Factors Affecting Access to Healthcare: An Observational Study of Children under 5 Years of Age Presenting to a Rural Gambian Primary Healthcare Centre

Validation of the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in low- and middle-income countries: A multicentre observational study

Early recognition of children at risk of serious illness is essential in preventing morbidity and mortality, particularly in low- and middle-income countries (LMICs). This study aimed to validate the Emergency Department-Paediatric Early Warning Score (ED-PEWS) for use in acute care settings in LMICs. This observational study is based on previously collected clinical data from consecutive children attending four diverse settings in LMICs. Inclusion criteria and study periods (2010-2021) varied. We simulated the ED-PEWS, consisting of patient age, consciousness, work of breathing, respiratory rate, oxygen saturation, heart rate, and capillary refill time, based on the first available parameters. Discrimination was assessed by the area under the curve (AUC), sensitivity and specificity (previously defined cut-offs < 6 and ≥ 15). The outcome measure was for each setting a composite marker of high urgency. 41,917 visits from Gambia rural, 501 visits from Gambia urban, 2,608 visits from Suriname, and 1,682 visits from Tanzania were included. The proportion of high urgency was variable (range 4.6% to 24.9%). Performance ranged from AUC 0.80 (95%CI 0.70-0.89) in Gambia urban to 0.62 (95%CI 0.55-0.67) in Tanzania. The low-urgency cut-off showed a high sensitivity in all settings ranging from 0.83 (95%CI 0.81-0.84) to 1.00 (95%CI 0.97-1.00). The high-urgency cut-off showed a specificity ranging from 0.71 (95%CI 0.66-0.75) to 0.97 (95%CI 0.97-0.97). The ED-PEWS has a moderate to good performance for the recognition of high urgency children in these LMIC settings. The performance appears to have potential in improving the identification of high urgency children in LMICs.

Mapping Access to Children's Hospitals in Texas

Vehicle access, travel time, and distance to hospitals and emergency rooms with sufficient patient beds are critical healthcare accessibility measures, especially for children who require specific pediatric services. In a large state like Texas with vast rural areas and limited public transit infrastructure, 75% of the children live over an hour from the closest facility that provides pediatric emergency services or specialty care. In view of this challenge, this study first sought to map the prevailing geographical accessibility to children's hospitals and, second, to model the hospital beds per capita for each hospital's service area within the state of Texas. The results showed disparities in accessing emergency pediatric care, especially in rural areas. However, despite major metro areas recording better geographical accessibility to pediatric healthcare, residents in these areas may experience limited hospital bed availability. The findings indicate an urgent need for more pediatric healthcare services in rural Texas. Given the increasing population growth in metro areas and their surroundings, there is also a need for the expansion of healthcare infrastructure in these areas.

Healthcare access for children in a low-income area in Cape Town: A mixed-methods case study

BACKGROUND

 In Cape Town, the under-5 mortality rate has plateaued to 20 per 1000 live births, with 60% of child deaths occurring out of hospital. The southern subdistrict has the largest paediatric population in Metro West and accounts for 31% of deaths. This study aimed to uncover the access barriers and facilitators underlying this high burden of out-of-hospital deaths.

METHODS

 An exploratory mixed-methods case study design employed three data collection strategies: a quantitative survey with randomly sampled community members, semi-structured interviews with purposively sampled caregivers whose children presented critically ill or deceased (January 2017 - December 2020) and a nominal group technique (NGT) to build solution-oriented consensus among purposively sampled health workers, representing different levels of care in the local health system.

RESULTS

 A total of 62 community members were surveyed, 11 semi-structured caregiver interviews were conducted, and 11 health workers participated in the NGT. Community members (74%) experienced barriers in accessing care. Knowledge of basic home care for common conditions was limited. Thematic analysis of interviews showed affordability, acceptability, and access, household and facility factor barriers. The NGT suggested improvement in community-based services, transport access and lengthening service hours would facilitate access.

CONCLUSION

 While multiple barriers to accessing care were identified, facilitators addressing these barriers were explored. Healthcare planners should examine the barriers within their geographic areas of responsibility to reduce child deaths.Contribution: This study uncovers community perspectives on childhood out-of-hospital deaths and makes consensus-based recommendations for improvement.

