Sleep characteristics and changes in sleep patterns among infants in Bhaktapur, Nepal

OBJECTIVE

Sleep undergoes major changes during the first year of life, but the characteristics of sleep among infants in low and middle-income countries are not well documented. This study describes sleep characteristics and changes in sleep patterns in infants at 6 and 12months of age from Bhaktapur, Nepal.

METHODS

This was a community-based longitudinal study comprising 735 infants. Sleep characteristics were obtained by interview with the mother using the Brief Infant Sleep Questionnaires. The stability of sleep duration and night awakenings were estimated by logistic regression analysis.

RESULTS

Cosleeping in the parent's bed at 6 and 12months of age was almost universal (>97%). At 6months of age, 254 (35%) and at 12months of age, 341 (46%) infants had a total 24-hour sleep duration <12 hours. Night awakenings >3 times per night were common (65%) both at 6 and 12months of age. Infants with frequent nightly awakenings at 6months had increased odds of frequent nightly awakenings at 12months (OR=2.2; 95% CI: 1.6, 2.9). Very few (<3%) mothers reported sleep problems in their infants at 6 and 12months of age.

CONCLUSIONS

Cosleeping was almost universal among Nepalese infants, and very few of the mothers reported sleep problems in their infants. Infants at 6 and 12months had similar patterns for both sleep duration and nocturnal awakenings. For infants, there were increased odds of having similar sleep duration and nocturnal awakening at 6 and 12months.

The Effect of Vitamin B12 Supplementation on Leukocyte Telomere Length in Mildly Stunted Nepalese Children: A Secondary Outcome of a Randomized Controlled Trial

BACKGROUND

Vitamin B12 is essential for deoxyribonucleic acid synthesis and genome stability. A deficiency of vitamin B12 is associated with telomere shortening, genomic aging, and increased risk of chronic disease and mortality.

OBJECTIVES

The study aims to determine the effect of vitamin B12 supplementation on leukocyte telomere length (LTL) in infants at risk of vitamin B12 deficiency.

METHODS

The study was a predefined secondary analysis of a randomized controlled trial enrolling 600 Nepalese infants aged 6 -11 mo, who were supplemented with 2 μg (2-3 recommended daily allowances) vitamin B12 or placebo daily for 1 y. At the end of the study, LTL was measured in 497 participants. Mean LTL was compared between the treatment arms in the full sample and predefined subgroups based on markers of vitamin B12 status, hemoglobin, sex, and growth indices.

RESULTS

LTL at end-study did not differ between the vitamin B12 and placebo arm with a standardized mean difference (95% confidence interval) of 0.04 (-0.14, 0.21). There was no effect of vitamin B12 on LTL in any of the subgroups.

CONCLUSIONS

Providing daily vitamin B12 for 1 y during infancy in a population at risk of vitamin B12 deficiency does not affect LTL. This trial was registered at clinicaltrials.gov as NCT02272842.

Prognostic value of different anthropometric indices over different measurement intervals to predict mortality in 6-59-month-old children

OBJECTIVE

To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children.

DESIGN

Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations.

SETTING

Community-based, prospective studies from twelve countries in Africa and Asia.

PARTICIPANTS

Children aged 6-59 months living in the study areas.

RESULTS

For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone.

CONCLUSIONS

Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.

The association between household biomass fuel use and leukocyte telomere length among toddlers in Bhaktapur, Nepal

BACKGROUND

Biomass fuels are still in use for cooking by many households in resource poor countries such as Nepal and is a major source of household air pollution (HAP). Chronic exposure to HAP has been shown to be associated with shorter telomere length in adults.

OBJECTIVES

To measure the association between exposure related to household biomass fuel in infancy and leukocyte telomere length (LTL) at 18-23 months of age among 497 children from Bhaktapur, Nepal.

METHODS

In a prospective cohort study design, we have collected information on household cooking fuel use and several clinical, anthropometric, demographic, and socioeconomic variables. We estimated the association between biomass fuel use and the relative LTL in multiple linear regression models.

RESULTS

Most of the families (78%) reported liquified petroleum gas (LPG) as the primary cooking fuel, and 18.7% used biomass. The mean relative (SD) LTL was 1.03 (0.19). Children living in households using biomass fuel had on average 0.09 (95% CI: 0.05 to 0.13) units shorter LTL than children in households with no biomass fuel use. The observed association was unaltered after adjusting for relevant confounders. The association between LTL and biomass use was strongest among children from households with ≤2 rooms and without separate kitchen.

