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.

Periapical infection may affect birth outcomes via systemic inflammation

OBJECTIVES

Maternal dental periapical infections are associated with preterm birth and intrauterine growth restriction. This study investigates whether the association is mediated through bacterial spread from periapical lesions to placenta (direct pathway) or systemic inflammatory reaction (indirect pathway).

MATERIALS AND METHODS

We compared birth outcomes in Malawian mothers with and without periapical infection. As markers of a direct pathway, we identified placental bacteria using a 16S rDNA approach and assessed histological evidence of inflammation in the placenta and amniotic membranes. We measured C-reactive protein, alpha-1-acid glycoprotein, and salivary cortisol as markers of an indirect pathway. We used regression models to associate the predictor variables with duration of pregnancy and newborn size.

RESULTS

Of 1,024 women, 23.5% had periapical infection. There was no association of periapical infection with either bacterial DNA or histological inflammation in placenta or membranes. Periapical infection was associated with C-reactive protein, alpha-1-acid glycoprotein, and cortisol concentrations in a dose-dependent manner at 36 weeks. Addition of alpha-1-acid glycoprotein or cortisol concentration into regression models attenuated the association between periapical infection and pregnancy outcomes.

CONCLUSION

There was no evidence of direct spread of periapical bacteria to the placenta. Periapical infections and adverse pregnancy outcomes are in part mediated through systemic inflammation.

Breast milk from women living near Lake Malawi is high in docosahexaenoic acid and arachidonic acid

Adequate long-chain polyunsaturated fatty acid (LCPUFA) intake is critical during the fetal and infant periods. We quantified fatty acid content of breast milk (n=718) and plasma from six month old infants (n=412) in southern Malawi, and in usipa (n=3), a small dried fish from Lake Malawi. Compared to global norms, Malawian breast milk fatty acid content (% of total fatty acids) was well above average levels of arachidonic acid [ARA] (0.69% vs. 0.47%) and docosahexaenoic acid [DHA] (0.73% vs. 0.32%). Average Malawian infant plasma ARA (7.5%) and DHA (3.8%) levels were comparable to those reported in infants consuming breast milk with similar fatty acid content. The amounts (mg) of DHA, EPA and ARA provided by a 3 oz (85 g) portion of dried usipa (1439, 659 and 360, respectively) are considerably higher than those for dried salmon. Usipa may be an important source of LCPUFA for populations in this region.

Evaluating environmental and social influences on iron and zinc status of pregnant subsistence farmers in two geographically contrasting regions of Southern Malawi

Micronutrient deficiency affects over 4.5 billion people worldwide, the majority in developing countries. Deficiencies of iron (and associated anaemia) and zinc in pregnancy are associated with complications, maternal and neonatal mortality, and developmental disorders in the foetus and growing child. We report the results of pilot study which used an interdisciplinary approach to explore environmental and sociocultural factors influencing the micronutrient status in the soil-plant-human transfer for pregnant subsistence farmers in two geographically contrasting regions of Southern Malawi. It evaluated micronutrient status in soil and the staple crop and explored the context for their transfer to pregnant women. Scientific and social science methods were used to collect data, following full sensitisation of the communities. A total of 99 participants were recruited from Chiradzulu (plateau) and Chikwawa (floodplain). Soil, maize and blood samples were collected, along with food frequency and health behaviour questionnaires and anthropological observation. Statistical analysis revealed that soil iron was significantly higher in Chiradzulu than in Chikwawa; total iron concentration is not deemed to be deficient in either area. Soil zinc was not significantly different between areas. Maize concentrations of iron and zinc were not significantly different between areas, and were not deficient relative to improved cultivars. Blood iron deficiency and associated anaemia were problematic in both areas, but more so in Chikwawa than in Chiradzulu, and zinc deficiency was similar in both areas. The study has identified a significant difference in the blood iron status of the participants of the two communities, and has shown that this difference is not accounted for by the staple crop maize. Socio-geographical factors appear to play a significant role in the micronutrient health of the populations. The findings lend support to multifaceted community intervention studies which educate communities on strategies to tackle micronutrient deficiencies.

