Maternal education and its influence on child growth and nutritional status during the first two years of life: a systematic review and meta-analysis

Background

The first 1000 days of life are critical for a child's health and development. Impaired growth during this period is linked to increased child morbidity, mortality, and long-term consequences. Undernutrition is the main cause, and addressing it within the first 1000 days of life is vital. Maternal education is consistently identified as a significant predictor of child undernutrition, but its specific impact remains to be determined. This study presents a systematic review and meta-analysis investigating the influence of high versus low maternal education levels on child growth from birth to age two, using population-based cohort studies.

Methods

Databases including PubMed, Scopus, EMBASE, Web of Science, ERIC, and Google Scholar were searched from January 1990 to January 2024 using appropriate search terms. We included population-based cohort studies of healthy children aged two years and under and their mothers, categorizing maternal education levels. Child growth and nutritional outcomes were assessed using various indicators. Two reviewers independently conducted data extraction and assessed study quality. The Newcastle Ottawa scale was utilized for quality assessment. Random-effects models were used for meta-analysis, and heterogeneity was assessed using the Cochrane Q and I2 statistic. Subgroup and sensitivity analyses were performed, and publication bias was evaluated.

Findings

The literature search retrieved 14,295 titles, and after full-text screening of 639 reports, 35 studies were included, covering eight outcomes: weight for age z-score (WAZ), height for age z-score (HAZ), BMI for age z-scores (BMIZ), overweight, underweight, stunting, wasting, and rapid weight gain. In middle-income countries, higher maternal education is significantly associated with elevated WAZ (MD 0.398, 95% CI 0.301-0.496) and HAZ (MD 0.388, 95% CI 0.102-0.673) in children. Similarly, in studies with low-educated population, higher maternal education is significantly linked to increased WAZ (MD 0.186, 95% CI 0.078-0.294) and HAZ (0.200, 95% CI 0.036-0.365). However, in high-income and highly educated population, this association is either absent or reversed. In high-income countries, higher maternal education is associated with a non-significant lower BMI-Z (MD -0.028, 95% CI -0.061 to 0.006). Notably, this inverse association is statistically significant in low-educated populations (MD -0.045, 95% CI -0.079 to -0.011) but not in highly educated populations (MD 0.003, 95% CI -0.093 to 0.098).

Interpretation

Maternal education's association with child growth varies based on country income and education levels. Further research is needed to understand this relationship better.

Funding

This study was a student thesis supported financially by Tehran University of Medical Sciences (TUMS).

Tehran environmental and neurodevelopmental disorders (TEND) cohort study: Phase I, feasibility assessment

PURPOSE

To advance knowledge about childhood neurodevelopmental disorders and study their environmental determinants, we conducted a study in Tehran, Iran to assess the feasibility of prospective birth cohort study.

METHODS

We evaluated participation of pregnant women, feasibility of sampling biological material, and health care services availability in Tehran in four steps: (1) first trimester of pregnancy; (2) third trimester of pregnancy; (3) at delivery; and (4) two to three months after delivery. We collected related data through questionnaires, also various biological samples were obtained from mothers (blood, urine, milk and nails-hands and feet) and newborns (umbilical cord blood, meconium, and urine samples) from February 2016 to October 2017.

RESULTS

overall 838 eligible pregnant women were approached. The participation rate was 206(25%) in our study and about 185(90%) of subjects were recruited in hospitals. Out of 206 participants in the first trimester, blood, urine, hand nail, and foot nail samples were collected from 206(100%),193(93%), 205(99%), and 205(99%), respectively. These values dropped to 65(54%), 83(69%), 84(70%), and 84(70%) for the remaining participants 120(58%) in the third trimester, respectively. Also, we gathered milk samples from 125(60%) of mothers at two to three months after delivery.

CONCLUSION

Our findings suggest that hospitals were better places for recruitment of subjects in a birth cohort in Tehran. We further concluded that birth cohort study recruitment can be improved by choosing appropriate gestational ages. Obtaining the newborn's urine, meconium, and umbilical cord blood were challenging procedures and require good collaboration between hospital staff and researchers.