SIGNIFICANCE

Exposure to biomass fuel use in early life might have consequences for longevity, and risk of chronic illnesses reflected in shortening of the telomeres. Our findings support the ongoing effort to reduce exposure to biomass fuel in low-resource settings.

IMPACT STATEMENTS

Biomass for cooking is a leading source of household air pollution in low and middle-income countries, contributing to many chronic diseases and premature deaths. Chronic exposure to biomass fuel through oxidative stress and inflammation has been associated with a shortening of the telomeres, a "biological marker" of longevity. This prospective cohort study describes the association between household biomass fuel use and leukocyte telomere length among 497 toddlers. Leukocyte telomere length was significantly shorter among children living in households with biomass fuel than in children from homes where mainly LPG was used for cooking.

CLINICAL TRIAL REGISTRATION

Clinicaltrials.gov: NCT02272842, registered October 21, 2014, Universal Trial Number: U1111-1161-5187 (September 8, 2014).

The effect of vitamin B12 supplementation during pregnancy on infant growth and development in Nepal: a community-based, double-blind, randomised, placebo-controlled trial

BACKGROUND

Vitamin B12 is required for healthy infant growth and development, but low and marginal vitamin B12 status is endemic in low-income and middle-income countries. We aimed to measure the effect of vitamin B12 supplementation from early pregnancy until 6 months post partum on infant growth and neurodevelopment.

METHODS

In this community-based, double-blind, placebo-controlled trial, we randomly assigned (1:1) 800 pregnant women (aged 20-40 years) who were up to 15 weeks pregnant-recruited from home visits and outpatient departments at three hospitals in Nepal-to daily supplementation with 50 μg oral vitamin B12 or placebo until 6 months postpartum. Independent scientists generated the list that linked allocation to participants' study identification number. Participants were masked to group assignment and all investigators were masked until data cleaning was completed. The primary outcomes were length-for-age Z score (LAZ) at age 12 months and the cognitive composite score of the Bayley Scales of Infant and Toddler Development (3rd edition) at age 6 months and 12 months. The primary and secondary outcomes, including adverse events, were assessed in the intention-to-treat population, for all participants with available outcome data. This trial is registered with ClinicalTrials.gov, NCT03071666.

FINDINGS

800 eligible pregnant women were enrolled in the trial between March 28, 2017, and Oct 15, 2020, with 400 women randomly assigned to each group. Follow-up was completed on May 18, 2022. At baseline, 569 (71%) of 800 women had plasma vitamin B12 indicating low or marginal status (<221 pmol/L). We found no effect of vitamin B12 on the primary outcomes. The mean LAZ at age 12 months were -0·57 (SD 1·03) in the B12 group and -0·55 (1.03) in the placebo group (366 infants in the vitamin B12 group vs 363 infants in the placebo group) with a mean difference of -0·02 (95% CI -0·16 to 0·13). The mean cognitive composite scores were 97·7 (SD 10·5) in the B12 group and 97·1 (10·2) in the placebo group, with a mean difference of 0·5 (95% CI -0·6 to 1·7) measured in 364 and 361 infants. Stillbirths or infant deaths occurred in three (1%) of 374 women in the vitamin B12 group and nine (2%) of 379 women in the placebo group.

INTERPRETATION

Although vitamin B12 deficiency was prevalent in our study population and vitamin B12 supplementation from early pregnancy substantially improved vitamin B12 status, supplementation did not improve infant growth or neurodevelopment. Our findings support the current WHO recommendations of no routine vitamin B12 supplementation during pregnancy.

FUNDING

Research Council of Norway.

The reliability and predictive ability of the Test of Infant Motor Performance (TIMP) in a community-based study in Bhaktapur, Nepal

AIM

In a Nepalese setting, to measure the reliability of the Test of Infant Motor Performance (TIMP) and its ability to predict development scores at 6 months.

METHODS

Nepalese infants (n = 705) were assessed by the TIMP when they were 8-12 weeks old and the Bayley Scales of Infant and Toddler Development, 3rd edition (Bayley-III) at 6 months. Inter-rater agreement was expressed by intraclass correlation coefficients (ICCs), the internal consistency by Cronbach's alphas and Pearson correlation coefficients. Predictive ability was estimated in linear regression models.

RESULTS

Inter-rater agreement was excellent (ICCs > 0.93). Alphas for the TIMP total scores were 0.76 for infants born to term and 0.72 in those born preterm. Correlation coefficients between TIMP total and Bayley-III subscale-scores ranged from 0.05 to 0.28 for term infants and from 0.15 to 0.43 for preterm infants. Using American norms, 56.3 % had TIMP scores within average and 43.7 % below average range. Bayley-III subscale scores were lower in children with TIMP scores below the average range, with the strongest estimates for Gross motor and Socio-emotional development.

