High prevalence of selected viruses and parasites and their predictors in Malawian children.

Enteric pathogens have been related to child undernutrition. Whereas there are lots of data on enteric bacterial microbiota and infections, much less is known about the incidence of prevalence of intestinal colonisation with viruses or important parasitic species. This study assessed the presence of selected viruses and parasites in stools of 469, 354, 468 Malawian children at 6, 12 and 18 months. We also assessed environmental predictors of the presence of viruses and parasites among 6-month infants. Microbial presence was documented using real-time polymerase chain reaction (PCR). Enteroviruses were identified in 68%, 80% and 81% of the stool samples at 6, 12 and 18 months children, rhinovirus in 28%, 18% and 31%, norovirus in 24%, 22% and 16%, parechovirus in 23%, 17% and 17%, rotavirus in 3%, 1% and 0.6%, Giardia lamblia in 9.6%, 23.5% and 26%, and Cryptosporidium (spp.) in 6%, 8% and 2% of the 6, 12 and 18 months stool samples. Dry season (May-October) was associated with a low infection rate of enterovirus, norovirus and Cryptosporidium (spp.). Higher father's education level, less number of person in the household and higher sanitation were associated with a low infection rate of enterovirus, norovirus and rotavirus, respectively. The results suggest that the prevalence of asymptomatic viral and parasitic infections is high among Malawian children and that the family's living conditions and seasonality influence the rate of infections.

Periapical infection may affect birth outcomes via systemic inflammation.

OBJECTIVES: Maternal dental periapical infections are associated with preterm birth and intrauterine growth restriction. This study investigates whether the association is mediated through bacterial spread from periapical lesions to placenta (direct pathway) or systemic inflammatory reaction (indirect pathway). MATERIALS AND METHODS: We compared birth outcomes in Malawian mothers with and without periapical infection. As markers of a direct pathway, we identified placental bacteria using a 16S rDNA approach and assessed histological evidence of inflammation in the placenta and amniotic membranes. We measured C-reactive protein, alpha-1-acid glycoprotein, and salivary cortisol as markers of an indirect pathway. We used regression models to associate the predictor variables with duration of pregnancy and newborn size. RESULTS: Of 1,024 women, 23.5% had periapical infection. There was no association of periapical infection with either bacterial DNA or histological inflammation in placenta or membranes. Periapical infection was associated with C-reactive protein, alpha-1-acid glycoprotein, and cortisol concentrations in a dose-dependent manner at 36 weeks. Addition of alpha-1-acid glycoprotein or cortisol concentration into regression models attenuated the association between periapical infection and pregnancy outcomes. CONCLUSION: There was no evidence of direct spread of periapical bacteria to the placenta. Periapical infections and adverse pregnancy outcomes are in part mediated through systemic inflammation.

Effect of 12-month intervention with lipid-based nutrient supplement on the physical activity of Malawian toddlers: a randomised, controlled trial.

Physical activity is beneficial for children's well-being. The effect of dietary supplementation on children's physical activity in food-insecure areas remains little studied. We examined the effects of a lipid-based nutrient supplement (LNS) on children's objectively measured physical activity in a randomised, controlled, outcome-assessor-blinded trial. Mothers of the children received one capsule daily of Fe-folic acid (IFA), one capsule containing eighteen micronutrients (MMN) or one 20 g sachet of LNS (containing twenty-two MMN, protein, carbohydrates, essential fatty acids and 494 kJ (118 kcal)) during pregnancy and for 6 months thereafter. Children in the IFA and MMN groups received no supplementation, and these groups were collapsed into a single control group; children in the LNS group received 20 g LNS from 6 to 18 months. We measured physical activity with accelerometers over 1 week at 18 months. The main outcome was mean vector magnitude counts/15 s. Of the 728 children at the beginning of child intervention at 6 months, 570 (78 %) provided sufficient data for analysis. The mean accelerometer counts for the 190 children in the LNS group and for the 380 children in the control group were 303 (sd 59) and 301 (sd 56), respectively (P for difference=0·65). LNS, given to mothers during pregnancy and 6 months postpartum and to their infants from 6 to 18 months of age, did not increase physical activity among 18-month-old children.

Breast milk from women living near Lake Malawi is high in docosahexaenoic acid and arachidonic acid.