Postnatal growth velocity and overweight in early adolescents: a comparison of rural and urban African boys and girls

Objectives

To compare growth velocity of two African child cohorts and examine the relationship between postnatal growth velocity in infancy/early childhood and the risk of overweight/stunting in early adolescence.

Methods

The study used data from two child cohorts from urban (Birth to Twenty Cohort, South Africa) and rural (Lungwena Child Survival Study, Malawi) African settings. Mixed effect modelling was used to derive growth and peak growth velocities. T-tests were used to compare growth parameters and velocities between the two cohorts. Linear and logistic regression models were used to determine the relationship between growth velocity and early adolescent (ages 9–11 years) body mass index and odds of being overweight.

Results

Children in the BH cohort were significantly taller and heavier than those in the Lungwena cohort, and exhibited faster weight and height growth velocity especially in the first year of life (P < 0.05). No significant association was shown between baseline weight (α_w) and overweight in early adolescence (OR = 1.25, CI = 0.67, 2.34). The weight growth velocity parameter β_w was highly associated with odds of being overweight. Association between overweight in adolescence and weight velocity was stronger in infancy than in early childhood (OR at 3 months = 4.80, CI = 2.49, 9.26; OR at 5 years = 2.39, CI = 1.65, 3.47).

Conclusion

High weight and height growth velocity in infancy, independent of size at birth, is highly associated with overweight in early adolescence. However, the long term effects of rapid growth in infancy may be dependent on a particular population's socio-economic status and level of urbanization. Am. J. Hum. Biol. 26:643–651, 2014. © 2014 The Authors American Journal of Human Biology Published by Wiley Periodicals, Inc.

Feasibility and validity of the ActiGraph GT3X accelerometer in measuring physical activity of Malawian toddlers

AIM

To test the feasibility and validity of the ActiGraph GT3X accelerometer in measuring physical activity of rural Malawian toddlers.

METHODS

Fifty-six children aged 16.0-18.5 months wore the accelerometer on their right hip for 7 days. We analysed days with a minimum of 600 min of wear time, excluding night time and periods when the unit registered zero for 20 consecutive minutes. The first and last days were excluded as they were incomplete. Accelerometer counts were compared with coded free play video recordings to define median accelerometer counts for sedentary, light, moderate and vigorous activity. Count cut points were defined for moderate to vigorous physical activity, with predictive validity assessed using a second set of video recordings.

RESULTS

Median wear time was 797 min/day, with 79% of participants completing at least four eligible days. Accelerometer counts were significantly higher for observed moderate to vigorous physical activity, than lighter activity, with cut points of 208 counts/15 sec for vector magnitude and 35 counts/15 sec for vertical axis, showing sensitivity of 94.2% and 84.1% and specificity of 90.9% and 84.6%, respectively.

CONCLUSION

The accelerometer proved a feasible and valid method of assessing physical activity among Malawian toddlers.

"PHC leadership: are health centres in good hands? Perspectives from 3 districts in Malawi"

AIM

The study aimed to document the kinds of leadership styles are practiced at health centres (H/C) and how these styles can be explained by the contexts, characteristics of the health centre in charge (IC) and subordinate trained health staff (STHS).

METHODS

A well-researched leadership style model was applied, which included task, relation and change styles. This is a cross-sectional study using self-administered questionnaires in 47 H/C in 3 districts. 347 STHSs (95%) and 46 ICs (98%) responded. Questions explored background data and perceived leadership behaviour. Style items were factor analysed, and bivariate analyses and hierarchical regressions determined how styles could be explained.