INTERPRETATION

The reliability of the TIMP was acceptable, and the TIMP could be a feasible tool to monitor infant motor development in low-resource settings. Properties of the TIMP differed according to gestational age.

The effect of infant vitamin B12 supplementation on neurodevelopment: a follow-up of a randomised placebo-controlled trial in Nepal

The most critical period for brain development is before a child's second birthday. Standardised tests measuring neurodevelopment are more reliable when administered after this period. Severe vitamin B12 deficiency affects brain development and function. In a randomised, double-blind, placebo-controlled trial in 600 Nepalese infants (6-11 months at enrolment), we found no effect of 2 µg vitamin B12 daily for a year on neurodevelopment. The primary objective of the current study was to measure the effect of the intervention on the Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) full scale intelligence quotient (FSIQ). We measured the effect on the Bayley Scales of Infant and Toddler Development 3rd edition at age 30-35 months (n 555). At age 42-47 months (n 533), we used the WPPSI-IV and subtests from the Neuropsychological Assessment, 2nd edition (NEPSY-II). We also used the FSIQ to estimate subgroup specific effects. The mean (sd) WPPSI-IV FSIQ in the vitamin B12 group was 84·4 (8·4) and 85·0 (8·6) in the placebo group (mean difference -0·5 (95 % CI -1·97, 0·94), P = 0·48). There were no effect of the vitamin B12 on any of the other neurodevelopmental outcomes and no beneficial effect in any of the subgroups. In conclusion, providing 2 µg of vitamin B12 for a year in infants at risk of vitamin B12 deficiency does not improve preschool cognitive function.

Associations between biomass fuel use and child health: a community-based study in Bhaktapur, Nepal

Background

Biomass fuel use for cooking is widespread in low- and middle-income countries. Previous studies have mainly focused on adverse health outcomes in adults or specific diseases. In a cohort among young children living in Bhaktapur, Nepal, we aimed to describe the association between the use of biomass cooking fuels in families with child health using measures of linear growth, cognition and chronic illness.

Methods

Caregivers of 600 marginally stunted children aged 6-11 months were interviewed about their primary source of cooking fuel at enrolment into a randomized controlled trial. Children's body length (n = 572) was measured at age 18-23 months. At the same time, blood samples (n = 497) were taken, and we measured leukocyte telomere length (LTL) as a marker of chronic disease risk. We chose LTL expressed as z-scores as a measure of chronic disease. Cognitive abilities were measured by the Wechsler Preschool and Primary Scale of Intelligence, 4th edition (WPPSI-IV) and NEPSY-II subtests when the children were 4 years old (n = 531). Associations were estimated in multiple regression models.

Results

About 18% of all families used biomass as primary cooking fuel. Children from families using biomass fuel were on average slightly shorter (mean difference 0.14 Z-scores, 95% CI: 0.28, 0.00), had lower IQ scores (mean difference 2.2 (95% CI: 0.5, 3.9), and shorter LTL (mean difference: 0.09 (95% CI: 0.05 to 0.13) compared to those not using biomass fuel. The observed associations were unaltered after adjusting for relevant confounders.

Conclusions

In children from households in poor, urban neighborhoods in Nepal, biomass fuel use for cooking was associated with health indicators for child growth and cognition as well as longevity and chronic illnesses reflected in shortening of telomeres. As this was an observational study, residual confounding cannot be excluded. Our findings support the ongoing effort to reduce exposure to biomass fuel in low-resource settings.

Key messages

Biomass fuel use for cooking in Nepalese families and child cognitive abilities, results from a community-based study

BACKGROUND

Biomass fuel use for cooking is widespread in low to middle income countries. Studies on the association between biomass fuel use and cognitive abilities in children are limited.

OBJECTIVE

To examine the association between biomass fuel use for cooking and cognitive abilities in Nepalese children at 4 years of age.

METHODS

In a cohort design we have information on biomass fuel use in the households of 533 children in infancy and cognitive abilities when they were 4 years old from a community-based sample. Cognitive abilities were measured by the Wechsler Preschool and Primary Scale of Intelligence, 4th edition (WPPSI-IV) and the NEPSY-II. We examined the associations between biomass fuel use and scores on the WPPSI-IV Full-Scale IQ (FSIQ) (primary outcome), and WPPSI index and NEPSY-II subtest scores in multiple linear regression models. The associations were also examined in predefined subgroups.

