Predictive Accuracy of Infant Clinical Sign Algorithms for Mortality in Young Infants Aged 0 to 59 Days: A Systematic Review.

CONTEXT: Clinical sign algorithms are a key strategy to identify young infants at risk of mortality. OBJECTIVE: Synthesize the evidence on the accuracy of clinical sign algorithms to predict all-cause mortality in young infants 0-59 days. DATA SOURCES: MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials. STUDY SELECTION: Studies evaluating the accuracy of infant clinical sign algorithms to predict mortality. DATA EXTRACTION: We used Cochrane methods for study screening, data extraction, and risk of bias assessment. We determined certainty of evidence using Grading of Recommendations Assessment Development and Evaluation. RESULTS: We included 11 studies examining 26 algorithms. Three studies from non-hospital/community settings examined sign-based checklists (n = 13). Eight hospital-based studies validated regression models (n = 13), which were administered as weighted scores (n = 8), regression formulas (n = 4), and a nomogram (n = 1). One checklist from India had a sensitivity of 98% (95% CI: 88%-100%) and specificity of 94% (93%-95%) for predicting sepsis-related deaths. However, external validation in Bangladesh showed very low sensitivity of 3% (0%-10%) with specificity of 99% (99%-99%) for all-cause mortality (ages 0-9 days). For hospital-based prediction models, area under the curve (AUC) ranged from 0.76-0.93 (n = 13). The Score for Essential Neonatal Symptoms and Signs had an AUC of 0.89 (0.84-0.93) in the derivation cohort for mortality, and external validation showed an AUC of 0.83 (0.83-0.84). LIMITATIONS: Heterogeneity of algorithms and lack of external validation limited the evidence. CONCLUSIONS: Clinical sign algorithms may help identify at-risk young infants, particularly in hospital settings; however, overall certainty of evidence is low with limited external validation.

Efficacy of Antibiotic Regimens for Pneumonia in Young Infants Aged 0-59 Days: A Systematic Review.

CONTEXT: Pneumonia is a leading cause of death in young infants. OBJECTIVES: To evaluate the efficacy of different antibiotic regimens to treat young infant pneumonia on critical clinical outcomes. DATA SOURCES: MEDLINE, Embase, CINAHL, World Health Organization (WHO) Global Index Medicus, Cochrane Central Registry of Trials. STUDY SELECTION: We included randomized controlled trials of young infants aged 0 to 59 days with pneumonia (population) comparing the efficacy of antibiotic regimens (intervention) with alternate regimens or management (control) on clinical outcomes. DATA EXTRACTION: We extracted data and assessed risk of bias in duplicate. We used Grading of Recommendations, Assessment, Development, and Evaluation to assess certainty of evidence. LIMITATIONS: Trials were heterogeneous, which precluded data pooling. RESULTS: Of 2601 publications screened, 10 randomized controlled trials were included. Seven trials were hospital-based (n = 869) and 3 were nonhospital-based (n = 4329). No hospital-based trials evaluated WHO-recommended first-choice regimens. One trial found the WHO-recommended second-choice antibiotic, cefotaxime, to have similar rates of treatment success as non-WHO-recommended regimens of either amoxicillin-clavulanate (RR 0.99, 95% confidence interval 0.82-1.10) or amoxicillin-clavulanate/cefotaxime (RR 1.02, 95% confidence interval 0.86-1.12). Among 3 nonhospital-based trials comparing oral amoxicillin to alternate regimens to treat isolated tachypnea among infants aged 7-59 days, there were no differences in treatment failure between amoxicillin and alternate regimens. Certainty of evidence was low or very low for all primary outcomes. CONCLUSIONS: We found limited evidence to support the superiority of any single antibiotic regimen over alternate regimens to treat young infant pneumonia.

Efficacy of Antibiotic Regimens for Meningitis in Young Infants Aged 0-59 Days: A Systematic Review.

