[Mortality pattern in children aged 3-59 months hospitalized in the Intensive Care Unit at a Paediatric Center in Yaounde-Cameroon]. / Profil des décès survenus chez les enfants âgés de 3 à 59 mois dans l'unité des soins intensifs d'un centre pédiatrique à Yaoundé-Cameroun.

INTRODUCTION: mortality risk is high at the Intensive Care Units (ICU) in developing countries. We here report the deaths occurred in the ICU at the Mother and Child Center in Yaounde, Cameroon. METHODS: we conducted a retrospective study on the clinical, socio-demographic features, the therapeutic strategy as well as some of the factors associated with deaths occurred in 200 patients aged 3-59 months between 2010 and 2014. RESULTS: out of 2675 patients included in the study, 1807 were aged 3-59 months and 303 died. The overall and cause-specific mortality rate in this age group was 11.3% and 16.7% respectively. Most patients (152/200; 76.0%) died within 24 months and the median admission time was 7 days. More than half of patients (57.0%) presented to a health center and only 66 (33.0%) presented to a referral hospital. Severe malaria (41.5%), pneumonia (22.7%) and gastroenteritis (27.8%) were the most common diseases. Malnutrition and HIV/AIDS were the underlying causes of death in 23.0% and 20.5% of patients respectively. Gastroenteritis multiplied the risk of death of approximately 6 times (OR = 5.76; p = 0.000) in patients affected by malnutrition and HIV infection. Deaths mainly occurred (90.0%) within 72 hours of admission. CONCLUSION: despite limited resources, some diseases could have been easily treated avoiding complications which require reanimation. It is essential to intensify the fight against malaria, HIV infection and malnutrition.

Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study.

BACKGROUND: In South Africa, 30.9% of children under five years with Severe Acute Malnutrition (SAM) died in 2018. We aimed to identify factors associated with mortality among children under five years hospitalized with SAM in Limpopo province, South Africa. METHODS: We conducted a cross-sectional study including children under five years admitted with SAM from 2014 to 2018 in public hospitals of Limpopo province. We extracted socio-demographic and clinical data from hospital records. We used logistic regression to identify factors associated with mortality. FINDINGS: We included 956 children, 50.2% (480/956) male and 49.8% (476/956) female. The median age was 13 months (inter quartile range: 9-19 months). The overall SAM mortality over the study period was 25.9% (248/956). The most common complications were diarrhea, 63.8% (610/956), and lower respiratory tract infections (LRTIs), 42.4% (405/956). Factors associated with mortality included herbal medication use (adjusted Odds Ratio (aOR): 2.2, 95% Confidence Interval (CI): 1.4-3.5, p = 0.001), poor appetite (aOR: 2.7, 95% CI: 1.4-5.2, p = 0.003), Mid-upper circumference (MUAC) <11.5 cm (aOR: 3.0, 95% CI: 1.9-4.7, p<0.001), lower respiratory tract infections (LRTIs) (aOR: 1.6, 95% CI: 1.2-2.0, p<0.001), anemia (aOR: 2.5, 95% CI: 1.1-5.3, p = 0.021), hypoglycemia (aOR: 12.4, 95% CI: 7.1-21.8, p<0.001) and human immunodeficiency virus (HIV) infection (aOR: 2.3, 95% CI: 1.6-3.3, p<0.001). INTERPRETATION: Herbal medication use, poor appetite, LRTIs, anemia, hypoglycemia, and HIV infection were associated with mortality among children with SAM. These factors should guide management of children with SAM.

A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol.

BACKGROUND: Acute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention. METHODS: ABCD is a double-blind, randomised trial recruiting 11,500 children aged 2-23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment. DISCUSSION: Expanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines. TRIAL REGISTRATION: Clinicaltrials.gov, NCT03130114. Registered on April 26 2017.

Trends in infant mortality in Venezuela between 1985 and 2016: a systematic analysis of demographic data.