RESULTS

Ninety-nine (18.6%) of the families used biomass fuel for cooking. Children in these families had lower mean FSIQ than children in families with no biomass use (83.3 (95%CI 81.7, 85.0) vs. 85.3 (95%CI 84.5, 86.0)), with a mean difference of -2.2 (95%CI -3.9, -0.5) adjusting for demographics and socio-economic status. The association between biomass fuel use and cognitive abilities was strongest in subgroups of children from households with more than three rooms, with separate kitchen and bedroom, and with higher wealth-score. These interactions were significant for number of rooms in the home (p = 0.04), if the household had separate bedroom and kitchen (p = 0.05), and for the wealth-score (p = 0.03).

CONCLUSION

Biomass fuel use for cooking in Nepalese families was associated with lower overall cognitive abilities at 4 years. Uncertainties include exposure misclassification and unmeasured confounding. The associations between biomass fuel use and neurodevelopment in children needs further investigation with more precise measurements of the exposure.

The association between biomass fuel use for cooking and linear growth in young children in Bhaktapur, Nepal

BACKGROUND

There are still many people in the world who prepare their meals on open fires or stoves using solid fuels from biomass, especially in low-and middle-income countries. Although biomass cooking fuels have been associated with adverse health impacts and diseases, the association with child linear growth remains unclear.

OBJECTIVES

In a cohort design, we aimed to describe the association between the use of biomass cooking fuels and linear growth in children aged 18-23 months living in the urban and peri-urban community of Bhaktapur, situated in the Kathmandu valley in Nepal.

METHODS

Caretakers of 600 marginally stunted children aged 6-11 months were interviewed about their source of cooking fuel and other socio-demographic characteristics at enrolment into a randomized controlled trial. Children's body length was measured when children were 18-23 months old. In linear regression models, we estimated the association between the use of biomass fuel and length-for-age Z-scores (LAZ), adjusted for relevant confounders. We repeated these analyses in pre-defined sub-groups and different percentiles of LAZ using quantile regression models.

RESULTS

Among study participants, 101 (18%) used biomass as cooking fuel. The association between biomass fuel and LAZ was not statistically significant in the full sample (adjusted regression coefficient: -0.14, 95% CI: -0.28, 0.00). The association was stronger in some of the sub-groups and in the lower tail of the LAZ distribution (those who are stunted), but neither reached statistical significance.

DISCUSSION

Children from households in poor, urban neighborhoods in Nepal which used biomass fuel for cooking were on average slightly shorter than other children, although the association only approached statistical significance. As this was an observational study, residual confounding cannot be excluded. Further studies are needed to confirm these associations, in particular those seen in certain sub-groups.

Impact of the COVID-19 pandemic on daily life and worry among mothers in Bhaktapur, Nepal

The COVID-19 pandemic has affected many aspects of daily life worldwide, but the impact may be higher for impoverished populations. The main aim of this study is to describe the impact of the COVID-19 pandemic on different aspects of daily life in mothers in Nepal. We included 493 mothers of children aged 54-71 months participating in a randomized controlled trial on vitamin B12 supplementation. Mothers answered questions regarding the exposure and impact of the pandemic on their daily lives, and pandemic-related worries and sleep problems. We examined the extent to which worry, and sleep problems differed between mothers according to their exposure to COVID-19, socioeconomic status, and previous symptoms of depression. The mean age (SD) of the mothers was 32.3 (4.6) years and 54% had education below the secondary level. Of the mothers, 5.4% had either been exposed to someone who had tested positive or who had a family member with COVID-19. One-third of the participants responded that the pandemic had affected their economic situation, employment, and family life to a great deal. Both mothers and fathers with educational levels above 10 years or households with higher socioeconomic status had significantly higher average worry scores (maternal p = 0.020 and paternal p = 0.005). Mothers with a history of symptoms of depression had significantly more worry-related sleep problems during the pandemic (p = 0.020) than those without a history of depressive symptoms. Our study underlines the negative impact of the COVID-19 pandemic on diverse aspects of everyday life of mothers in Nepal.

The effect of vitamin B12-supplementation on actigraphy measured sleep pattern; a randomized control trial

BACKGROUND

Vitamin B12 deficiency is common worldwide and has been associated with poor sleep. The effect of vitamin B12 supplementation on sleep in infants is not known.

AIMS

To measure the effect of daily supplementation of vitamin B12 for one year on sleep in infants at risk of deficiency.

