Low-birthweight rates higher among Bangladeshi neonates measured during active birth surveillance compared to national survey data

Young Infant Mortality Associated with Preterm and Small-for-Gestational-Age Births in Rural Bangladesh: A Prospective Cohort Study

OBJECTIVE

To assess the relative risk of mortality in infants born preterm and small for gestational age (SGA) during the first and second months of life in rural Bangladesh.

STUDY DESIGN

We analyzed data from a cohort of pregnant women and their babies in Sylhet, Bangladesh, assembled between 2011 and 2014. Community health workers visited enrolled babies up to 10 times from birth to age 59 days. Survival status was recorded at each visit. Gestational age was estimated from mother's reported last menstrual period. Birth weights were measured within 72 hours of delivery. SGA was defined using the INTERGROWTH-21st standard. We estimated unadjusted and adjusted hazard ratios (HRs) and corresponding 95% CIs for babies born preterm and SGA separately for the first and second month of life using bivariate and multivariable weighted Cox regression models.

RESULTS

The analysis included 17 643 singleton live birth babies. Compared with infants born at term-appropriate for gestational age, in both unadjusted and adjusted analyses, infants born preterm-SGA had the greatest risk of death in the first (HR 13.25, 95% CI 8.65-20.31; adjusted HR 12.05, 95% CI 7.82-18.57) and second month of life (HR 4.65, 95% CI 1.93-11.23; adjusted HR 4.1, 95% CI 1.66-10.15), followed by infants born preterm-appropriate for gestational age and term-SGA.

CONCLUSIONS

The risk of mortality in infants born preterm and/or SGA is increased and extends through the second month of life. Appropriate interventions to prevent and manage complications caused by prematurity and SGA could improve survival during and beyond the neonatal period.

Neonatal mortality risk of vulnerable newborns by fine stratum of gestational age and birthweight for 230 679 live births in nine low- and middle-income countries, 2000-2017

OBJECTIVE

To describe the mortality risks by fine strata of gestational age and birthweight among 230 679 live births in nine low- and middle-income countries (LMICs) from 2000 to 2017.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America.

POPULATION

Liveborn infants from 15 population-based cohorts.

METHODS

Subnational, population-based studies with high-quality birth outcome data were invited to join the Vulnerable Newborn Measurement Collaboration. All studies included birthweight, gestational age measured by ultrasound or last menstrual period, infant sex and neonatal survival. We defined adequate birthweight as 2500-3999 g (reference category), macrosomia as ≥4000 g, moderate low as 1500-2499 g and very low birthweight as <1500 g. We analysed fine strata classifications of preterm, term and post-term: ≥42+0 , 39+0 -41+6 (reference category), 37+0 -38+6 , 34+0 -36+6 ,34+0 -36+6 ,32+0 -33+6 , 30+0 -31+6 , 28+0 -29+6 and less than 28 weeks.

MAIN OUTCOME MEASURES

Median and interquartile ranges by study for neonatal mortality rates (NMR) and relative risks (RR). We also performed meta-analysis for the relative mortality risks with 95% confidence intervals (CIs) by the fine categories, stratified by regional study setting (sub-Saharan Africa and Southern Asia) and study-level NMR (≤25 versus >25 neonatal deaths per 1000 live births).

RESULTS

We found a dose-response relationship between lower gestational ages and birthweights with increasing neonatal mortality risks. The highest NMR and RR were among preterm babies born at <28 weeks (median NMR 359.2 per 1000 live births; RR 18.0, 95% CI 8.6-37.6) and very low birthweight (462.8 per 1000 live births; RR 43.4, 95% CI 29.5-63.9). We found no statistically significant neonatal mortality risk for macrosomia (RR 1.1, 95% CI 0.6-3.0) but a statistically significant risk for all preterm babies, post-term babies (RR 1.3, 95% CI 1.1-1.5) and babies born at 370 -386  weeks (RR 1.2, 95% CI 1.0-1.4). There were no statistically significant differences by region or underlying neonatal mortality.