BACKGROUND: Between the 1950s and 2000, Venezuela showed one of the most substantial improvements in infant mortality rates in Latin America. However, the recent economic crisis alongside an increase in infectious and parasitic diseases might be reversing previous patterns. Because no official updated mortality statistics have been published since 2013, the effect of these recent events has been difficult to assess accurately. We therefore aimed to estimate infant mortality rate trends and report the effect of the crisis. METHODS: We estimated infant mortality rates using direct methods (ie, death counts from Venezuelan Ministry of Health via yearbooks and notifiable diseases bulletins, and birth records published by the UN Economic Commission for Latin America and the Caribbean and the Venezuelan National Institute of Statistics) and indirect methods (using census data and a Living Conditions Survey ENCOVI 2016). We shaped yearly estimations using a semiparametric regression model, specifically a P-Spline model with a cubic thin plate base. The primary objective was to estimate infant mortality rate trends from 1985 to 2016. FINDINGS: Around 2009, the long-term decline in infant mortality rate stopped, and a new pattern of increase was observed. The infant mortality rate reached 21·1 deaths per 1000 livebirths (90% CI -17·8 to 24·3) in 2016, almost 1·4 times the rate of 2008 (15·0, -14·0 to 16·1). This increase represents a huge setback on previous achievements in reducing infant mortality. INTERPRETATION: Our conservative estimation indicates that Venezuela is in the throes of a humanitarian crisis. The increase in infant mortality rate in 2016 compared with 2008 takes the country back to the level observed at the end of the 1990s, wiping out 18 years of expected progress, and leaves the Venezuelan Government far from achieving the target of nine deaths per 1000 livebirths stated in the UN Millennium Development Goals. FUNDING: None.

Neonatal, infant and child health in South Africa: Reflecting on the past towards a better future.

Although the neonatal mortality rate in South Africa (SA) has remained stagnant at 12 deaths per 1 000 live births, the infant and under-5 mortality rates have significantly declined since peaking in 2003. Policy changes that have influenced this decline include policies to prevent vertical HIV transmission, earlier treatment of children living with HIV, expanded immunisation policies, strengthening breastfeeding practices, and health policies to contain tobacco and sugar use. The Sustainable Development Goals (2016 - 2030) have shifted the focus from keeping children alive, as expressed in the Millennium Development Goals (1990 - 2015), to achieving optimal health through the 'Survive, thrive and transform' global agenda. This paper focuses on important remaining causes of childhood mortality and morbidity in SA, specifically respiratory illness, environmental pollution, tuberculosis, malnutrition and vaccine-preventable conditions. The monitoring of maternal and child health (MCH) outcomes is crucial, and has improved in SA through both the District Health Information and Civil Registration and Vital Statistics systems, although gaps remain. Intermittent surveys and research augment the routinely collected data. However, availability and use of local data to inform quality and effectiveness of care is critical, and this requires ownership at the collection point to facilitate local redress. Potential game changers to improve MCH outcomes include mobile health and community-based interventions. In SA, improved MCH remains a crucial factor for human capital development. There is a pressing need to focus beyond childhood mortality and to ensure that each child thrives.

Follow-up between 6 and 24 months after discharge from treatment for severe acute malnutrition in children aged 6-59 months: A systematic review.