METHODS

This was an individually randomized double-blind placebo-controlled trial in 600 infants in low-to middle-income neighborhoods in Bhaktapur, Nepal of daily supplementation of vitamin B12 for one year. Infants were included if they were 6-11 month year-old and with a length-for-age less than one z-score. Sleep was a predefined, secondary outcome, and was measured by actigraphy including sleep duration at night and total sleep duration (day and night), sleep onset latency (SOL), and wake after sleep onset (WASO). The effect of vitamin B12 on sleep was additionally assessed in predefined subgroups defined by stunting, underweight, vitamin B12 status, low birthweight, anemia and exclusive breastfeeding for 3 months.

RESULTS

There was no effect of vitamin B12 supplementation on sleep duration at night, total sleep duration, or WASO. There was a small significant negative effect for SOL. None of the included subgroup analyses revealed effect modification on any of the sleep outcomes.

CONCLUSION

Overall, vitamin B12 supplementation did not have an effect on sleep in infants or for high-risk subgroups, with the exception of a small negative effect for SOL. The present study does not support vitamin B12 supplementation to improve sleep in infants.

TRIAL REGISTRATION

clinicaltrials.gov: NCT02272842.

UNIVERSAL TRIAL NUMBER

U1111-1161-5187.

Comparing Attained Weight and Weight Velocity during the First 6 Months in Predicting Child Undernutrition and Mortality

BACKGROUND

The first 6 mo of life are critical for subsequent risk of undernutrition and mortality. The predictive abilities of attained weight at the end of each month and monthly weight velocity for undernutrition and mortality need to be compared.

OBJECTIVES

This study aimed to examine the predictive abilities of different weight metrics during the first 6 mo of life in predicting undernutrition and mortality.

METHODS

This study used a cohort of infants in Tanzania. Weight and length were measured monthly from birth to 18 mo of age. Three weight metrics during the first 6 mo of life were considered as predictors, including attained weight-for-age z score (WAZ) at the end of each month, monthly change in WAZ, and monthly weight velocity z score (WVZ). Logistic models were used with undernutrition (at 6 or 12 mo) and mortality (over the first 18 mo) as outcomes. AUC values were compared across metrics.

RESULTS

For predicting wasting at 6 mo, WVZ (AUC: 0.80) had a greater predictive ability than attained WAZ (AUC: 0.76) and change in WAZ (AUC: 0.71) during the second month of life. After 2 mo, attained WAZ (AUC: 0.81-0.89) had greater predictive abilities than WVZ (AUC: 0.71-0.77) and change in WAZ (AUC: 0.65-0.67). For predicting stunting at 6 mo, attained WAZ (AUC: 0.75-0.79) had consistently greater predictive abilities than WVZ (AUC: 0.56-0.66) and change in WAZ (AUC: 0.50-0.57). The weight metrics had similar abilities in predicting mortality, with the AUC rarely reaching >0.65.

CONCLUSIONS

Attained weight at the end of each month had greater abilities than monthly weight velocity in the same month in predicting undernutrition. Attained weight remains a useful indicator for identifying infants at greater risk of undernutrition.

Agreement Between Mothers and Fieldworkers While Assessing Child Development Using Ages and Stages Questionnaires, Third Edition in Nepal

Background: The Ages and Stages Questionnaires, Third Edition (ASQ-3) is becoming a widely used developmental assessment tool. The ASQ-3 can be completed by the caregivers (referred to as “mail out”), or by trained personnel under direct observation of the children (referred to as “home procedure”).

Aim: The study was carried out to compare results obtained by the ASQ mail out with those of the ASQ home procedure in a community setting of Bhaktapur, Nepal.

Methods: Trained fieldworkers (FWs) performed developmental assessment of 134 children aged 9 months in their homes using the ASQ home procedure. A few days before these assessments, mothers were asked to fill in the same ASQ-3 questionnaire. The concordance correlation coefficient (CCC) was calculated to measure their agreement.

Result: The agreement between the ASQ mail out and home procedure was fair for the total score (CCC = 0.54). For the sub-scales, the agreement was good for the gross motor (CCC = 0.65), for the remaining subscales agreement was poor (CCC < 0.4).

Conclusion: In resource limited setting like Nepal, the ASQ mail out represents an easy method to assess child development by caretakers at home; however, with the poor agreement between different methods of assessments, we cannot conclude that a single method is superior or most optimal and this question should be investigated further. When either of the method home procedure or mail out is opted, the results should be interpreted with cautions.

Prevalence of Underweight, Overweight, and Obesity in Adults in Bhaktapur, Nepal in 2015-2017

Introduction: There is an increase in the double burden of malnutrition globally, with a particular rise documented in Asia. In Nepal, undernutrition has been prevalent for decades. Today, however, the incidence of overweight and obesity (OWOB) in the country has increased substantially. There is a need to conduct local studies reporting on the concurrent burden of both underweight and OWOB across adult populations. This study addresses this need by describing the distribution of body mass index (BMI) in a defined population of adults living in the peri-urban community of Bhaktapur, Nepal.