CONCLUSIONS

In addition to tracking vulnerable newborn types, monitoring finer categories of birthweight and gestational age will allow for better understanding of the predictors, interventions and health outcomes for vulnerable newborns. It is imperative that all newborns from live births and stillbirths have an accurate recorded weight and gestational age to track maternal and neonatal health and optimise prevention and care of vulnerable newborns.

Neonatal mortality risk of vulnerable newborns: A descriptive analysis of subnational, population-based birth cohorts for 238 203 live births in low- and middle-income settings from 2000 to 2017

OBJECTIVE

We aimed to understand the mortality risks of vulnerable newborns (defined as preterm and/or born weighing smaller or larger compared to a standard population), in low- and middle-income countries (LMICs).

DESIGN

Descriptive multi-country, secondary analysis of individual-level study data of babies born since 2000.

SETTING

Sixteen subnational, population-based studies from nine LMICs in sub-Saharan Africa, Southern and Eastern Asia, and Latin America.

POPULATION

Live birth neonates.

METHODS

We categorically defined five vulnerable newborn types based on size (large- or appropriate- or small-for-gestational age [LGA, AGA, SGA]), and term (T) and preterm (PT): T + LGA, T + SGA, PT + LGA, PT + AGA, and PT + SGA, with T + AGA (reference). A 10-type definition included low birthweight (LBW) and non-LBW, and a four-type definition collapsed AGA/LGA into one category. We performed imputation for missing birthweights in 13 of the studies.

MAIN OUTCOME MEASURES

Median and interquartile ranges by study for the prevalence, mortality rates and relative mortality risks for the four, six and ten type classification.

RESULTS

There were 238 203 live births with known neonatal status. Four of the six types had higher mortality risk: T + SGA (median relative risk [RR] 2.6, interquartile range [IQR] 2.0-2.9), PT + LGA (median RR 7.3, IQR 2.3-10.4), PT + AGA (median RR 6.0, IQR 4.4-13.2) and PT + SGA (median RR 10.4, IQR 8.6-13.9). T + SGA, PT + LGA and PT + AGA babies who were LBW, had higher risk compared with non-LBW babies.

CONCLUSIONS

Small and/or preterm babies in LIMCs have a considerably increased mortality risk compared with babies born at term and larger. This classification system may advance the understanding of the social determinants and biomedical risk factors along with improved treatment that is critical for newborn health.

Low birth weight and birth weight status in Bangladesh: A systematic review and meta-analysis

The prevalence of low birth weight (LBW) is high in Bangladesh, but no study has collated recent estimates of LBW prevalence from throughout the country. The aim of this meta-analysis was to evaluate the prevalence of LBW and birth weight status in Bangladesh. We searched PubMed, Medline, Ovo and Google Scholar to find published articles in national and international journals from 2000–2020 and reviewed for relevance. Meta-analysis and Q test were performed to estimate the prevalence and heterogeneity of LBW from all included articles. Meta-regression was done to quantify associations with sample size and study year. Stratified analysis was conducted and effect size calculated for differences in LBW prevalence by sex, division and urban/rural area. In total 48 studies with 166,520 births were found and included in this meta-analysis. The pooled prevalence of LBW was 29.1% (95% CI, 28.9–29.3%) in overall, 29.9% (29.7–30.2%) in rural and 15.7% (14.9–16.6%) in urban areas. There was no significant difference in average birth weight between boys and girls (SD, 0.71; 95% CI, −0.43–1.83). Prevalence of LBW was higher in north-east Bangladesh compared to other zones (p<0.05). The pooled prevalence of LBW did not change significantly for last two decades. The prevalence of LBW in Bangladesh remains high. Lack of improvement suggests an urgent need for scaled up maternal and prenatal interventions and services known to reduce LBW. Urban/rural and divisional differences in rates suggest areas of greatest need.

