Factors associated with mortality in children under five years old hospitalized for Severe Acute Malnutrition in Limpopo province, South Africa, 2014-2018: A cross-sectional analytic study

Background

In South Africa, 30.9% of children under five years with Severe Acute Malnutrition (SAM) died in 2018. We aimed to identify factors associated with mortality among children under five years hospitalized with SAM in Limpopo province, South Africa.

Methods

We conducted a cross-sectional study including children under five years admitted with SAM from 2014 to 2018 in public hospitals of Limpopo province. We extracted socio-demographic and clinical data from hospital records. We used logistic regression to identify factors associated with mortality.

Findings

We included 956 children, 50.2% (480/956) male and 49.8% (476/956) female. The median age was 13 months (inter quartile range: 9–19 months). The overall SAM mortality over the study period was 25.9% (248/956). The most common complications were diarrhea, 63.8% (610/956), and lower respiratory tract infections (LRTIs), 42.4% (405/956). Factors associated with mortality included herbal medication use (adjusted Odds Ratio (aOR): 2.2, 95% Confidence Interval (CI): 1.4–3.5, p = 0.001), poor appetite (aOR: 2.7, 95% CI: 1.4–5.2, p = 0.003), Mid-upper circumference (MUAC) <11.5 cm (aOR: 3.0, 95% CI: 1.9–4.7, p<0.001), lower respiratory tract infections (LRTIs) (aOR: 1.6, 95% CI: 1.2–2.0, p<0.001), anemia (aOR: 2.5, 95% CI: 1.1–5.3, p = 0.021), hypoglycemia (aOR: 12.4, 95% CI: 7.1–21.8, p<0.001) and human immunodeficiency virus (HIV) infection (aOR: 2.3, 95% CI: 1.6–3.3, p<0.001).

Interpretation

Herbal medication use, poor appetite, LRTIs, anemia, hypoglycemia, and HIV infection were associated with mortality among children with SAM. These factors should guide management of children with SAM.

A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol

BACKGROUND

Acute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention.

METHODS

ABCD is a double-blind, randomised trial recruiting 11,500 children aged 2-23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment.

DISCUSSION

Expanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03130114. Registered on April 26 2017.

Follow-up between 6 and 24 months after discharge from treatment for severe acute malnutrition in children aged 6-59 months: A systematic review

BACKGROUND

Severe acute malnutrition (SAM) is a major global health problem affecting some 16.9 million children under five. Little is known about what happens to children 6-24 months post-discharge as this window often falls through the gap between studies on SFPs and those focusing on longer-term effects.

METHODS

A protocol was registered on PROSPERO (PROSPERO 2017:CRD42017065650). Embase, Global Health and MEDLINE In-Process and Non-Indexed Citations were systematically searched with terms related to SAM, nutritional intervention and follow-up between June and August 2017. Studies were selected if they included children who experienced an episode of SAM, received a therapeutic feeding intervention, were discharged as cured and presented any outcome from follow-up between 6-24 months later.

RESULTS

3,691 articles were retrieved from the search, 55 full-texts were screened and seven met the inclusion criteria. Loss-to-follow-up, mortality, relapse, morbidity and anthropometry were outcomes reported. Between 0.0% and 45.1% of cohorts were lost-to-follow-up. Of those discharged as nutritionally cured, mortality ranged from 0.06% to 10.4% at an average of 12 months post-discharge. Relapse was inconsistently defined, measured, and reported, ranging from 0% to 6.3%. Two studies reported improved weight-for-height z-scores, whilst three studies that reported height-for-age z-scores found either limited or no improvement.

CONCLUSIONS

Overall, there is a scarcity of studies that follow-up children 6-24 months post-discharge from SAM treatment. Limited data that exists suggest that children may exhibit sustained vulnerability even after achieving nutritional cure, including heightened mortality and morbidity risk and persistent stunting. Prospective cohort studies assessing a wider range of outcomes in children post-SAM treatment are a priority, as are intervention studies exploring how to improve post-SAM outcomes and identify high-risk children.

Survival and nutritional status of children with severe acute malnutrition, six months post-discharge from outpatient treatment in Jigawa state, Nigeria

Background

The Outpatient Therapeutic Program (OTP) for treatment brings the management of Severe Acute Malnutrition (SAM) closer to the community. Many lives have been saved through this approach, but little data exists on the outcome of the children after discharge from such programmes. This study was aimed to determine the survival and nutritional status of children at six months after discharge from OTP for SAM.

Methodology

This was a prospective study of children with SAM admitted into 10 OTPs in two local government areas of Jigawa state from June 2016 to July 2016.

Home visits at six months after discharge enabled the collection of data on survival and nutritional status.

The primary outcome measures were survival and nutritional status (Mid upper arm circumference and weight-for-height z-score).

Result

Of 494 children with SAM, 410 were discharged and 379 were followed up. Of these, 354, (93.4%) were found alive while 25 (6.6%) died. Among the survivors 333 (94.1%) had MUAC ≥12.5cm and 64 (18.1%) had WHZ<-3.

Mortality rates were higher 10 (8.4%) among the 6-11months old. Most deaths 16 (64%) occurred within the first 3months post-discharge. Those who died were significantly more stunted, p = 0.016 and had a smaller head circumference, p = 0.005 on entry to OTP programme.

There was improvement from admission to six months follow up in the number of children with complete immunization (27.4% to 35.6%), and a decrease in the number of unimmunized children (34.8% vs 20.6%) at follow-up.

Conclusion

The study demonstrates good post discharge survival rate and improved nutritional status for SAM patients managed in OTPs. There were, however considerable post discharge mortality, especially in the first three months and lower immunization uptake post discharge. A follow-up programme will improve these indices further.

Effects of food price inflation on infant and child mortality in developing countries

BACKGROUND

After a historic low level in the early 2000s, global food prices surged upwards to bring about the global food crisis of 2008. High and increasing food prices can generate an immediate threat to the security of a household's food supply, thereby undermining population health. This paper aims to assess the precise effects of food price inflation on child health in developing countries.