BACKGROUND: Severe acute malnutrition (SAM) is a major global health problem affecting some 16.9 million children under five. Little is known about what happens to children 6-24 months post-discharge as this window often falls through the gap between studies on SFPs and those focusing on longer-term effects. METHODS: A protocol was registered on PROSPERO (PROSPERO 2017:CRD42017065650). Embase, Global Health and MEDLINE In-Process and Non-Indexed Citations were systematically searched with terms related to SAM, nutritional intervention and follow-up between June and August 2017. Studies were selected if they included children who experienced an episode of SAM, received a therapeutic feeding intervention, were discharged as cured and presented any outcome from follow-up between 6-24 months later. RESULTS: 3,691 articles were retrieved from the search, 55 full-texts were screened and seven met the inclusion criteria. Loss-to-follow-up, mortality, relapse, morbidity and anthropometry were outcomes reported. Between 0.0% and 45.1% of cohorts were lost-to-follow-up. Of those discharged as nutritionally cured, mortality ranged from 0.06% to 10.4% at an average of 12 months post-discharge. Relapse was inconsistently defined, measured, and reported, ranging from 0% to 6.3%. Two studies reported improved weight-for-height z-scores, whilst three studies that reported height-for-age z-scores found either limited or no improvement. CONCLUSIONS: Overall, there is a scarcity of studies that follow-up children 6-24 months post-discharge from SAM treatment. Limited data that exists suggest that children may exhibit sustained vulnerability even after achieving nutritional cure, including heightened mortality and morbidity risk and persistent stunting. Prospective cohort studies assessing a wider range of outcomes in children post-SAM treatment are a priority, as are intervention studies exploring how to improve post-SAM outcomes and identify high-risk children.

Survival and nutritional status of children with severe acute malnutrition, six months post-discharge from outpatient treatment in Jigawa state, Nigeria.

BACKGROUND: The Outpatient Therapeutic Program (OTP) for treatment brings the management of Severe Acute Malnutrition (SAM) closer to the community. Many lives have been saved through this approach, but little data exists on the outcome of the children after discharge from such programmes. This study was aimed to determine the survival and nutritional status of children at six months after discharge from OTP for SAM. METHODOLOGY: This was a prospective study of children with SAM admitted into 10 OTPs in two local government areas of Jigawa state from June 2016 to July 2016. Home visits at six months after discharge enabled the collection of data on survival and nutritional status. The primary outcome measures were survival and nutritional status (Mid upper arm circumference and weight-for-height z-score). RESULT: Of 494 children with SAM, 410 were discharged and 379 were followed up. Of these, 354, (93.4%) were found alive while 25 (6.6%) died. Among the survivors 333 (94.1%) had MUAC ≥12.5cm and 64 (18.1%) had WHZ<-3. Mortality rates were higher 10 (8.4%) among the 6-11months old. Most deaths 16 (64%) occurred within the first 3months post-discharge. Those who died were significantly more stunted, p = 0.016 and had a smaller head circumference, p = 0.005 on entry to OTP programme. There was improvement from admission to six months follow up in the number of children with complete immunization (27.4% to 35.6%), and a decrease in the number of unimmunized children (34.8% vs 20.6%) at follow-up. CONCLUSION: The study demonstrates good post discharge survival rate and improved nutritional status for SAM patients managed in OTPs. There were, however considerable post discharge mortality, especially in the first three months and lower immunization uptake post discharge. A follow-up programme will improve these indices further.

Maternal HIV infection is an important health determinant in non-HIV-infected infants.

OBJECTIVE: To assess morbidity and mortality in HIV-exposed uninfected (HEU) children to help guiding appropriate clinical care and effective preventive interventions. DESIGN: This is a longitudinal study comparing two cohorts of children; one born to HIV-infected women and the other born to HIV-uninfected women. METHODS: We have analyzed prospectively obtained information on nutritional status, morbidity and mortality from 966 HEU and 909 HIV-unexposed infants followed up until their first 18 months of life at a referral health facility in southern Mozambique. Determinants for adverse health outcomes in HEU children were also assessed using multivariate logistic regression. RESULTS: Increased incidence of hospital admissions (P = 0.0015), shorter survival in the first 18 months of life (P = 0.0510) and moderate and severe malnutrition (P = 0.0006 and 0.0014, respectively) were observed among HEU children compared with HIV-unexposed children. Incidence of outpatient attendance in HEU children was associated with being men, older age and the mother being on antiretroviral treatment. Among HEU children, those who were never breastfed, or who were weaned or were partially breastfed, had an increased incidence of hospital admissions compared with children who were exclusively breastfed. CONCLUSION: Maternal HIV infection has important health consequences in non-HIV-infected children. As the prevalence of HIV-infected pregnant women is maintained and the proportion of HIV-infected children declines because of the scale-up of antiretroviral treatment during pregnancy and breastfeeding, more focus should be given to the health needs of HEU children to ensure that the post-2015 sustainable development goals are met.