CONTEXT: Meningitis is associated with high mortality risk in young infants, yet the optimal treatment regimen is unclear. OBJECTIVES: To systematically evaluate the efficacy of antibiotic regimens to treat meningitis in young infants aged 0 to 59 days on critical clinical outcomes. DATA SOURCES: MEDLINE, Embase, CINAHL, WHO Global Index Medicus, and Cochrane Central Registry of Trials. STUDY SELECTION: We included randomized controlled trials (RCTs) of young infants with meningitis (population) comparing the efficacy of antibiotic regimens (interventions) with alternate regimens (control) on clinical outcomes. DATA EXTRACTION: We extracted data on study characteristics and assessed risk of bias in duplicate. Grading of Recommendations Assessment, Development, and Evaluation was used to assess certainty of evidence. RESULTS: Of 1088 studies screened, only 2 RCTs were identified. They included 168 infants from 5 countries and were conducted between 1976 and 2015. Neither study compared current World Health Organization-recommended regimens. One multisite trial from 4 countries compared intrathecal gentamicin plus systemic ampicillin/gentamicin to systemic ampicillin/gentamicin and found no difference in mortality (relative risk, 0.88; 95% confidence interval, 0.41-1.53; 1 trial, n = 98, very low certainty of evidence) or adverse events (no events in either trial arm). Another trial in India compared a 10-day versus 14-day course of antibiotics and found no difference in mortality (relative risk, 0.88; 95% confidence interval, 0.41-1.53; 1 trial, n = 98, very low certainty of evidence) or other outcomes. CONCLUSIONS: Trial data on the efficacy of antibiotic regimens in young infant meningitis are scarce. Rigorous RCTs are needed to inform recommendations for optimal antibiotic regimens for meningitis treatment in this vulnerable population, particularly within the context of changing epidemiology and increasing antimicrobial resistance.

Global Management of Serious Bacterial Infections in Young Infants Aged 0 to 59 Days: An Overview of Systematic Reviews.

BACKGROUND: To inform World Health Organization guidelines for the management of serious bacterial infection (SBI) (suspected or confirmed sepsis, pneumonia, or meningitis) in infants aged 0-59 days. OBJECTIVE: To conduct an "overview of systematic reviews" to: (1) understand which systematic reviews have examined diagnosis and management of SBI in infants aged 0-59 days in the last 5 years; and (2) assess if the reviews examined PICOs (population, intervention, comparator, outcomes) and regimens currently being recommended in low and middle income countries (LMICs) by the World Health Organization. DATA SOURCES: MEDLINE; Embase; Cochrane Library; Epistemonikos; PROSPERO. STUDY SELECTION: Systematic reviews of randomized controlled trials or observational studies of infants aged 0-59 days examining diagnostic accuracy and antibiotic regimens for SBI from January 1, 2018 to November 3, 2023. DATA EXTRACTION: Dual independent extraction of study characteristics, PICOs, and methodological quality. RESULTS: Nine systematic reviews met our criteria. Two reviews examined diagnostic accuracy for sepsis, and no reviews examined pneumonia or meningitis. Five reviews examined antibiotic effectiveness (sepsis [n = 4]; pneumonia [n = 1]), and no reviews examined meningitis. One review examined antibiotic duration for sepsis and one for meningitis, and no reviews for pneumonia. Only 4 of the 9 systematic reviews met criteria for high-quality. LIMITATIONS: Our review was limited to the last 5 years to inform current guideline updates. CONCLUSIONS: Few studies have examined antibiotic regimens currently being used in LMICs and quality is of concern in many studies. More high-quality data are needed to inform management of SBI in newborns, especially in LMICs.

Efficacy of Antibiotic Regimens for Sepsis or Possible Serious Bacterial Infection in Young Infants Aged 0 to 59 Days: A Systematic Review and Meta-analysis.

CONTEXT: Sepsis is a leading cause of young infant mortality. OBJECTIVE: To evaluate the efficacy of different antibiotic regimens to treat young infant sepsis or possible serious bacterial infection (PSBI) on clinical outcomes. DATA SOURCES: MEDLINE, Embase, CINAHL, World Health Organization Global Index Medicus, Cochrane Central Registry of Trials. STUDY SELECTION: We included randomized controlled trials (RCTs) of young infants 0 to 59 days with sepsis or PBSI (population) comparing the efficacy of antibiotic regimens (intervention) with alternate regimens or management (control) on clinical outcomes. DATA EXTRACTION: We extracted data and assessed risk of bias in duplicate. We performed random-effects meta-analysis, and used Grading of Recommendations, Assessment, Development, and Evaluation to assess certainty of evidence. RESULTS: Of 2390 publications, we included 41 RCTs (n = 18 054). Thirty-five trials were hospital-based and 6 were nonhospital-based. Meta-analysis of 4 trials demonstrated similar rates of treatment success with intramuscular/intravenous third generation cephalosporins versus intramuscular/intravenous penicillin or ampicillin + gentamicin (RR 1.03, 95% CI 0.93-1.13]; n = 1083; moderate certainty of evidence). Meta-analysis of 3 trials demonstrated similar rates of treatment failure with oral amoxicillin + intramuscular gentamicin versus intramuscular penicillin + gentamicin for nonhospital treatment of clinical severe illness (RR 0.86, 95% CI 0.72-1.02]; n = 5054; low certainty of evidence). Other studies were heterogeneous. LIMITATIONS: RCTs evaluated heterogeneous regimens, limiting our ability to pool data. CONCLUSIONS: We found limited evidence to support any single antibiotic regimen as superior to alternate regimens to treat young infant sepsis or PSBI.