METHODS

This paper employs a panel dataset covering 95 developing countries for the period 2001-2011 to make a comprehensive assessment of the effects of food price inflation on child health as measured in terms of infant mortality rate and child mortality rate.

RESULTS

Focusing on any departure of health indicators from their respective trends, we find that rising food prices have a significant detrimental effect on nourishment and consequently lead to higher levels of both infant and child mortality in developing countries, and especially in least developed countries (LDCs).

DISCUSSION

High food price inflation rates are also found to cause an increase in undernourishment only in LDCs and thus leading to an increase in infant and child mortality in these poorest countries. This result is consistent with the observation that, in lower-income countries, food has a higher share in household expenditures and LDCs are likely to be net food importing countries.

CONCLUSIONS

Hence, there should be increased efforts by both LDC governments and the international community to alleviate the detrimental link between food price inflation and undernourishment and also the link between undernourishment and infant mortality.

Feasibility and effectiveness of the baby friendly community initiative in rural Kenya: study protocol for a randomized controlled trial

BACKGROUND

Interventions promoting optimal infant and young child nutrition could prevent a fifth of under-5 deaths in countries with high mortality. Poor infant and young child feeding practices are widely documented in Kenya, with potential detrimental effects on child growth, health and survival. Effective strategies to improve these practices are needed. This study aims to pilot implementation of the Baby Friendly Community Initiative (BFCI), a global initiative aimed at promoting optimal infant and young child feeding practices, to determine its feasibility and effectiveness with regards to infant feeding practices, nutrition and health outcomes in a rural setting in Kenya.

METHODS

The study, employing a cluster-randomized trial design, will be conducted in rural Kenya. A total of 12 clusters, constituting community units within the government's Community Health Strategy, will be randomized, with half allocated to the intervention and the other half to the control arm. A total of 812 pregnant women and their respective children will be recruited into the study. The mother-child pairs will be followed up until the child is 6 months old. Recruitment will last approximately 1 year from January 2015, and the study will run for 3 years, from 2014 to 2016. The intervention will involve regular counseling and support of mothers by trained community health workers and health professionals on maternal, infant and young child nutrition. Regular assessment of knowledge, attitudes and practices on maternal, infant and young child nutrition will be done, coupled with assessment of nutritional status of the mother-child pairs and morbidity for the children. Statistical methods will include analysis of covariance, multinomial logistic regression and multilevel modeling. The study is funded by the NIH and USAID through the Program for Enhanced Research (PEER) Health.

DISCUSSION

Findings from the study outlined in this protocol will inform potential feasibility and effectiveness of a community-based intervention aimed at promoting optimal breastfeeding and other infant feeding practices. The intervention, if proved feasible and effective, will inform policy and practice in Kenya and similar settings, particularly regarding implementation of the baby friendly community initiative.

TRIAL REGISTRATION

ISRCTN03467700 ; Date of Registration: 24 September 2014.

Feasibility and pilot study of the effects of microfinance on mortality and nutrition in children under five amongst the very poor in India: study protocol for a cluster randomized controlled trial

BACKGROUND

The United Nations Millennium Development Goals include targets for the health of children under five years old. Poor health is linked to poverty and microfinance initiatives are economic interventions that may improve health by breaking the cycle of poverty. However, there is a lack of reliable evidence to support this. In addition, microfinance schemes may have adverse effects on health, for example due to increased indebtedness. Rojiroti UK and the Centre for Promoting Sustainable Livelihood run an innovative microfinance scheme that provides microcredit via women's self-help groups (SHGs). This pilot study, conducted in rural Bihar (India), will establish whether it is feasible to collect anthropometric and mortality data on children under five years old and to conduct a limited cluster randomized trial of the Rojiroti intervention.

METHODS/DESIGN

We have designed a cluster randomized trial in which participating tolas (small communities within villages) will be randomized to either receive early (SHGs and microfinance at baseline) or late intervention (SHGs and microfinance after 18 months). Using predesigned questionnaires, demographic, and mortality data for the last year and information about participating mothers and their children will be collected and the weight, height, and mid upper arm circumference (MUAC) of children will be measured at baseline and at 18 months. The late intervention group will establish SHGs and microfinance support at this point and data collection will be repeated at 36 months.The primary outcome measure will be the mean weight for height z-score of children under five years old in the early and late intervention tolas at 18 months. Secondary outcome measures will be the mortality rate, mean weight for age, height for age, prevalence of underweight, stunting, and wasting among children under five years of age.

DISCUSSION

Despite economic progress, marked inequalities in child health persist in India and Bihar is one of the worst affected states. There is a need to evaluate programs that may alleviate poverty and improve health. This study will help to inform the design of a definitive trial to determine if the Rojiroti scheme can improve the nutrition and survival of children under five years of age in deprived rural communities.

TRIAL REGISTRATION

Clinicaltrials.gov (study ID: NCT01845545). Registered on 24 April 2013.

Treatment of severe acute malnutrition in infants aged <6 months in Niger

OBJECTIVE

To report a nutritional rehabilitation program in Niger for the management of severe acute malnutrition in infants aged <6 months.

STUDY DESIGN

This is a presentation of a case series (n = 632) of young infants who were admitted to a nutrition rehabilitation program in 2010-2011. The main characteristics of the inpatient treatment protocol where the use of diluted F-100 milk via a supplementary suckling technique until exclusive breastfeeding was reinitialized, coaching of mothers on infant feeding, and intensive antibiotic therapy as indicated during the stabilization phase. Semistructured interviews were conducted with 103 mothers.