Mortality after Inpatient Treatment for Severe Pneumonia in Children: a Cohort Study.

BACKGROUND: Although pneumonia is a leading cause of inpatient mortality, deaths may also occur after discharge from hospital. However, prior studies have been small, in selected groups or did not fully evaluate risk factors, particularly malnutrition and HIV. We determined 1-year post-discharge mortality and risk factors among children diagnosed with severe pneumonia. METHODS: A cohort study of children aged 1-59 months admitted to Kilifi County Hospital with severe pneumonia (2007-12). The primary outcome was death <1 year after discharge, determined through Kilifi Health and Demographic Surveillance System (KHDSS) quarterly census rounds. RESULTS: Of 4184 children (median age 9 months) admitted with severe pneumonia, 1041 (25%) had severe acute malnutrition (SAM), 267 (6.4%) had a positive HIV antibody test, and 364 (8.7%) died in hospital. After discharge, 2279 KHDSS-resident children were followed up; 70 (3.1%) died during 2163 child-years: 32 (95% confidence interval (CI) 26, 41) deaths per 1000 child years. Post-discharge mortality was greater after admission for severe pneumonia than for other diagnoses, hazard ratio 2.5 (95% CI 1.2, 5.3). Malnutrition, HIV status, age and prolonged hospitalisation, but not signs of pneumonia severity, were associated with post-discharge mortality. Fifty-two per cent (95% CI 37%, 63%) of post-discharge deaths were attributable to low mid-upper arm circumference and 11% (95% CI 3.3%, 18%) to a positive HIV test. CONCLUSIONS: Admission with severe pneumonia is an important marker of vulnerability. Risk stratification and better understanding of the mechanisms underlying post-discharge mortality, especially for undernourished children, are needed to reduce mortality after treatment for pneumonia.

Nutritional status in children and adolescents with leukemia: An emphasis on clinical outcomes in low and middle income countries.

OBJECTIVE: The purpose of this narrative review is to examine the information available on the nutritional status of children with leukemia in low and middle income countries (LMICs), where the great majority of them live and malnutrition is prevalent, in order to identify best practices and remaining deficits in knowledge. METHODS: Literature relevant to measurement of nutritional status and the impact of nutritional status on important clinical outcomes in this population, and others of relevance, was reviewed. RESULTS: Arm anthropometry provides more accurate information on nutritional status than measures based on body weight in children with cancer. Both over- and under-nutrition are important determinants of tolerance of chemotherapy, compliance with treatment, relapse of disease, and survival. These relationships are subject to change with nutritional intervention. There are valuable roles for educational tools and 'ready-to-use-therapeutic-foods'. DISCUSSION: Assessment of nutritional status is mandatory in this population and accomplishable at various levels of sophistication according to available resources. Recognition of the fundamental role of nutritional status in affecting outcomes in children with leukemia is expanding, but knowledge gaps remain. An apparently counter-intuitive strategy of caloric restriction may be worthy of exploration. There is a particular need to establish normative data, including measures of body composition, in children in LMICs. CONCLUSIONS: Developing adaptive clinical practice guidelines for the measurement of nutritional status and for nutritional interventions, incorporating assessment of health-related quality of life, are evident priorities in the care of children with leukemia in LMICs.

Effects of food price inflation on infant and child mortality in developing countries.