RESULTS

Two leadership styles were revealed: "Trans" style contained all relation and the majority of task and change items; "Control" style focused on health statistics (Health Management Information System), reporting and evaluation. STHS and IC had a median age/median work experience of 34/5 years and 38,5/2 years, respectively. 48% of IC reported having no management training. CHAM H/Cs had the lowest score on "Control" style. Distance to referral hospital had no impact on style scores. No contexts or STHS characteristics predicted any leadership styles. For ICs, young age and increasing work experience were significant predictors for both styles, while Nurse ICs were negative predictors for "Control style". Management training was not a significant predictor for any style.

CONCLUSION

Frontline PHC leadership may be forced by situation and context to use a comprehensive style which could lack the diversity and flexibility needed for effective leadership. The missing associations between staff characteristics and leadership styles might indicate that this group is not sufficiently considered and included in leadership processes in the PHC organization. Leadership competency for the ICs seems not to be based on formal training, but substituted by young age and work experience. Health centre organization could also influence the options for leadership behaviour. In conclusion this calls for a reassessment of H/C leadership and formal leadership training.

Locally produced ready-to-use supplementary food is an effective treatment of moderate acute malnutrition in an operational setting

BACKGROUND

Typical treatment of moderate acute malnutrition, simple wasting, in sub-Saharan Africa consists of dietary counselling and/or general or targeted distribution of corn/soy-blended flour (CSB). A randomised clinical effectiveness trial in 2007 showed CSB to be less effective than ready-to-use supplementary food (RUSF).

AIM

To determine the operational effectiveness of treating moderate acute malnutrition with RUSF.

METHODS

Children aged 6-59 months were recruited in rural southern Malawi. Each child received 65 kcal/kg/d of locally produced soy/peanut RUSF, a product that provided about 1 RDA of each micronutrient. Anthropometric measurements were taken every 2 weeks and additional rations of RUSF were distributed at this time if the child remained wasted. Study participation lasted up to 8 weeks.

RESULTS

Of the 2417 children enrolled, 80% recovered, 4% defaulted, 0.4% died, 12% remained moderately wasted and 3% developed severe acute malnutrition. Weight, length and MUAC gain were 2.6 g/kg/d, 0.2 mm/d and 0.1 mm/d respectively. Cost per child treated was $5.39.

CONCLUSIONS

This intervention proved to be robust, maintaining high recovery rates and low default rates when instituted without the additional supervision and beneficiary incentives of a research setting.

Breastfeeding perceptions in communities in Mangochi district in Malawi

AIM

To investigate mothers' perceptions of breastfeeding and influences from their social network.

METHODS

A cross-sectional survey was carried out in Mangochi district, Malawi where questionnaire data from 157 rural and 192 semi-urban mother-infant pairs were obtained.

RESULTS

The proportion of mothers who thought that exclusive breastfeeding should last for 6 months and those who reported to have actually exclusively breastfed were 40.1% and 7.5% respectively. Of those who reported practising exclusive breastfeeding for 6 months, 77.5% stated that exclusive breastfeeding should last for 6 months. This opinion was independently associated with giving birth in a Baby-Friendly facility, OR = 5.22; 95% CI (1.92-14.16). Among the mothers who thought that exclusive breastfeeding should last for less than 6 months, 43.9% reported having been influenced in their opinion by health workers. Infant crying was the most common (62.4%) reason for stopping exclusive breastfeeding.

CONCLUSION

The findings illustrate the positive impact health workers can have, as well as the need to raise awareness of the benefits of exclusive breastfeeding among both health workers and mothers. Furthermore, continued counselling of mothers on how to deal with stressful infant behaviour such as crying may assist to prolong exclusive breastfeeding.

Food intake of selenium and sulphur amino acids in tuberculosis patients and healthy adults in Malawi

Wasting in tuberculosis (TB) patients is associated with the severity of lung disease and low serum level of selenium. Low serum levels of selenium may be due to low food intake or altered absorption/metabolism in the body. We therefore wanted to measure and compare the intake of selenium and sulphur amino acids in smear-positive TB patients and appropriately matched adults. We found a low intake of selenium but no significant difference in intake of selenium and sulphur amino acids between the groups in this study.

