A Predictive Model for Thiamine Responsive Disorders Among Infants and Young Children: Results from a Prospective Cohort Study in Lao People's Democratic Republic.

OBJECTIVE: To develop a predictive model for thiamine responsive disorders (TRDs) among infants and young children hospitalized with signs or symptoms suggestive of thiamine deficiency disorders (TDDs) based on response to therapeutic thiamine in a high-risk setting. STUDY DESIGN: Children aged 21 days to <18 months hospitalized with signs or symptoms suggestive of TDD in northern Lao People's Democratic Republic were treated with parenteral thiamine (100 mg daily) for ≥3 days in addition to routine care. Physical examinations and recovery assessments were conducted frequently for 72 hours after thiamine was initiated. Individual case reports were independently reviewed by three pediatricians who assigned a TRD status (TRD or non-TRD), which served as the dependent variable in logistic regression models to identify predictors of TRD. Model performance was quantified by empirical area under the receiver operating characteristic curve. RESULTS: A total of 449 children (median [Q1, Q3] 2.9 [1.7, 5.7] months old; 70.3% exclusively/predominantly breastfed) were enrolled; 60.8% had a TRD. Among 52 candidate variables, those most predictive of TRD were exclusive/predominant breastfeeding, hoarse voice/loss of voice, cyanosis, no eye contact, and no diarrhea in the previous 2 weeks. The area under the receiver operating characteristic curve (95% CI) was 0.82 (0.78, 0.86). CONCLUSIONS: In this study, the majority of children with signs or symptoms of TDD responded favorably to thiamine. While five specific features were predictive of TRD, the high prevalence of TRD suggests that thiamine should be administered to all infants and children presenting with any signs or symptoms consistent with TDD in similar high-risk settings. The usefulness of the predictive model in other contexts warrants further exploration and refinement. TRIAL REGISTRATION: Clinicaltrials.gov NCT03626337.

Addressing Fecal Contamination in Rural Kenyan Households: The Roles of Environmental Interventions and Animal Ownership.

Combined water, sanitation, and handwashing (WSH) interventions could reduce fecal contamination along more transmission pathways than single interventions alone. We measured Escherichia coli levels in 3909 drinking water samples, 2691 child hand rinses, and 2422 toy ball rinses collected from households enrolled in a 2-year cluster-randomized controlled trial evaluating single and combined WSH interventions. Water treatment with chlorine reduced E. coli in drinking water. A combined WSH intervention improved water quality by the same magnitude but did not affect E. coli levels on hands or toys. One potential explanation for the limited impact of the sanitation intervention (upgraded latrines) is failure to address dog and livestock fecal contamination. Small ruminant (goat or sheep) ownership was associated with increased E. coli levels in stored water and on child hands. Cattle and poultry ownership was protective against child stunting, and domesticated animal ownership was not associated with child diarrhea. Our findings do not support restricting household animal ownership to prevent child diarrheal disease or stunting but do support calls for WSH infrastructure that can more effectively reduce household fecal contamination.

Estimating minimum dietary diversity for children aged 6-23 months: a comparison of agreement and cost of two recall methods in Cambodia and Zambia.

OBJECTIVE: To compare the agreement and cost of two recall methods for estimating children's minimum dietary diversity (MDD). DESIGN: We assessed child's dietary intake on two consecutive days: an observation on day one, followed by two recall methods (list-based recall and multiple-pass recall) administered in random order by different enumerators at two different times on day two. We compared the estimated MDD prevalence using survey-weighted linear probability models following a two one-sided test equivalence testing approach. We also estimated the cost-effectiveness of the two methods. SETTING: Cambodia (Kampong Thom, Siem Reap, Battambang, and Pursat provinces) and Zambia (Chipata, Katete, Lundazi, Nyimba, and Petauke districts). PARTICIPANTS: Children aged 6-23 months: 636 in Cambodia and 608 in Zambia. RESULTS: MDD estimations from both recall methods were equivalent to the observation in Cambodia but not in Zambia. Both methods were equivalent to the observation in capturing most food groups. Both methods were highly sensitive although the multiple-pass method accurately classified a higher proportion of children meeting MDD than the list-based method in both countries. Both methods were highly specific in Cambodia but moderately so in Zambia. Cost-effectiveness was better for the list-based recall method in both countries. CONCLUSION: The two recall methods estimated MDD and most other infant and young child feeding indicators equivalently in Cambodia but not in Zambia, compared to the observation. The list-based method produced slightly more accurate estimates of MDD at the population level, took less time to administer and was less costly to implement.

