Acceptability and Experiences with the Use of 3D Scans to Measure Anthropometry of Young Children in Surveys and Surveillance Systems from the Perspective of Field Teams and Caregivers.

Background: Portable systems using three-dimensional (3D) scan data to calculate young child anthropometry measurements in population-based surveys and surveillance systems lack acceptability data from field workers and caregivers. Objective: The aim was to assess acceptability and experiences with 3D scans measuring child aged 0-59 mo anthropometry in population-based surveys and surveillance systems in Guatemala, Kenya, and China (0-23 mo only) among field teams and caregivers of young children as secondary objectives of an external effectiveness evaluation. Methods: Manual data were collected twice and 12 images captured per child by anthropometrist/expert and assistant (AEA) field teams (individuals/country, n = 15/Guatemala, n = 8/Kenya, n = 6/China). Caregivers were interviewed after observing their child's manual and scan data collection. Mixed methods included an administered caregiver interview (Guatemala, n = 465; Kenya, n = 496; China, n = 297) and self-administered AEA questionnaire both with closed- and open-ended questions, and 6 field team focus group discussions (FGDs; Guatemala, n = 2; Kenya, n = 3; China, n = 1). Qualitative data were coded by 2 authors and quantitative data produced descriptive statistics. Mixed-method results were compared and triangulated. Results: Most AEAs were female with secondary or higher education. Approximately 80-90% of caregivers were the child's mother. To collect all anthropometry data, 62.1% of the 29 AEAs preferred scan, while 31% preferred manual methods. In FGDs, a key barrier for manual and scan methods was lack of child cooperation. Across countries, approximately 30% to almost 50% of caregivers said their child was bothered by each manual and scan method, while ≥95% of caregivers were willing to have their child measured by scans in the future. Conclusions: Use of 3D scans to calculate anthropometry measurements was generally at least as acceptable as manual anthropometry measurement among AEA field workers and caregivers of young children aged <60 mo, and in some cases preferred.

Accuracy of a handheld 3D imaging system for child anthropometric measurements in population-based household surveys and surveillance platforms: an effectiveness validation study in Guatemala, Kenya, and China.

BACKGROUND: An efficacy evaluation of the AutoAnthro system to measure child (0-59 months) anthropometry in the United States found 3D imaging performed as well as gold-standard manual measurements for biological plausibility and precision. OBJECTIVES: We conducted an effectiveness evaluation of the accuracy of the AutoAnthro system to measure 0- to 59-month-old children's anthropometry in population-based surveys and surveillance systems in households in Guatemala and Kenya and in hospitals in China. METHODS: The evaluation was done using health or nutrition surveillance system platforms among 600 children aged 0-59 months (Guatemala and Kenya) and 300 children aged 0-23 months (China). Field team anthropometrists and their assistants collected manual and scan anthropometric measurements, including length or height, midupper arm circumference (MUAC), and head circumference (HC; China only), from each child. An anthropometry expert and assistant later collected both manual and scan anthropometric measurements on the same child. The expert manual measurements were considered the standard compared to field team scans. RESULTS: Overall, in Guatemala, Kenya, and China, for interrater accuracy, the average biases for length or height were -0.3 cm, -1.9 cm, and -6.2 cm, respectively; for MUAC were 0.9 cm, 1.2 cm, and -0.8 cm, respectively; and for HC was 2.4 cm in China. The inter-technical errors of measurement (inter-TEMs) for length or height were 2.8 cm, 3.4 cm, 5.5 cm, respectively; for MUAC were 1.1 cm, 1.5 cm, and 1.0 cm, respectively; and for HC was 2.8 cm in China. For intrarater precision, the absolute mean difference and intra-TEM (interrater, intramethod TEM) were 0.1 cm for all countries for all manual measurements. For scans, overall, absolute mean differences for length or height were 0.4-0.6 cm; for MUAC were 0.1-0.1 cm; and for HC was 0.4 cm. For the intra-TEM, length or height was 0.5 cm in Guatemala and China and 0.7 cm in Kenya, and other measurements were ≤0.3 cm. CONCLUSIONS: Understanding the factors that cause the many poor scan results and how to correct them will be needed prior to using this instrument in routine, population-based survey and surveillance systems.

TSH Mediated the Effect of Iodized Salt on Child Cognition in a Randomized Clinical Trial.