Material and methods: For this cross-sectional analysis, we used data that were available from 600 women and 445 men whose children were enrolled in an individually randomized, double-blind, placebo-controlled trial assessing the effect of daily vitamin B12 supplementation. Upon enrolment of their 6–11-month old children, mothers and fathers were interviewed about their socio-demographic details. In addition, their weight and height were measured by trained field workers. Each parent's BMI was calculated as the ratio of body weight (in kg) and height squared (in m), expressed as kg/m², and categorized according to the WHO recommendation. We used linear and multinomial logistic regression models to assess associations between the BMI of the mothers and fathers, and their baseline characteristics.

Results: The mean BMI was 23.7 kg/m² for both the mothers and fathers with a standard deviation (SD) of 3.6 and 3.7, respectively. The proportion categorized as underweight, overweight, and obese was also similar in the two groups with around 5% being underweight, 30% being overweight and 5% being obese. Age was positively associated with BMI in both groups. Those categorized as daily wage earner had a lower mean BMI than those in other occupational groups.

Conclusion: Our results contribute to documenting the burden of both under- and overnutrition in a selected group of young adults living in a peri-urban community in Nepal. As Nepal is undergoing an improvement in its economic situation, as well as a nutrition transition, it is important to provide sufficient information to enable timely action, and evidence-based decision-making to prevent a further increase in Nepal's growing double burden of malnutrition.

Association of Plasma Total Cysteine and Anthropometric Status in 6-30 Months Old Indian Children

High-quality protein has been associated with child growth; however, the role of the amino acid cysteine remains unclear. The aim was to measure the extent to which plasma total cysteine (tCys) concentration is associated with anthropometric status in children aged 6–30 months living in New Delhi, India. The study was a prospective cohort study including 2102 children. We calculated Z-scores for height-for-age (HAZ), weight-for-height (WHZ), or weight-for-age (WAZ) according to the WHO Child Growth Standards. We used multiple regression models to estimate the association between tCys and the anthropometric indices. A high proportion of the children were categorized as malnourished at enrolment; 41% were stunted (HAZ ≤ −2), 19% were wasted (WHZ ≤ −2) and 42% underweight (WAZ ≤ −2). Plasma total cysteine (tCys) was significantly associated with HAZ, WHZ and WAZ after adjusting for relevant confounders (p < 0.001). Low tCys (≤25th percentile) was associated with a decrease of 0.28 Z-scores for HAZ, 0.10 Z-scores for WHZ, and 0.21 Z-scores for WAZ compared to being >25th percentile. In young Indian children from low-to-middle socioeconomic neighborhoods, a low plasma total cysteine concentration was associated with an increased risk of poor anthropometric status.

Association of Maternal Plasma Total Cysteine and Growth among Infants in Nepal: A Cohort Study

Cysteine is a semi-essential amino acid that has been positively associated with growth in children. However, transgenerational effects remain unclear. The aim of this analysis was to assess whether maternal plasma total cysteine (tCys) concentration is associated with various growth indicators in infants living in peri-urban settings in Bhaktapur, Nepal. We used data from the 561 mothers enrolled in an ongoing randomized controlled trial. We built linear regression models to evaluate the associations between maternal tCys and birth weight, length-for-age Z-scores (LAZ) and weight-for-length Z-scores (WLZ) at birth and six months of age. Maternal tCys was inversely associated with birth weight among boys after adjusting for confounders (p < 0.05). In addition, there was a negative association between maternal tCys and LAZ at birth (p < 0.01). No associations between maternal tCys and the other anthropometric indicators were found significant, although there was a tendency for maternal tCys to be associated positively with WLZ at birth among girls (p < 0.10). This is a first study evaluating transgenerational relation of tCys on growth in infants. Further, larger and more comprehensive studies are needed to determine if and how maternal tCys alters child growth.

Severe acute malnutrition and mortality in children in the community: Comparison of indicators in a multi-country pooled analysis

OBJECTIVES

This study aims to describe the mortality risk of children in the community who had severe acute malnutrition (SAM) defined by either a mid-upper arm circumference (MUAC) <115mm, a low weight-for-height Z-score (WHZ) <-3 or both criteria.

METHODS

We pooled individual-level data from children aged 6-59 months enrolled in 3 community-based studies in the Democratic Republic of the Congo (DRC), Senegal and Nepal. We estimate the mortality hazard using Cox proportional hazard models in groups defined by either anthropometric indicator.