Adequate long-chain polyunsaturated fatty acid (LCPUFA) intake is critical during the fetal and infant periods. We quantified fatty acid content of breast milk (n=718) and plasma from six month old infants (n=412) in southern Malawi, and in usipa (n=3), a small dried fish from Lake Malawi. Compared to global norms, Malawian breast milk fatty acid content (% of total fatty acids) was well above average levels of arachidonic acid [ARA] (0.69% vs. 0.47%) and docosahexaenoic acid [DHA] (0.73% vs. 0.32%). Average Malawian infant plasma ARA (7.5%) and DHA (3.8%) levels were comparable to those reported in infants consuming breast milk with similar fatty acid content. The amounts (mg) of DHA, EPA and ARA provided by a 3 oz (85 g) portion of dried usipa (1439, 659 and 360, respectively) are considerably higher than those for dried salmon. Usipa may be an important source of LCPUFA for populations in this region.

Exclusive breastfeeding duration during the first 6 months of life is positively associated with length-for-age among infants 6-12 months old, in Mangochi district, Malawi.

OBJECTIVES: To examine the association between breastfeeding pattern and growth in the first year of life. METHODS: A cross-sectional survey was carried out on 349 mothers with infants <12 months in a rural and a semi-urban community in Mangochi district, Malawi. Data on socio-demographic characteristics, infant weight, length and feeding patterns since birth were collected. Multivariate linear regression was performed to test the association between feeding pattern and infant anthropometric status. RESULTS: Exclusive breastfeeding (EBF) until 6 months was practised by 13.1% semi-urban and 1.3% rural mothers. No infant was exclusively breastfed beyond 6 months. Breastfeeding was continued among all infants who had stopped EBF. Among infants 6-12 months of age, duration of EBF during the first 6 months was positively associated with length-for-age Z-score (LAZ) (regression coefficient=0.19, 95% confidence interval: 0.06, 0.31) in a model adjusted for socio-demographic factors. Urban residence and female gender yielded positive associations in the same model. The model explained 27% of the variation in LAZ. Among infants <6 months, duration of EBF was not significantly associated with LAZ, but being female and urban residence yielded positive associations. Breastfeeding patterns were not associated with weight-for-age Z-score (WAZ) or weight-for-height Z-score (WLZ) either in the 0-6-month or in the 6-12-month group. Birth outside a health facility was negatively associated with WAZ and WLZ in the older group. CONCLUSION: EBF in the first 6 months of life was associated with increased linear growth, but not weight gain, in later infancy. Promotion of EBF could reduce the prevalence of chronic child undernutrition in the study area.

Effect of 12-month intervention with lipid-based nutrient supplements on physical activity of 18-month-old Malawian children: a randomised, controlled trial.

BACKGROUND/OBJECTIVES: This study measured the effects of dietary supplementation with lipid-based nutrient supplements (LNSs) on 18-month-old children's physical activity. SUBJECTS/METHODS: In a randomised, controlled, outcome-assessor blinded trial 1932 six-month-old children from Malawi received one of five interventions daily from 6-18 months of age: 10-g milk-LNS, 20-g milk-LNS, 20-g non-milk-LNS, 40-g milk-LNS or 40-g non-milk-LNS, or received no intervention in the same period (control). The control group received delayed intervention with corn-soy blend from 18-30 months. Physical activity was measured over 1 week by ActiGraph GT3X+ accelerometer at 18 months. Main outcome was mean vector magnitude accelerometer counts/15 s. Analyses were restricted to children with valid accelerometer data on at least 4 days with minimum 6 h of wearing time per day. RESULTS: Of the 1435 children recruited to this substudy, 1053 provided sufficient data for analysis. The mean (s.d.) vector magnitude accelerometer counts in the total sample were 307 (64). The difference (95% CI) in mean accelerometer counts, compared with the control group, was 8 (-6 to 21, P=0.258) in 10-g milk-LNS, 3 (-11 to 17, P=0.715) in 20-g milk-LNS, 5 (-8 to 19, P=0.445) in 20-g non-milk-LNS, 10 (-3 to 23, P=0.148) in 40-g milk-LNS and 2 (-12 to 16, P=0.760) in 40-g non-milk-LNS groups. CONCLUSIONS: Provision of 10-40 g doses of LNS daily for 12 months did not increase physical activity of Malawian toddlers.

Evaluating environmental and social influences on iron and zinc status of pregnant subsistence farmers in two geographically contrasting regions of Southern Malawi.