Review of the Iranian Newborns' Health, Survival, and Care and Future Challenges

INTRODUCTION

Providing, maintaining, and improving the health of newborns is one of the most important goals of the health care system in the Islamic Republic of Iran. On the eve of the 40th anniversary of the Islamic Revolution of Iran, we will review factors affecting the health of Iranian neonates over the past 40 years.

METHODS

We investigated the evolution of neonatal health and contributing factors in all reports, documents, and articles published by the Iranian Ministry of Health and Medical Education and the former Iranian Ministry of Health as well as WHO, and UNICEF databases from 1970 to 2018. The main topics of the present study include recent developments in reduction of maternal and neonatal mortality, major measures taken to decrease risk of neonatal death, and future challenges.

RESULTS

We have reviewed more than 3500 pages of documents and articles published by authoritative sources before and after the Islamic Revolution. A neonatal mortality rate (NMR) of 9.6 per 1000 in 2017 was recordred in Iran, demonstrating a reduction of over three-quarters compared with the pre-Revolution period. Improved prenatal care and nutrition, tetanus vaccination of pregnant mothers, performance of 96.4% of deliveries by trained individuals, circulation of clinical protocols for the integration of midwifery and maternity services, provision of neonatal resuscitation equipment in delivery rooms, promotion of breastfeeding from the first hour after birth onward, establishing and equipping NICUs, increased training of specialists and sub-specialists, prevention and treatment of infections, increasing awareness in families and family-centered neonatal care focused on neonatal brain development, the Newborn Indivisualized Developmental Care and Assessment Program (NIDCAP) and Kangaroo-Mother Care (KMC) are examples of progress made in neonate healthcare after the Islamic Revolution.

CONCLUSION

Despite 8 years of war and a variety of sanctions being imposed against I.R. of Iran, very substantial improvements have been achieved in neonatal health and relevant underlying factors. However, we are still faced with challenges that require the engagement of experts and researchers in neonatal medicine.

The Iranian Neonatal Registry: Primary Results

BACKGROUND

Neonatal registry network systems are conducted worldwide in order to improve the quality of neonatal care and also to integrate research into daily practice.

METHODS

We designed a neonatal registry system and conducted a pilot study in Vali-Asr Hospital to explore its effectiveness to develop an overview of our neonatal status. This study is a report of three years of data registry (2013-2016) in above mentioned system.

RESULTS

Data were collected from 3360 neonates admitted to level 2 of neonatal ward, and NICU (level 3) of the Vali-Asr Hospital. Among them, 184 (5.5%) neonates didn't survive. The mean ± SD of gestational age (GA) was 35.92 ± 3.352 weeks and the mean ± SD of the birth weight was 2609.23 ± 829.751 g.

CONCLUSION

This pilot study indicated that the neonatal registry system can help us to have a better overview of the performance of neonatal wards, and also to find new aspects of neonatal disorders. In addition, this study showed that neonatal registry is an essential tool to improve neonatal care.

In Depth Analysis of the Leading Causes of Maternal Mortality Due to Cesarean Section in Iran

Objective: Despite the declining trend of maternal mortality (MMR) in Iran between 1990 and 2013, direct causes are still the major reasons for maternal death. One of these direct causes is complications of cesarean section (CS). Since the rate of CS in Iran is quite high (47.9%) and the trend continues to rise, there is an alarming threat of the possibility of increasing MMR in the country as a result of cesarean section complications, especially in repeated cases. In this study, we attempted to determine the indications of CS in reported maternal mortality, with special attention to risk factors predisposing to CS and/or to maternal mortality. Materials and methods: A retrospective study was implemented for the period between March 2009 and March 2012. All nationally reported data regarding maternal death during pregnancy, labor and 42 days after parturition during these 3 years was collected and input to software specially designed for this project. Subsequently, cases of maternal death related to pregnancy termination by cesarean section were selected for analysis. Results: There were 393 cases of maternal death with cesarean section as the termination method. Indications of CS were mostly emergency and repeat and the leading causes of death were postpartum hemorrhage and hypertensive disorders. Most of these deaths occurred in academic hospitals and the most common type of delay was brought about by hospital management, specifically personnel issues. Conclusion: Based on this study, acknowledging CS as a serious health threat endangering every achievement in the maternal health program is the most important policy and efforts should be focused on provision of guidelines for realistic CS indications, standardized CS procedures, and post CS care as well as propagation of training courses in risk management and high risk case-finding protocols.