Diagnostic Accuracy of Clinical Sign Algorithms to Identify Sepsis in Young Infants Aged 0 to 59 Days: A Systematic Review and Meta-analysis.

CONTEXT: Accurate identification of possible sepsis in young infants is needed to effectively manage and reduce sepsis-related morbidity and mortality. OBJECTIVE: Synthesize evidence on the diagnostic accuracy of clinical sign algorithms to identify young infants (aged 0-59 days) with suspected sepsis. DATA SOURCES: MEDLINE, Embase, CINAHL, Global Index Medicus, and Cochrane CENTRAL Registry of Trials. STUDY SELECTION: Studies reporting diagnostic accuracy measures of algorithms including infant clinical signs to identify young infants with suspected sepsis. DATA EXTRACTION: We used Cochrane methods for study screening, data extraction, risk of bias assessment, and determining certainty of evidence using Grading of Recommendations Assessment Development and Evaluation. RESULTS: We included 19 studies (12 Integrated Management of Childhood Illness [IMCI] and 7 non-IMCI studies). The current World Health Organization (WHO) 7-sign IMCI algorithm had a sensitivity of 79% (95% CI 77%-82%) and specificity of 77% (95% CI 76%-78%) for identifying sick infants aged 0-59 days requiring hospitalization/antibiotics (1 study, N = 8889). Any IMCI algorithm had a pooled sensitivity of 84% (95% CI 75%-90%) and specificity of 80% (95% CI 64%-90%) for identifying suspected sepsis (11 studies, N = 15523). When restricting the reference standard to laboratory-supported sepsis, any IMCI algorithm had a pooled sensitivity of 86% (95% CI 82%-90%) and lower specificity of 61% (95% CI 49%-72%) (6 studies, N = 14278). LIMITATIONS: Heterogeneity of algorithms and reference standards limited the evidence. CONCLUSIONS: IMCI algorithms had acceptable sensitivity for identifying young infants with suspected sepsis. Specificity was lower using a reference standard of laboratory-supported sepsis diagnosis.

Effect of early childhood development interventions delivered by healthcare providers to improve cognitive outcomes in children at 0-36 months: a systematic review and meta-analysis.

OBJECTIVE: To determine the effect of early childhood development interventions delivered by healthcare providers (HCP-ECD) on child cognition and maternal mental health. DESIGN: Systematic review, meta-analysis. SETTING: Healthcare setting or home. PARTICIPANTS: Infants under 1 month of age. INTERVENTIONS: HCP-ECD interventions that supported responsive caregiving, early learning and motor stimulation. MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Health Technology Assessment Database, Database of Abstracts of Reviews of Effects and Cochrane Database of Systematic Reviews were searched until 15 November 2021. Studies reporting prespecified outcomes were pooled using standard meta-analytical methods. MAIN OUTCOME MEASURES: Cognitive development in children at 0-36 months. RESULTS: Forty-two randomised controlled trials with 15 557 infants were included in the narrative synthesis. Twenty-seven trials were included in the meta-analyses. Pooled data from 13 trials suggest that HCP-ECD interventions may improve cognitive outcomes in children between 0 and 36 months (Bayley Scales of Infant Development version IIII (BSID-III) mean difference (MD) 2.65; 95% CI 0.61 to 4.70; 2482 participants; low certainty of evidence). Pooled data from nine trials suggest improvements in motor development (BSID-III MD 4.01; 95% CI 1.54 to 6.48; 1437 participants; low certainty of evidence). There was no evidence of improvement in maternal mental health (standardised MD -0.13; 95% CI -0.28 to 0.03; 2806 participants; 11 trials; low certainty of evidence). CONCLUSIONS: We report promising evidence, particularly for cognitive and motor outcomes, of the effect of HCP-ECD interventions. However, effect sizes were small, and the certainty of evidence ranged from very low to moderate. Additional high-quality research is required. PROSPERO REGISTRATION NUMBER: CRD42019122021.

Family-centred interventions for Indigenous early childhood well-being by primary healthcare services.