Time Series Prediction Using Deep Learning Methods in Healthcare

Traditional Machine Learning (ML) methods face unique challenges when applied to healthcare predictive analytics. The high-dimensional nature of healthcare data necessitates labor-intensive and time-consuming processes when selecting an appropriate set of features for each new task. Furthermore, ML methods depend heavily on feature engineering to capture the sequential nature of patient data, oftentimes failing to adequately leverage the temporal patterns of medical events and their dependencies. In contrast, recent Deep Learning (DL) methods have shown promising performance for various healthcare prediction tasks by specifically addressing the high-dimensional and temporal challenges of medical data. DL techniques excel at learning useful representations of medical concepts and patient clinical data as well as their nonlinear interactions from high-dimensional raw or minimally-processed healthcare data.

In this paper we systematically reviewed research works that focused on advancing deep neural networks to leverage patient structured time series data for healthcare prediction tasks. To identify relevant studies, we searched MEDLINE, IEEE, Scopus, and ACM digital library for relevant publications through November 4 th , 2021. Overall, we found that researchers have contributed to deep time series prediction literature in ten identifiable research streams: DL models, missing value handling, addressing temporal irregularity, patient representation, static data inclusion, attention mechanisms, interpretation, incorporation of medical ontologies, learning strategies, and scalability. This study summarizes research insights from these literature streams, identifies several critical research gaps, and suggests future research opportunities for DL applications using patient time series data.

Sub-national disparities in accessing anti-malarial drug treatment in eastern Indonesia

BACKGROUND

Poor access to health care providers was among the contributing factors to less prompt and ineffective malaria treatment. This limitation could cause severe diseases in remote areas. This study examined the sub-national disparities and predictors in accessing anti-malarial drug treatment among adults in Eastern Indonesia.

METHODS

The study analyzed a subset of the 2018 National Basic Health Survey conducted in all 34 provinces in Indonesia. We extracted socio-demographic data of 4655 adult respondents diagnosed with malaria in the past 12 months in five provinces in Eastern Indonesia. The association between socio-demographic factors and the access to anti-malarial drug treatment was assessed using logistic regression.

RESULTS

Over 20% of respondents diagnosed with malaria within last 12 months admitted that they did not receive anti-malarial drug treatment (range 12-29.9%). The proportion of untreated cases was 12.0% in East Nusa Tenggara, 29.9% in Maluku, 23.1% in North Maluku, 12.7% in West Papua, and 15.6% in Papua. The likelihood of receiving anti-malarial drug treatment was statistically lower in Maluku (adjusted OR = 0.258; 95% CI 0.161-0.143) and North Maluku (adjusted OR = 0.473; 95% CI 0.266-0.840) than those in Eastern Nusa Tenggara (reference). Urban respondents were less likely to receive malaria treatment than rural (adjusted OR = 0.545; 95% CI 0.431-0.689).

CONCLUSIONS

This study found that there were sub-national disparities in accessing anti-malarial drug treatment in Eastern Indonesia, with a high proportion of untreated malaria cases across the areas. Findings from this study could be used as baseline information to improve access to anti-malarial drug treatment and better target malaria intervention in Eastern Indonesia.

Patient characteristics associated with COVID-19 positivity and fatality in Nigeria: retrospective cohort study

OBJECTIVE

Despite the increasing disease burden, there is a dearth of context-specific evidence on the risk factors for COVID-19 positivity and subsequent death in Nigeria. Thus, the study objective was to identify context-specific factors associated with testing positive for COVID-19 and fatality in Nigeria.

DESIGN

Retrospective cohort study.

SETTING

COVID-19 surveillance and laboratory centres in 36 states and the Federal Capital Territory reporting data to the Nigeria Centre for Disease Control.

PARTICIPANTS

Individuals who were investigated for SARS-CoV-2 using real-time PCR testing during the study period 27 February-8 June 2020.

METHODS

COVID-19 positivity and subsequent mortality. Multivariable logistic regression analyses were performed to identify factors independently associated with both outcome variables, and findings are presented as adjusted ORs (aORs) and 95% CIs.