A systematic review of the uterine relaxant effect of herbal sources

BACKGROUND

Preterm birth is a worldwide tragedy with a high incidence. Several medications are used to inhibit acute preterm labor, but tocolysis by these medicines do not extend pregnancy beyond 1-2 days.

OBJECTIVES

The purpose of this study was to discover new medications from plant extracts or their active compounds which inhibit the uterine contractions in order to treat preterm labor.

DATA SOURCES

PubMed, Google Scholar, Scopus and IranMedex databases were searched up to 1st February 2012 with the most relevant keywords.

STUDY SELECTION

All studies in which plant extracts or their active compounds inhibited the uterine contractions both in vivo and in vitro were included.

THE RESULTS

Of initial search, 259 records were reviewed and finally 72 were included among which only 31 studies isolated an active compound from the plants extract belonging mostly to classes of flavonoids and terpenes classes. Flavonoids have been known as a phosphodiesterase (PDE) and a protein kinase C (PKC) inhibitor. It seems that the uterolytic activity of reviewed flavonoids such as naringenin, kaempferol and quercetin, especially in a calcium free solution, was via these inhibitory pathways.

CONCLUSION

Laboring uterus response to dissimilar tocolytics differs from that of non-laboring uterus. In order to find a treatment for preterm labor, future studies should focus on the laboring uterus and also determine the structure activity relationship of the different tocolytics. This systematic review was registered to the PROSPERO with code number CRD42015027551.

Evaluation of Serum Zinc Levels in Hyperbilirubinemic Neonates Before and After Phototherapy

Background

The existing therapeutic methods for neonatal jaundice are costly, time-consuming and potentially risky. Zinc salts can reduce phototherapy duration by precipitating unconjugated bilirubin in the intestine (bilirubin and zinc can form a complex in physiologic pH); however, zinc toxicity is an issue that must be considered since theoretically bilirubin reduction by phototherapy may increase serum zinc levels, making additional zinc supplementation the potential cause of zinc toxicity.

Objectives

So, our purpose was evaluating the serum zinc level alterations before and after phototherapy, in hyperbilirubinemic newborns.

Materials and Methods

A prospective cohort study was performed at the children’s medical center of Tehran University of Medical Sciences from 2012 to 2014. Healthy, full-term exclusively breast fed newborns with non-hemolytic jaundice were enrolled in the study. Participants were divided into two groups based on serum bilirubin levels (TSB < 18 mg/dL and TSB ≥ 18 mg/dL) at admission. Pre- and post-phototherapy total serum zinc level was measured before and 12 - 24 hours after termination of phototherapy.

Results

Phototherapy was associated with a significant increase in the serum zinc level in neonates with severe hyperbilirubinemia (TSB ≥ 18 mg/dL) but not in those with mild-moderate hyperbilirubinemia (TSB < 18 mg/dL). In addition, phototherapy caused a significant increase in the rate of zinc with potentially toxic levels (zinc > 200) in only neonates with severe hyperbilirubinemia.

Conclusions

Phototherapy increases serum zinc level by reducing bilirubin level so that additional supplementation of this element can lead potentially to zinc toxicity.

A Systematic Review of the Uterine Relaxant Effect of Herbal Sources

BACKGROUND

Preterm birth is a worldwide tragedy with a high incidence. Several medications are used to inhibit acute preterm labor, but tocolysis by these medicines do not extend pregnancy beyond 1-2 days.

OBJECTIVES

The purpose of this study was to discover new medications from plant extracts or their active compounds which inhibit the uterine contractions in order to treat preterm labor.

DATA SOURCES

PubMed, Google Scholar, Scopus and IranMedex databases were searched up to 1st February 2012 with the most relevant keywords.

STUDY SELECTION

All studies in which plant extracts or their active compounds inhibited the uterine contractions both in vivo and in vitro were included.