RESULTS

In total, we had 49,001 time points provided by 15,060 children available for analysis, summing to a total of 143,512 person-months. We found an increasing death rate with a deteriorating nutritional status for all anthropometrical indicators. Children identified as SAM only by a low MUAC (<115mm) and those identified only by a low WHZ (Z-score <-3) had a similar mortality hazard which was about 4 times higher than those without an anthropometric deficit. Having both a low MUAC and a low WHZ was associated with an 8 times higher hazard of dying compared to children within the normal range. The 2 indicators identified a different set of children; the proportion of children identified by both indicators independently ranged from 7% in the DRC cohort, to 35% and 37% in the Senegal and the Nepal cohort respectively.

CONCLUSION

In the light of an increasing popularity of using MUAC as the sole indicator to identify SAM children, we show that children who have a low WHZ, but a MUAC above the cut-off would be omitted from diagnosis and treatment despite having a similar risk of death.

Predicting Undernutrition at Age 2 Years with Early Attained Weight and Length Compared with Weight and Length Velocity

OBJECTIVE

To estimate the abilities of weight and length velocities vs attained growth measures to predict stunting, wasting, and underweight at age 2 years.

STUDY DESIGN

We analyzed data from a community-based cohort study (The Etiology, Risk Factors, and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development study [MAL-ED] study) in Bhaktapur, Nepal. A total of 240 randomly selected children were enrolled at birth and followed up monthly up to age 24 months. Linear and logistic regression models were used to predict malnutrition at 2 years of age with growth velocity z scores at 0-3, 0-6, 3-6, 6-9, 6-12, and 9-12 months (using the World Health Organization Growth Standards) or attained growth at 0, 3, 6, and 12 months as predictors.

RESULTS

At age 2 years, 4% of the children were wasted, 13% underweight, and 21% stunted. Children who were malnourished at age 2 years had lower mean growth z scores already at birth and throughout the study period. Anthropometric indicators in infancy were significant predictors for growth at the age of 2 years during most periods and at most ages in infancy. Weight-for-age z score, length-for-age z score, and weight-for-length z score at age 12 months had excellent areas under the curve (91-95) to predict the value of the same indicator at age 24 months. Maximum area under the curve values for weight and length velocity were somewhat lower (70-84).

CONCLUSIONS

Growth measured at one time point in infancy was better correlated with undernutrition at age 2 years than growth velocity.

Using growth velocity to predict child mortality

BACKGROUND

Growth assessment based on the WHO child growth velocity standards can potentially be used to predict adverse health outcomes. Nevertheless, there are very few studies on growth velocity to predict mortality.

OBJECTIVES

We aimed to determine the ability of various growth velocity measures to predict child death within 3 mo and to compare it with those of attained growth measures.

DESIGN

Data from 5657 children <5 y old who were enrolled in a cohort study in the Democratic Republic of Congo were used. Children were measured up to 6 times in 3-mo intervals, and 246 (4.3%) children died during the study period. Generalized estimating equation (GEE) models informed the mortality risk within 3 mo for weight and length velocity z scores and 3-mo changes in midupper arm circumference (MUAC). We used receiver operating characteristic (ROC) curves to present balance in sensitivity and specificity to predict child death.

RESULTS

GEE models showed that children had an exponential increase in the risk of dying with decreasing growth velocity in all 4 indexes (1.2- to 2.4-fold for every unit decrease). A length and weight velocity z score of <-3 was associated with an 11.8- and a 7.9-fold increase, respectively, in the RR of death in the subsequent 3-mo period (95% CIs: 3.9, 35.5, and 3.9, 16.2, respectively). Weight and length velocity z scores had better predictive abilities [area under the ROC curves (AUCs) of 0.67 and 0.69] than did weight-for-age (AUC: 0.57) and length-for-age (AUC: 0.52) z scores. Among wasted children (weight-for-height z score <-2), the AUC of weight velocity z scores was 0.87. Absolute MUAC performed best among the attained indexes (AUC: 0.63), but longitudinal assessment of MUAC-based indexes did not increase the predictive value.

CONCLUSION

Although repeated growth measures are slightly more complex to implement, their superiority in mortality-predictive abilities suggests that these could be used more for identifying children at increased risk of death.

Incidence and course of child malnutrition according to clinical or anthropometrical assessment: a longitudinal study from rural DR Congo

Background

Longitudinal studies describing incidence and natural course of malnutrition are scarce. Studies defining malnutrition clinically [moderate clinical malnutrition (McM) marasmus, kwashiorkor] rather than anthropometrically are rare. Our aim was to address incidence and course of malnutrition among pre-schoolers and to compare patterns and course of clinically and anthropometrically defined malnutrition.