RESULTS

Rates of recovery, mortality, and default were 85% (537 of 632), 6% (37 of 632), and 9% (55 of 632), respectively. The majority of infants had an infectious disease at study entry (81%), particularly acute watery diarrhea and respiratory tract infections. Infection on admission was a predictor of death during treatment (OR, 3.9; 95% CI, 1.6-9.2). Anorexia at entry was a risk factor for treatment failure (OR, 4.4; 95% CI, 1.71-11.1). Interviews revealed a very low rate of exclusive breastfeeding (3%), with delayed initiation in 68% of cases. Traditional beliefs, perceived insufficiency of breast milk, and psychological problems played important roles in feeding choices.

CONCLUSION

Severe acute malnutrition in infants aged <6 months can be successfully treated by managing cases as inpatients with an adapted protocol, intensive clinical supervision, and intensive drug treatment if indicated. Whether similar outcomes are achievable in community-based programs remains to be verified. Effective interventions for improving breastfeeding practices are needed.

Use of new World Health Organization child growth standards to assess how infant malnutrition relates to breastfeeding and mortality

OBJECTIVE

To compare the estimated prevalence of malnutrition using the World Health Organization's (WHO) child growth standards versus the National Center for Health Statistics' (NCHS) growth reference, to examine the relationship between exclusive breastfeeding and malnutrition, and to determine the sensitivity and specificity of nutritional status indicators for predicting death during infancy.

METHODS

A secondary analysis of data on 9424 mother-infant pairs in Ghana, India and Peru was conducted. Mothers and infants were enrolled in a trial of vitamin A supplementation during which the infants' weight, length and feeding practices were assessed regularly. Malnutrition indicators were determined using WHO and NCHS growth standards.

FINDINGS

The prevalence of stunting, wasting and underweight in infants aged < 6 months was higher with WHO than NCHS standards. However, the prevalence of underweight in infants aged 6-12 months was much lower with WHO standards. The duration of exclusive breastfeeding was not associated with malnutrition in the first 6 months of life. In infants aged < 6 months, severe underweight at the first immunization visit as determined using WHO standards had the highest sensitivity (70.2%) and specificity (85.8%) for predicting mortality in India. No indicator was a good predictor in Ghana or Peru. In infants aged 6-12 months, underweight at 6 months had the highest sensitivity and specificity for predicting mortality in Ghana (37.0% and 82.2%, respectively) and Peru (33.3% and 97.9% respectively), while wasting was the best predictor in India (sensitivity: 54.6%; specificity: 85.5%).

CONCLUSION

Malnutrition indicators determined using WHO standards were better predictors of mortality than those determined using NCHS standards. No association was found between breastfeeding duration and malnutrition at 6 months. Use of WHO child growth standards highlighted the importance of malnutrition in the first 6 months of life.

Fraction of all hospital admissions and deaths attributable to malnutrition among children in rural Kenya

BACKGROUND

Malnutrition is common in the developing world and associated with disease and mortality. Because malnutrition frequently occurs among children in the community as well as those with acute illness, and because anthropometric indicators of nutritional status are continuous variables that preclude a single definition of malnutrition, malnutrition-attributable fractions of admissions and deaths cannot be calculated by simply enumerating individual children.

OBJECTIVE

We determined the malnutrition-attributable fractions among children admitted to a rural district hospital in Kenya, among inpatient deaths and among children with the major causes of severe disease.

DESIGN

We analyzed data from children between 6 and 60 mo of age, comprising 13,307 admissions, 674 deaths, 3068 admissions with severe disease, and 562 community controls by logistic regression, using anthropometric z scores as the independent variable and admission or death as the outcome, to calculate the probability of admission as a result of "true malnutrition" for individual cases. Probabilities were averaged to calculate attributable fractions.

RESULTS

Z scores < -3 were insensitive for malnutrition-attributable deaths and admissions, and no single threshold was both specific and sensitive. The overall malnutrition-attributable fraction for in-hospital deaths was 51% (95% CI: 42%, 61%) with midupper arm circumference. Similar malnutrition-attributable fractions were seen for the major causes of severe disease (severe malaria, gastroenteritis, lower respiratory tract infection, HIV, and invasive bacterial disease).

CONCLUSIONS

Despite global improvements, malnutrition still underlies half of the inpatient morbidity and mortality rates among children in rural Kenya. This contribution is underestimated by using conventional clinical definitions of severe malnutrition.

Mainstreaming nutrition into maternal and child health programmes: scaling up of exclusive breastfeeding

Interventions to promote exclusive breastfeeding have been estimated to have the potential to prevent 13% of all under-5 deaths in developing countries and are the single most important preventive intervention against child mortality. According to World Health Organization and United Nations Children Funds (UNICEF), only 39% infants are exclusively breastfed for less than 4 months. This review examines programme efforts to scale up exclusive breastfeeding in different countries and draws lesson for successful scale-up. Opportunities and challenges in scaling up of exclusive breastfeeding into Maternal and Child Health programmes are identified. The key processes required for exclusive breastfeeding scale-up are: (1) an evidence-based policy and science-driven technical guidelines; and (2) an implementation strategy and plan for achieving high exclusive breastfeeding rates in all strata of society, on a sustainable basis. Factors related to success include political will, strong advocacy, enabling policies, well-defined short- and long-term programme strategy, sustained financial support, clear definition of roles of multiple stakeholders and emphasis on delivery at the community level. Effective use of antenatal, birth and post-natal contacts at homes and through community mobilization efforts is emphasized. Formative research to ensure appropriate intervention design and delivery is critical particularly in areas with high HIV prevalence. Strong communication strategy and support, quality trainers and training contributed significantly to programme success. Monitoring and evaluation with feedback systems that allow for periodic programme corrections and continued innovation are central to very high coverage. Legal framework must make it possible for mothers to exclusively breastfeed for at least 4 months. Sustained programme efforts are critical to achieve high coverage and this requires strong national- and state-level leadership.

[Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso]

BACKGROUND

Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach.

METHODS

Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used.

RESULTS

From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD.

CONCLUSION

The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.

