Low birth weight babies under village conditions: feeding pattern, growth and motor development.

Feeding, growth and motor development of low birth weight babies (LBW) were assessed among infants born from September 1982 through December 1984 in 3 villages in Madura. Mean birth weight of Madurese infants ranged from 2850-2950 g and the incidence of LBW from 9.5-12.2%. A larger percentage of the very small LBW babies (birth weight 2.0-2.2 kg) received breastmilk as the sole food in the first 6 months. Yet, force-feeding was also practiced for LBW babies. Infants remained in their growth channel according to birth weight, however, relative to the NCHS centiles at birth, LBW infants grew better in the first 6 months than normal birth weight (NBW) infants. Growth deteriorated conspicuously in the second half of infancy, irrespective of birth weight. There was no difference in motor development between LBW and NBW infants. Once they had survived, LBW infants appeared to do as well as NBW under village conditions.

PIP: Researchers followed at least 561 single births born between September 1982-December 1984 in 3 villages in Madura, Indonesia from birth to 12 months to assess infant feeding, growth, and motor development of full term, low birth weight (LBW) infants. Mean birth weight varied from 2850-2950 g and the incidence of LBW from 9.5-12.2%. No special interventions were employed with the LBW infants. Only about 15% of the infants were exclusively breast fed in the 1st 12 months, but not all of the 15% were the same infants. Most infants who returned to exclusive breast feeding refused other food. Some infants received their 1st supplementary food by the end of the 1st week. Apparently this did not adversely affect the infants health, however. Mothers of infants 2300 g tended to exclusively breast feed more and longer than all other mothers. All infants stayed in their growth category by birth weight cohort. In fact, LBW infants grew better than normal birth weight (NBW) infants according to the NCHS centiles at birth during the 1st 6 months. The fact that the LBW infants were wasted may have explained the catch up in growth with NBW infants during the 1st 6 months. During 6-12 months, however, the weight and length of both LBW and NBW infants faltered. The deflection from the reference level at birth was greater for NBW infants, however. Further the motor development of both NBW and LBW infants progressed at basically the same rate. In conclusion, surviving LBW infants grew quite well and their motor skills developed satisfactorily under village conditions in rural Madura, Indonesia.

When does growth faltering start?

Three indicators were used to assess the onset of growth faltering: (a) average weight - and length - for - age as percentage of the NCHS references or (b) the Cambridge references based on breastfed infants and (c) incremental growth over 4 weeks in which "faltering" was defined as a weight increment less than minus 2 standard deviations, calculated by Waterlow from USA and British data or no gain in length. The population covered were singleton infants born in two villages in Madura in September 1982 through December 1984 (N = 391). Weight and length were measured at 4 week intervals. The first two indicators did not properly identify the age period at which growth became unacceptable according to weight or length increments. This was mainly due to the large variation and the skewed distribution of weight and length of Madurese infants. Arbitrarily a magnitude of 20% weight falterers was used as a cut-off point for the onset of growth faltering. Among Madurese infants it would be at or before 3-4 months. It is recommended to analyse weight increments from data, generated by growth monitoring at POSYANDUS for mapping of the age period at risk throughout Indonesia.

Energy supplementation in the last trimester of pregnancy in East Java, Indonesia: effect on maternal anthropometry.

The effect of prenatal energy supplementation on maternal anthropometry was assessed in a controlled, randomized trial in Madura, East Java. At 26-28 wk of gestation women were either given 465 kcal/d (HE group) or 52 kcal/d (LE group). Two hundred seventy-six women were enrolled in the HE group and 266 women, in the LE group. Supplement intake was variable. Testing of effect by treatment and compliance was thus done by subcategories (HE 1-3 and LE 1-3, corresponding to less than 45, 45-89, and greater than or equal to 90 packets of supplement consumed). Analysis of variance did not show significant differences among the six subcategories in third-trimester weight gain, sum of skinfold thicknesses, 4-wk postpartum weight, or body mass index. In this population energy supplementation for the short duration of the last 90-110 d of pregnancy was not sufficient to improve maternal nutrition as judged by anthropometry.

The effects on weight and attendance of a supplementary feeding programme operating in two under-5 clinics in Lesotho.

The routinely collected weight data of 2202 pre-school children who visited two under-5 clinics in Lesotho between 1978 and 1983 were used to calculate growth curves and to assess the effects of supplementary feeding. Up to the age of 5 months growth curves were above the NCHS reference. Growth started to decrease at the age of 3 months and stabilized at 11-13 months at the 10th percentile of the reference. The decrease of growth might have been due to environmental factors such as under-nutrition and disease. If this was the case, supplementary feeding might have had a positive impact on weight, but such an effect was not observed in this study. Supplementary feeding had, however, a positive effect on attendance rates and hence contributed to higher coverage of other under-5 clinic activities, such as immunization, health and nutrition education, and growth monitoring. Whether this positive effect warrants its extra cost remains open to question.

Energy supplementation in the last trimester of pregnancy in East Java, Indonesia: effect on breast-milk output.