RESULTS

A total of 36 496 patients were tested for COVID-19, with 10 517 confirmed cases. Of 3215 confirmed cases with available clinical outcomes, 295 died. Factors independently associated with COVID-19 positivity were older age (p value for trend<0.0001), male sex (aOR 1.11, 95% CI 1.04 to 1.18) and the following presenting symptoms: cough (aOR 1.23, 95% CI 1.13 to 1.32), fever (aOR 1.45, 95% CI 1.45 to 1.71), loss of smell (aOR 7.78, 95% CI 5.19 to 11.66) and loss of taste (aOR 2.50, 95% CI 1.60 to 3.90). An increased risk of mortality following COVID-19 was observed in those aged ≥51 years, patients in farming occupation (aOR 7.56, 95% CI 1.70 to 33.53) and those presenting with cough (aOR 2.06, 95% CI 1.41 to 3.01), breathing difficulties (aOR 5.68, 95% CI 3.77 to 8.58) and vomiting (aOR 2.54, 95% CI 1.33 to 4.84).

CONCLUSION

The significant risk factors associated with COVID-19 positivity and subsequent mortality in the Nigerian population are similar to those reported in studies from other countries and should guide clinical decisions for COVID-19 testing and specialist care referrals.

The impact of delayed treatment of uncomplicated P. falciparum malaria on progression to severe malaria: A systematic review and a pooled multicentre individual-patient meta-analysis

BACKGROUND

Delay in receiving treatment for uncomplicated malaria (UM) is often reported to increase the risk of developing severe malaria (SM), but access to treatment remains low in most high-burden areas. Understanding the contribution of treatment delay on progression to severe disease is critical to determine how quickly patients need to receive treatment and to quantify the impact of widely implemented treatment interventions, such as 'test-and-treat' policies administered by community health workers (CHWs). We conducted a pooled individual-participant meta-analysis to estimate the association between treatment delay and presenting with SM.

METHODS AND FINDINGS

A search using Ovid MEDLINE and Embase was initially conducted to identify studies on severe Plasmodium falciparum malaria that included information on treatment delay, such as fever duration (inception to 22nd September 2017). Studies identified included 5 case-control and 8 other observational clinical studies of SM and UM cases. Risk of bias was assessed using the Newcastle-Ottawa scale, and all studies were ranked as 'Good', scoring ≥7/10. Individual-patient data (IPD) were pooled from 13 studies of 3,989 (94.1% aged <15 years) SM patients and 5,780 (79.6% aged <15 years) UM cases in Benin, Malaysia, Mozambique, Tanzania, The Gambia, Uganda, Yemen, and Zambia. Definitions of SM were standardised across studies to compare treatment delay in patients with UM and different SM phenotypes using age-adjusted mixed-effects regression. The odds of any SM phenotype were significantly higher in children with longer delays between initial symptoms and arrival at the health facility (odds ratio [OR] = 1.33, 95% CI: 1.07-1.64 for a delay of >24 hours versus ≤24 hours; p = 0.009). Reported illness duration was a strong predictor of presenting with severe malarial anaemia (SMA) in children, with an OR of 2.79 (95% CI:1.92-4.06; p < 0.001) for a delay of 2-3 days and 5.46 (95% CI: 3.49-8.53; p < 0.001) for a delay of >7 days, compared with receiving treatment within 24 hours from symptom onset. We estimate that 42.8% of childhood SMA cases and 48.5% of adult SMA cases in the study areas would have been averted if all individuals were able to access treatment within the first day of symptom onset, if the association is fully causal. In studies specifically recording onset of nonsevere symptoms, long treatment delay was moderately associated with other SM phenotypes (OR [95% CI] >3 to ≤4 days versus ≤24 hours: cerebral malaria [CM] = 2.42 [1.24-4.72], p = 0.01; respiratory distress syndrome [RDS] = 4.09 [1.70-9.82], p = 0.002). In addition to unmeasured confounding, which is commonly present in observational studies, a key limitation is that many severe cases and deaths occur outside healthcare facilities in endemic countries, where the effect of delayed or no treatment is difficult to quantify.

CONCLUSIONS

Our results quantify the relationship between rapid access to treatment and reduced risk of severe disease, which was particularly strong for SMA. There was some evidence to suggest that progression to other severe phenotypes may also be prevented by prompt treatment, though the association was not as strong, which may be explained by potential selection bias, sample size issues, or a difference in underlying pathology. These findings may help assess the impact of interventions that improve access to treatment.

Using longitudinal data to understand nutrition and health interactions in rural Gambia

Context: Population-based cohort studies have been pivotal in establishing a number of nutrition-health interactions, especially in high-income settings. Less research is available from low- and middle-income countries due to the lack of detailed longitudinal data.