THE RESULTS

Of initial search, 259 records were reviewed and finally 72 were included among which only 31 studies isolated an active compound from the plants extract belonging mostly to classes of flavonoids and terpenes classes. Flavonoids have been known as a phosphodiesterase (PDE) and a protein kinase C (PKC) inhibitor. It seems that the uterolytic activity of reviewed flavonoids such as naringenin, kaempferol and quercetin, especially in a calcium free solution, was via these inhibitory pathways.

CONCLUSION

Laboring uterus response to dissimilar tocolytics differs from that of non-laboring uterus. In order to find a treatment for preterm labor, future studies should focus on the laboring uterus and also determine the structure activity relationship of the different tocolytics. This systematic review was registered to the PROSPERO with code number CRD42015027551.

Iodine-containing disinfectants in preparation for caesarean section: impact on thyroid profile in cord blood

BACKGROUND

Iodine-containing disinfectants are widely used for skin preparation before caesarean section. Current evidence suggests that maternal exposure to these disinfectants results in thyroid dysfunction in the newborns, but its extent is not known.

OBJECTIVES

The purpose of this study was to explain the quality of the effect of these disinfectants on the thyroid function of newborns.

METHODS

This cohort study was performed on all the healthy mothers with a term pregnancy who underwent caesarean section in the obstetrics emergency department of an educational hospital affiliated with Tehran University of Medical Sciences from December 2013 to December 2014. We divided this 12-month period into two consecutive 6 months. Povidone-iodine 10% (PVP-I) and chlorhexidine gluconate 4% (CHX) were used in the first and second 6 months, respectively, for skin preparation before caesarean section and also for umbilical cord disinfection. Cord blood thyroid stimulating hormone (TSH) and thyroxine (T4) were assayed by the ELISA method.

RESULTS

We included 326 cases in this study, 153 in the PVP-I group and 173 in the CHX group. The incidence of cord blood TSH ≥ 10 mIU/L and T4 ≤ 7.3 µg/dL was significantly higher in the PVP-I than the CHX group. Cord blood TSH concentration showed a significant positive correlation with cord blood T4 concentration in the CHX group. Through selection of cases with cord blood T4 < 13 µg/dL, we found a negative correlation between cord blood TSH and T4 concentration in the PVP-I group.

CONCLUSIONS

It seems that PVP-I has the potential to cause false-positive screening-test results and increase recall rates, which should be evaluated in further studies.

TRIAL REGISTRATION NUMBER

Iranian Registry of Clinical Trials (IRCT) number IRCT201204289568N1.

A history of neonatal medicine in Iran

Neonatal medicine was officially initiated in the United States of America in 1973, and in the same year, the American Board of Pediatrics held the first subspecialty examination in the field of neonatal-perinatal medicine. The first Newborn Intensive Care Unit (NICU) in Tehran began its work with great efforts of Prof. Hadi Samaee at Ali-Asghar Children's Hospital, approved by the Ministry of Health as the first standard center for training neonatologists. Hence, the first neonatology fellowship program began in 1986 and two years later (1988) its graduate started work at Ali-Asghar Children's Hospital. Afterwards, more NICUs were built all over the country and equipped gradually. The Iranian Association of Neonatology and Perinatology were founded in 1998 and 2003, respectively. These two scientific associations jointly made recommendations to health officials to develop consistent educational programs for neonatal and maternal health promotion in Iran. Regionalization of maternal-neonatal health services was also another recommendation which has now been presented to the Ministry of Health as a national program to promote neonatal and maternal health status. Thanks to the measures taken so far over the last few years, the index of neonatal mortality has declined from 26 per 1,000 live births in 1990 to 11 per 1,000 live births in 2012.

Assessment of Hearing Loss by OAE in Asphyxiated Newborns

BACKGROUND

Severe birth asphyxia (apgar < 7 at the 5th minute of birth) is recognized as a hearing loss risk factor by the joint committee on infant hearing (JCIH). About half of the newborns with hearing loss do not indicate any sign and risk factor at birth. Accordingly, the joint committee recommended performance of hearing screening test in 2000, especially for babies born with risk factors.

OBJECTIVES

The aim of this study was to evaluate hearing loss in asphyxiated neonates. Early diagnosis would result in early treatment of these newborns.