Severity of meningococcal infections is related to anthropometrical parameters

BACKGROUND

Invasive meningococcal infections remain an important cause of death in children. In addition, malnutrition has been classically associated with increased severity of infectious diseases. However, in our experience lethal meningococcaemia in clinically malnourished children is extremely rare. Our purpose was to determine whether there is an association between nutritional status and outcome in children with invasive meningococcal infection.

METHODS

We carried out an observational study and prospectively determined anthropometrical parameters in 127 children aged 1 month to 4 years with invasive meningococcal infection seen in our inpatient facilities from August 1999 to May 2004. Severity and survival were the clinical end points analysed.

RESULTS

Children with severe disease had higher weight for age (1.02 vs -0.19) and height for age (1.12 vs -0.58) z scores than those with non-severe disease. Non-survivors had higher weight for age (0.90 vs -0.16) and height for age (0.73 vs -0.57) z scores than survivors. Clinical and biological variables usually accepted as predictors of high mortality or severity in patients with meningococcal infection were not significantly associated with weight for age and height for age z scores.

CONCLUSION

In the present prospective series of children with invasive meningococcal disease, severity and death were linked to anthropometrical parameters and seemed to be associated with a very good nutritional status, which confirmed our previous uncontrolled observations.

Constraints on good child-care practices and nutritional status in urban Dar-es-Salaam, Tanzania

BACKGROUND

Care is increasingly being recognized as a crucial input to child health and nutrition, along with food security, availability of health services, and a healthy environment. Although significant gains have been made in the fight against malnutrition in Tanzania, the nutritional status of preschool children in urban areas is not improving.

OBJECTIVE

To assess child-care practices and the nutritional status of infants and young children with the aim of improvingfeeding practices and child nutritional status.

METHODS

A cross-sectional study was undertaken in urban Dar-es-Salaam, Tanzania. The study involved 100 randomly selected mothers of children 6 to 24 months old from households in Ilala Municipality, one of the three municipalities that constitute the Dar-es-Salaam City Council. Data were collected by a structured questionnaire, spot-check observations, and anthropometric measurements.

RESULTS

The prevalence rates of stunting, underweight, wasting, and morbidity were 43%, 22%, 3%, and 80%, respectively. The prevalence of exclusive breastfeeding was very low (9%), and most stunted children (88%) were not exclusively breastfed for the first 6 months. The mean age at which complementary foods and fluids were introduced was 3.26 +/- 1.12 months (range, 1 to 5 months). The fluids given were mainly water and thin cereal-based porridge. More than half of the households practiced good hygiene. Most of the psychosocial practices (e.g., caregiver's attention, affection, and involvement in child feeding, hygiene, health care, and training) were performed by mothers, except for cooking and feeding the children and child training, which were done mostly by alternative caregivers. Nearly half of the mothers (44%) worked out of the home. The mean number of working hours per day was long (10.32 +/- 2.13), necessitating the use of alternative caregivers. A negative correlation was found between height-for-age z-scores and the number of hours mothers worked outside the home.

CONCLUSIONS

The prevalence rates of chronic malnutrition and morbidity are high, and child-feeding practices are inadequate in this urban population. Maternal employment and educational characteristics constrain good child-care practices, and alternative caregivers are taking a more important role in child care as mothers join the work force. We recommend that formative research be conducted to study the actual practices of caregivers in order to form the basis for a child-care education program. There is also a need to strengthen national health system support for improved child feeding.

Predictors of poor anthropometric status among children under 2 years of age in rural Uganda

OBJECTIVE

To assess predictors of poor anthropometric status among infants and young children.

DESIGN

Cross-sectional survey.

SETTING

The rural subsistence agricultural district of Hoima, western Uganda.

SUBJECTS

Seven hundred and twenty children aged 0-23 months with their mothers/carers.

METHODS

Participants were recruited in September 2002, using a two-stage cluster sampling methodology. A structured questionnaire was administered to mothers in their home settings. Information on health, household socio-economic status, child feeding practices and anthropometric measurement was gathered. Conditional logistic regression analysis was applied taking into account the hierarchical relationships between potential determinants of poor anthropometric status.

RESULTS

The mean Z-score for weight-for-height was -0.2 (95% confidence interval (CI) -0.1, -0.7), for height-for-age was -1.1 (95% CI -1.2, -0.9) and for weight-for-age was -0.7 (95% CI -0.8, -0.6). Wasting was independently associated only with a history of fever in the 2 weeks prior to the survey (odds ratio (OR)=4.4, 95% CI 1.5, 13), while underweight was associated with a history of fever (OR=2.4, 95% CI 1.3, 4.4) and cough (OR=3.0, 95% CI 1.3, 6.8). Stunting was positively associated with a wider range of factors, including: history of a fever episode (OR=1.7, 95% CI 1.0, 2.9), lack of a latrine in the household (OR=2.7, 95% CI 1.5, 4.9), failure to de-worm children 12 months or older (OR=1.7, 95% CI 1.1, 2.8), and being born to a non-formally educated mother compared with mothers educated above primary school (OR=2.1, 95% CI 1.1, 4.0).

CONCLUSIONS

In analyses guided by the hierarchical interrelationships of potential determinants of malnutrition, wasting and underweight turned out to be independently predicted by morbidity (proximal) factors. Stunting, however, was predicted by socio-economic (distal), environmental and health-care (intermediate) factors in addition to morbidity. Strategies aimed at improving the growth of infants and young children in rural communities should address morbidity due to common childhood illness coupled with environmental and socio-economically oriented measures.

