Vulnerable newborn types: analysis of subnational, population-based birth cohorts for 541 285 live births in 23 countries, 2000-2021

OBJECTIVE

To examine prevalence of novel newborn types among 541 285 live births in 23 countries from 2000 to 2021.

DESIGN

Descriptive multi-country secondary data analysis.

SETTING

Subnational, population-based birth cohort studies (n = 45) in 23 low- and middle-income countries (LMICs) spanning 2000-2021.

POPULATION

Liveborn infants.

METHODS

Subnational, population-based studies with high-quality birth outcome data from LMICs were invited to join the Vulnerable Newborn Measurement Collaboration. We defined distinct newborn types using gestational age (preterm [PT], term [T]), birthweight for gestational age using INTERGROWTH-21st standards (small for gestational age [SGA], appropriate for gestational age [AGA] or large for gestational age [LGA]), and birthweight (low birthweight, LBW [<2500 g], nonLBW) as ten types (using all three outcomes), six types (by excluding the birthweight categorisation), and four types (by collapsing the AGA and LGA categories). We defined small types as those with at least one classification of LBW, PT or SGA. We presented study characteristics, participant characteristics, data missingness, and prevalence of newborn types by region and study.

RESULTS

Among 541 285 live births, 476 939 (88.1%) had non-missing and plausible values for gestational age, birthweight and sex required to construct the newborn types. The median prevalences of ten types across studies were T+AGA+nonLBW (58.0%), T+LGA+nonLBW (3.3%), T+AGA+LBW (0.5%), T+SGA+nonLBW (14.2%), T+SGA+LBW (7.1%), PT+LGA+nonLBW (1.6%), PT+LGA+LBW (0.2%), PT+AGA+nonLBW (3.7%), PT+AGA+LBW (3.6%) and PT+SGA+LBW (1.0%). The median prevalence of small types (six types, 37.6%) varied across studies and within regions and was higher in Southern Asia (52.4%) than in Sub-Saharan Africa (34.9%).

CONCLUSIONS

Further investigation is needed to describe the mortality risks associated with newborn types and understand the implications of this framework for local targeting of interventions to prevent adverse pregnancy outcomes in LMICs.

Association between aflatoxin M1 exposure through breast milk and growth impairment in infants from Northern Tanzania

Infants breastfeeding from mothers consuming aflatoxin contaminated foods may be exposed to aflatoxin M1 (AFM1), a metabolite of aflatoxin B1. This study estimated the association between AFM1 exposure levels and growth indicators, for infants under six months of age in the Rombo district in Northern Tanzania. A total of 143 infants and their mothers were involved. Breast-milk samples, infants' anthropometric data and 24 h dietary recall for mothers were taken at the 1st, 3rd and 5th months of children age. AFM1 contaminations in the samples were determined using HPLC. Aflatoxin M1 exposure by an infant was estimated by multiplying contamination in the breast milk consumed by him/her with the breast milk intake recorded by the United States Environmental Protection Agency for infants of his/her age divided by the infant's body weight. All the breast-milk samples were contaminated by AFM1 at levels ranging from 0.01 to 0.55 ng/ml. Above 90% of samples exceeded the EU limit of 0.025 ng/ml for infants' foods while over 76% exceeded the EU limit of 0.05 ng/ml for dairy milk and milk products. Only 1% of the samples exceeded the limit of 0.5 ng/ml set for dairy milk in the United States and several countries in Asia. AFM1 Exposures ranged from 1.13-66.79 ng/kg body weight per day. A small but significant (P<0.05) inverse association was observed between AFM1 exposure levels and weight for age Z-score or height for age Z-score. Appropriate strategies should be applied to minimise aflatoxin B1 exposure in lactating mothers in order to protect infants from AFM1 exposure.

Eating out of home and its association with dietary intake: a systematic review of the evidence

During the last decades, eating out of home (OH) has gained importance in the diets worldwide. We document the nutritional characteristics of eating OH and its associations with energy intake, dietary quality and socioeconomic status. We carried out a systematic review of peer-reviewed studies in eight databases up to 10 March 2011. Of the 7,319 studies retrieved, 29 met the inclusion criteria and were analysed in this review. The quality of the data was assessed and a sensitivity analysis was conducted by isolating nationally representative or large cohort data from 6 and 11 countries, respectively. OH foods were important sources of energy in all age groups and their energy contribution increased in adolescents and young adults. Eating OH was associated with a higher total energy intake, energy contribution from fat in the daily diet and higher socioeconomic status. Two large studies showed how eating OH was also associated with a lower intake of micronutrients, particularly vitamin C, Ca and Fe. Although the studies were cross-sectional and heterogeneous in the way they classified eating OH, we conclude that eating OH is a risk factor for higher energy and fat intake and lower micronutrient intake.

