Building for the future: influence of housing on intelligence quotients of children in an urban slum

INTRODUCTION

Interventions on behalf of the marginalized in society can assume many formats. In an urban slum the Government of Delhi built one-room houses for some of the residents in what is termed a 'plot area'. Not all residents could be accommodated in the project and the remainder continued to live next door in shanty houses of the slum. Nineteen years later, young children who had migrated with their parents, have grown up and have children of their own. We looked at the development of the children living in the two types of accommodation.

METHODS

A total of 373 children were studied. All children (n = 200) between the ages of 3.5 and 5.5 years in a cluster of five residential blocks in the plot area were studied. As a control, children in two large clusters of shanty houses (n = 173) were also studied. For development assessment the Central Institute of Education (CIE) Test was performed. This is an Indian adaptation of the Standford-Binet Test. Multiple regression analysis was utilized to determine the factors that influenced IQ most.

RESULTS

The mean IQ of the children in the plot area was 92.5 (s.d. 13.38) and in the shanty houses 89.5 (s.d. 12.9) (p = 0.05). Analysis showed that the most significant factors affecting IQ were malnutrition in the first 6 months of life and attendance of the child at pre-school. For nutrition in the first 6 months, there was no difference between the groups. For attendance at pre-school, 110 of 200 in the plot area and 47 of 173 in the shanty houses were attending pre-school (p < 0.01).

CONCLUSION

We find that children living in the permanent houses had a significantly better IQ than those in shanty houses. A review of the literature did not reveal a comparable study.

The clinical risk index of babies (CRIB) score in India

OBJECTIVE

To assess the usefulness of clinical risk index of babies (CRIB score) in predicting neonatal mortality in extremely preterm neonates, compared to birth weight and gestation.

METHODS

97 preterm neonates with gestational age less than 31 weeks or birth weight less than or equal to 1500 g were enrolled for the prospective longitudinal study. Relevant neonatal data was recorded. Blood gas analysis results and the maximum and the minimum FiO2 required by babies in first 12 hours of life were noted. Mortality was taken as death while the baby was in nursery. The prediction of mortality by birth weight, gestational age and CRIB score was done using the Logistic model, and expressed as area under the ROC curve.

RESULTS

The area under the ROC curve for birth weight, gestational age and CRIB score was almost the same, the areas being 0.829, 0.819 and 0.823 respectively. Hence CRIB score did not fare better than birth weight and gestational age in predicting neonatal mortality.

CONCLUSION

The CRIB score did not improve on the ability of birth weight and gestational age to predict neonatal mortality in the study.

Not by bread alone': impact of a structured 90-minute play session on development of children in an orphanage

BACKGROUND AND OBJECTIVES

In developing countries, caring for the large number of babies in orphanages is very hard work. Whereas the physical needs of most of the children are met, play often gets neglected. Studies have repeatedly shown that babies in such institutionalized settings suffer from severe psychomotor retardation. The aim of this project was to develop an intervention programme of structured play. We hypothesized that such an intervention would result in acceleration of psychosocial development in otherwise healthy institutionalized children.

DESIGN

Prospective longitudinal.

SETTING

Mother Teresa's Orphanage, run by Missionaries of Charity.

SUBJECT AND METHODS

All 30 children in the orphanage aged 6 months-2.5 years, were assessed for their Motor, Mental and Social Quotients, using the Indian adaptation of Bailey's Scale of Infant Development(DASII) and the Vineland's Social Maturity Scale. A structured 'Regime of Play' was then built into the routine of the orphanage. A repeat developmental assessment was performed at the end of 3 months to assess the impact.

RESULTS

Out of the original cohort of 30, 19 children were available for post-intervention assessments. The remainder were adopted before their assessments. Their mean Motor Quotient rose from 63.7 to 81.7, mean Mental Quotient rose from 65.8 to 89.6 and the mean Social Quotient rose from 61.9 to 91.3, a gain of 18, 23 and 30 points respectively (p < 0.0001). There was also an overall change in the environment of the orphanage. Children became more active, playful, responsive and independent. Contrary to what caretakers assumed, their workload actually decreased. The responsiveness in the children awakened as a result of play, acted as a positive feedback for caretakers to continue the play sessions.

CONCLUSIONS

This study shows that short daily sessions of play can significantly improve the development of children in such institutions. It is vital to remember that children grow 'Not by Bread Alone'.