Can Western developmental screening tools be modified for use in a rural Malawian setting?

OBJECTIVE

To create a more culturally relevant developmental assessment tool for use in children in rural Africa.

DESIGN

Through focus groups, piloting work and validation, a more culturally appropriate developmental tool, based on the style of the Denver II, was created. Age standardised norms were estimated using 1130 normal children aged 0-6 years from a rural setting in Malawi. The performance of each item in the tool was examined through goodness of fit on logistic regression, reliability and interpretability at a consensus meeting. The instrument was revised with removal of items performing poorly.

RESULTS

An assessment tool with 138 items was created. Face, content and respondent validity was demonstrated. At the consensus meeting, 97% (33/34) of gross motor items were retained in comparison to 51% (18/35) of social items, and 86% (69/80) of items from the Denver II or Denver Developmental Screening Test (DDST) were retained in comparison to 69% (32/46) of the newly created items, many of these having poor reliability and goodness of fit. Gender had an effect on 23% (8/35) of the social items, which were removed. Items not attained by 6 years came entirely from the Denver II fine motor section (4/34). Overall, 110 of the 138 items (80%) were retained in the revised instrument with some items needing further modification.

CONCLUSIONS

When creating developmental tools for a rural African setting, many items from Western tools can be adapted. The gross motor domain is more culturally adaptable, whereas social development is difficult to adapt and is culturally specific.

Seasonality of gestational weight gain and foetal growth in rural Malawi

OBJECTIVE

To study seasonal variation of maternal anthropometry and newborn weights.

DESIGN

A retrospective descriptive study from 1995 to 1998.

SETTING

Lungwena, a rural health centre in Malawi, southeast Africa.

SUBJECTS

One thousand and thirty two women with singleton pregnancy, a minimum of eight weeks antenatal follow-up and a baby who was weighed in the first month of life. Maternal data were sought from a health centre antenatal register and linked with infant information collected from a newborn clinic.

RESULTS

The mean (SD) gestational weight and fundal height gains among the pregnant women were 240 (200) grams and 0.9 (0.2) cm/week and the mean (SD) newborn weight 3360 (530) grams. Gestational weight gains followed a seasonal pattern and they were typically highest among women delivering in the third quarter of the year (mean gain 250-300 g/week) and lowest among those delivering in January-May (mean gain 100-200 g/week) (p < 0.001 for seasonality, ANOVA). For maternal fundal height gains and newborn weights, seasonality was less obvious (but statistically significant, p < 0.05, ANOVA) and its pattern was influenced by year of study. On average, newborn weights peaked in the last quarter (mean 3350-3400 grams) and nadired during the second quarter (mean 3200-3300 grams). There was only a modest correlation between maternal weight gain in pregnancy and the weight of her newborn (Pearson's correlation coefficient 0.13).

CONCLUSION

In rural Malawi, maternal weight gains during pregnancy are more strongly associated with season than fundal height gains or newborn weights. In adverse environmental conditions, foetal growth ismaintained at least partially at the expense of mother's nutritional status.

Home based therapy for severe malnutrition with ready-to-use food

BACKGROUND

The standard treatment of severe malnutrition in Malawi often utilises prolonged inpatient care, and after discharge results in high rates of relapse.

AIMS

To test the hypothesis that the recovery rate, defined as catch-up growth such that weight-for-height z score >0 (WHZ, based on initial height) for ready-to-use food (RTUF) is greater than two other home based dietary regimens in the treatment of malnutrition.

METHODS

HIV negative children >1 year old discharged from the nutrition unit in Blantyre, Malawi were systematically allocated to one of three dietary regimens: RTUF, RTUF supplement, or blended maize/soy flour. RTUF and maize/soy flour provided 730 kJ/kg/day, while the RTUF supplement provided a fixed amount of energy, 2100 kJ/day. Children were followed fortnightly. Children completed the study when they reached WHZ >0, relapsed, or died. Outcomes were compared using a time-event model.