Estado nutricional e fatores associados à estatura de crianças da Terra Indígena Guarita, Sul do Brasil

O estado nutricional de crianças menores de cinco anos e fatores associados à estatura foram estudados usando dados de um programa para controle da desnutrição e mortalidade na Terra Indígena Guarita, Rio Grande do Sul, Brasil, 2001/2002. Índices antropométricos foram calculados em escores-z da referência CDC/2000. Na primeira avaliação pelo programa, 34,7%, das crianças apresentavam baixa estatura, 12,9% baixo peso para idade, 4,2% baixo peso para estatura e 8,7% sobrepeso. Baixa estatura foi mais prevalente em meninos e maiores de um ano. Modelos de regressão linear múltipla sugerem que a altura foi, em média, menor quando a água para alimentação era de fonte/poço/rio (p = 0,046), não havia geladeira para conservar alimentos (p = 0,021), a mãe era menor de 16 anos ao nascimento do mais velho entre os filhos menores de cinco anos (p = 0,019) e analfabeta (p = 0,083). O destino dos dejetos evidenciou efeito apenas no modelo bruto. Não houve evidência de efeito do número de filhos menores de cinco anos. Políticas de inclusão social e provisão de recursos sociais e de saúde são potencialmente relevantes para a saúde e nutrição nessa população.

Managing child malnutrition in a drought affected district of Rajasthan--a case study

Rajasthan is the largest state in the country frequently affected by droughts. The year 2002 happened to be the fifth consecutive year of drought. Almost all districts of the State were hit by it. The district of Baran located in South-East of Rajasthan has 'Sahariya' tribal population concentrated in its Kishanganj and Shahabad blocks. Press reports of starvation deaths amongst tribal children in these blocks created a stir in the local district and the State Government set ups. The paper describes an objective and professional approach to deal with the situation. Rapid nutritional assessment indicated very high prevalence of severe under weight (28.3%) and wasting (4.7%) amongst under five children. Nutrition Care Centres (NCC) were set up in selected villages to provide targeted feeding and care to these children as per WHO guidelines. Local 'Sahariya' community was involved to run these NCC. Intensive public education campaign was carried out to promote improved child caring practices and referral of malnourished children with complication to hospitals. Orientation of press and electronic media on factual details regarding the situation helped create an enabling environment to implement remedial measures. The impact of 'Nutrition Care Centres' assessed after six months was found to be positive in terms of reduction in prevalence of under nutrition in children from 66.7% to 59.6%. Successful management of severe malnutrition amongst children by workers at Nutrition Care Centes and in family settings using standard protocols led to the wide scale replication of the approach by Anganwadi centres in different district of Rajasthan. The State Government also created an additional cadre of worker called 'Sahayogini' to support Anganwadi worker and promote better child caring practices at family level.

Action for tackling malnutrition: growth monitoring or surveillance?

Malnutrition is an important Public Health problem globally as well as in India. Mortality is a multi-causal phenomenon in which malnutrition is but one factor directly or indirectly contributing 55% mortality of children under-five years of age. Authors observed higher prevalence of severe degree of Malnutrition in the underserved section of population with specific reference to girl child, under 3 years of age, where there were large number of children in the family, repeated infections and Measles. Growth monitoring Services in the ICDS scheme meant only weight recording and was not at all satisfactory. Even the majority of the Anganwadi workers (AWW) stated that it meant monthly weight recording of children while only few knew it is in addition plotting these on growth charts and advising mothers if growth was not proper. Around 60% of caregivers did not know about growth monitoring. The concept of growth monitoring should be changed to Growth surveillance to emphasize more on the action components of it.

Assessment of severe malnutrition among hospitalized children in rural Kenya: comparison of weight for height and mid upper arm circumference

CONTEXT

Severe malnutrition has a high mortality rate among hospitalized children in sub-Saharan Africa. However, reports suggest that malnutrition is often poorly assessed. The World Health Organization recommends using weight for height, but this method is problematic and often not undertaken in practice. Mid upper arm circumference (MUAC) and the clinical sign "visible severe wasting" are simple and inexpensive methods but have not been evaluated in this setting.

OBJECTIVES

To evaluate MUAC and visible severe wasting as predictors of inpatient mortality at a district hospital in sub-Saharan Africa and to compare these with weight-for-height z score (WHZ).

DESIGN, SETTING, AND PARTICIPANTS

Cohort study with data collected at admission and at discharge or death. Predictive values for inpatient death were determined using the area under receiver operating characteristic curves. Participants were children aged 12 to 59 months admitted to a district hospital in rural Kenya between April 1, 1999, and July 31, 2002.

MAIN OUTCOME MEASURE

MUAC, WHZ, and visible severe wasting as predictors of inpatient death.

RESULTS

Overall, 4.4% (359) of children included in the study died while in the hospital. Sixteen percent (1282/8190) of admitted children had severe wasting (WHZ < or =-3) (n = 756), kwashiorkor (n = 778), or both. The areas under the receiver operating characteristic curves for predicting inpatient death did not significantly differ (MUAC: 0.75 [95% confidence interval, 0.72-0.78]; WHZ: 0.74 [95% confidence interval, 0.71-0.77]) (P = .39). Although sensitivity and specificity for subsequent inpatient death were 46% and 91%, respectively, for MUAC less than or equal to 11.5 cm, 42% and 92% for WHZ less than or equal to -3, and 47% and 93% for visible severe wasting, the 3 indices identified different sets of children and were independently associated with mortality. Clinical features of malnutrition were significantly more common among children with MUAC less than or equal to 11.5 cm than among those with WHZ less than or equal to -3.

CONCLUSIONS

MUAC is a practical screening tool that performs at least as well as WHZ in predicting subsequent inpatient mortality among severely malnourished children hospitalized in rural Kenya. Visible severe wasting is also a potentially useful sign at this level, providing appropriate training has been given.

Effect of postpartum maternal or neonatal vitamin A supplementation on infant mortality among infants born to HIV-negative mothers in Zimbabwe

BACKGROUND

Young infants are at risk of vitamin A deficiency. Supplementation of breastfeeding mothers improves the vitamin A status of their infants, but there are no data regarding its effect on infant mortality, and data on the effect of directly supplementing infants during the first few weeks of life are conflicting.