Ultrasonographic femur-tibial length ratio: a marker of Down syndrome from the late second trimester

An observational prospective study reported that newborn babies with Down syndrome (DS) had short upper limbs that reach up to their pelvis. The shortening was most marked in the forearm (the middle segment of the upper limb) and this relative shortening resulted in an alteration of the proximal to middle segment length ratio. This study assumes that there is a similar alteration in the ratio of the lower limb. We propose to study the proximal to middle segment ratio in the lower limb in normal fetuses at different gestational ages. Against these norms we propose to study the ratio in fetuses with DS to see at what stage in intrauterine life the altered ratio becomes evident. We also propose to take postnatal measurements of upper and middle segments of both upper and lower limbs of babies born with DS and compare them with normal babies. Fetal femoral and tibial lengths were measured by routine antenatal ultrasound scans at a General hospital with 6000 deliveries a year. All babies delivered were examined for phenotypical evidence of DS. The in utero measurements recorded of babies born with DS were compared with the measurements in normal babies. Postnatal measurements of the arm and forearm, and the thigh and leg of babies with DS were taken soon after birth. These were compared with a control group of 20 consecutive normal babies born over 2 days. There were 3690 readings of 3075 normal fetuses and 8 measurements of 7 Down fetuses. The leg, the upper arm, and arm of newborns with DS were significantly shorter than controls (p<0.01). The upper limb reached up to the pelvis in infants with DS and not up to mid thigh as in normal babies. The forearm was shorter than the arm in infants with DS. This is a reversal of the ratio seen in controls. The ratio of femoral to tibial length remains near constant at 1.1 after 13 weeks' gestation in normal fetuses. It rises from 1.2 to 1.4 from 22 weeks' to 38 weeks' gestation in fetuses with DS. The mean standard deviation score of fetuses with DS was 4.53 compared with norms (SD 1.7, p<0.01). Conclusions of this study are: (1) short upper limbs (reaching only up to the pelvis) is a clinical feature of DS at birth; and (2) after 20 weeks' gestation, the ratio of femoral-tibial length can be a marker of DS in utero.

A rural population based case-control study of senile cataract in India

PURPOSE

Senile cataract contributes to 75% of blindness in India and there is a growing backlog of cataract cases needing surgery. The present study seeks clues to the etiology of senile cataract, so that strategies to prevent or even delay cataract formation could be planned.

METHODS

Using a community based case-control design, 258 cases & 308 controls from one centre and 301 cases & 591 controls from another were studied. The subjects were from rural areas and were aged 40-60 years. Logistic regression analysis technique was employed to study the associations between senile cataract and various variables.

RESULTS

Systolic blood pressure, duration of exposure to sunlight per day were associated with senile cataract in both the centres (OR = 1.4 & 1.5 for systolic BP and 1.6 & 1.4 for exposure to sunlight). Utilization of rice gruel (OR = 0.5), duration of exposure to fire & dust per day (OR = 1.8), family history of cataract (OR = 5.0), use of cheap cooking fuels (OR = 1.8), increased height (OR = 0.7) and increased number of hours of work per day (OR = 0.7) were other variables that showed significant association in either of the centres.

CONCLUSION

Senile cataract appears to have a multi factorial etiology. Though the study provided some clues to the etiology of senile cataract, further studies are needed to know the specific role of these factors in the causation of cataract, so that any preventive or control measures could be initiated in the community. Till such time, we have to fall back on the available surgical approach in control of senile cataract.

Fulminant hepatitis in a tropical population: clinical course, cause, and early predictors of outcome

The profiles of patients with fulminant hepatic failure (FHF) from developing countries have not been reported earlier. The current study was conducted prospectively, at a single tertiary care center in India, to document the demographic and clinical characteristics, natural course, and causative profile of patients with FHF as well as to define simple prognostic markers in these patients. Four hundred twenty-three consecutive patients with FHF admitted from January 1987 to June 1993 were included in the study. Each patient's serum was tested for various hepatotropic viruses. Univariate Cox's regression for 28 variables, multivariate Cox's proportional hazard regression, stepwise logistic regression, and Kaplan-Meier survival analysis were done to identify independent predictors of outcome at admission. All patients presented with encephalopathy within 4 weeks of onset of symptoms. Hepatotropic viruses were the likely cause in most of these patients. Hepatitis A (HAV), hepatitis B (HBV), hepatitis D (HDV) viruses, and antitubercular drugs could be implicated as the cause of FHF in 1.7% (n= 7), 28% (n= 117), 3.8% (n= 16), and 4.5% (n= 19) patients, respectively. In the remaining 62% (n= 264) of patients the serological evidence of HAV, HBV, or HDV infection was lacking, and none of them had ingested hepatotoxins. FHF was presumed to be caused by non-A, non-B virus(es) infection. Sera of 50 patients from the latter group were tested for hepatitis E virus (HEV) RNA and HCV RNA. In 31 (62%), HEV could be implicated as the causative agent, and isolated HCV RNA could be detected in 7 (19%). Two hundred eighty eight (66%) patients died. Approximately 75% of those who died did so within 72 hours of hospitalisation. One quarter of the female patients with FHF were pregnant. Mortality among pregnant females, nonpregnant females, and male patients with FHF was similar (P > .1). Univariate analysis showed that age, size of the liver assessed by percussion, grade of coma, presence of clinical features of cerebral edema, presence of infection, serum bilirubin, and prothrombin time prolongation over controls at admission were related to survival (P < .01). The rapidity of onset of encephalopathy and cause of FHF did not influence the outcome. Cox's proportional hazard regression showed age > or = 40 years, presence of cerebral edema, serum bilirubin > or = 15 mg/dL, and prothrombin time prolongation of 25 seconds or more over controls were independent predictors of outcome. Ninety-three percent of the patients with three or more of the above prognostic markers died. The sensitivity, specificity, positive predictive value, and the negative predictive value of the presence of three or more of these prognostic factors for mortality was 93%, 80%, 86%, and 89.5%, respectively, with a diagnostic accuracy of 87.3%. We conclude that most of our patients with FHF might have been caused by hepatotropic viral infection, and non-A, non-B virus(es) seems to be the dominant hepatotropic viral infection among these patients. They presented with encephalopathy within 4 weeks of the onset of symptoms. Pregnancy, cause, and rapidity of onset of encephalopathy did not influence survival. The prognostic model developed in the current study is simple and can be performed at admission.