BACKGROUND: Primary healthcare, particularly Indigenous-led services, are well placed to deliver services that reflect the needs of Indigenous children and their families. Important characteristics identified by families for primary health care include services that support families, accommodate sociocultural needs, recognise extended family child-rearing practices, and Indigenous ways of knowing and doing business. Indigenous family-centred care interventions have been developed and implemented within primary healthcare services to plan, implement, and support the care of children, immediate and extended family and the home environment. The delivery of family-centred interventions can be through environmental, communication, educational, counselling, and family support approaches. OBJECTIVES: To evaluate the benefits and harms of family-centred interventions delivered by primary healthcare services in Canada, Australia, New Zealand, and the USA on a range of physical, psychosocial, and behavioural outcomes of Indigenous children (aged from conception to less than five years), parents, and families. SEARCH METHODS: We used standard, extensive Cochrane search methods. The latest search date was 22 September 2021. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster RCTs, quasi-RCTs, controlled before-after studies, and interrupted time series of family-centred care interventions that included Indigenous children aged less than five years from Canada, Australia, New Zealand, and the USA. Interventions were included if they met the assessment criteria for family-centred interventions and were delivered in primary health care. Comparison interventions could include usual maternal and child health care or one form of family-centred intervention versus another. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were 1. overall health and well-being, 2. psychological health and emotional behaviour of children, 3. physical health and developmental health outcomes of children, 4. family health-enhancing lifestyle or behaviour outcomes, 5. psychological health of parent/carer. 6. adverse events or harms. Our secondary outcomes were 7. parenting knowledge and awareness, 8. family evaluation of care, 9. service access and utilisation, 10. family-centredness of consultation processes, and 11. economic costs and outcomes associated with the interventions. We used GRADE to assess the certainty of the evidence for our primary outcomes. MAIN RESULTS: We included nine RCTs and two cluster-RCTs that investigated the effect of family-centred care interventions delivered by primary healthcare services for Indigenous early child well-being. There were 1270 mother-child dyads and 1924 children aged less than five years recruited. Seven studies were from the USA, two from New Zealand, one from Canada, and one delivered in both Australia and New Zealand. The focus of interventions varied and included three studies focused on early childhood caries; three on childhood obesity; two on child behavioural problems; and one each on negative parenting patterns, child acute respiratory illness, and sudden unexpected death in infancy. Family-centred education was the most common type of intervention delivered. Three studies compared family-centred care to usual care and seven studies provided some 'minimal' intervention to families such as education in the form of pamphlets or newsletters. One study provided a minimal intervention during the child's first 24 months and then the family-centred care intervention for one year. No studies had low or unclear risk of bias across all domains. All studies had a high risk of bias for the blinding of participants and personnel domain. Family-centred care may improve overall health and well-being of Indigenous children and their families, but the evidence was very uncertain. The pooled effect estimate from 11 studies suggests that family-centred care improved the overall health and well-being of Indigenous children and their families compared no family-centred care (standardised mean difference (SMD) 0.14, 95% confidence interval (CI) 0.03 to 0.24; 2386 participants). We are very uncertain whether family-centred care compared to no family-centred care improves the psychological health and emotional behaviour of children as measured by the Infant Toddler Social Emotional Assessment (ITSEA) (Competence domain) (mean difference (MD) 0.04, 95% CI -0.03 to 0.11; 2 studies, 384 participants). We assessed the evidence as being very uncertain about the effect of family-centred care on physical health and developmental health outcomes of children. Pooled data from eight trials on physical health and developmental outcomes found there was little to no difference between the intervention and the control groups (SMD 0.13, 95% CI -0.00 to 0.26; 1961 participants). The evidence is also very unclear whether family-centred care improved family-enhancing lifestyle and behaviours outcomes. Nine studies measured family health-enhancing lifestyle and behaviours and pooled analysis found there was little to no difference between groups (SMD 0.16, 95% CI -0.06 to 0.39; 1969 participants; very low-certainty evidence). There was very low-certainty evidence of little to no difference for the psychological health of parents and carers when they participated in family-centred care compared to any control group (SMD 0.10, 95% CI -0.03 to 0.22; 5 studies, 975 parents/carers). Two studies stated that there were no adverse events as a result of the intervention. No additional data were provided. No studies reported from the health service providers perspective or on outcomes for family's evaluation of care or family-centredness of consultation processes. AUTHORS' CONCLUSIONS: There is some evidence to suggest that family-centred care delivered by primary healthcare services improves the overall health and well-being of Indigenous children, parents, and families. However, due to lack of data, there was not enough evidence to determine whether specific outcomes such as child health and development improved as a result of family-centred interventions. Seven of the 11 studies delivered family-centred education interventions. Seven studies were from the USA and centred on two particular trials, the 'Healthy Children, Strong Families' and 'Family Spirit' trials. As the evidence is very low certainty for all outcomes, further high-quality trials are needed to provide robust evidence for the use of family-centred care interventions for Indigenous children aged less than five years.

Early Enteral Feeding for Preterm or Low Birth Weight Infants: a Systematic Review and Meta-analysis.