Breast-milk output was measured in women who during the last trimester of pregnancy consumed a high- or low-energy supplement (53 and 55 women, respectively). Infant and mother pairs were enrolled at 2 or 6 wk postpartum. Test weighings were done four times at 8-wk intervals. Mean breast-milk output ranged from 682 to 744 g/d in the age period of 2 wk to 7 mo. There was no difference in milk output between the two experimental groups. In all cohorts, breast-feeding frequency influenced milk output positively. Only at age 18-22 wk did the mothers' prepregnancy or 4-wk postpartum body mass index play an additional role. The results confirm that breast-milk output of mildly undernourished women is comparable with that of well-nourished women. Short-term energy supplementation during pregnancy did not increase breast-milk output, probably because the sample studied was not at nutritional risk.

Infant mortality in Madura, Indonesia. Implications for action.

Infant mortality by age at death and birth weight was assessed in a prospective, population-based study in Madura, East Java. Even after elimination of neonatal tetanus by vaccination during pregnancy as a major cause of death, the infant mortality rate was high, viz. 121 per 1000 live births. The majority of live born infants died in the first 6 months of life. Birth weight was the best practical indicator of survival. The implications for Primary Health Care are discussed.

Birthweight distribution in a healthy urban population in Surabaya-Indonesia.

The birthweight distribution was assessed in an apparently healthy urban population in Surabaya, Indonesia. A total of 924 pregnant women of a middle income group were enrolled at 20-24 weeks of gestation of which 543 women delivered in the university hospital. In the latter group mean birthweight of liveborn singletons was 3047 g for males and 2900 g for females. The percentages of low birthweight by sex were 7.9% and 13.8% respectively. These values were lower than those reported for more affluent women in Indonesia and comparable with those of rural Madurese women studied in the same time period.

Energy supplementation in the last trimester of pregnancy in East Java: I. Effect on birthweight.

The effect of two levels of energy supplementation in the last trimester of pregnancy on birthweight was tested in a controlled randomized trial in three villages in Madura, East Java. The high and low energy supplements provided 1.95 MJ (465 kcal) and 218 kJ (52 kcal) per day respectively. In the baseline period the home diet provided on average 6.28 MJ (1500 kcal) (SD 2.1 MJ (499 kcal] and 41 g (SD 13 g) of protein. The mean birthweight was 2835 g and the rate of low birthweight 12.2%. In the experimental period the home diet was better. The average intake ranged from 6.45 to 7.19 MJ (1541-1717 kcal) and 41.4-44.2 g per day, depending on the degree of compliance. Mean birthweight increased by 100 g and the rate of low birthweight dropped to 9.5%. There was no difference between the high and low energy supplemented group as a whole, probably due to the masking effect of the better home diet in the experimental period. It is likely that a positive effect of energy supplementation on birthweight was restricted to the group of pregnant women with the lowest home dietary intake and/or a low prepregnant weight. In this community targeting of supplementation to lean seasons and/or to women with a low prepregnant weight may be cost-effective.

Early postnatal growth of Basotho infants in the Mantsonyane area, Lesotho.

The records of 814 infants born in a rural hospital in Lesotho were analysed. It was calculated that on average Basotho infants regained their birthweight between 3 and 4 days of age and the average weight loss amounted to 3%. Compared with Caucasian infants, Basotho infants regained their birthweight sooner. Of 289 infants in whom the gestational age was assessed, small-for-dates infants showed an increased mean growth rate compared with pre-term and appropriate-for-dates full-term infants.

Birthweight distribution in the Mantsonyane area: Lesotho.

A total of 832 maternal and newborn records in a rural hospital in Lesotho were analysed. The mean birthweight was 3.07 kg and the incidence of low birthweight rate 7.5%. This was compared with other countries in Africa. Increasing birth order was associated with higher birthweight irrespective of maternal age, except for the very young mothers. No seasonal variation in birthweight was observed. Of 313 newborns the gestational age was assessed. The overall anthropometric measurements of newborns in the Mantsonyane area were comparable to better off industrialized countries.

Predictive value of the abnormal PAP smear: a retrospective analysis of error rates.

The validity and performance of the Papanicolaou (PAP) smear, as a diagnostic test, was retrospectively analysed in 806 patients who presented with at least one abnormal smear. Histological tissue examination was available in 620 of these patients. It is shown that the definition of errors, selection criteria of smears, time intervals between examinations, definition of 'disease' and the values separating 'positive' and negative' test results must be clearly defined before comparison with other published error rates is possible. Consequently, a standardized method of reporting is recommended. Exact agreement between the results of cytology and histology was poor. The use of sensitivity, specificity and predictive values is preferred, but it is shown that precise definitions are still necessary. The optimal choice of the value separating positive and negative test results, i.e., the choice between an expectant and an active management of patients, must be tailored to the anticipated prevalence of the disease.

Methods for comparing groups of growth curves when patterns of observation times vary among subjects.

A variety of statistical techniques is available if growth is to be compared for two groups followed up over a certain period. In practice straightforward application of such techniques may be hampered if patterns of observation times vary among subjects. Different approaches to deal with such variation are illustrated by analysing data from infants (0-18 months) living in Lesotho, Southern Africa. Data comprises 236 individual series of multiple measurements on five anthropometric variables. Individual patterns of observation times differ because of variation in a) age at entry, b) length of follow-up, and c) observation intervals (nominally 4 weeks). First an ad hoc approach is followed by taking a few summary measures for each individual series, e.g. 'growth velocity'. By contrast two other approaches hinge on preliminary data transformation required to make standard techniques applicable. The pros and cons of the different approaches are discussed.