Validity of photographs for food portion estimation in a rural West African setting

Objective

To validate food photographs for food portion size estimation of frequently consumed dishes, to be used in a 24-hour recall food consumption study of pregnant women in a rural environment in Burkina Faso. This food intake study is part of an intervention evaluating the efficacy of prenatal micronutrient supplementation on birth outcomes.

Subjects

Women of childbearing age (15–45 years).

Design

A food photograph album containing four photographs of food portions per food item was compiled for eight selected food items. Subjects were presented two food items each in the morning and two in the afternoon. These foods were weighed to the exact weight of a food depicted in one of the photographs and were in the same receptacles. The next day another fieldworker presented the food photographs to the subjects to test their ability to choose the correct photograph.

Results

The correct photograph out of the four proposed was chosen in 55% of 1028 estimations. For each food, proportions of underestimating and overestimating participants were balanced, except for rice and couscous. On a group level, mean differences between served and estimated portion sizes were between −8.4% and 6.3%. Subjects who attended school were almost twice as likely to choose the correct photograph. The portion size served (small vs. largest sizes) had a significant influence on the portion estimation ability.

Conclusions

The results from this study indicate that in a West African rural setting, food photographs can be a valuable tool for the quantification of food portion size on group level.

Iron supplementation in previously anemic Bolivian children normalized hematologic parameters, but not immunologic parameters

Iron deficiency anemia (IDA) is considered to be the most prevalent micronutrient deficiency in the world. Estimates indicate that 1.2 billion people suffer mild to severe forms of anemia and that up to 46% of schoolchildren in developing countries are affected. In 2003, ENDSA, the national demographic and health survey of Bolivia showed that 60% of children under five and 72% of children under 2 years old were anemic. Micronutrient deficiency has been suggested to impair cell-mediated immunity. In particular, iron, zinc and vitamin A deficiencies have an impact on the immune system. In vitro and in vivo laboratory studies indicate a link between iron deficiency and impaired T-lymphocyte proliferation. The exact effects or mechanisms of iron deficiency on maturation and proliferation of T-lymphocytes in vivo are, however, not yet known. This study investigated the effects of iron on the maturation of T-lymphocytes in anemic but otherwise healthy schoolchildren (no apparent protein-energy deficiency or other morbidity). Anemic children of a poor peri-urban school of Cochabamba city, Bolivia, were given iron treatment for three consecutive months. We chose to look at CD1a+ lymphocytes, which are immature thymocytes. The proportions of CD1a+ lymphocytes in the peripheral circulation measured at baseline and after treatment were compared with a reference group of age-matched non-anemic children controls from the same school. The immunologic parameters, although improved, did not reach the proportions of the control group. Overall, the proportion of circulating immature T-lymphocytes decreased from 18.3% to 9.2% in the treated following iron supplementation in anemic children, compared with 3.4% in non-anemic children.

Plot and see! Maternal comprehension of growth charts worldwide

OBJECTIVE

To evaluate maternal comprehension of growth charts used in growth monitoring and promotion (GMP), a worldwide programme with important budgets but contrasting results.

METHODS

Systematic literature review through MEDLINE, POPLINE, Global Health, ERIC and the Cochrane Library with the keywords 'growth monitoring' or 'growth chart' limited to the title/abstract field and to the 0-5 years age range.

RESULTS

Twenty studies from Asia (8), Africa (8) and Latin America/Caribbean (3) were included in the review. The results of the 14 non-intervention, cross-sectional studies provide convincing evidence that a third to three-fourths of carers in developing countries do not understand the growth charts. Literacy had a strong effect on women's ability to interpret the cards. Appropriate training and educational activities also increased substantially maternal comprehension as demonstrated in five of the six intervention trials.

CONCLUSIONS

Many carers have poor comprehension of growth charts, but their comprehension increases not only with literacy, but also with training. Activities aimed at improving communication skills of health staff and at empowering parents to practice responsive parenting could greatly improve GMP outcomes.

[Development and testing of a semi-quantitative food frequency questionnaire for Bolivian adolescents]

INTRODUCTION

Since previous studies suggest that the dietary patterns and lifestyle in adolescence have an impact in health later in life, it is pertinent to monitor and document their dietary patterns.

OBJECTIVE

To develop and test the reliability and validity of a semi-quantitative food frequency questionnaire for Bolivian adolescents.

SETTING

La Paz, September - October 2004.

METHODOLOGY

A convenience sample of 82 students from a secondary participated in the study. A semi quantitative food frequency questionnaire was applied twice with one month interval (Q1 and Q2). A 3 days dietary record (3R) was obtained from 32 of the Students as standard.

RESULTS

Most of the questions (87%) reporting intake of each individual food item agreed moderately to substantially while only 2 individual food items fell into the category of slight agreement and 11 into the category of fair agreement using the kappa statistic. Quantities obtained from both applications of the questionnaire yielded similar results (P > 0.05). Nutrient estimates obtained from the Q1 and Q2 and the 3R were not statistically different (P > 0.05).