CONTEXT: Early enteral feeding has been associated with adverse outcomes such as necrotizing enterocolitis in preterm and low birth weight infants. OBJECTIVES: To assess effects of early enteral feeding initiation within the first days after birth compared to delayed initiation. DATA SOURCES: Medline, Scopus, Web of Science, CINAHL from inception to June 30, 2021. STUDY SELECTION: Randomized trials (RCTs) were included. Primary outcomes were mortality, morbidity, growth, neurodevelopment, feed intolerance, and duration of hospitalization. DATA EXTRACTION: Data were extracted and pooled with random-effects models. RESULTS: We included 14 randomized controlled trials with 1505 participants in our primary analysis comparing early (<72 hours) to delayed (≥72 hours) enteral feeding initiation. Early initiation likely decreased mortality at discharge and 28 days (1292 participants, 12 trials, relative risk 0.69, 95% confidence interval [95% CI] 0.48-0.99, moderate certainty evidence) and duration of hospitalization (1100 participants, 10 trials, mean difference -3.20 days, 95%CI -5.74 to -0.66, moderate certainty evidence). The intervention may also decrease sepsis and weight at discharge. Based on low certainty evidence, early feeding may have little to no effect on necrotizing enterocolitis, feed intolerance, and days to regain birth weight. The evidence is very uncertain regarding the effect of initiation time on intraventricular hemorrhage, length, and head circumference at discharge. CONCLUSIONS: Enteral feeding within 72 hours after birth likely reduces the risk of mortality and length of hospital stay, may reduce the risk of sepsis, and may reduce weight at discharge.

Mother's Own Milk Compared With Formula Milk for Feeding Preterm or Low Birth Weight Infants: Systematic Review and Meta-analysis.

OBJECTIVES: We assessed the effect of feeding preterm or low birth weight infants with infant formula compared with mother's own milk on mortality, morbidity, growth, neurodevelopment, and disability. METHODS: We searched Medline (Ovid), Embase (Ovid), and Cochrane Central Register of Controlled Studies to October 1, 2021. RESULTS: Forty-two studies enrolling 89 638 infants fulfilled the inclusion criteria. We did not find evidence of an effect on mortality (odds ratio [OR] 1.26, 95% confidence interval [CI] 0.91-1.76), infection (OR 1.52, 95% CI 0.98-2.37), cognitive neurodevelopment (standardized mean difference -1.30, 95% CI -3.53 to 0.93), or on growth parameters. Formula milk feeding increased the risk of necrotizing enterocolitis (OR 2.99, 95% CI 1.75-5.11). The Grading of Recommendations Assessment, Development, and Evaluation certainty of evidence was low for mortality and necrotizing enterocolitis, and very low for neurodevelopment and growth outcomes. CONCLUSIONS: In preterm and low birth weight infants, low to very low-certainty evidence indicates that feeding with infant formula compared with mother's own milk has little effect on all-cause mortality, infection, growth, or neurodevelopment, and a higher risk of developing necrotizing enterocolitis.

Non-specific effects of BCG and DTP vaccination on infant mortality: An analysis of birth cohorts in Ghana and Tanzania.

BACKGROUND: Vaccines may induce non-specific effects on survival and health outcomes, in addition to protection against targeted pathogens or disease. Observational evidence suggests that infant Baccillus Calmette-Guérin (BCG) vaccination may provide non-specific survival benefits, while diphtheria-tetanus-pertussis (DTP) vaccination may increase the risk of mortality. Non-specific vaccine effects have been hypothesized to modify the effect of neonatal vitamin A supplementation (NVAS) on mortality. METHODS: 22,955 newborns in Ghana and 31,999 newborns in Tanzania were enrolled in two parallel, randomized, double-blind, placebo-controlled trials of neonatal vitamin A supplementation from 2010 to 2014 and followed until 1-year of age. Cox proportional hazard models were used to estimate associations of BCG and DTP vaccination with infant survival. RESULTS: BCG vaccination was associated with a decreased risk of infant mortality after controlling for confounders in both countries (Ghana adjusted hazard ratio (aHR): 0.51, 95% CI: 0.38-0.68; Tanzania aHR: 0.08, 95% CI: 0.07-0.10). Receiving a DTP vaccination was associated with a decreased risk of death (Ghana aHR: 0.39, 95% CI: 0.26-0.59; Tanzania aHR: 0.19, 95% CI: 0.16-0.22). There was no evidence of interaction between BCG or DTP vaccination status and infant sex or NVAS. CONCLUSION: We demonstrated that BCG and DTP vaccination were associated with decreased risk of infant mortality in Ghana and Tanzania with no evidence of interaction between DTP or BCG vaccination, NVAS, and infant sex. Our study supports global recommendations on BCG and DTP vaccination and programmatic efforts to ensure all children have access to timely vaccination. CLINICAL TRIALS REGISTRATION: Ghana (Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12610000582055) and Tanzania (ANZCTR: ACTRN12610000636055).