OBJECTIVES: This study examines the hormonal mediators of the effect of iodized salt in pregnancy on child cognition. METHODS: Sixty districts across 6 zones in the Amhara region of Ethiopia were randomly allocated to a control or intervention arm of early market access to iodized salt. Twenty-two villages per arm were randomly selected for this sub-study. A total of 1220 pregnant women who conceived after the intervention began were enrolled and assessed for their iodine and iron status. Data were collected once on the household socio-demographic status and iodized salt use, and maternal urinary iodine during pregnancy. Then, infants' diet, urinary iodine level, cognitive development (Bayley III), serum hormonal levels, iron status, and inflammation markers were measured between 2 and 13 months of age. RESULTS: The median maternal urinary iodine concentration was adequate and significantly higher in the intervention mothers than that of the controls (163 vs 121 µg/L, P < .0001). Intervention children compared to the control children had lower thyroid-stimulating hormone (TSH) (mean: 2.4 ± 1.0 µIU/mL vs 2.7 ± 1.0 µIU/mL, effect size = 0.18, P < .01) and thyroglobulin (Tg) (41.6 ± 1.0 ng/mL vs 45.1 ± 1.0 ng/mL, effect size = 0.14, P < .05). There was an interaction between the intervention and iron stores such that cognition was higher with iron (effect size = 0.28, 100 vs 94 IQ points). TSH was a partial mediator (12%) of the effect of the intervention on child cognition (Sobel z-score = 2.1 ± 0.06, P < .05). CONCLUSION: TSH partially mediated the effect of the iodized salt intervention on child cognition.

Pre-pregnancy iodized salt improved children's cognitive development in randomized trial in Ethiopia.

The overarching Ethiopia project examined the effects of early market introduction of iodized salt on the growth and mental development of young children. Sixty districts were randomly assigned to intervention (early market access to iodized salt) or control (later access through market forces), and one community per district was randomly chosen as the sampling unit. For this project, 22 of the districts were included. The participants were 1,220 pregnant women who conceived after the intervention began. When their children were 2 to 13 months old, field staff collected information on household sociodemographic status and iodized salt intake, child stimulation, maternal depression symptoms, children's diet, anthropometry, urinary iodine concentration (UIC), hemoglobin, and mental development scores (Bayley III scales). Fewer mothers prepartum (28% vs. 41%, p < .05) and their children (13% vs. 20%, p < .05) were iodine deficient (UIC <50 µg/L) in the intervention compared with the control group. The intervention children had higher cognitive scores (33.3 ± 0.3 vs. 32.6 ± 0.3; Δ = 0.6; 95% CI [0.0, 1.3]; d = 0.17; p = .01; 4 IQ points) than their controls. The other Bayley subscale scores did not differ from control children. The intervention group had a higher child stimulation (22.7 ± 0.2 vs. 22.1 ± 0.2; Δ = 0.5; 95% CI [0.02, 0.89]; d = 0.17; p = .01) but not growth indicators (weight-for-age z score, length-for-age z score, and weight-for-length z score: -1.1 ± 0.1 vs. -1.1 ± 0.1, -1.7 ± 0.1 vs. -1.7 ± 0.1; -0.2 ± 0.1 vs. -0.1 ± 0.1, respectively, all p > .05) compared with their controls. Iodized salt intake improved iodine status of both pregnant women and their children and also child cognitive development.

Spatial Variation of Human Selenium in Ethiopia.

Selenium is an important nutrient for humans and livestock. Soil selenium concentration in the world is highly variable; deficiency and toxicity occur in populations living short distance apart. Knowledge of Se concentrations in humans and the environments, especially because the range for toxicity and deficiency is narrow, is important for effective intervention. Dietary data and serum samples were collected from children (n = 555) 69-78 months old from rural villages of the Amhara Region, Ethiopia. In addition, information on the socio-demography of households was collected. Serum Se was analyzed by inductively coupled plasma mass spectrometer. Almost all (90.3%) of participants reported eating grain, roots, or tubers 24 h preceding the survey followed by legumes, nuts, and seeds (64.6%). Consumption of animal source foods was very low (4.6%). Compared to children from the western part of the region, children from eastern Amhara had higher dietary diversity score (2.1 ± 0.9 vs 1.8 ± 0.7; p < 0.001).The median serum Se concentration was 70.6 µg/l (IQR 48.2, 96.6). Selenium inadequacy (serum Se < 70 µg/l) was detected in 49.1% of children. However, the distribution had an important geographical pattern across administrative zones. Children from the western part of the Amhara Region were highly deficient (up to 91.1% prevalence), while there was little or no Se deficiency in children from the eastern part of the region. Serum Se level exhibited an important spatial variation in the Amhara Region, Ethiopia. Further studies investigating contributing factors for the variation such as soil characteristics and Se concentration in staple crops are needed.

Selenium inadequacy hampers thyroid response of young children after iodine repletion.