CONCLUSION

The semi-quantitative food frequency questionnaire is apparently reliable and valid for the measurement of absolute food intake in Bolivian adolescents. Care will be taken in the future to prevent overestimation of intake measured by this particular questionnaire.

Do growth monitoring and promotion programs answer the performance criteria of a screening program? A critical analysis based on a systematic review

OBJECTIVE

Growth Monitoring and Promotion programs (GMP) have been intensively promoted to improve children's health in developing countries. It has been hoped that regularly weighing children would result in the early detection of growth falterers, and that the growth chart would serve as an educational tool to make that state apparent to both health workers and caretakers in order to trigger improved caring practices. Our objective was to review whether GMP answers the theoretical grounds of a screening and intervention program.

METHOD

A systematic literature review was performed. The WHO framework developed by Wilson and Jungner for planning and evaluating screening programs guided the analysis.

RESULTS

Sixty-nine studies were retrieved. Overall, evidence is weak on the performance of GMP as a screening program for malnutrition through early detection of growth falterers. The main results are: (1) malnutrition remains a public health problem, but its importance is context specific; (2) the value of a low weight velocity to predict malnutrition is unknown and likely to vary in different contexts; (3) the performance of GMP for improving nutrition status of children and in reducing mortality and morbidity is unknown; (4) the performance of the screening is affected by the unreliability of weight measurements; (5) the promotional and educational effectiveness of GMP is low, in particular the growth chart is poorly understood by mothers; (6) the acceptability seems low in regards of low attendance rates; (7) evidence is lacking regarding cost-effectiveness.

CONCLUSIONS

We conclude that there is too little scientific evidence to indiscriminately support international promotion of GMP. However GMP could constitute a valid strategy of public nutrition in specific situations. We indicate paths for further research and how prevention programs could be developed.

Economic hardship and sexually transmitted diseases in Haiti's rural Artibonite Valley

A study was conducted to determine the prevalence rate and risk factors for sexually transmitted diseases (STDs) in Haiti's rural Artibonite Valley. Women attending antenatal services at Hospital Albert Schweitzer from October to December 1996 were tested for gonorrhea, chlamydia, trichomonas, syphilis, and human immunodeficiency virus (HIV). Of the 476 women tested, 121 (25.4%) had trichomonas, 11/475 (2.3%) had gonorrhea, 51/475 (10.7%) had chlamydia, 32/474 (6.8%) were seropositive for syphilis, 20/469 (4.3%) were seropositive for HIV, and 191 (40.1%) had at least one STD. Nearly 30% of the women reported having entered a sexual relationship out of economic necessity and had increased odds of HIV infection, Odds Ratio (OR) 6.3 (P < 0.001). We postulate that due to recent economic hardship in rural Haiti, women are entering into sexual relationships out of economic necessity and that this trend is contributing to the growing HIV epidemic. We recommend STD prevention and development programs that target young people and economically disadvantaged women.

Prevalence, burden, and control of syphilis in Haiti's rural Artibonite region

OBJECTIVES

A study was conducted to determine the prevalence and health consequences of syphilis and to evaluate existing control measures in a Haitian rural district of 200,000 people served by 12 community dispensaries and Hospital Albert Schweitzer.

METHODS

Syphilis seroprevalence among consecutive women receiving antenatal services was assessed using rapid plasma reagin (RPR) screening and fluorescent treponemal antibody absorption (FTA-ABS) confirmatory testing. Hospital and dispensary records were used to review genital ulcer disease and syphilis cases seen during 1995.

RESULTS

Of 811 pregnant women attending prenatal clinics during a 3-month period in 1996, 46 (5.7%) were RPR reactive. Syphilis seroreactivity was confirmed in 45 (97.8%) of 46 samples by FTA-ABS. Of 649 women attending dispensaries in the valley 41 (6.3%) were syphilis seroreactive compared with 4 (2.5%) of 162 women attending dispensaries in the mountains (OR = 2.66; P = 0.056). In 1995, 620 cases of genital ulcer disease were seen at the community dispensaries. At the central hospital, 257 new diagnoses of syphilis were made in 1995, including 30 cases of primary and secondary syphilis, 168 cases of latent disease, 17 cases of recurrent infection, 9 cases of tertiary disease, and 33 cases of congenital syphilis.

CONCLUSIONS

The 33 cases of congenital syphilis, a rate of 550 cases for 100,000 live births, clearly demonstrated a failure of local control measures. Decentralized prenatal screening for syphilis, same-day treatment of seroreactors, and strengthened partner treatment were initiated. Further studies to improve primary prevention of syphilis in rural populations have been started. Other strategies, including mass treatment of high-risk groups, should be investigated.