Pyogenic hepatic abscess in a community hospital

Pyogenic hepatic abscesses are rare lesions and are most commonly the result of biliary tract disease. During a 3-year period at our institution, 15 patients were diagnosed with pyogenic hepatic abscess. Ten cases were related to biliary disease. Of these, five were associated with previous biliary tract operations. The remaining five were due to metastases, infection at another site, or cryptogenic causes. Most abscesses were multiple. Treatment consisted of antibiotics alone for three patients, percutaneous drainage and intravenous antibiotics for seven patients, open drainage with intravenous antibiotics for three patients, and papillotomy with intravenous antibiotics for one patient. The single untreated patient died. The other death occurred among those patients treated with intravenous antibiotics alone. Four patients initially treated by percutaneous drainage required subsequent open drainage. All of these patients had multiple abscesses. The mean length of stay in the hospital was least among the group treated by operative drainage. Our review suggests that pyogenic hepatic abscesses may be treated by several different modalities, the choice of management should be individualized, and the length of stay may be decreased by operative drainage.

An autopsy study of relationship between perinatal stomach capacity and birth weight

BACKGROUND

Aspiration pneumonia is a common complication of overfeeding in neonates. Since overfeeding may be related to neonatal stomach capacity, it was considered worthwhile to obtain such data.

AIMS

To measure the capacity of stomach obtained from fresh stillbirths and liveborn infants at autopsy and correlate the same with their birth weights.

METHODS

Stomach capacity was measured at autopsy in 63 stillborn and 37 newborn infants with birth weights ranging from 500 g to 3500 g.

RESULTS

Stomach capacity had a significant positive correlation with birth weight (r = 0.56, p < 0.001). A formula and a nomogram have been derived to estimate stomach capacity from birth weight. There was no significant difference in stomach capacity between liveborn and stillborn infants in any of the weight groups, except in the 1501-2000 g weight group (p < 0.001).

CONCLUSIONS

Our results have provided normative data on stomach capacity across a wide birth weight range in the perinatal period.

Some indices pertaining to the leprosy control programme in Tamil Nadu, based on data from a random sample of fourteen government control units

From a random sample of 14 Government Leprosy Control Units in Tamil Nadu, information on the profile of the newly-diagnosed leprosy patients and some important aspects of the control programme in 1978-81 was collected when monotherapy with dapsone was the practice. Among the new patients, 55 per cent were males, 24 per cent were children, 6 per cent had lepromatous leprosy and 9 per cent had a deformity. About 65 per cent were detected by active case-finding methods and 25 per cent were voluntary referrals. Of the total diagnosed patients, only 68 per cent started treatment; further, of these, about 40 per cent collected drugs for at least 6 months in the first year of treatment. The average attendance at the clinic was 34 per cent of the due attendance. Coverage in the annual examination of family contacts was 57 per cent. During the 4 yr period, about 70 per cent of the villages had population surveys with a coverage of 75 per cent or more. The introduction of multi-drug therapy has provided a new impetus to the programme and therefore a similar study is called for to provide valuable information about the extent of improvement in completion rates and overall impact.

New manifestations of Neu-Laxova syndrome

We report on a newborn boy with Neu-Laxova syndrome and spina bifida, bilateral cryptorchidism, and shallow orbital cavities. Association of these manifestations in Neu-Laxova syndrome is the first to be reported in the literature. This is the first report of Neu-Laxova syndrome from India.

Controlled, semielective, segmental resection for massive colonic hemorrhage

An aggressive diagnostic work-up to determine the site of bleeding was employed in all 25 patients requiring transfusion of over 1,500 cc of blood for colonic hemorrhage in New Haven in 1977 and 1978. A specific bleeding site that permitted segmental colectomy was found in 23 patients (92 percent). The mortality rate was zero, reflecting the rapid improvement in survival that has occurred in the last decade among patients with massive colonic hemorrhage.