Selenium (Se) is an integral component of iodothyronine deiodinase, glutathione peroxidase and thioredoxin reductase enzymes and thus is important for normal thyroid function. This study investigated the influence of Se inadequacy on thyroid response of iodine-replete young children. Serum thyroxine (T4), triiodothyronine (T3), thyroglobulin (Tg), thyroid stimulating hormone (TSH), and Se were analyzed in 54-60 mo old children (n = 628) from the Amhara region of Ethiopia before salt iodization was commenced; analyses were repeated (n = 555) 15 mo after iodized salt became available. Iodized salt coverage increased from 12.2% to 91.6% of households. Median urinary iodine concentration (UIC) among children increased from 9 µg/l to 167 µg/l (p < 0.001). In addition, all thyroid indices except T3 showed significant improvement (p < 0.05). Nearly, half of the study children (49.1%) had Se inadequacy (serum Se < 70 µg/l). Serum Se was significantly correlated with T3 (r = 0.38, p < 0.001), T4 (r = 0.15, p < 0.001), TSH (r=-0.205, p < 0.001) and Tg (r= -0.11, p < 0.01) concentrations 15 mo after iodine repletion; baseline serum Se and T4(r= -0.22, p < 0.01) were inversely correlated. Despite adequate iodine status, children with low serum Se had lower serum T4 (p = 0.003) and T3(p < 0.001) but higher TSH concentration (p = 0.003). In the partial least square regression model, Se was among the latent variables significantly explaining T4 and T3. Results of the present study suggest that Se inadequacy negatively affects the thyroid metabolism of iodine-replete children and may present a substantial public health concern thus emphasize the need to consider correction of Se status for normal thyroid function as well as for benefits from its diverse biological roles.

Introduction of iodised salt benefits infants' mental development in a community-based cluster-randomised effectiveness trial in Ethiopia.

The effectiveness of salt iodisation in improving the mental development of young children has not been assessed. We implemented a community-based cluster-randomised effectiveness trial in sixty randomly selected districts in the Amhara region of Ethiopia. We randomly allocated each district to treatment and randomly selected one of its villages. In parallel to national salt iodisation efforts, iodised salt was brought early into the markets of the thirty intervention villages before it became widely available in the thirty control villages 4-6 months later. The primary outcome was children's mental development scores on the Bayley Scales. This was an intention-to-treat analysis using mixed linear models adjusted for covariates and clusters. The trial was registered at ClinicalTrials.gov, NCT013496. We assessed 1835 infants aged 5-11 months at baseline. The same children (85 % of the sample) were re-assessed at 20-29 months when all villages had iodised salt. At endline, urinary iodine concentration was higher in children in the intervention group compared with those in the control group (median 228·0 v. 155·1 µg/l, P=0·001). The intervention group had higher scores compared with the control group on the Bayley composite score (raw scores:130·60 v. 128·51; standardised scores: 27·8 v. 26·9; d=0·13; 95 % CI 0·02, 0·23) and three of the four subscales: cognitive (53·27 v. 52·54, d=0·13; 95 % CI 0·03, 0·23), receptive language (20·71 v. 20·18, d=0·13; 95 % CI 0·03, 0·24) and fine motor (35·45 v. 34·94, d=0·15; 95 % CI 0·04, 0·25). The introduction of iodised salt contributes to children's higher urinary iodine concentration and mental development.

Evaluation of the effects of iodized salt on the mental development of preschool-aged children: a cluster randomized trial in northern Ethiopia.

A cluster randomized effectiveness trial was used to examine the effects on mental development of introducing iodized salt to children 4 to 6 years of age in Ethiopia, where there were reportedly high levels of iodine deficiency. Sixty district clusters were randomized to receive iodized salt early at their markets with assistance from regular salt distributors or later as introduced by market forces. At pre- and post-iodization, 1602 children were given cognitive/language tests (namely School Readiness, WPPSI verbal reasoning, WPPSI Matrix reasoning), and mothers were interviewed concerning demographics, nutrition and health. Children's weight, height, urine and a blood sample were taken. Analyses of covariance, adjusting for clustering and baseline levels were conducted. Urinary iodine concentrations were significantly higher at endline in the intervention children than controls though both medians were above threshold. Overall, less than 5% were anemic. There were no significant main effect differences between groups on the cognitive/language tests, but there were effect modifiers, namely mother's education, child's sex and diet. For example, the intervention group performed better on the school readiness test than controls if their mothers had attended school, but not otherwise. In conclusion, the data are consistent with negative findings from studies where children 6 to 12 years were supplemented with an iodine capsule, indicating that the benefits of iodine, in salt or capsule form, for brain development may be restricted to children under 3 years. Yet, benefits may be tied to those with more educational resources or may compensate for conditions of disadvantage.