Characterization of pubertal development of girls in rural Bangladesh

This study aimed to describe the timing and patterns of pubertal maturation of girls living in rural Bangladesh. Starting in September 2015, a total of 15,320 girls from a birth cohort, aged 9 to 15 years at initial encounter, were visited twice at about a one year interval, typically in their birth month. Participants were asked to self-report extent of pubertal maturation, including breast development, pubic hair growth and age at menarche, if applicable. Pubertal stage (abbreviated as B2 and B3-4 for breast development and PH2 and PH3-4 for pubic hair growth) was assigned. Data from both visits were pooled, yielding a total of 29,377 age-related observations per pubertal characteristic. Probit regression models were used to estimate distributions of age at which each stage of pubertal development was attained. Before age 8, <3% of the study population initiated pubertal maturation as indicated by onset of breast development (B2). The median (95% confidence interval) age of B2 and B3-4 was 11.02 (11.00–11.04) and 12.82 (12.80–12.83) years, respectively; and 12.93 (12.91–12.94) and 14.29 (14.27–14.31) years for the onset (PH2) and advanced stage (PH3-4) of pubic hair growth, respectively. Median age at menarche was 13.17 (13.15–13.19) years, with 2.15 years of timespan from B2 to menarche. Girls in rural Bangladesh progressed through puberty following a well-documented sequence of sexual maturation stages. The age at which each pubertal milestone took place was somewhat later, but the tempo from breast development to menarche was comparable to that observed elsewhere. Our findings present a current norm of pubertal maturation in a typical, rural adolescent population in South Asia, which could help inform future studies and interventions to preserve or improve early adolescent health and development.

Shonjibon cash and counselling: a community-based cluster randomised controlled trial to measure the effectiveness of unconditional cash transfers and mobile behaviour change communications to reduce child undernutrition in rural Bangladesh

BACKGROUND

Undernutrition is strongly associated with poverty - levels of undernutrition are higher in poor countries than in better-off countries. Social protection especially cash transfer is increasingly recognized as an important strategy to accelerate progress in improving maternal and child nutrition. A critical method to improve nutrition knowledge and influence feeding practices is through behaviour change communication intervention. The Shonjibon Cash and Counselling study aims to assess the effectiveness of unconditional cash transfers combined with a mobile application on nutrition counselling and direct counselling through mobile phone in reducing the prevalence of stunting in children at 18 months.

METHOD

The study is a longitudinal cluster randomised controlled trial, with two parallel groups, and cluster assignment by groups of villages. The cohort of mother-child dyads will be followed-up over the intervention period of approximately 24 months, starting from recruitment to 18 months of the child's age. The study will take place in north-central Bangladesh. The primary trial outcome will be the percentage of stunted children at 18 m as measured in follow up assessments starting from birth. The secondary trial outcomes will include differences between treatment arms in (1) Mean birthweight, percentage with low birthweight and small for gestational age (2) Mean child length-for age, weight for age and weight-for-length Z scores (3) Prevalence of child wasting (4) Percentage of women exclusively breastfeeding and mean duration of exclusive breastfeeding (5) Percentage of children consuming > 4 food groups (6) Mean child intake of energy, protein, carbohydrate, fat and micronutrients (7) Percentage of women at risk of inadequate nutrient intakes in all three trimesters (8) Maternal weight gain (9) Household food security (10) Number of events for child suffering from diarrhoea, acute respiratory illness and fever (11) Average costs of mobile phone BCC and cash transfer, and benefit-cost ratio for primary and secondary outcomes.

DISCUSSION

The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of mobile phone nutrition behavior change communication, combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh.

TRIAL REGISTRATION

The study has been registered in the Australian New Zealand Clinical Trials Registry ( ACTRN12618001975280 ).

Impact of World War 1 on placenta weight, birth weight and other anthropometric parameters of neonatal health

BACKGROUND

Wars do not only affect combatant countries, populations in neutral zones can be afflicted by circumjacent conflicts as well, posing a great health burden on mothers and newborns. As neonatal health remains an ongoing cause for concern, identifying determinants that impede fetal growth is crucial. Under this pretext, the study aimed to analyze the impact of World War 1 in the neutral city of Basel on neonatal health by assessing changes in anthropometric parameters.

METHODS

A retrospective analysis of yearly cross sections of term births in the maternity hospital of Basel from 1912 to 1923 was conducted (n = 3718). We tested adjusted anthropometry for time trends in comparison to a pre-war baseline, including birth weight, placenta weight, birth length, ponderal index and gestational age. Interrelations of placenta weights and birth weights were examined separately through birth weight to placenta weight (BW/PW) ratios and residuals of placenta weight to birth weight regressions.