Community health worker service delivery for maternal and child health: an observational study from Afghanistan.

OBJECTIVE: To understand the reach of the community health worker (CHW) programme in remote and non-remote districts of Afghanistan. METHODS: Using data collected from the Ministry of Public Health's National Health Management Information System, we conducted a population-based study from 2018 to 2019 in 401 districts across 34 provinces of Afghanistan. We assessed the availability of CHWs, antenatal visits (ANV) and postnatal visits (PNV) conducted by the CHWs, and the availability of CHW supplies. Districts were classified as remote if the district centre was >2 hours by any form of transport from provincial capital, and non-remote if <2 hours. Data were analysed using multivariable regression models. RESULTS: 15 562 CHWs were working in the districts of Afghanistan, 13 482 (87%) in remote and 2080 (13%) in non-remote districts. The mean of the proportion of CHWs per pregnant woman was higher in remote (0.019 (SD 0.011)) compared with non-remote (0.012 (SD 0.006)) districts (adjusted mean difference (AMD) 0.008, 95% CI 0.004 to 0.01). The mean of the proportion of ANVs received from a CHW per pregnant women was higher in remote (0.88 (SD 0.82)) compared with non-remote (0.62 (SD 0.50)) districts (AMD 0.28, 95% CI 0.02 to 0.54). The mean of the proportion of PNVs received from a CHW per pregnant women was higher in remote (0.54 (SD 0.53)) compared with non-remote (0.36 (SD 0.25)) districts (AMD 0.19, 95% CI 0.02 to 0.36). The mean of the proportion of CHWs who reported that they had stocks of cotrimoxazole and oral contraceptives in the previous month per district was higher in remote compared with non-remote districts. CONCLUSIONS: In Afghanistan, the CHW programme appears to be effective and proportionate to need in remote regions.

Modelling factors for Aboriginal and Torres Strait Islander child neurodevelopment outcomes: A latent class analysis.

BACKGROUND: The Australian Early Development Census (AEDC) provides a measure of early child development upon school entry. Understanding which combination of factors influences Aboriginal child neurodevelopment is important to inform policy and practice. OBJECTIVE: The primary objective was to use latent class analysis (LCA) to model AEDC profiles and identify the highest need profiles. The secondary objective was to determine the associations of these high need profiles on the likelihood of a child becoming developmentally vulnerable. METHODS: We designed a prospective population-based birth cohort study (n = 2715) using linked data sets with information on Aboriginal cohort children, and their mothers and siblings in Western Australia. Specific developmental indicators in the 2009 and 2012 AEDC were used to assess developmental vulnerability. LCA methods were used to determine need profiles and their association with developmental vulnerability. RESULTS: 49.3% of Aboriginal children were vulnerable on at least one developmental domain, and 37.5% were vulnerable on two or more domains. LCA found six unique profiles. High needs family, High needs young mother, and Preterm infant comprised 42% of the cohort and were considered to have high need configurations. These groups were at least 1.7 times as likely to have children who had at least one or two developmental vulnerabilities compared with the Healthy family group. CONCLUSION: Many Aboriginal children in Western Australia enter school with at least one developmental vulnerability. This study highlights a range of unique profiles that can be used to empower Aboriginal families for change and develop targeted programmes for improving the early development of young Aboriginal children.

Assessing the quality, efficiency and usefulness of the Western Australian population-based Intellectual Disability Exploring Answers (IDEA) surveillance system: a surveillance system evaluation.

OBJECTIVES: Our overall aim was to evaluate the Western Australian Intellectual Disability Exploring Answers (IDEA) surveillance system. The primary objective was to evaluate the attributes of the system. The secondary objective was to provide recommendations to data custodians and stakeholders to strengthen the system. METHOD: The IDEA system was evaluated using process observation, interviews and secondary data analysis of system attributes: usefulness, simplicity, data quality, acceptability, representativeness, timeliness and stability. 2001 US Centers for Disease Control and Prevention guidelines were used. RESULTS: We found that the IDEA system was useful, simple, flexible, acceptable, representative, timely and stable. We compared individuals from the IDEA system (n=10 593) with those with cerebral palsy and intellectual disability (ID) (n=582) from another surveillance system. Of the 582 with cerebral palsy and ID, 501 (86.1%) were in the IDEA system and 81 (13.9%) were not. In total, 0.7% of cases (81/10674) with ID were not identified in the IDEA system. There were little differences in cases that were not identified in the IDEA system between Indigenous status, sex and place of residence. CONCLUSIONS: The strengths of the IDEA system include having a high data quality resource contributing to national and international data on ID, strong government support and a dedicated management team. Output from studies linking to IDEA data have had major contributions to the international literature about ID. However, limited resources have prevented it from realising its full potential in relation to translational activities. The IDEA system is a valuable resource to address the needs of people living with ID.