Micronutrient deficiency affects over 4.5 billion people worldwide, the majority in developing countries. Deficiencies of iron (and associated anaemia) and zinc in pregnancy are associated with complications, maternal and neonatal mortality, and developmental disorders in the foetus and growing child. We report the results of pilot study which used an interdisciplinary approach to explore environmental and sociocultural factors influencing the micronutrient status in the soil-plant-human transfer for pregnant subsistence farmers in two geographically contrasting regions of Southern Malawi. It evaluated micronutrient status in soil and the staple crop and explored the context for their transfer to pregnant women. Scientific and social science methods were used to collect data, following full sensitisation of the communities. A total of 99 participants were recruited from Chiradzulu (plateau) and Chikwawa (floodplain). Soil, maize and blood samples were collected, along with food frequency and health behaviour questionnaires and anthropological observation. Statistical analysis revealed that soil iron was significantly higher in Chiradzulu than in Chikwawa; total iron concentration is not deemed to be deficient in either area. Soil zinc was not significantly different between areas. Maize concentrations of iron and zinc were not significantly different between areas, and were not deficient relative to improved cultivars. Blood iron deficiency and associated anaemia were problematic in both areas, but more so in Chikwawa than in Chiradzulu, and zinc deficiency was similar in both areas. The study has identified a significant difference in the blood iron status of the participants of the two communities, and has shown that this difference is not accounted for by the staple crop maize. Socio-geographical factors appear to play a significant role in the micronutrient health of the populations. The findings lend support to multifaceted community intervention studies which educate communities on strategies to tackle micronutrient deficiencies.

Postnatal growth velocity and overweight in early adolescents: a comparison of rural and urban African boys and girls.

OBJECTIVES: To compare growth velocity of two African child cohorts and examine the relationship between postnatal growth velocity in infancy/early childhood and the risk of overweight/stunting in early adolescence. METHODS: The study used data from two child cohorts from urban (Birth to Twenty Cohort, South Africa) and rural (Lungwena Child Survival Study, Malawi) African settings. Mixed effect modelling was used to derive growth and peak growth velocities. T-tests were used to compare growth parameters and velocities between the two cohorts. Linear and logistic regression models were used to determine the relationship between growth velocity and early adolescent (ages 9-11 years) body mass index and odds of being overweight. RESULTS: Children in the BH cohort were significantly taller and heavier than those in the Lungwena cohort, and exhibited faster weight and height growth velocity especially in the first year of life (P < 0.05). No significant association was shown between baseline weight (αw ) and overweight in early adolescence (OR = 1.25, CI = 0.67, 2.34). The weight growth velocity parameter ßw was highly associated with odds of being overweight. Association between overweight in adolescence and weight velocity was stronger in infancy than in early childhood (OR at 3 months = 4.80, CI = 2.49, 9.26; OR at 5 years = 2.39, CI = 1.65, 3.47). CONCLUSION: High weight and height growth velocity in infancy, independent of size at birth, is highly associated with overweight in early adolescence. However, the long term effects of rapid growth in infancy may be dependent on a particular population's socio-economic status and level of urbanization.

Feasibility and validity of the ActiGraph GT3X accelerometer in measuring physical activity of Malawian toddlers.

AIM: To test the feasibility and validity of the ActiGraph GT3X accelerometer in measuring physical activity of rural Malawian toddlers. METHODS: Fifty-six children aged 16.0-18.5 months wore the accelerometer on their right hip for 7 days. We analysed days with a minimum of 600 min of wear time, excluding night time and periods when the unit registered zero for 20 consecutive minutes. The first and last days were excluded as they were incomplete. Accelerometer counts were compared with coded free play video recordings to define median accelerometer counts for sedentary, light, moderate and vigorous activity. Count cut points were defined for moderate to vigorous physical activity, with predictive validity assessed using a second set of video recordings. RESULTS: Median wear time was 797 min/day, with 79% of participants completing at least four eligible days. Accelerometer counts were significantly higher for observed moderate to vigorous physical activity, than lighter activity, with cut points of 208 counts/15 sec for vector magnitude and 35 counts/15 sec for vertical axis, showing sensitivity of 94.2% and 84.1% and specificity of 90.9% and 84.6%, respectively. CONCLUSION: The accelerometer proved a feasible and valid method of assessing physical activity among Malawian toddlers.

"PHC Leadership: Are Health Centres in Good Hands?Perspectives from 3 districts in Malawi"""

"The study aimed to document the kinds of leadership styles are practiced at health centres (H/C) and how these styles can be explained by the contexts; characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS). Methods A well-researched leadership style model was applied; which included task; relation and change styles. This is a cross-sectional study using self-administered questionnaires in 47 H/C in 3 districts. 347 STHSs (95) and 46 ICs (98) responded. Questions explored background data and perceived leadership behaviour. Style items were factor analysed; and bivariate analyses and hierarchical regressions determined how styles could be explained. Results Two leadership styles were revealed: ""Trans""style contained all relation and the majority of task and change items; ""Control"" style focused on health statistics (Health Management Information System); reporting and evaluation. STHS and IC had a median age/median work experience of 34/5 years and 38;5/2 years; respectively. 48"

"PHC leadership: are health centres in good hands? Perspectives from 3 districts in Malawi".