BACKGROUND: After a historic low level in the early 2000s, global food prices surged upwards to bring about the global food crisis of 2008. High and increasing food prices can generate an immediate threat to the security of a household's food supply, thereby undermining population health. This paper aims to assess the precise effects of food price inflation on child health in developing countries. METHODS: This paper employs a panel dataset covering 95 developing countries for the period 2001-2011 to make a comprehensive assessment of the effects of food price inflation on child health as measured in terms of infant mortality rate and child mortality rate. RESULTS: Focusing on any departure of health indicators from their respective trends, we find that rising food prices have a significant detrimental effect on nourishment and consequently lead to higher levels of both infant and child mortality in developing countries, and especially in least developed countries (LDCs). DISCUSSION: High food price inflation rates are also found to cause an increase in undernourishment only in LDCs and thus leading to an increase in infant and child mortality in these poorest countries. This result is consistent with the observation that, in lower-income countries, food has a higher share in household expenditures and LDCs are likely to be net food importing countries. CONCLUSIONS: Hence, there should be increased efforts by both LDC governments and the international community to alleviate the detrimental link between food price inflation and undernourishment and also the link between undernourishment and infant mortality.

Feasibility and effectiveness of the baby friendly community initiative in rural Kenya: study protocol for a randomized controlled trial.

BACKGROUND: Interventions promoting optimal infant and young child nutrition could prevent a fifth of under-5 deaths in countries with high mortality. Poor infant and young child feeding practices are widely documented in Kenya, with potential detrimental effects on child growth, health and survival. Effective strategies to improve these practices are needed. This study aims to pilot implementation of the Baby Friendly Community Initiative (BFCI), a global initiative aimed at promoting optimal infant and young child feeding practices, to determine its feasibility and effectiveness with regards to infant feeding practices, nutrition and health outcomes in a rural setting in Kenya. METHODS: The study, employing a cluster-randomized trial design, will be conducted in rural Kenya. A total of 12 clusters, constituting community units within the government's Community Health Strategy, will be randomized, with half allocated to the intervention and the other half to the control arm. A total of 812 pregnant women and their respective children will be recruited into the study. The mother-child pairs will be followed up until the child is 6 months old. Recruitment will last approximately 1 year from January 2015, and the study will run for 3 years, from 2014 to 2016. The intervention will involve regular counseling and support of mothers by trained community health workers and health professionals on maternal, infant and young child nutrition. Regular assessment of knowledge, attitudes and practices on maternal, infant and young child nutrition will be done, coupled with assessment of nutritional status of the mother-child pairs and morbidity for the children. Statistical methods will include analysis of covariance, multinomial logistic regression and multilevel modeling. The study is funded by the NIH and USAID through the Program for Enhanced Research (PEER) Health. DISCUSSION: Findings from the study outlined in this protocol will inform potential feasibility and effectiveness of a community-based intervention aimed at promoting optimal breastfeeding and other infant feeding practices. The intervention, if proved feasible and effective, will inform policy and practice in Kenya and similar settings, particularly regarding implementation of the baby friendly community initiative. TRIAL REGISTRATION: ISRCTN03467700 ; Date of Registration: 24 September 2014.

Metabolomics in nutrition research: biomarkers predicting mortality in children with severe acute malnutrition.