Assessing Children's Autonomic Nervous System Activity During Structured Tasks: A Feasibility and Reliability Study in Ghana.

The significance of physiological regulation in relation to behavioral and emotional regulation is well documented, but primarily in economically advantaged contexts. Few studies have been conducted in low- and middle-income countries. We investigated the feasibility and reliability of measuring autonomic nervous system (ANS) activity and behavior during challenge tasks in 30 children aged 8-10 years in Ghana during two visits, 1 week apart. Completeness of ANS data ranged from 80% to 100% across all tasks. There was low-to-moderate test-retest reliability of video mood induction (VMI) emotion ratings and balloon analog risk task (BART) pumps (r = 0.34-0.52). VMI elicited higher targeted emotion ratings in Visit 2 than Visit 1. Respiratory sinus arrhythmia (RSA) was higher, and pre-ejection period (PEP) was longer at Visit 2 than Visit 1 for baseline and both tasks. RSA was higher at baseline than during the VMI anger scene at Visit 1, whereas PEP was shorter at baseline than during all VMI emotion scenes at Visit 2. RSA was higher at baseline than during BART at both visits. In conclusion, ANS data collection within evocative and arousing challenge tasks was feasible in Ghana, and the tasks were generally reliable and effective in eliciting target emotions and risk-taking behavior in this sample.

Associations of fish and meat intake with iron and anaemia in Malawian children.

Animal flesh foods are rich in bioavailable iron but infrequently consumed by young children. We aimed to determine whether flesh food intake was associated with iron and anaemia status among 585 Malawian infants enroled in a 6-month egg-feeding trial. The percentage of days of small fish, large fish and meat consumption were assessed through weekly 7-day animal-source food screeners. Grams of intake were assessed through 24-h recalls conducted at 6-9, 9-12 and 12-15 months of age. Plasma ferritin, soluble transferrin receptor (sTfR) and haemoglobin concentrations were measured at 6-9 and 12-15 months of age. Iron biomarkers were adjusted for inflammation during analysis. At enrolment, each flesh food category was consumed by <5% of children in the past 24 h. Over the next 6 months, small fish, large fish and meat were consumed on 25%, 8% and 6% of days, respectively, with mean usual intakes of <5 g/day. More frequent small fish consumption was associated with lower sTfR (geometric mean ratio [95% CI]: 0.98 mg/L [0.96, 1.00] per 10 percentage point difference) but not ferritin (1.03 µg/L [0.98, 1.07]) or haemoglobin (1.01 g/dL [1.00, 1.01]). Large fish consumption was associated with higher anaemia (prevalence ratio [95% CI]: 1.09 [1.01, 1.19]) and lower iron deficiency (0.96 [0.93, 1.00]) prevalence. Gram intakes of flesh food categories were not associated with any iron or anaemia indicators. Small fish were a primary contributor to flesh food intake in this cohort of Malawian children, although usual portions were small. Fish was associated with modest improvements to iron status, but meat was too infrequent to be associated with anaemia and iron deficiency.

Risk factors for anaemia among women and their young children hospitalised with suspected thiamine deficiency in northern Lao PDR.