Methods

Using a historical, longitudinal study from Bwamanda, DR Congo, we studied incidence of clinical versus anthropometrical malnutrition in 5 657 preschool children followed 3-monthly during 15 months.

Results

Incidence rates were highest in the rainy season for all indices except McM. Incidence rates of McM and marasmus tended to be higher for boys than for girls in the dry season. Malnutrition rates increased from the 0–5 to the 6 – 11 months age category. McM and marasmus had in general a higher incidence at all ages than their anthropometrical counterparts, moderate and severe wasting. Shifts back to normal nutritional status within 3 months were more frequent for clinical than for anthropometrical malnutrition (62.2-80.3% compared to 3.4-66.4.5%). Only a minority of moderately stunted (30.9%) and severely stunted children (3.4%) shifted back to normal status. Alteration from severe to mild malnutrition was more characteristic for anthropometrically than for clinically defined malnutrition.

Conclusions

Our data on age distribution of incidence and course of malnutrition underline the importance of early life intervention to ward off malnutrition. In principle, looking at incidence may yield different findings from those obtained by looking at prevalence, since incidence and prevalence differ approximately differ by a factor “duration”. Our findings show the occurrence dynamics of general malnutrition, demonstrating that patterns can differ according to nutritional assessment method. They suggest the importance of applying a mix of clinical and anthropometric methods for assessing malnutrition instead of just one method. Functional validity of characterization of aspects of individual nutritional status by single anthropometric scores or by simple clinical classification remain issues for further investigation.

Alginate encapsulation of genetically engineered mammalian cells: comparison of production devices, methods and microcapsule characteristics

PRIMARY OBJECTIVE

Microencapsulation is a novel method for in vivo immunoprotection of genetically engineered mammalian cells. This study aimed at optimizing alginate/poly-l-lysine/alginate (APA) microencapsulation of mammalian cells in small size (< 300 microm) hollow core microcapsules and at evaluating some of the physical characteristics of APA microcapsules produced by different devices and with different alginate preparations.

METHODS AND PROCEDURES

Alginate preparations with higher or lower viscosity were used with three different methods: (i) vibrating nozzle, (ii) coaxial gas flow extrusion (AirJet) and (iii) laminar jet break-up (JetCutter). Parameters and device settings for the production of microcapsules with specific characteristics were defined for all three methods. Mechanical stability of APA microcapsules and cell viability of encapsulated cells were investigated in long-term culture and in an animal model.

MAIN RESULTS

Uniform spherical beads with a mean diameter < 300 microm could be produced by all three encapsulation methods. For the production of uniform microcapsules with a small diameter (< 300 microm) the vibrating nozzle technique required a relatively low viscosity of alginate (< 0.2 Pa/s), while the AirJet and JetCutter devices performed equally well with alginate of higher viscosity. In all cases, alginate with a lower molar mass was inferior to higher molar mass alginate in terms of mechanical stability of the microcapsules. Microcapsules with optimized mechanical properties were injected intravascularly in rats and shown to maintain their shape and the viability of encapsulated cells.

CONCLUSIONS

The described methods and devices are able to produce APA microcapsules of small size and uniform shape which are mechanically stable in culture and may maintain the viability of the enclosed cells over extended periods of time. These microcapsules seem to be suitable for further therapeutic studies in an animal model of human disease.

High throughput encapsulation of murine fibroblasts in alginate using the JetCutter technology

The JetCutter technology originally developed for high-throughput encapsulation of particles and substances into small beads was applied in this study for the entrapment of mammalian cells in alginate beads. In contrast to other established techniques such as the air jet droplet generation or laminar jet break-up, the JetCutter is capable of working with highly viscous fluids necessary for the production of stable beads based on hydrogels. A 1.5% (w/v) sodium alginate solution containing 2.0 x 106 murine fibroblasts/ml was processed under good manufacturing practice (GMP) conditions to beads with a mean diameter of 320 microm. The production capacity of the JetCutter technology was 5200 beads/s or to approximately 330 ml bead suspension per h. Beads were coated with poly-L-lysine and with an additional alginate layer to produce hollow microcapsules containing living cells. The influence of this method of encapsulation on the cell viability and morphology was investigated by light microscopic techniques. Encapsulated cells showed unchanged rates of proliferation and preserved morphology. They were able to survive in culture for extended periods of time. In conclusion, the JetCutter technology seems to be well suitable for alginate bead encapsulation of living mammalian cells.