AIM: The study aimed to document the kinds of leadership styles are practiced at health centres (H/C) and how these styles can be explained by the contexts, characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS). METHODS: A well-researched leadership style model was applied, which included task, relation and change styles. This is a cross-sectional study using self-administered questionnaires in 47 H/C in 3 districts. 347 STHSs (95%) and 46 ICs (98%) responded. Questions explored background data and perceived leadership behaviour. Style items were factor analysed, and bivariate analyses and hierarchical regressions determined how styles could be explained. RESULTS: Two leadership styles were revealed: "Trans" style contained all relation and the majority of task and change items; "Control" style focused on health statistics (Health Management Information System), reporting and evaluation. STHS and IC had a median age/median work experience of 34/5 years and 38,5/2 years, respectively. 48% of IC reported having no management training. CHAM H/Cs had the lowest score on "Control" style. Distance to referral hospital had no impact on style scores. No contexts or STHS characteristics predicted any leadership styles. For ICs, young age and increasing work experience were significant predictors for both styles, while Nurse ICs were negative predictors for "Control style". Management training was not a significant predictor for any style. CONCLUSION: Frontline PHC leadership may be forced by situation and context to use a comprehensive style which could lack the diversity and flexibility needed for effective leadership. The missing associations between staff characteristics and leadership styles might indicate that this group is not sufficiently considered and included in leadership processes in the PHC organization. Leadership competency for the ICs seems not to be based on formal training, but substituted by young age and work experience. Health centre organization could also influence the options for leadership behaviour. In conclusion this calls for a reassessment of H/C leadership and formal leadership training.

Locally produced ready-to-use supplementary food is an effective treatment of moderate acute malnutrition in an operational setting.

BACKGROUND: Typical treatment of moderate acute malnutrition, simple wasting, in sub-Saharan Africa consists of dietary counselling and/or general or targeted distribution of corn/soy-blended flour (CSB). A randomised clinical effectiveness trial in 2007 showed CSB to be less effective than ready-to-use supplementary food (RUSF). AIM: To determine the operational effectiveness of treating moderate acute malnutrition with RUSF. METHODS: Children aged 6-59 months were recruited in rural southern Malawi. Each child received 65 kcal/kg/d of locally produced soy/peanut RUSF, a product that provided about 1 RDA of each micronutrient. Anthropometric measurements were taken every 2 weeks and additional rations of RUSF were distributed at this time if the child remained wasted. Study participation lasted up to 8 weeks. RESULTS: Of the 2417 children enrolled, 80% recovered, 4% defaulted, 0.4% died, 12% remained moderately wasted and 3% developed severe acute malnutrition. Weight, length and MUAC gain were 2.6 g/kg/d, 0.2 mm/d and 0.1 mm/d respectively. Cost per child treated was $5.39. CONCLUSIONS: This intervention proved to be robust, maintaining high recovery rates and low default rates when instituted without the additional supervision and beneficiary incentives of a research setting.

Breastfeeding perceptions in communities in Mangochi district in Malawi.

AIM: To investigate mothers' perceptions of breastfeeding and influences from their social network. METHODS: A cross-sectional survey was carried out in Mangochi district, Malawi where questionnaire data from 157 rural and 192 semi-urban mother-infant pairs were obtained. RESULTS: The proportion of mothers who thought that exclusive breastfeeding should last for 6 months and those who reported to have actually exclusively breastfed were 40.1% and 7.5% respectively. Of those who reported practising exclusive breastfeeding for 6 months, 77.5% stated that exclusive breastfeeding should last for 6 months. This opinion was independently associated with giving birth in a Baby-Friendly facility, OR = 5.22; 95% CI (1.92-14.16). Among the mothers who thought that exclusive breastfeeding should last for less than 6 months, 43.9% reported having been influenced in their opinion by health workers. Infant crying was the most common (62.4%) reason for stopping exclusive breastfeeding. CONCLUSION: The findings illustrate the positive impact health workers can have, as well as the need to raise awareness of the benefits of exclusive breastfeeding among both health workers and mothers. Furthermore, continued counselling of mothers on how to deal with stressful infant behaviour such as crying may assist to prolong exclusive breastfeeding.

Food intake of selenium and sulphur amino acids in tuberculosis patients and healthy adults in Malawi.

Wasting in tuberculosis (TB) patients is associated with the severity of lung disease and low serum level of selenium. Low serum levels of selenium may be due to low food intake or altered absorption/metabolism in the body. We therefore wanted to measure and compare the intake of selenium and sulphur amino acids in smear-positive TB patients and appropriately matched adults. We found a low intake of selenium but no significant difference in intake of selenium and sulphur amino acids between the groups in this study.