RESULTS

Birth weights, placenta weights and residuals were at their lowest in 1918/19, a trend not reflected in BW/PW ratios. Birth lengths remained low while ponderal indexes declined during the entire period of war, gestational age remained rather stable.

DISCUSSION

1918/19 were the pinnacle years for the population of Basel, who were suffering from general detrimental economic conditions, a food supply crisis and an outbreak of the Spanish Flu. These adverse circumstances coincided with low birth and placenta weights, residuals depicting the correlation of birth weights to placental weights more closely than bw/pw ratios.

Women's empowerment is associated with maternal nutrition and low birth weight: evidence from Bangladesh Demographic Health Survey

Background

The burden of maternal undernutrition and low birth weight (LBW) incurs enormous economic costs due to their adverse consequences. Women’s empowerment is believed to be one of the key factors for attaining maternal and child health and nutritional goals. Our objective was to investigate the association of women’s empowerment with maternal undernutrition and LBW.

Methods

We used nationally representative data from the Bangladesh Demographic Health Survey for 2011 and 2014. We analysed 27357 women and 9234 mother-child pairs. A women’s empowerment index (WEI) was constructed using principal component analysis with five groups of indicators: a) education, b) access to socio-familial decision making, c) economic contribution and access to economic decision making, d) attitudes towards domestic violence and e) mobility. We estimated odds ratios as the measure of association between the WEI and the outcome measures using generalized estimating equations to account for the cluster level correlation.

Results

The overall prevalence of maternal undernutrition was 20% and LBW was 18%. The WEI was significantly associated with both maternal undernutrition and LBW with a dose-response relationship. The adjusted odds of having a LBW baby was 32% [AOR (95% CI): 0.68 (0.57, 0.82)] lower in the highest quartile of the WEI relative to the lowest quartile. Household wealth significantly modified the effect of the WEI on maternal nutrition; in the highest wealth quintile, the odds of maternal undernutrition was 54% [AOR (95% CI): 0.46 (0.33, 0.64)] lower while in the lowest wealth quintile the odds of undernutrition was only 18% [AOR (95% CI): 0.82 (0.67, 1.00)] lower comparing the highest WEI quartile with the lowest WEI quartile. However, the absolute differences in prevalence of undernutrition between the highest and lowest WEI quartiles were similar across wealth quintiles (6–8%).

Conclusions

This study used a comprehensive measure of women’s empowerment and provides strong evidence that low levels of women’s empowerment are associated with maternal undernutrition as well as with delivering LBW babies in Bangladesh. Therefore, policies to increase empowerment of women would contribute to improved public health.

Gestational weight gain and newborn anthropometric outcomes in rural Bangladesh

Low gestational weight gain (GWG) is a known predictor of fetal growth restriction in higher income countries, but there is little information on this association in lower income countries. Our objective is to describe the association between GWG and birth outcomes among pregnant women in rural Bangladesh. Pregnant women were identified in a community-based programme and enrolled into the study at an average of 13 weeks' gestation (n = 4,011). Maternal weight and height were measured at enrolment, maternal weight was measured at 36 weeks' gestation, and newborns were measured after birth. Rate of GWG (g/weeks) was calculated, and women were categorized as having adequate or inadequate GWG (Institute of Medicine recommendations). Newborn anthropometric outcomes included weight-for-age z score (WAZ), length-for-age z score (LAZ), head-circumference-for-age z score (HCZ), body mass index (BMI)-for-age z score (BMIZ), low birthweight (LBW < 2,500 g), WAZ < -2, LAZ < -2, HCZ < -2, BMIZ < -2, and small for gestational age (SGA: <10th percentile). Multivariate models were adjusted for confounders. Only 26% of the 2,562 women in these analyses had adequate GWG. Compared with newborns of women with inadequate GWG, infants of women with adequate GWG had a lower risk of adverse anthropometric outcomes (relative risk [95% confidence interval]: LBW = 0.68 [0.59, 0.80], LAZ < -2 = 0.64 [0.51, 0.80], HCZ < -2 = 0.75 [0.60, 0.93], BMIZ < -2 = 0.70 [0.59, 0.83], and SGA = 0.80 [0.73, 0.86]), but there was no significant difference in mean (SE) duration of gestation, 39.7 (0.08) versus 39.7 (0.05) weeks. In this population, GWG rate is a strong predictor of newborn anthropometric outcomes, but not duration of gestation.