RESULTS

A total of 282 children were enrolled. Children receiving RTUF were more likely to reach WHZ >0 than those receiving RTUF supplement or maize/soy flour (95% v 78%, RR 1.2, 95% CI 1.1 to 1.3). The average weight gain was 5.2 g/kg/day in the RTUF group compared to 3.1 g/kg/day for the maize/soy and RTUF supplement groups. Six months later, 96% of all children that reached WHZ >0 were not wasted.

CONCLUSIONS

Home based therapy of malnutrition with RTUF was successful; further operational work is needed to implement this promising therapy.

Timing of growth faltering in rural Malawi

AIM

To determine the timing of growth faltering among under 3 year old children.

METHODS

Prospective population based cohort study in Lungwena, rural Malawi, southeast Africa. A total of 767 live born babies were regularly visited from birth until 3 years of age. Weight, height, and mid upper arm circumference were measured at monthly intervals until 18 months and at three month intervals thereafter. Growth charts were constructed using the LMS method and comparisons made to two international databases: the traditional United States National Center for Health Statistics/World Health Organisation (NCHS/WHO) reference and the recently developed 2000 Centers for Disease Control (CDC) growth reference.

RESULTS

Compared to the 2000 CDC reference population, newborns in Lungwena were on average 2.5 cm shorter and 510 g lighter. On a population level, height faltering was present at birth and continued throughout the first three years. Weight faltering, on the other hand, occurred mainly between 3 and 12 months of age. At 36 months, the mean weight and height of the study children were 2.3 kg and 10.5 cm lower than those of the reference population, respectively. The results remained essentially similar when the comparisons were made to the NCHS/WHO reference.

CONCLUSIONS

The fact that weight and height faltering do not follow identical time patterns suggests that they may have different origin and determinants. Further studies on the aetiology of height faltering and different approaches to preventive interventions are needed.

Determinants of linear growth and predictors of severe stunting during infancy in rural Malawi

Stunting is common among children under 5 y of age in sub-Saharan Africa. Several risk factors have been associated with poor growth but few studies have prospectively addressed the development of linear growth faltering and stunting during the first year of life. The present study was designed to analyse typical growth among rural Malawian infants, focusing particularly on the impact of birth size, adherence to feeding guidelines and morbidity in the development of severe stunting during infancy. A community-based cohort of 613 singleton newborns was prospectively followed by monthly home visits. Data were collected on the children's socioeconomic background, maternal size and weight gain during pregnancy, birth events, morbidity, breastfeeding and complementary feeding, growth and mortality. Univariate and multivariate analyses were used to determine associations between predictor variables and poor linear growth. The proportions of stunted infants (Height-for-age Z-score < -2) at 3, 6 and 9 mo of age were 27%, 51%, and 63%, respectively. At I y of age, over two-thirds (71%) of the infants were at least moderately (HAZ < -2) and 31% severely stunted (HAZ < -3).

CONCLUSION

The strongest predictor of severe stunting at 12 mo of age was small birth size. Other variables independently associated with this outcome included inappropriate complementary feeding, high morbidity, maternal short stature, male gender, and home delivery. Faltering of linear growth started soon after birth and continued throughout infancy. Interventions increasing birth size could have a significant role in the prevention of early childhood stunting. The ideal strategy should also emphasize the importance of appropriate infant feeding and decreasing the number of illness episodes amongst the infants.

Seasonality of growth and the relationship between weight and height gain in children under three years of age in rural Malawi

AIM

To describe the seasonal pattern of growth and analyse the relationship between weight and height gain in children under 3 y of age.