Can Western developmental screening tools be modified for use in a rural Malawian setting?

OBJECTIVE: To create a more culturally relevant developmental assessment tool for use in children in rural Africa. DESIGN: Through focus groups, piloting work and validation, a more culturally appropriate developmental tool, based on the style of the Denver II, was created. Age standardised norms were estimated using 1130 normal children aged 0-6 years from a rural setting in Malawi. The performance of each item in the tool was examined through goodness of fit on logistic regression, reliability and interpretability at a consensus meeting. The instrument was revised with removal of items performing poorly. RESULTS: An assessment tool with 138 items was created. Face, content and respondent validity was demonstrated. At the consensus meeting, 97% (33/34) of gross motor items were retained in comparison to 51% (18/35) of social items, and 86% (69/80) of items from the Denver II or Denver Developmental Screening Test (DDST) were retained in comparison to 69% (32/46) of the newly created items, many of these having poor reliability and goodness of fit. Gender had an effect on 23% (8/35) of the social items, which were removed. Items not attained by 6 years came entirely from the Denver II fine motor section (4/34). Overall, 110 of the 138 items (80%) were retained in the revised instrument with some items needing further modification. CONCLUSIONS: When creating developmental tools for a rural African setting, many items from Western tools can be adapted. The gross motor domain is more culturally adaptable, whereas social development is difficult to adapt and is culturally specific.

Seasonality of gestational weight gain and foetal growth in rural Malawi.

OBJECTIVE: To study seasonal variation of maternal anthropometry and newborn weights. DESIGN: A retrospective descriptive study from 1995 to 1998. SETTING: Lungwena, a rural health centre in Malawi, southeast Africa. SUBJECTS: One thousand and thirty two women with singleton pregnancy, a minimum of eight weeks antenatal follow-up and a baby who was weighed in the first month of life. Maternal data were sought from a health centre antenatal register and linked with infant information collected from a newborn clinic. RESULTS: The mean (SD) gestational weight and fundal height gains among the pregnant women were 240 (200) grams and 0.9 (0.2) cm/week and the mean (SD) newborn weight 3360 (530) grams. Gestational weight gains followed a seasonal pattern and they were typically highest among women delivering in the third quarter of the year (mean gain 250-300 g/week) and lowest among those delivering in January-May (mean gain 100-200 g/week) (p < 0.001 for seasonality, ANOVA). For maternal fundal height gains and newborn weights, seasonality was less obvious (but statistically significant, p < 0.05, ANOVA) and its pattern was influenced by year of study. On average, newborn weights peaked in the last quarter (mean 3350-3400 grams) and nadired during the second quarter (mean 3200-3300 grams). There was only a modest correlation between maternal weight gain in pregnancy and the weight of her newborn (Pearson's correlation coefficient 0.13). CONCLUSION: In rural Malawi, maternal weight gains during pregnancy are more strongly associated with season than fundal height gains or newborn weights. In adverse environmental conditions, foetal growth ismaintained at least partially at the expense of mother's nutritional status.

Home based therapy for severe malnutrition with ready-to-use food.

BACKGROUND: The standard treatment of severe malnutrition in Malawi often utilises prolonged inpatient care, and after discharge results in high rates of relapse. AIMS: To test the hypothesis that the recovery rate, defined as catch-up growth such that weight-for-height z score >0 (WHZ, based on initial height) for ready-to-use food (RTUF) is greater than two other home based dietary regimens in the treatment of malnutrition. METHODS: HIV negative children >1 year old discharged from the nutrition unit in Blantyre, Malawi were systematically allocated to one of three dietary regimens: RTUF, RTUF supplement, or blended maize/soy flour. RTUF and maize/soy flour provided 730 kJ/kg/day, while the RTUF supplement provided a fixed amount of energy, 2100 kJ/day. Children were followed fortnightly. Children completed the study when they reached WHZ >0, relapsed, or died. Outcomes were compared using a time-event model. RESULTS: A total of 282 children were enrolled. Children receiving RTUF were more likely to reach WHZ >0 than those receiving RTUF supplement or maize/soy flour (95% v 78%, RR 1.2, 95% CI 1.1 to 1.3). The average weight gain was 5.2 g/kg/day in the RTUF group compared to 3.1 g/kg/day for the maize/soy and RTUF supplement groups. Six months later, 96% of all children that reached WHZ >0 were not wasted. CONCLUSIONS: Home based therapy of malnutrition with RTUF was successful; further operational work is needed to implement this promising therapy.