Mediating role of arsenic in the relationship between diet and pregnancy outcomes: prospective birth cohort in Bangladesh

BACKGROUND

Epidemiological evidence suggests that arsenic (As) exposure during pregnancy may reduce infant birth weight. One significant source of As exposure is diet; thus, As may indirectly affect infant growth by mediating the effect of maternal diet on birth weight (BW). This study evaluated the potential mediating effect of As in the relationship between maternal diet and BW, gestational age (GA), and gestational weight gain (GWG).

METHOD

The study used a prospective birth cohort in Bangladesh that captured the dietary habits of 1057 pregnant women through validated semi-quantitative food frequency questionnaires. We applied a causal mediation model with counterfactual approach and performed analyses with and without adjustment for total energy intake. Other potential confounders captured by self-report questionnaire were exposure to secondhand tobacco smoke, betel nut chewing, maternal age, education level, household income level, physical activity level during pregnancy, and daily hours spent cooking over open fire.

RESULT

No association was found between maternal toenail As and BW. Higher absolute and energy-adjusted protein, fat and fiber intakes were associated with higher toenail As and lower GA and GWG, while higher absolute and energy-adjusted carbohydrate intake was associated with lower toenail As and greater GA and GWG. Mediation analysis showed significant natural indirect effects by toenail As in the relationships between absolute fat, carbohydrate and fiber intake with GA. Specifically, 3% (95% CI: 1-6%) of the association between carbohydrate intake and GA was mediated by change in toenail As, 6% (95% CI: 1-9%) for absolute fat intake and 10% (95% CI: 4-13%) for absolute fiber intake. After adjusting for total energy, no significant mediating effect was observed, suggesting the mediating effect might be due to measurement error or that absolute amount of As exposure rather than the amount in relationship to total energy intake was a more important factor to consider when understanding the negative implication of As on fetal growth.

CONCLUSION

The mediating effect of As in the relationship between maternal diet and birth outcome was small and might be due to measurement error.

Epidemiological characteristics of Hirschsprung's disease (HSCR): Results of a case series of fifty patients from Bangladesh

BACKGROUND

The epidemiology of Hirschsprung's disease (HSCR) in Bangladesh has never been studied. The aim of this study was to determine the epidemiological characteristics of HSCR in Bangladesh.

METHODS

Data from fifty patients were collected prospectively from two hospitals in Chittagong, Bangladesh.

RESULTS

The rate of consanguinity (16%) among parents of HSCR patients was higher than that of the general population (10%). Maternal age at the time of birth of the affected child was ≤30years in all cases except one. No association was found between parents' occupation and HSCR. No patient was born preterm and only three patients (6%) had low birth weight. Nine patients (18%) had associated anomalies. We found coexistence of bilateral accessory tragi and ankyloglossia in one patient, and coexistence of rectal duplication cyst in another. Neither anomaly had been previously reported in HSCR patients.

CONCLUSIONS

Our study suggests that consanguinity might increase the risk of HSCR whereas advanced maternal age does not. HSCR patients were found more likely to born at term and with normal birth weight. The coexistence of HSCR with previously unreported anomalies highlights the diversity of conditions that can co-occur with HSCR.

LEVELS OF EVIDENCE

IV.

Household Food Security and Birth Size of Infants: Analysis of the Bangladesh Demographic and Health Survey 2011

BACKGROUND

More than one-third of the population in Bangladesh is affected by household food insecurity in a setting where child survival and well-being are under threat. The relation between household food security and birth size of infants is an important area to explore given its explicit effect on mortality and morbidity.

OBJECTIVE

Our study aims to estimate the association between household food security and birth size of infants.