Anaemia among women and young children remains a major public health concern. This secondary study describes the anaemia prevalence among young hospitalised children and their mothers in northern Lao People's Democratic Republic and explores possible nutritional causes and risk factors for anaemia. Hospitalised children (ages 21 days to <18 months) with clinical symptoms suggestive of thiamine deficiency disorders were eligible along with their mothers. Venous blood was collected for determination of haemoglobin, ferritin, soluble transferrin receptor (sTfR), retinol-binding protein (RBP), erythrocyte glutathione reductase activation coefficient (EGRac), thiamine diphosphate (ThDP) and acute phase proteins. Risk factors for anaemia were modelled using minimally adjusted logistic regression controlling for age. Haemoglobin results were available for 436 women (mean ± SD age 24.7 ± 6.4 years; 1.6% pregnant) and 427 children (4.3 ± 3.5 months; 60.3% male). Anaemia prevalence (Hb < 120 g/L for nonpregnant women and <110 g/L for pregnant women and children) was 30.7% among women and 55.2% among children. In bivariate analyses, biomarkers significantly associated with anaemia in women were ferritin, sTfR, RBP, EGRac and ThDP. Other risk factors for women were lower BMI, mid-upper arm circumference < 23.5 cm, lower education, lower socioeconomic index, food insecurity, Hmong ethnicity, not/rarely having attended antenatal care, not having taken antenatal iron-containing supplements and not meeting minimum dietary diversity. Risk factors for anaemia among children were older age, male sex, stunting, sTfR, ThDP and alpha-1-acid-glycoprotein. Anaemia was common among women and their hospitalised children and was associated with micronutrient deficiencies and socioeconomic, dietary and health care-seeking risk factors, suggesting that multiple strategies are required to prevent anaemia among women and children.

The Infant Diet Quality Index Predicts Dietary and Adiposity Outcomes in US Children 2 to 4 years old.

BACKGROUND: Healthy nutrition during the first year of life is critical for optimal growth and development. Limited techniques are available to assess diet quality in infancy, and few have been shown to be predictive of dietary and adiposity outcomes in low-income children. OBJECTIVE: The objectives of this study were to construct an Infant Diet Quality Index (IDQI) to assess the diet quality from birth to 12 mo and to determine whether the IDQI exhibits predictive validity by estimating the longitudinal associations of IDQI scores with diet quality and weight status at 2 to 4 y. DESIGN: Data were analyzed from the longitudinal Women, Infants, and Children Infant and Toddler Feeding Practices Study-2 (unweighted, n = 2858; weighted. N = 392,439) using one 24-h dietary recall and survey responses during infancy. The newly constructed IDQI consists of 16 equally-weighted components: 1) breastfeeding duration; 2) exclusive breastfeeding; age of first introduction of: 3) solids, 4) iron-rich cereals, 5) cow milk, 6) sugar-sweetened beverages, 7) salty/sweet snacks, 8) other drinks/liquids, and 9) textured foods; frequency of consuming 10) fruit or 11) vegetables; frequency of consuming different 12) fruit or 13) vegetables; 14) nonrecommended bottle-feeding practices; 15) use of commercial baby foods; and 16) number of meals and snacks. Regression analysis was used to estimate associations between the total IDQI score (range, 0-1) and Healthy Eating Index-2015 (HEI-2015) scores and body mass index z-scores (BMIz) at 2 to 4 y of age, adjusted for covariates (e.g., child age, sex and race/ethnicity; maternal education level, etc.) RESULTS: The total IDQI score was positively associated with HEI-2015 at the age of 2 y (ß = 16.7; 95% CI: 12.6, 20.9; P < 0.001), 3 y (ß = 14.5; 95% CI: 8.1, 21.0; P < 0.001), and 4 y (ß = 15.4; 95% CI: 8.4, 22.4; P < 0.001); and negatively associated with BMIz at the age of 2 y (ß = -1.24; 95% CI: -2.01, -0.47; P = 0.002) and 4 y (ß = -0.92; 95% CI: -1.53, -0.30; P = 0.003). CONCLUSIONS: The IDQI has predictive validity for diet quality and weight status in low-income US children.

Differences in Infant Diet Quality Index by Race and Ethnicity Predict Differences in Later Diet Quality.