OBJECTIVE

The objective was to measure the effect on infant mortality of supplementing neonates and their HIV-negative mothers with single, large doses of vitamin A during the immediate postpartum period.

DESIGN

A randomized, placebo-controlled, 2-by-2 factorial design trial was conducted in 14,110 mothers and their infants; 9208 of the mothers were HIV-negative at delivery, remained such during the postpartum year, and were retained in the current analysis. The infants were randomly assigned within 96 h of delivery to 1 of 4 treatment groups: mothers and infants received vitamin A (Aa), mothers received vitamin A and infants received placebo (Ap), mothers received placebo and infants received vitamin A (Pa), and both mothers and infants received placebo (Pp). The vitamin A dose in the mothers was 400,000 IU and in the infants was 50,000 IU. The mother-infant pairs were followed to 12 mo.

RESULTS

Hazard ratios (95% CI) for 12 mo mortality among infants in the maternal-supplemented and infant-supplemented groups were 1.17 (0.87, 1.58) and 1.08 (0.80, 1.46), respectively. Hazard ratios (95% CI) for the Aa, Ap, and Pa groups compared with the Pp group were 1.28 (0.83, 1.98), 1.27 (0.82, 1.97), and 1.18 (0.76, 1.83), respectively. These data indicate no overall effect. Serum retinol concentrations among a subsample of women were similar to reference norms.

CONCLUSION

Postpartum maternal or neonatal vitamin A supplementation may not reduce infant mortality in infants of HIV-negative women with an apparently adequate vitamin A status.

Food insecurity, malnutrition and mortality in Maewo and Ambae islands, Vanuatu

This study reports on findings from the ex post evaluation of the Maewo Capacity Building project in Vanuatu which was funded by World Vision Australia. The objective of the evaluation was to examine the extent to which the infrastructure and systems left behind by the project contributed to the improvement of household food security, and health and nutritional outcomes in Maewo island, using Ambae island as a comparator The household food security of 817 households selected by a two stage cluster sampling method was assessed using a modified version of the Radimer-Comell hunger scale and the US National Measure of food security. Anthropometric measurement in children (6-59 months) and mortality data were also obtained. The prevalence of food insecurity without hunger was estimated at 15.3% (95%CI: 12.1% to 19.2%) in Maewo versus 38.2% (95%CI: 33.6% to 43.0%) in Ambae while food insecurity with hunger in children did not vary by location. After controlling for age, gender and household food security status, children aged 6-59 months in Maewo were less likely to be underweight than children of the same age in Ambae (OR: 0.66, 95%CI 0.38 to 0.99). No difference was detected between the two locations in terms of stunting and wasting prevalence. The crude mortality rate (CMR) was lower in Maewo (CTvIIR=0.47/10,000/day, 95%CI: 0.39 to 0.55) than Ambae (CMR= 0.59/10,000/day, 95%CI: 0.51 to 0.67) but no difference existed in mortality in children under five years old. The major causes of death were similar in both locations and the causes frequently reported were malaria, acute respiratory infection and dianheal diseases. The evaluation found that Maewo had better health and nutrition outcomes but the infrastructure left behind by the project and the livelihood system may have been weakened by cyclone Ivy that devastated the region from 25 to 27 February 2004.

Breastfeeding behavior and infant survival with emphasis on reverse causation bias: some evidence from Nigeria

The possibility of selection bias in the estimation of the effects of breastfeeding on subsequent survival is implied by the clinical evidence that children who are healthier at birth are more likely to be breastfed than their less healthy counterparts who may be prone to difficulties in sustaining breastfeeding. This paper addresses an important problem in understanding the association of breastfeeding and child survival with regard to reverse causation. It utilizes data on the reported reason for weaning to assess the degree to which reverse causality may be responsible for observed associations. The analysis indicates that children who are weaned in the neonatal period because of illness or weakness to suckle, experience a much higher risk of dying than others. This is not mainly because of the cessation of breastfeeding, but because of the original factor, being their illness. Any biases imparted by an initial selection mechanism appear, therefore, to have influence on the effectiveness of breastfeeding behavior.

Food supplementation with encouragement to feed it to infants from 4 to 12 months of age has a small impact on weight gain

It is unclear whether a substantial decline in malnutrition among infants in developing countries can be achieved by increasing food availability and nutrition counseling without concurrent morbidity-reducing interventions. The study was designed to determine whether provision of generous amounts of a micronutrient-fortified food supplement supported by counseling or nutritional counseling alone would significantly improve physical growth between 4 and 12 mo of age. In a controlled trial, 418 infants 4 mo of age were individually randomized to one of the four groups and followed until 12 mo of age. The first group received a milk-based cereal and nutritional counseling; the second group monthly nutritional counseling alone. To control for the effect of twice-weekly home visits for morbidity ascertainment, similar visits were made in one of the control groups (visitation group); the fourth group received no intervention. The median energy intake from nonbreast milk sources was higher in the food supplementation group than in the visitation group by 1212 kJ at 26 wk (P < 0.001), 1739 kJ at 38 wk (P < 0.001) and 2257 kJ at 52 wk (P < 0.001). The food supplementation infants gained 250 g (95% confidence interval: 20--480 g) more weight than did the visitation group. The difference in the mean increment in length during the study was 0.4 cm (95% confidence interval: -0.1--0.9 cm). The nutritional counseling group had higher energy intakes ranging from 280 to 752 kJ at different ages (P < 0.05 at all ages) but no significant benefit on weight and length increments. Methods to enhance the impact of these interventions need to be identified.

Intestinal and systemic infection, HIV, and mortality in Zambian children with persistent diarrhea and malnutrition

BACKGROUND

Persistent diarrhea-malnutrition syndrome is a complex of infection and immune failure that involves protein, calorie and micronutrient depletion, and metabolic disturbances. We report an analysis of the impact of HIV infection on infectious disease, clinical presentation, and mortality in Zambian children with persistent diarrhea and malnutrition.

