determine the predictors of low HC (<- 2 SD) at birth and during first 2 years of life in a semi- urban settlement of Vellore. METHODS: The study uses baseline data and serial HC measurements from the birth cohort of MAL-ED study, where 228 children from Vellore completed follow-up between March 2010 to February 2014. Analysis of baseline, maternal and paternal characteristics, micro-nutrient status and cognition with HC measurements was performed using STATA version 13.0 software. RESULTS: The mean HC (±SD) at 1st, 12th and 24th month were 33.37 (1.29) cm, 42.76 (1.23) cm and 44.9 (1.22) cm respectively. A third of the infants (75/228) had HC less than - 2 SD at first month of life, and on follow-up, 50% of the cohort had HC ≤ -2 SD both at 12th and 24th month. Low HC measurements at all three time-points were observed for 21.6% (46/222) infants. Low HC was significantly associated with stunting in 37.3% (OR = 10.8), 57.3% (OR = 3.1) and 44.4% (OR = 2.6) children at 1st, 12th and 24th month respectively. Bivariate analysis of low HC (<- 2 SD) at 12th month showed a statistically significant association with lower socioeconomic status, low paternal and maternal HC and low maternal IQ. Multivariable logistic regression analysis showed maternal (AOR = 0.759, 95% CI = 0.604 to 0.954) and paternal (AOR = 0.734, 95% CI = 0.581 to 0.930) HC to be significantly associated with HC attained by the infant at the end of 12 months. CONCLUSIONS: One-third of the children in our cohort had low head circumference (HC) at birth, with one-fifth recording low HC at all time-points until 2 years of age. Low HC was significantly associated with stunting. Paternal and maternal HC predicted HC in children. HC measurement, often less used, can be a simple tool that can be additionally used by clinicians as well as parents/caregivers to monitor child growth.

Unintentional injuries among children aged 1-5 years: understanding the burden, risk factors and severity in urban slums of southern India.

BACKGROUND: Globally, 5.82 million deaths occurred among children under the age of five years in 2015 and injury specific mortality rate was 73 per 100,000 population. In India, injury specific mortality rate is around 2.1 per 1000 live births contributing to 4% of the total under 5 mortality rate. This study aims to estimate the burden and understand factors associated with unintentional injuries among children aged 1-5 years residing in urban slums of Vellore, southern India. We also attempted to assess the hazards posed by the living environment of these children and study their association with unintentional injury patterns. METHODS: This cross-sectional study was conducted in eight urban slums of Vellore, southern India and primary caregivers of children aged 1-5 years were interviewed with a questionnaire to obtain the details of injuries sustained in the past three months. Environmental hazard risk assessment was conducted at places frequented by these children and their scores calculated. Baseline prevalence and incidence rates of unintentional injuries were estimated. Multivariate logistic regression and poisson regression analysis were performed to examine factors associated with unintentional injuries and repeated injuries respectively. Association between environmental hazard risk and unintentional injuries was estimated. RESULTS: Prevalence of unintentional injuries was 39.1% (95% CI 35.4-42.9%) and incidence rate was 16.5 (95% CI 14.7-18.3) per 100 child months (N = 662). Bivariate analysis revealed that children of working mothers (OR 1.48; 1.01-2.18) and children from overcrowded families (OR 1.78; 1.22-2.60) had increased odds of sustaining unintentional injuries. Multivariate regression analysis revealed that children from overcrowded families had increased odds of sustaining unintentional injuries (AOR 1.66, 95% CI 1.14-2.41). Boys (IRR 1.33, 95% CI 1.07-1.66) and children from overcrowded families (IRR 1.50; 1.14-1.98) were at increased risk of having repeated injuries. There is an increase in incidence rate of injuries with an increased environmental hazard risk, although not statistically significant. CONCLUSIONS: The burden of unintentional injuries was very high among study children when compared to studies in other urban slums in India. Environment plays an important role in the epidemiology of unintentional injuries; providing safe play environment and adequate supervision of children is important to reduce its burden.