Objective: To describe the use of prospectively collected longitudinal data from the rural West Kiang region of The Gambia to explore nutrition-health interactions in a rural sub-Saharan African context.

Methods: Demographic records initiated in 1947, coupled with data on maternal and child health, have been used to explore nutrition-health relationships.

Results: An analysis of the longitudinal demographic data demonstrated a highly significant association between season of birth and infection-related adult mortality in this context. Additionally, using routine data on childhood anthropometry, it has been shown that, despite a significant decline in child undernutrition, rates remain unacceptably high, likely reflecting the very high socio-economic threshold required to eliminate undernutrition.

Conclusion: The foresight to establish demographic data collection over seventy years ago has supported a wealth of novel research within a traditional African context. The availability of detailed clinical records on maternal and child health is helping to unravel the factors driving child undernutrition in rural Africa, and to identify targets for interventions to improve health in this context.

Nutritional status and disease severity in children acutely presenting to a primary health clinic in rural Gambia

BACKGROUND

Accurate and timely data on the health of a population are key for evidence-based decision making at both the policy and programmatic level. In many low-income settings, such data are unavailable or outdated. Using an electronic medical records system, we determined the association between nutritional status and severe illness and mortality among young children presenting to a rural primary health care facility in the Gambia.

METHODS

Clinical data collected over five years (2010-2014) on children aged under 60 months making acute visits to a primary health care clinic in the rural Gambian district of Kiang West were retrospectively extracted from the medical records system. Generalised estimating equation models were used to investigate associations between nutritional status and illness severity, accounting for repeat visits, gender, age and access to transport to the clinic. The Population Attributable Fraction (PAF) was used to determine the proportion of severe illness likely attributable to different grades of malnutrition.

RESULTS

3839/5021 (77%) children under 60 months of age living in Kiang West presented acutely to the clinic at least once, yielding 21,278 visits (47% girls, median age 20.2 months (Interquartile Range (IQR) 23.92 months)) and 26,001 diagnoses, 86% being infectious diseases. Severe illness was seen in 4.5% of visits (961/21,278). Wasting was associated with an increased risk of severe illness in a dose-dependent manner, ('WHZ < -1' adjusted Odds Ratio (aOR) 1.68, 95% CI:1.43-1.98, p < 0.001, 'WHZ <-2 and ≥-3' aOR 2.78, 95% CI:2.31-3.36, p < 0.001 and 'WHZ < -3' aOR 7.82, 95% CI:6.40-9.55, p < 0.001) the PAF for wasting (WHZ < -2) was 0.21 (95% CI: 0.18-0.24). Stunting, even in the most severe form (HAZ < -3), was not significantly associated with severe illness (aOR 1.19 95% CI:0.94-1.51) but was associated with a significantly increased risk of death (aOR 6.04 95% CI:1.94-18.78).

CONCLUSION

In this population-based cohort of young children in rural Gambia, wasting was associated with disease severity in a dose-dependent manner. Further research is needed into strategies to identify and reach these children with effective interventions to improve their nutritional status.

In rural Gambia, do adolescents have increased nutritional vulnerability compared with adults?

Adolescents may be particularly susceptible to malnutrition owing to the energy and nutrient costs of the pubertal growth spurt. Here, our aim is to compare differences in selected markers of nutritional status between adolescents and adults in rural Gambia. The Keneba Biobank collects cross‐sectional data and samples for all consenting individuals resident in the West Kiang region of the Gambia. For this study, participants between the ages of 10 and 40 years were selected (n = 4201, females 2447). Height, body mass index, body composition, hemoglobin concentration, fasting glucose concentration, and blood pressure were compared using linear regression models adjusting for age, parity, season of measurement, and residence, across three age groups: early adolescent (10–14.9 years), late adolescent (15–19.9 years), and adult (20–39.9 years). Adolescents, particularly early‐adolescent girls and boys, were shorter, lighter, and leaner than adults. By late adolescence, differences were smaller, particularly in girls where, notably, the prevalence of overweight, hypertension, and impaired fasting glucose was low. Given the importance of maternal health for reproductive outcomes and intergenerational health, the results of the study, albeit with limited biomarkers available, indicate that adolescent girls are no more compromised than adult women or males from the same population.