METHODS

Two hundred children (94 boys and 106 girls, 6-24 months old) were examined on admission to the malnutrition ward of University Teaching Hospital in Lusaka, Zambia. There was then 1 month of follow-up.

RESULTS

Antibodies to HIV were found in 108 of the children (54%). The common intestinal infections (Cryptosporidium parvum [26%] and nontyphoid Salmonella spp [18%]), septicemia (17%), and pulmonary tuberculosis confirmed by gastric lavage (13.5%) were not significantly more common in HIV-seropositive than in HIV-seronegative children. HIV-seropositive children were more likely to have marasmus whereas HIV-seronegative children were more likely to have kwashiorkor. Weight-for-age z scores at nadir (postedema) were lower in HIV-seropositive children (median, -4.4; interquartile range [IQR], -5.0 to -3.8) than in HIV-seronegative children (median, -3.7; IQR, -4.2 to -3.1; P < 0.0001). Height-for-age and weight-for-height z scores and mid-upper arm circumference showed a similar difference. Of the 200 children, 39 (19.5%) died within 28 days; cryptosporidiosis and marasmus were the only independent predictors of death.

CONCLUSIONS

Although intestinal and systemic infections did not differ for HIV-seropositive and HIV-seronegative children, HIV influenced nutritional states of all children. Cryptosporidiosis and marasmus were associated with higher mortality.

Malnutrition: trials and triumphs

Severe malnutrition is uncommon but often fatal, particularly in very young infants or when oedema is present. Another major contributor to mortality is undiagnosed infection. Three pilot studies have recently been performed in severely malnourished patients in therapeutic feeding centres in sub-Saharan Africa. In each, a practical management problem was addressed and a potential solution tested. Three conclusions were reached: young breastfeeding infants were best managed using a supplemented suckling technique; routine antibiotics from admission reduced mortality; and in adults with oedematous malnutrition, therapeutic diets with a lower-than-usual protein:energy ratio were effective in reducing mortality and permitting catch-up weight gain.

[The effect of nutritional management on the mortality of malnourished children, uninfected and infected with the human immunodeficiency virus]

Weight loss is a major complication in children infected with HIV. Very few studies have focused on the nutritional management of malnourished HIV-positive children, particularly in developing countries, although there have been some studies in adults. Therefore, the aim of this retrospective study was to evaluate, as a function of HIV status, the effect of a nutritional rehabilitation program on the mortality of malnourished children in an Ivory Coast nursery. We studied 193 malnourished children over the age of 15 months from January 1 1994 to December 31 1996; 41 % of these children (80 of 193) were HIV-positive. The nutritional rehabilitation program was introduced in 1995. It had a beneficial effect in HIV-negative children because the setback rate (the number of deaths and transfers x 1,000/the number of child-months at risk) decreased significantly over the three years of the study (1994: 130; 1995: 113; 1996: 26; p < 0.05). The rate in HIV-positive children did fall slightly, but this decrease was not statistically significant. These results demonstrate the difficulties involved in the nutritional management of malnourished HIV-positive children. However, recent studies have suggested that nutritional rehabilitation (by mouth) combined with total vitamin and mineral supplementation may be more effective. Given the frequency of malnutrition in HIV-positive children, clinical studies aimed at improving the nutritional management of these children should be a priority in developing countries.

Long-term prospects of malnourished children after rehabilitation at the Nutrition Rehabilitation Centre of St Mary's Hospital, Mumias, Kenya

The growth and survival of children was studied after rehabilitation for malnutrition at the Nutrition Rehabilitation Centre (NRC) of St Mary's Hospital on average 1.5 year after discharge. The findings are intended partly to provide descriptive information on later progress in the community of these children and also to identify specific risk factors. Of 50 children eligible for follow-up, 39 (78 per cent) could be traced. Overall mortality was 36 per cent, 28 per cent were found to be underweight, and 36 per cent were in good condition with satisfactory catch up in weight. Mortality was determined by age, duration of stay in hospital and centre, and nutritional status. Most literature on the subject implies that the long-term effectiveness of the NRC is affected by limiting factors at home and in the centre itself. Our data suggest that the poor results are mainly due to improper use of the NRC. The NRC was called in too early by the hospital and children were discharged too soon from the NRC. As evidenced by the frequent presence of infectious symptoms, the severity of nutritional status, inadequate weight gain, and short duration of stay in the hospital and the NRC.

[Dehydration: an important factor of mortality in human immunodeficiency virus (HIV) seropositive malnourished children]

A combination of diarrhoea and malnutrition frequently occurs in HIV seropositive children and constitutes a bad prognosis factor. The impact of dehydration induced by diarrhoea in these children has not as yet been assessed and constitutes the aim of this study. This retrospective analysis was conducted on 121 malnourished children monitored in 1994 at an infant home in Cöte d'lvoire. 46.2% of the children were HIV seropositive and their mortality rate was significantly higher than that observed among seronegative children (42.8% vs. 15.3%; p < 0.01). Among the various pathologies observed in these children, diarrhoea and oral candidosis were discriminating factors in seropositive children. Besides, the findings confirmed the effect of dehydration on the mortality of malnourished children as a whole. Studies allowing a better understanding of factors involved in diarrhoea or dehydration among HIV seropositive malnourished children appears to be essential to improve the management of these children.

Nutritional status as a predictor of child survival: summarizing the association and quantifying its global impact

By pooling the results from five previously published prospective studies, we have obtained estimates of the relative risks of mortality among young children 6-24 months after they had been identified as having mild-to-moderate or severe malnutrition. These risk estimates, along with global malnutrition prevalence data, were then used to calculate the total number of young-childhood deaths "attributable" to malnutrition in developing countries. Young children (6-60 months of age) with mild-to-moderate malnutrition (60-80% of the median weight-for-age of the reference population) had 2.2 times the risk of dying during the follow-up period than their better nourished counterparts (> 80% of the median reference weight-for-age). Severely malnourished young children (< 60% of the reference median weight-for-age) had 6.8 times the risk of dying during the follow-up period than better nourished children. Each year approximately 2.3 million deaths of young children in developing countries (41% of the total for this age group) are associated with malnutrition. The comparability of studies, methods used to derive pooled values, potentially confounding factors that may influence risk estimates, and the validity of the results are discussed. Child survival programmes should assign greater priority to the control of childhood malnutrition.