METHODS

A population-based cohort of 767 children was prospectively followed from birth until 36 mo of age in rural Malawi, southeast Africa. Weight and height measurements were collected at monthly intervals until 18 mo of age and quarterly thereafter. Gains in weight and height and prevalence of malnutrition in different seasons were calculated. The relationship between weight and height gain was analysed using a series of correlation analyses.

RESULTS

Both weight gain and linear growth velocity showed an age-dependent seasonal pattern. After infancy, periods of maximal or minimal height increments systematically occurred 3 mo after those for weight gain. The prevalence of malnutrition also followed a seasonal pattern, peaking a few months after periods of reduced growth. Despite the overall pattern, weight gain and subsequent linear growth were not correlated on an individual level. At any point, however, a child's weight for height was directly, albeit weakly, correlated to height gain in the subsequent 3-mo interval.

CONCLUSION

Growth of children under 3 y of age followed an age-dependent seasonal pattern. The poor correlation between children's weight and height increments suggests that seasonality affected weight gain and linear growth through different mechanisms.

Male biased mortality among 1-2 year old children in rural Malawi

We performed a community based cohort study in rural Malawi and documented a twofold mortality risk among 1-2 year old boys compared to girls of the same age. Because of its potential implications for child survival programmes, further studies should investigate whether sex differences in childhood mortality are more widespread in Sub-Saharan Africa.

Childhood immunization in rural Malawi: time of administration and predictors of non-compliance

A cohort of 760 newborns was followed prospectively for 2 years to ascertain the time of administration of childhood vaccinations in rural Malawi and to study predictors of non-compliance with national vaccination recommendations. At 1 year of age, 99% of the infants were fully vaccinated against tuberculosis, 91% against polio, 90% against diphtheria, pertussis and tetanus and 64% against measles. At 2 years, the corresponding vaccination coverages were 99%, 93%, 93% and 84%. On average, all vaccinations were given 1-3 months later than recommended. Many of the delayed measles vaccinations were given during a separate vertical campaign, during which 25% of previously unvaccinated 21-23-month-old children were identified and immunized. Non-compliance with vaccination recommendations was associated with living in villages with no access to mobile vaccination teams, birth between April and June and birth at home. In this rural Malawian area, most vaccination services were functioning well. To increase measles vaccination coverage, regular outreach activities should be encouraged.

Epidemiology and predictors of infant morbidity in rural Malawi

In rural Malawi, 703 newborns were visited monthly for 1 year to describe the epidemiology and health-seeking behaviour during acute episodes of diarrhoea, respiratory infections (ARI) and malaria. On average, the infants suffered from 1.3 annual episodes (11.0 illness days) of diarrhoea, 1.1 episodes (9.4 days) of ARI and 0.7 episodes (4.8 days) of malaria. Multivariate analysis with polychotomous logistic regression indicated that the amount of morbidity was associated with the child's area of residence, weight in early life, number of siblings, father's marital status and the source of drinking water. Diarrhoea and malaria were most common at 6-12 months of age and during the rainy months whereas respiratory infections peaked at 1-3 months of age and in the cold season. Ten per cent of diarrhoea, 9% of ARI and 7% of malaria episodes lasted for more than 14 days. Fifty-eight infants died, giving case fatality rates of 1% for diarrhoea, 2% for ARI and 4% for malaria. One-third (37%) of the illness episodes were managed at home without external advice. A traditional healer was consulted in 16% of episodes and a medical professional in 55% of episodes. If consulted, traditional healers were seen earlier than medical professionals (median duration after the onset of symptoms 0.7 vs. 1.8 days, P < 0.001). Traditional healers were significantly more commonly used by those families whose infants died than by those whose infants did not die (odds ratio 1.8, 95% CI 1.1, 3.0). Our results emphasise the influence of seasonality, care and living conditions on the morbidity of infants in rural Malawi. Case fatality for diarrhoea, ARI and malaria was high and associated with health-seeking behaviour among the guardians. Future interventions must aim at early and appropriate management of common childhood illnesses during infancy.