BACKGROUND: Millions of the world's children suffer from malnutrition, which predisposes to death from diarrhea and a variety of infectious diseases. Mortality rates among infants and toddlers remain staggeringly high, in part because the pathogenesis of acute malnutrition and its complications remains poorly understood. OBJECTIVE: We used metabolomic analysis to characterize the metabolic status of Ugandan children with severe acute malnutrition (SAM) and to delineate changes in hormones, metabolites, growth factors, and cytokines during nutritional therapy. We hypothesized that hormonal and metabolic factors measured at presentation would associate with, or predict, subsequent mortality during treatment. METHODS: This was a prospective cohort study of 75 severely malnourished children 6 months to 5 years of age treated as inpatients with F-75 and F-100 and supplemental micronutrients; after discharge, they received ready-to-use therapeutic food (RUTF). This increased the mean weight-for-height z-score (WHZ) from -4.27 to -1.75 SD. Blood samples were obtained at presentation, after 2 weeks of inpatient therapy, and after 4 to 10 weeks of RUTF. Plasma samples were analyzed by tandem mass spectrometry and microassays. RESULTS: At presentation there were high levels of nonesterified fatty acids (NEFA), ketones, and even-chain acylcarnitines, indicating active lipolysis and fatty acid oxidation. In contrast, albumin, amino acids, and C3 carnitine, a by-product of branched-chain amino acids, were low. Levels of insulin, insulin-like growth factor 1 (IGF-1), adiponectin, and leptin were low, while levels of ghrelin, growth hormone, cortisol, interleukin 6 (IL-6), peptide YY (PYY), and glucagon-like peptide 1 (GLP-1) were high. The metabolic and hormonal changes were reversed by formula feeding and RUTF. Biomarkers associated with mortality included HIV, WHZ, and mid-upper-arm circumference (MUAC); the biochemical factor associated most strongly with mortality was low leptin, a marker of adipose reserve and modulator of immune function. CONCLUSIONS: Low leptin predicts mortality in edematous and nonedematous-patients with SAM. Leptin assays might be used to identify malnourished children at highest risk for death.

Socio-cultural determinants of infant malnutrition in Cameroon.

This study seeks to explore and explain the socio-cultural factors responsible for the incidence of infant malnutrition in Cameroon with particular emphasis on northern Cameroon where it is most accentuated. It combines quantitative data drawn from the 1991, 1998, 2004 and 2011 Cameroon Demographic and Health Surveys, as well as a literature review of publications by the WHO and UNICEF. This is further complemented with qualitative data from various regions of Cameroon, partly from a national ethnographic study on the ethno-medical causes of infertility in Cameroon conducted between 1999 and 2000. Whereas socio-cultural factors related to child feeding and maternal health (breast-feeding, food taboos and representations of the colostrum as dangerous for infants) are widespread throughout Cameroon, poverty-related factors (lack of education for mothers, natural disaster, unprecedented influx of refugees, inaccessibility and inequity in the distribution of health care services) are pervasive in northern Cameroon. This conjunction of factors accounts for the higher incidence of infant malnutrition and mortality in northern Cameroon. The study suggests the need for women's empowerment and for health care personnel in transcultural situations to understand local cultural beliefs, practices and sentiments before initiating change efforts in infant feeding practices and maternal health. Biomedical services should be tailored to the social and cultural needs of the target population--particularly women--since beliefs and practices underpin therapeutic recourse. Whereas infant diarrhoea might be believed to be the result of sexual contact, in reality, it is caused by unhygienic conditions. Similarly, weaning foods aimed at transmitting ethnic identity might not meet a child's age-specific food needs and might instead give rise to malnutrition.

Feasibility and pilot study of the effects of microfinance on mortality and nutrition in children under five amongst the very poor in India: study protocol for a cluster randomized controlled trial.