PATIENTS AND METHODS

We assessed the relationship between asphyxia and hearing impairment in newborns admitted to a referral hospital, Tehran, Iran within 3 years (2003 - 2006). Hearing problems were diagnosed and followed by otoacoustic emission (OAE) in the third and fifth days of birth. Asphyxiated neonates with abnormal OAE were referred to an ENT specialist; second OAE and tympanometry were carried out after 2 weeks. Based on the results, newborns underwent treatment or were discharged.

RESULTS

Of 149 asphyxiated neonates, 80 had mean first minute apgar score of 4.01, and mean 5th minute score was 7.24. Two percent (3/149) of asphyxiated neonates had abnormal OAEs. No statistical correlation was found between the 5th minute apgar score and abnormal OAE (P value = 0.391). However, a significant relationship between the mean birth weight and abnormal OAE (P value = 0.0406) was found.

CONCLUSIONS

It seems that birth asphyxia is not correlated with hearing loss.

Risk factors of intracranial hemorrhage in premature neonates

Intraventricular hemorrhage (IVH) is an important cause of brain injury in premature neonates. Current study tries to define associated risk factors of IVH in preterm neonates in Aliasghar Children Hospital during 2008 to 2011. In this study, the risk factors have been evaluated in premature neonates with IVH, who had at least one brain sonography since their admission in NICU. A total of 63 premature neonates with IVH were assessed. Mean gestational age was 29.81 (24-34) weeks and mean birth weight was 1290.83±382.96 gr. Other risk factors such as sex, mode of delivery, history of using infertility drugs, maternal disease, maternal hypertension and preeclampsia, lumbar puncture, ventilator therapy and pneumothorax were considered. Because no absolute treatment for IVH is available, identifying risk factors is important in prevention and management of IVH.

A systematic review of the uterine relaxant effect of potassium channel openers

Despite significant advances in the understanding of uterine physiology, preterm labor is still a predicament with a high incidence. The mechanism that triggers uterine contraction is currently unclear. ATP-sensitive potassium (KATP) channel stimulation has an inhibitory effect on uterine contractile pursuit through hyperpolarization of myometrial cells where KATP channels openers (KCOs) act as a tocolytic. In this review, studies that report the effects of KCOs on the contractile activity of the myometrium have been collected and evaluated. All electronic databases were searched up to 1(st)December 2012 with the most relevant keywords. Studies related to the effect of KCOs on the human or animal myometrium both in vivo and in vitro were included. Of initial search, 45 records were reviewed and finally, 23 were included. All of these studies found that KCOs have an inhibitory effect on the myometrium contractions, but different sample size and inconsistencies in reporting the effects make the absolute judgment about efficacy of these compounds too difficult. Of course, we can state that the inhibitory effects of KCOs were greater in myometrium of non-labor group. Conclusion is that although some positive effects are expected, yet further placebo-controlled studies are needed to reach a consensus.

Antimicrobial susceptibility of bacteria isolated from cerebrospinal fluids in an Iranian referral pediatric center, 1998-2008

Antimicrobial susceptibility patterns of bacterial meningitis provide essential information regarding selection of antibiotic therapy for patients with bacterial meningitis. This study presents data on causes of bacterial meningitis and their susceptibility pattern among children at Children's Medical Center (CMC), a referral tertiary care center in Iran. In this comprehensive retrospective study we reviewed microbiology records of all inpatients suspected to bacterial meningitis, during 1998-2008 of period. Of 11269 CSF cultures examined in the study, 329 (2.9%) were positive for bacterial growth. Overall, coagulase negative staphylococci (CONS) were the most frequent group of organism recovered from our CSF cultures (40%), followed by gram negative enteric bacilli (19.7%). Also, high rates of oxacillin and vancomycin resistance were found among staphylococci. In our study more than 80% of gram-negative enteric bacteria were resistant to ampicillin; we also found high rates of cephalosporin resistance among these organisms. Over 55% of S. pneumoniae were resistant to penicillin. Staphylococci species and gram-negative enteric organisms were the most common pathogens isolated from CSF cultures in this study. It seems that nosocomial meningitis is the main cause of bacterial meningitis in CMC Hospital. Our report draws attention to the importance devising a national strategy to control the spread of resistance in Iran.