BACKGROUND: Racial and ethnic disparities in infant-feeding practices may negatively influence diet quality and health. OBJECTIVES: This study investigated the racial, ethnic, and language (English or Spanish) differences in infant diet quality, later diet quality, and weight status at 2-5 y, and whether these differences were explained through infant diet quality among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). METHODS: Using the WIC Infant and Toddler Feeding Practices Study-2 (unweighted n = 2663; weighted n = 362,712), relationships between the Infant Dietary Quality Index (IDQI; range 0-1) and Healthy Eating Index-2020 (HEI-2020; range 0-100) and BMI z-score (BMIz) at 2-5 y were analyzed by race, ethnicity, and language preference [Hispanic Spanish-speaking, Hispanic English-speaking, non-Hispanic (NH) White, and NH Black participants]. Statistical interaction between IDQI and each group was evaluated in multivariable models. The mediation of each group through the IDQI was assessed using causal mediation methods. RESULTS: Differences in IDQI [mean (standard deviation)] were observed between Hispanic Spanish-speaking participants [0.41 (0.10)], Hispanic English-speaking participants [0.37 (0.10)], NH White participants [0.36 (0.10)], and NH Black participants [0.35 (0.09)], P < 0.001. Differences in HEI-2020 occurred at 2-5 y, with the Hispanic Spanish-speaking participants having consistently higher HEI-2020 scores. Differences in BMIz were observed at 5 y, with higher scores among Hispanic Spanish-speaking participants. Interaction between race, ethnicity, and IDQI was observed for all outcomes except for BMIz at 3 y. Through mediation, IDQI explained 13%-20% of the difference in HEI-2020 scores between Hispanic Spanish-speaking and NH White participants at 2-5 y. IDQI explained 22%-25% of the difference in HEI-2020 scores between the Hispanic Spanish-speaking and NH Black participants at 4 y and 5 y. CONCLUSIONS: Higher infant diet quality scores observed in Hispanic Spanish-speaking participants explain some of the racial and ethnic differences observed in later diet quality, suggesting that improving infant diet quality may help reduce diet disparities during early childhood.

Examining infants' visual paired comparison performance in the US and rural Malawi.

Measures of attention and memory were evaluated in 6- to 9-month-old infants from two diverse contexts. One sample consisted of African infants residing in rural Malawi (N = 228, 118 girls, 110 boys). The other sample consisted of racially diverse infants residing in suburban California (N = 48, 24 girls, 24 boys). Infants were tested in an eye-tracking version of the visual paired comparison procedure and were shown racially familiar faces. The eye tracking data were parsed into individual looks, revealing that both groups of infants showed significant memory performance. However, how a look was operationally defined impacted some-but not other-measures of infant VPC performance. RESEARCH HIGHLIGHTS: In both the US and Malawi, 6- to 9-month-old infants showed evidence of memory for faces they had previously viewed during a familiarization period. Infant age was associated with peak look duration and memory performance in both contexts. Different operational definitions of a look yielded consistent findings for peak look duration and novelty preference scores-but not shift rate. Operationalization of look-defined measures is an important consideration for studies of infants in different cultural contexts.

The cost-effectiveness of small-quantity lipid-based nutrient supplements for prevention of child death and malnutrition and promotion of healthy development: modelling results for Uganda.

OBJECTIVE: Recent meta-analyses demonstrate that small-quantity lipid-based nutrient supplements (SQ-LNS) for young children significantly reduce child mortality, stunting, wasting, anaemia and adverse developmental outcomes. Cost considerations should inform policy decisions. We developed a modelling framework to estimate the cost and cost-effectiveness of SQ-LNS and applied the framework in the context of rural Uganda. DESIGN: We adapted costs from a costing study of micronutrient powder (MNP) in Uganda, and based effectiveness estimates on recent meta-analyses and Uganda-specific estimates of baseline mortality and the prevalence of stunting, wasting, anaemia and developmental disability. SETTING: Rural Uganda. PARTICIPANTS: Not applicable. RESULTS: Providing SQ-LNS daily to all children in rural Uganda (> 1 million) for 12 months (from 6 to 18 months of age) via the existing Village Health Team system would cost ∼$52 per child (2020 US dollars) or ∼$58·7 million annually. SQ-LNS could avert an average of > 242 000 disability-adjusted life years (DALYs) annually as a result of preventing 3689 deaths, > 160 000 cases of moderate or severe anaemia and ∼6000 cases of developmental disability. The estimated cost per DALY averted is $242. CONCLUSIONS: In this context, SQ-LNS may be more cost-effective than other options such as MNP or the provision of complementary food, although the total cost for a programme including all age-eligible children would be high. Strategies to reduce costs, such as targeting to the most vulnerable populations and the elimination of taxes on SQ-LNS, may enhance financial feasibility.