BACKGROUND: The United Nations Millennium Development Goals include targets for the health of children under five years old. Poor health is linked to poverty and microfinance initiatives are economic interventions that may improve health by breaking the cycle of poverty. However, there is a lack of reliable evidence to support this. In addition, microfinance schemes may have adverse effects on health, for example due to increased indebtedness. Rojiroti UK and the Centre for Promoting Sustainable Livelihood run an innovative microfinance scheme that provides microcredit via women's self-help groups (SHGs). This pilot study, conducted in rural Bihar (India), will establish whether it is feasible to collect anthropometric and mortality data on children under five years old and to conduct a limited cluster randomized trial of the Rojiroti intervention. METHODS/DESIGN: We have designed a cluster randomized trial in which participating tolas (small communities within villages) will be randomized to either receive early (SHGs and microfinance at baseline) or late intervention (SHGs and microfinance after 18 months). Using predesigned questionnaires, demographic, and mortality data for the last year and information about participating mothers and their children will be collected and the weight, height, and mid upper arm circumference (MUAC) of children will be measured at baseline and at 18 months. The late intervention group will establish SHGs and microfinance support at this point and data collection will be repeated at 36 months.The primary outcome measure will be the mean weight for height z-score of children under five years old in the early and late intervention tolas at 18 months. Secondary outcome measures will be the mortality rate, mean weight for age, height for age, prevalence of underweight, stunting, and wasting among children under five years of age. DISCUSSION: Despite economic progress, marked inequalities in child health persist in India and Bihar is one of the worst affected states. There is a need to evaluate programs that may alleviate poverty and improve health. This study will help to inform the design of a definitive trial to determine if the Rojiroti scheme can improve the nutrition and survival of children under five years of age in deprived rural communities. TRIAL REGISTRATION: Clinicaltrials.gov (study ID: NCT01845545). Registered on 24 April 2013.

A brief history of fatal child maltreatment and neglect.

Child abuse encompasses four major forms of abuse: physical abuse, sexual abuse, psychological abuse, and neglect. The United States retains one of the worst records of child abuse in the industrialized world. It has also been determined that a large portion of these cases are missed and go undocumented in state and federal reporting agencies. In addition, disparate risk factors have been identified for physical abuse and neglect cases, but substance abuse has been found to be a significant factor in all forms of abuse. Fatal child maltreatment and neglect investigations require a multi-pronged and multidisciplinary approach requiring the coordination and information gathering from various agencies. A major difficulty in determining the accidental or non-accidental nature of these cases is that the account surrounding the events of the death of child is acquired from the caretaker. In this review, we outline common diagnostic characteristics and patterns of non-accidental injuries and neglect as a result of nutritional deprivation.

The effect of preoperative nutritional status on postoperative outcomes in children undergoing surgery for congenital heart defects in San Francisco (UCSF) and Guatemala City (UNICAR).

OBJECTIVE: The objective of this study was to determine the association between preoperative nutritional status and postoperative outcomes in children undergoing surgery for congenital heart defects (CHD). METHODS: Seventy-one patients with CHD were enrolled in a prospective, 2-center cohort study. We adjusted for baseline risk differences using a standardized risk adjustment score for surgery for CHD. We assigned a World Health Organization z score for each subject's preoperative triceps skin-fold measurement, an assessment of total body fat mass. We obtained preoperative plasma concentrations of markers of nutritional status (prealbumin, albumin) and myocardial stress (B-type natriuretic peptide [BNP]). Associations between indices of preoperative nutritional status and clinical outcomes were sought. RESULTS: Subjects had a median (interquartile range [IQR]) age of 10.2 (33) months. In the University of California at San Francisco (UCSF) cohort, duration of mechanical ventilation (median, 19 hours; IQR, 29 hours), length of intensive care unit stay (median, 5 days; IQR 5 days), duration of any continuous inotropic infusion (median, 66 hours; IQR 72 hours), and preoperative BNP levels (median, 30 pg/mL; IQR, 75 pg/mL) were associated with a lower preoperative triceps skin-fold z score (P < .05). Longer duration of any continuous inotropic infusion and higher preoperative BNP levels were also associated with lower preoperative prealbumin (12.1 ± 0.5 mg/dL) and albumin (3.2 ± 0.1; P < .05) levels. CONCLUSIONS: Lower total body fat mass and acute and chronic malnourishment are associated with worse clinical outcomes in children undergoing surgery for CHD at UCSF, a resource-abundant institution. There is an inverse correlation between total body fat mass and BNP levels. Duration of inotropic support and BNP increase concomitantly as measures of nutritional status decrease, supporting the hypothesis that malnourishment is associated with decreased myocardial function.