Stunting, selenium deficiency and anemia are associated with poor cognitive performance in preschool children from rural Ethiopia.

BACKGROUND: Anthropometric characteristics and iron status affect cognitive performance in children. In addition, selenium can influence cognitive outcomes; protection of the brain from oxidative stress and its role in thyroid hormone metabolism are putative mechanisms. METHODS: To investigate their association with cognitive performance, anthropometric indicators, iron biomarkers, and serum selenium of children (n = 541) of 54-60mo of age from rural Ethiopia were assessed. Cognitive assessment was conducted with the administration of two reasoning subtests of the Wechsler Preschool and Primary Scale of Intelligence and the school readiness test. RESULTS: Stunting was found in 41.4 % of children, 28.7 % were underweight, and 6.3 % were wasted. The mean score of stunted children was lower than that of non-stunted children on non-verbal reasoning (7.0 ± 3.2vs7.9 ± 3.1; p = 0.01) and the school readiness tests (4.3 ± 2.2 vs 3.3 ± 2.1; p < 0.001). Compared to non-anemic children, anemic children had lower score for the verbal reasoning test (9.5 ± 1.7 vs 8.9 ± 2.2; p = 0.02). However, except for hemoglobin, none of the iron biomarkers had significant associations with the cognitive score of the study children (p > 0.05). Selenium deficient children had lower scores on all cognitive tests than normal children (p < 0.05). CONCLUSION: The present study finding linking chronic undernutrition and micronutrient deficiency to cognitive deficits suggests the need for designing effective intervention programmes to control for protein energy malnutrition and micronutrient deficiency and address cognitive development in children.

Ethiopian pre-school children consuming a predominantly unrefined plant-based diet have low prevalence of iron-deficiency anaemia.

OBJECTIVE: Children from low-income countries consuming predominantly plant-based diets but little animal products are considered to be at risk of Fe deficiency. The present study determined the Fe status of children from resource-limited rural households. DESIGN: A cross-sectional study. SETTING: Twenty six kebeles (the smallest administrative unit) from six zones of the Amhara region, Ethiopia. SUBJECTS: Children aged 54-60 months (n 628). RESULTS: Grain, roots or tubers were the main dietary components consumed by 100 % of the study participants, followed by pulses, legumes or nuts (66·6 %). Consumption of fruit and vegetables (19·3 %) and meat, poultry and fish (2·2 %) was low. Children had a mean dietary diversity score of 2·1 (sd 0·8). Most children (74·8 %, n 470) were in the lowest dietary diversity group (1-2 food groups). Rate of any morbidity in the preceding 14 d was 22·9 % (n 114). Infection or inflammation (α1-acid glycoprotein >1·2 g/l) was present in 30·2 % (n 184) of children. Children had a high rate of stunting (43·2 %). Of the total sample, 13·6 % (n 82) of children were anaemic, 9·1 % (n 57) were Fe deficient and 5·3 % (n 32) had Fe-deficiency anaemia. Fe-deficiency erythropoiesis was present in 14·2 % (n 60) of children. CONCLUSIONS: Despite consuming a predominantly plant-based diet and little animal-source foods, there was a low prevalence of Fe-deficiency anaemia. This illustrates that dietary patterns can be inharmonious with Fe biochemical status; thus, Fe-related interventions require biochemical screening.

Iodine and mental development of children 5 years old and under: a systematic review and meta-analysis.

Several reviews and meta-analyses have examined the effects of iodine on mental development. None focused on young children, so they were incomplete in summarizing the effects on this important age group. The current systematic review therefore examined the relationship between iodine and mental development of children 5 years old and under. A systematic review of articles using Medline (1980-November 2011) was carried out. We organized studies according to four designs: (1) randomized controlled trial with iodine supplementation of mothers; (2) non-randomized trial with iodine supplementation of mothers and/or infants; (3) prospective cohort study stratified by pregnant women's iodine status; (4) prospective cohort study stratified by newborn iodine status. Average effect sizes for these four designs were 0.68 (2 RCT studies), 0.46 (8 non-RCT studies), 0.52 (9 cohort stratified by mothers' iodine status), and 0.54 (4 cohort stratified by infants' iodine status). This translates into 6.9 to 10.2 IQ points lower in iodine deficient children compared with iodine replete children. Thus, regardless of study design, iodine deficiency had a substantial impact on mental development. Methodological concerns included weak study designs, the omission of important confounders, small sample sizes, the lack of cluster analyses, and the lack of separate analyses of verbal and non-verbal subtests. Quantifying more precisely the contribution of iodine deficiency to delayed mental development in young children requires more well-designed randomized controlled trials, including ones on the role of iodized salt.