METHODS

For the analysis we used a nationally representative cross-sectional survey of 8753 households with a live birth between 2006 and 2011, collected under the Bangladesh Demographic and Health Survey (BDHS) 2011. We investigated the association of small birth size with the following potential explanatory variables: sex of the child; birth interval; mother's age at birth, height, body mass index (BMI), anemia status, parity, previous pregnancy loss, antenatal care visits, exposure to television, and participation in health care decisions; cooking fuel; parents' education level; region; place of residence; and wealth index using Pearson's chi-square test. We then constructed a multivariable logistic regression model of birth size on food security after controlling for all potential confounders as well as the cluster sampling design. The odds ratio (OR) was reported for each of the covariates; a P value <0.05 was interpreted as statistically significant.

RESULTS

A total of 1485 (17.3%) children were reported as small at the time of birth and more than one-third of households (35.7%) experienced some degree of food insecurity. Mothers from food-insecure households had 38% higher odds of having small-size infants compared to food-secure households (adjusted OR: 1.38; 95% CI: 1.19, 1.59; P < 0.001).

CONCLUSION

Household food security is one of the key factors associated with small birth size. Interventions to increase birth size should target women belonging to food-insecure households.

Making a balanced plate for pregnant women to improve birthweight of infants: a study protocol for a cluster randomised controlled trial in rural Bangladesh

OBJECTIVES

Low birthweight significantly contributes to neonatal mortality, morbidities and psychosocial debilities throughout the course of life. A large proportion of infants (36-55%) in Bangladesh is born with low birthweight. Nutritional status of women during pregnancy is critical for optimal growth and development of the fetus. Nutrition education has been found to improve maternal nutritional status. Our study aims to determine whether nutrition education with a practical demonstration during pregnancy is an effective intervention for improving the birthweight of infants compared with standard nutrition education only.

METHODS AND ANALYSIS

We will conduct a community-based cluster randomised controlled trial in one rural district of Bangladesh. Treatments will be allocated evenly between the study clusters (n=36). Participants in the intervention clusters receive 'balanced plate nutrition education' with a practical demonstration from community health workers 4-7 times throughout their entire pregnancy, starting from the first trimester. The control clusters will receive standard nutrition education delivered by public and other healthcare providers as per ongoing antenatal care protocol. Our sample size would be 900 pregnant women to determine 100 g differences in mean birthweight, considering 5% type 1 error, 80% power and an intra-cluster correlation coefficient of 0.03. The primary outcome of the trial is birthweight of the infants and the secondary outcomes include daily caloric intake and dietary diversity score among the pregnant women. Outcomes will be measured at enrolment, third to ninth month of gestation (monthly) and at delivery. Community health workers blinded to the study hypothesis will collect all data.

ETHICS AND DISSEMINATION

The study was approved by the James P Grant School of Public Health, BRAC University Ethical Review Committee, Dhaka, Bangladesh. We will communicate the final results to relevant research and public health groups and publish research papers in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12616000080426.

Breastfeeding and infant growth outcomes in the context of intensive peer counselling support in two communities in Bangladesh

BACKGROUND

Exclusive breastfeeding and growth faltering during infancy remain challenges in Bangladesh. The Training & Assistance for Health & Nutrition Foundation has been working to address this gap through community-based peer counsellors since 2000. In this paper, we assessed the programme's progress, particularly with respect to early initiation of breastfeeding and exclusive breastfeeding for normal birth weight, as well as for low birth weight (LBW) infants.

METHODS

The peer counselling programme is continuing in rural and urban areas of Bangladesh, but only data collected between January 2013 and June 2015 is presented in this descriptive study. Intensive breastfeeding counselling was provided to women during the third trimester of pregnancy and 6 months postpartum by well-trained peer counsellors. They recorded data on infants' birth weight, feeding practices and body weight every month and submitted these for computer entry. Weight measurements were converted to weight-for-age Z-scores (WAZ) and growth patterns assessed by comparing attained body weights with the World Health Organization (WHO) 2006 Child Growth Standards.