Effect of early childhood development interventions implemented by primary care providers commencing in the neonatal period to improve cognitive outcomes in children aged 0-23 months: protocol for a systematic review and meta-analysis.

BACKGROUND: Impacts of early childhood development (ECD) interventions (such as fostering attachment and responsiveness through communication, play and stimulation) are well known. Globally, there is increasing recognition of the importance of the 'golden' minutes, hours and days after birth for infant health and development. However, only one systematic review has examined ECD interventions implemented in the neonatal period (0-27 days), and this review only assessed interventions implemented by specialised providers. Primary care providers have many potential contacts with mothers and infants throughout the neonatal period. However, it is unclear how many research studies or programmes have examined the effectiveness of ECD interventions commencing in the neonatal period and which methods were used. To date, there has been no systematic review of the effect of ECD interventions delivered by primary care providers commencing in the neonatal period. METHODS: Our overall aim is to conduct a systematic review of the effect of ECD interventions implemented by primary care providers in the neonatal period. We will assess effects by timing and number ('dose') of contacts with primary care providers. Subgroup assessment will include effects in disadvantaged infants such as those born with low birth weight and to mothers with mental health disorders. We will also assess effects in low- and high-income countries and by type of care provider. The primary outcome is cognitive status in children aged 0-23 months as measured using standardised scales. Secondary outcomes include other child neurodevelopment domains (speech, language, fine motor, gross motor, social, emotional, behaviour, executive functioning, adaptive functioning) in children aged 0-23 months. Effects on maternal mental health will also be assessed between 0-23 months postpartum. Databases such as MEDLINE (OVID), PsycINFO (OVID), EMBASE (OVID), CINAHL, Cochrane Library, WHO databases and reference lists of papers will be searched for relevant articles. Only randomised controlled trials will be included. A narrative synthesis for all outcomes will be reported. Meta-analyses will be performed where exposures and outcomes are sufficiently homogeneous. Guidelines for PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols) will be followed. DISCUSSION: This review appears to be the first to be conducted in this area. The findings will be an important resource for policymakers, primary care providers and researchers who work with young infants in primary care settings. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019122021.

Quality of essential newborn care and neonatal resuscitation at health facilities in Afghanistan: a cross-sectional assessment.

OBJECTIVE: To assess readiness and quality of essential newborn care and neonatal resuscitation practices in public health facilities in Afghanistan. DESIGN: Cross-sectional assessment. SETTING: 226 public health facilities in Afghanistan, including 77 public health facilities with at least five births per day (high-volume facilities) and 149 of 1736 public health facilities with fewer than five births per day (low-volume facilities). PARTICIPANTS: Managers of 226 public health facilities, 734 skilled birth attendants (SBAs) working at these facilities, and 643 women and their newborns observed during childbirth at 77 high-volume health facilities. OUTCOME MEASURES: Availability of knowledgeable SBAs, availability of supplies and compliance with global guidelines for essential newborn care and neonatal resuscitation practices. RESULTS: At high-volume facilities, 569/636 (87.9%) of babies were dried immediately after birth, 313/636 (49.2%) were placed in skin-to-skin contact with their mother and 581/636 (89.7%) had their umbilical cord cut with a sterile blade or scissors. A total of 87 newborn resuscitation attempts were observed. Twenty-four of the 87 (27.5%) began to breath or cry after simply clearing the airway or on stimulation. In the remaining 63 (72.5%) cases, a healthcare worker began resuscitation with a bag and mask; however, only 54 (62%) used a correct size of mask and three babies died as their resuscitation with bag and mask was unsuccessful. CONCLUSIONS: The study indicates room for improvement of the quality of neonatal resuscitation practices at public health facilities in Afghanistan, requiring only strengthening of the current best practices in newborn care. Certain basic and effective aspects of essential newborn care that can be improved on with little additional resources were also missing, such as skin-to-skin contact of the babies with their mother. Improvement of compliance with the standard newborn care practices must be ensured to reduce preventable newborn mortality and morbidity in Afghanistan.

Conditional cash transfers to improve use of health facilities by mothers and newborns in conflict affected countries, a prospective population based intervention study from Afghanistan.