Demographic, Socioeconomic, and Geographic Factors Leading to Severe Malaria and Delayed Care Seeking in Ugandan Children: A Case-Control Study

We studied associations between delayed care seeking, demographic, socioeconomic, and geographic factors and likelihood of severe malaria in Ugandan children. The study was based at Jinja Hospital, Uganda. We enrolled 325 severe malaria cases and 325 uncomplicated malaria controls matched by age and residence. Patient details, an itinerary of events in response to illness, household information, and location of participants' residences were captured. Conditional logistic regression was used to determine risk factors for severe malaria and delayed care seeking. Delayed care seeking (≥ 24 hours after fever onset; odds ratio [OR] 5.50; 95% confidence interval [CI] 2.70, 11.1), seeking care at a drug shop as the initial response to illness (OR 3.62; 95% CI 1.86, 7.03), and increasing distance from place of residence to the nearest health center (OR 1.45; 95% CI 1.17, 1.79) were independent risk factors for severe malaria. On subgroup analysis, delayed care seeking was a significant risk factor in children with severe malaria attributable to severe anemia (OR 15.6; 95% CI 3.02, 80.6), but not unconsciousness (OR 1.13; 95% CI 0.30, 4.28). Seeking care at a drug shop (OR 2.84; 95% CI 1.12, 7.21) and increasing distance to the nearest health center (OR 1.18; 95% CI 1.01, 1.37) were independent risk factors for delayed care seeking. Delayed care seeking and seeking care at a drug shop were risk factors for severe malaria. Seeking care at a drug shop was also a predictor of delayed care seeking. The role of drug shops in contributing to delayed care and risk of severe malaria requires further study.

Impact of fortified versus unfortified lipid-based supplements on morbidity and nutritional status: A randomised double-blind placebo-controlled trial in ill Gambian children

BACKGROUND

Multiple micronutrients (MMN) are commonly prescribed in pediatric primary healthcare in sub-Saharan Africa to improve nutritional status and appetite without evidence for their effectiveness or international clinical guidelines. Community-wide MMN supplementation has shown limited and heterogeneous impact on growth and morbidity. Short-term ready-to-use therapeutic foods in acutely sick children in a hospital setting also had limited efficacy regarding subsequent growth. The effectiveness of MMN in improving morbidity or growth in sick children presenting for primary care has not been assessed.

METHODS AND FINDINGS

We undertook a double-blind randomised controlled trial of small-quantity lipid-based nutrient supplements (SQ-LNS) fortified with 23 micronutrients in children aged 6 months (mo) to 5 years (y) presenting with an illness at a rural primary healthcare centre in The Gambia. Primary outcomes were repeat clinic presentations and growth over 24 wk. Participants were randomly assigned to receive 1 of 3 interventions: (1) supplementation with micronutrient-fortified SQ-LNS for 12 wk (MMN-12), (2) supplementation with micronutrient-fortified SQ-LNS for 6 wk followed by unfortified SQ-LNS for 6 wk (MMN-6), or (3) supplementation with unfortified SQ-LNS for 12 wk (MMN-0) to be consumed in daily portions. Treatment masking used 16 letters per 6-wk block in the randomisation process. Blinded intention-to-treat analysis based on a prespecified statistical analysis plan included all participants eligible and correctly enrolled. Between December 2009 and June 2011, 1,101 children (age 6-60 mo, mean 25.5 mo) were enrolled, and 1,085 were assessed (MMN-0 = 361, MMN-6 = 362, MMN-12 = 362). MMN supplementation was associated with a small increase in height-for-age z-scores 24 wk after recruitment (effect size for MMN groups combined: 0.084 SD/24 wk, 95% CI: 0.005, 0.168; p = 0.037; equivalent to 2-5 mm depending on age). No significant difference in frequency of morbidity measured by the number of visits to the clinic within 24 wk follow-up was detected with 0.09 presentations per wk for all groups (MMN-0 versus MMN-6: adjusted incidence rate ratio [IRR] 1.03, 95% CI: 0.92, 1.16; MMN-0 versus MMN-12: 1.05, 95% CI: 0.93, 1.18). In post hoc analysis, clinic visits significantly increased by 43% over the first 3 wk of fortified versus unfortified SQ-LNS (adjusted IRR 1.43; 95% CI: 1.07, 1.92; p = 0.016), with respiratory presentations increasing by 52% with fortified SQ-LNS (adjusted IRR 1.52; 95% CI: 1.01, 2.30; p = 0.046). The number of severe adverse events during supplementation were similar between groups (MMN-0 = 20 [1 death]; MMN-6 = 21 [1 death]; MMN-12 = 20 [0 death]). No participant withdrew due to adverse effects. Study limitations included the lack of supervision of daily supplementation.