Influence of nutritional status on child mortality in rural Zaire

Although the association between nutritional status and mortality risk is obvious for extreme malnutrition, the issue is not so clear for mild to moderate undernutrition. We have investigated this association in children of 0-5 years in the rural area of Bwamanda, Zaire, where an integrated development project, with good medical facilities, has operated for 20 years. A random cluster sample of 5167 children was taken; newborn infants and immigrants were included at six quarterly survey rounds from October, 1989, until February, 1991. All surveys included clinical and anthropometric assessment of nutritional status. Deaths were recorded up to April, 1992; there were 246 deaths. Marasmus, kwashiorkor, and other causes of death were defined by the verbal autopsy method and checked against medical records kept at the central hospital and the peripheral dispensaries. As expected, we found an increased risk of death in severe malnutrition. When deaths directly attributed to marasmus or kwashiorkor were excluded, mild to moderate stunting or wasting were not associated with higher mortality in the short term (within 3 months of the previous study round) or in the long term (from 3-30 months after study entry). The commonest causes of death were malaria and anaemia. Extreme marasmus and kwashiorkor caused 16% of deaths, and are important causes of death even in this favoured area with an integrated development project. Nutritional interventions should be targeted more selectively so that children with moderate malnutrition can be protected from progression to marasmus or kwashiorkor.

Effectiveness of measles immunization on diarrhea and malnutrition related mortality in 1-4 year olds

All the children between 1-4 year old were followed from January 1985 to December 1987 and all eligible children 9-24 months were given measles vaccine using annual pulse method in November-December 1985 and 86 in the study area. The children in C.R.H.S. Project area were used as controls for comparison. At the end of 2 years and 2 rounds of immunization with measles, significant reductions were observed in 1-4 year old mortality due to diarrhea and malnutrition in the study area in contrast to control area. Using epidemiological data and method of pulse immunization with measles vaccine can bring considerable benefit to this age group.

Transmission of HIV-1 infections from mothers to infants in Haiti. Impact on childhood mortality and malnutrition. The CDS/JHU AIDS Project Team

Of 4588 pregnant women in a high-risk Haitian population, 443 (9.7%) were serologically positive for the human immunodeficiency virus type 1 (HIV-1). Infants born to women who were HIV-1 seropositive were more likely to be premature, of low birth weight, and malnourished at 3 and 6 months of age than were infants born to women who were HIV-1 seronegative. Increased mortality was observed in infants born to women who were HIV-1 seropositive by 3 months of age. At 12 months of age, 23.4% of the infants born to women who were HIV-1 seropositive had died compared with 10.8% of the infants born to women who were HIV-1 seronegative; at 24 months of age, the mortality rates were 31.3% and 14.2%, respectively. Maternal HIV-1 infections resulted in an 11.7% increase in the overall infant mortality rate in this population. The estimated mother-to-infant HIV-1 transmission rate in these breast-fed infants was 25%, similar to the rates reported for non-breast-fed populations in the United States and Europe.

Nosocomial and community-acquired infections in malnourished children

A total of 206 community-acquired and 73 nosocomial infections in 50 malnourished Jamaican children were studied prospectively. Predominant community-acquired infections in the 50 children, included gastroenteritis (68%), otitis media (60%), rhinopharyngitis (60%), oral candidiasis (46%), skin infections (40%), pneumonia (28%), bacteraemia (24%) and bacteriuria (18%). The most frequent nosocomial infections were rhinopharyngitis (34%), lower respiratory tract infections (24%) and septicaemia (18%). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen, Staphylococcus epidermidis, the most frequent blood culture isolate and Klebsiella sp. were recovered from the majority of urines. The lack of clinical signs and symptoms and atypical clinical presentation in some infected malnourished children were attributed to impairment of the acute inflammatory response. Diagnosis of infection in these children required a high index of suspicion and a comprehensive screening system. Nasal, throat and axilla swabs taken on admission revealed significant colonization with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Four of the 50 children died and two of these deaths were attributed to infection.

Arm circumference and other factors in children at high risk of death in rural Bangladesh

Mid upper arm circumference (MUAC) was measured monthly for 6 months in about 500 children aged 6-36 months from rural Bangladesh. Children who would die within 1 month of screening could be identified with 94% specificity and 56% sensitivity--almost twice the sensitivity achieved by other anthropometric screening schemes for this level of specificity. Specificity was slightly improved when the absence of breast-feeding, concurrent diarrhoea, oedema, and acute respiratory infection were taken into account. Children at high risk of death can be detected by monthly measurement of MUAC, which may be used in poor communities where interventions have to be selective.

Perinatal mortality in rural India: intervention through primary health care. II Neonatal mortality

Early neonatal mortality is unacceptably high in most developing countries. A large majority of births in rural areas of these countries occur at home, attended by relatives or traditional birth attendants and without easy access to skilled professional care. Under these circumstances cause of death has to be based on lay descriptions of terminal events. Analysis of cause of death shows that 74% of the early neonatal deaths are amenable to intervention. Admittance to hospital of the "at risk" neonates is not practicable. Intervention through primary health care can be effective if based on scientific principles and offered through female community health workers. Objectives of domiciliary care given by these workers should be to educate and guide the mother to protect the delicate newborn from the effects of adverse environmental conditions, to ensure adequate nutrition, and to prevent infections. Interventions supporting beneficial traditional cultural practices as well as simple techniques for care of the newborn are discussed.