RESULTS

A total of 994 infants were born during the study period; 94 % were normal birth weight and 6 % were LBW (<2.5 kg). Initiation of breastfeeding within one hour of birth was reported by 94 % of counselled mothers in both groups. The prevalence of exclusive breastfeeding at 6 months was 94 % in the normal birth weight infants and 92 % in the LBW infants, and their mean body weights were 7.5 ± 0.8 kg and 6.6 ± 0.7 kg respectively. There was no growth faltering in these infants during 6 months. Underweight rates in normal birth weight infants remained similar (2.2 % at 1 month and 2.5 % at 6 months), whereas underweight rates in LBW infants decreased from 42.1 % at 1 month to 21.1 % at 6 months.

CONCLUSIONS

In the context of a well-structured programme setting, and under the described circumstances, it seems likely that the well-trained and supervised community-based peer counsellors could assist in encouraging and helping mothers of both normal birth weight and LBW infants to initiate breastfeeding within one hour and to continue exclusive breastfeeding until 6 months of age. Our data suggest that they may also have contributed towards prevention of growth faltering in these infants.

Effect of fortified complementary food supplementation on child growth in rural Bangladesh: a cluster-randomized trial

BACKGROUND

Growth faltering in the first 2 years of life is high in South Asia where prevalence of stunting is estimated at 40-50%. Although nutrition counselling has shown modest benefits, few intervention trials of food supplementation exist showing improvements in growth and prevention of stunting.

METHODS

A cluster-randomized controlled trial was conducted in rural Bangladesh to test the effect of two local, ready-to-use foods (chickpea and rice-lentil based) and a fortified blended food (wheat-soy-blend++, WSB++) compared with Plumpy'doz, all with nutrition counselling vs nutrition counselling alone (control) on outcomes of linear growth (length and length-for-age z-score, LAZ), stunting (LAZ < -2), weight-for-length z-score (WLZ) and wasting (WLZ < -2) in children 6-18 months of age. Children (n = 5536) were enrolled at 6 months of age and, in the food groups, provided with one of the allocated supplements daily for a year.

RESULTS

Growth deceleration occurred from 6 to 18 months of age but deceleration in LAZ was lower (by 0.02-0.04/month) in the Plumpy'doz (P = 0.02), rice-lentil (< 0.01), and chickpea (< 0.01) groups relative to control, whereas WLZ decline was lower only in Plumpy'doz and chickpea groups. WSB++ did not impact on these outcomes. The prevalence of stunting was 44% at 18 months in the control group, but lower by 5-6% (P ≤ 0.01) in those receiving Plumpy'doz and chickpea. Mean length and LAZ at 18 months were higher by 0.27-0.30 cm and 0.07-0.10 (all P < 0.05), respectively, in all four food groups relative to the control.

CONCLUSIONS

In rural Bangladesh, small amounts of daily fortified complementary foods, provided for a year in addition to nutrition counselling, modestly increased linear growth and reduced stunting at 18 months of age.

Low-birthweight rates higher among Bangladeshi neonates measured during active birth surveillance compared to national survey data

Birth size is an important gauge of fetal and neonatal health. Birth size measurements were collected within 72 h of life for 16 290 live born, singleton infants in rural Bangladesh from 2004 to 2007. Gestational age was calculated based on the date of last menstrual period. Newborns were classified as small-for-gestational age (SGA) based on a birthweight below the 10th percentile for gestational age, using three sets of US reference data. Birth size distributions were explored based on raw values as well as after z-score standardisation in reference to World Health Organization (WHO) 2006 growth standards. Mean (SD) birthweight (g), length (cm) and head circumference (cm) measurements, completed within [median (25th, 75th percentile)] 15 (8, 23) h of life, were 2433 (425), 46.4 (2.4) and 32.4 (1.6), respectively. Twenty-two per cent were born preterm. Over one-half (55.3%) of infants were born low birthweight; 46.6%, 37.0% and 33.6% had a weight, length and head circumference below -2 z-scores of the WHO growth standard at birth; and 70.9%, 72.2% and 59.8% were SGA for weight based on Alexander et al., Oken et al. and Olsen et al. references, respectively. Infants in this typical rural Bangladesh setting were commonly born small, reflecting a high burden of fetal growth restriction and preterm birth. Our findings, produced by active birth surveillance, suggest that low birthweight is far more common than suggested by cross-sectional survey estimates. Interventions that improve fetal growth during pregnancy may have the largest impact on reducing SGA rates.