CONCLUSION

Prescribing micronutrient-fortified SQ-LNS to ill children presenting for primary care in rural Gambia had a very small effect on linear growth and did not reduce morbidity compared to unfortified SQ-LNS. An early increase in repeat visits indicates a need for the establishment of evidence-based guidelines and caution with systematic prescribing of MMN. Future research should be directed at understanding the mechanisms behind the lack of effect of MMN supplementation on morbidity measures and limited effect on growth.

TRIAL REGISTRATION

ISRCTN 73571031.

Beyond causes of death: The social determinants of mortality among children aged 1-59 months in Nigeria from 2009 to 2013

Background

Millions of children worldwide suffer and die from conditions for which effective interventions exist. While there is ample evidence regarding these diseases, there is a dearth of information on the social factors associated with child mortality.

Methods

The 2014 Verbal and Social Autopsy Study was conducted based on a nationally representative sample of 3,254 deaths that occurred in children under the age of five and were reported on the birth history component of the 2013 Nigerian Demographic and Health Survey. We conducted a descriptive analysis of the preventive and curative care sought and obtained for the 2,057 children aged 1–59 months who died in Nigeria and performed regional (North vs. South) comparisons.

Results

A total of 1,616 children died in the northern region, while 441 children died in the South. The majority (72.5%) of deceased children in the northern region were born to mothers who had no education, married at a young age, and lived in the poorest two quintiles of households. When caregivers first noticed that their child was ill, a median of 2 days passed before they sought or attempted to seek healthcare for their children. The proportion of children who reached and departed from their first formal healthcare provider alive was greater in the North (30.6%) than in the South (17.9%) (p<0.001). A total of 548 children were moderately or severely sick at discharge from the first healthcare provider, yet only 3.9%-18.1% were referred to a second healthcare provider. Cost, lack of transportation, and distance from healthcare facilities were the most commonly reported barriers to formal care-seeking behavior.

Conclusions

Maternal, household, and healthcare system factors contributed to child mortality in Nigeria. Information regarding modifiable social factors may be useful in planning intervention programs to promote child survival in Nigeria and other low-income countries in sub-Saharan Africa.

Following the World Health Organization's Recommendation of Exclusive Breastfeeding to 6 Months of Age Does Not Impact the Growth of Rural Gambian Infants

BACKGROUND

The WHO recommends exclusive breastfeeding (EBF) for the first 6 mo of life.

OBJECTIVE

The objective of this study was to assess the benefit of EBF to age 6 mo on growth in a large sample of rural Gambian infants at high risk of undernutrition.

METHODS

Infants with growth monitoring from birth to 2 y of age (n = 756) from the ENID (Early Nutrition and Immune Development) trial were categorized as exclusively breastfed if only breast milk and no other liquids or foods were given. EBF status was entered into confounder-adjusted multilevel models to test associations with growth trajectories by using >11,000 weight-for-age (WAZ), length-for-age (LAZ), and weight-for-length (WLZ) z score observations.

RESULTS

Thirty-two percent of infants were exclusively breastfed to age 6 mo. The mean age of discontinuation of EBF was 5.2 mo, and growth faltering started at ∼3.5 mo of age. Some evidence for a difference in WAZ and WHZ was found between infants who were exclusively breastfed to age 6 mo (EBF-6) and those who were not (nEBF-6), at 6 and 12 mo of age, with EBF-6 children having a higher mean z score. The differences in z scores between the 2 groups were small in magnitude (at 6 mo of age: 0.147 WAZ; 95% CI: -0.001, 0.293 WAZ; 0.189 WHZ; 95% CI: 0.038, 0.341 WHZ). No evidence for a difference between EBF-6 and nEBF-6 infants was observed for LAZ at any time point (6, 12, and 24 mo of age). Furthermore, a higher mean WLZ at 3 mo of age was associated with a subsequent higher mean age at discontinuation of EBF, which implied reverse causality in this setting (coefficient: 0.060; 95% CI: 0.008, 0.120).

CONCLUSION

This study suggests that EBF to age 6 mo has limited benefit to the growth of rural Gambian infants. This trial was registered at http://www.isrctn.com as ISRCTN49285450.