BACKGROUND: The effects of conditional cash transfer (CCT) programs on maternal and child health (MCH) service use in conflicted affected countries such as Afghanistan are not known. METHODS: We conducted a non-randomised population based intervention study in six Afghanistan districts from December 2016 to December 2017. Six control districts were purposively matched. Women were eligible to be included in the baseline and endline evaluation surveys if they had given birth to one or more children in the last 12 months. The intervention was a CCT program including information, education, communication (IEC) program about CCT to community members and financial incentives to community health workers (CHWs) and families if mothers delivered their child at a health facility. Control districts received standard care. The primary objective was to assess the effect of CCT on use of health facilities for delivery. Secondary objectives were to assess the effect of CCT on antenatal care (ANC), postnatal care (PNC) and CHW motivation to perform home visits. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering and socio demographic variables. RESULTS: Overall, facility delivery increased in intervention villages by 14.3% and control villages by 8.4% (adjusted mean difference [AMD] 3.3%; 95% confidence interval [- 0.14 to 0.21], p value 0.685). There was no effect in the poorest quintile (AMD 0.8% [- 0.30 to 0.32], p value 0.953). ANC (AMD 45.0% [0.18 to 0.72] p value 0.004) and PNC (AMD 31.8% [- 0.05 to 0.68] p value 0.080) increased in the intervention compared to the control group. CHW home visiting changed little in intervention villages (- 3.0%) but decreased by - 23.9% in control villages (AMD 12.2% [- 0.27 to 0.51], p value 0.508). CCT exposure was 27.3% (342/1254) overall and 10.2% (17/166) in the poorest quintile. CONCLUSIONS: Our study demonstrated that a CCT program provided to women aged 16-49 years can be implemented in a highly conservative conflict affected population. CCT should be scaled up for the poorest women in Afghanistan.

Anemia in disadvantaged children aged under five years; quality of care in primary practice.

BACKGROUND: Anemia rates are over 60% in disadvantaged children yet there is little information about the quality of anemia care for disadvantaged children. METHODS: Our primary objective was to assess the burden and quality of anemia care for disadvantaged children and to determine how this varied by age and geographic location. We implemented a cross-sectional study using clinical audit data from 2287 Indigenous children aged 6-59 months attending 109 primary health care centers between 2012 and 2014. Data were analysed using multivariable regression models. RESULTS: Children aged 6-11 months (164, 41.9%) were less likely to receive anemia care than children aged 12-59 months (963, 56.5%) (adjusted odds ratio [aOR] 0.48, CI 0.35, 0.65). Proportion of children receiving anemia care ranged from 10.2% (92) (advice about 'food security') to 72.8% (728) (nutrition advice). 70.2% of children had a hemoglobin measurement in the last 12 months. Non-remote area families (115, 38.2) were less likely to receive anemia care compared to remote families (1012, 56.4%) (aOR 0.34, CI 0.15, 0.74). 57% (111) aged 6-11 months were diagnosed with anemia compared to 42.8% (163) aged 12-23 months and 22.4% (201) aged 24-59 months. 49% (48.5%, 219) of children with anemia received follow up. CONCLUSIONS: The burden of anemia and quality of care for disadvantaged Indigenous children was concerning across all remote and urban locations assessed in this study. Improved services are needed for children aged 6-11 months, who are particularly at risk.

Can community health worker home visiting improve care-seeking and maternal and newborn care practices in fragile states such as Afghanistan? A population-based intervention study.

BACKGROUND: The effects of community health worker (CHW) home visiting during the antenatal and postnatal periods in fragile- and conflicted-affected countries such as Afghanistan are not known. METHODS: We conducted a non-randomised population-based intervention study from March 2015 to February 2016. Two intervention and two control districts were selected. All female CHWs in the intervention districts were trained to provide eight home visits and behaviour change communication messages from pregnancy to 28 days postpartum. The primary outcome was the proportion of women who reported delivering in a health facility. Secondary outcomes were the proportion of women who reported attending a health facility for at least one antenatal and one postnatal visit. Outcomes were analysed at 12 months using multivariable difference-in-difference linear regression models adjusted for clustering. RESULTS: Overall, 289 female CHWs in the intervention districts performed home visits and 1407 eligible women (less than 12 months postpartum) at baseline and 1320 endline women provided outcome data (94% response rate). Facility delivery increased in intervention villages by 8.2% and decreased in the control villages by 6.3% (adjusted mean difference (AMD) 11.0%, 95% confidence interval (CI) 4.0-18.0%, p = 0.002). Attendance for at least one antenatal care visit (AMD 10.5%, 95% CI 4.2-16.9%, p = 0.001) and postnatal care visit (AMD 7.2%, 95% CI 0.2-14.2%, p = 0.040) increased in the intervention compared to the control districts. CONCLUSIONS: CHW home visiting during the antenatal and postnatal periods can improve health service use in fragile- and conflict-affected countries. Commitment to scale-up from Ministries and donors is now needed. TRIAL REGISTRATION: This trial was retrospectively registered at the Australian and New Zealand Clinical Trial Registry ( ACTRN12618000609257 ).