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Child acute malnutrition (AM) is an important cause of child mortality. Accurately estimating its burden requires cumulative incidence data from longitudinal studies, which are rarely available in low-income settings. In the absence of such data, the AM burden is approximated using prevalence estimates from cross-sectional surveys and the incidence correction factor \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$K$\end{document}, obtained from the few available cohorts that measured AM. We estimated \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$K$\end{document} factors for severe acute malnutrition (SAM) and moderate acute malnutrition (MAM) from AM incidence and prevalence using representative cross-sectional baseline and longitudinal data from 2 cluster-randomized controlled trials (Innovative Approaches for the Prevention of Childhood Malnutrition—PROMIS) conducted between 2014 and 2017 in Burkina Faso and Mali. We compared K estimates using complete (weight-for-length z score, mid-upper arm circumference (MUAC), and edema) and partial (MUAC, edema) definitions of SAM and MAM. \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$K$\end{document} estimates for SAM were 9.4 and 5.7 in Burkina Faso and in Mali, respectively; K estimates for MAM were 4.7 in Burkina Faso and 5.1 in Mali. The MUAC and edema–based definition of AM did not lead to different \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$K$\end{document} estimates. Our results suggest that \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{upgreek} \usepackage{mathrsfs} \setlength{\oddsidemargin}{-69pt} \begin{document} }{}$K$\end{document} can be reliably estimated when only MUAC and edema-based data are available. Additional studies, however, are required to confirm this finding in different settings.

Ramadan exposure in utero can be regarded as a natural experiment with which to study how nutritional conditions in utero influence susceptibility to disease later in life. We analyzed data from rural Burkina Faso on 41,025 children born between 1993 and 2012, of whom 25,093 were born to Muslim mothers. Ramadan exposure was assigned on the basis of overlap between Ramadan dates and gestation, creating 7 exclusive categories. We used proportional hazards regression with difference-in-differences analysis to estimate the association between Ramadan exposure at different gestational ages and mortality among children under 5 years of age. Under-5 mortality was 32 deaths per 1,000 child-years. Under-5 mortality among Muslims was 15% higher than that among non-Muslims (P < 0.001). In the difference-in-differences analysis, the occurrence of Ramadan during conception or the first or second trimester was associated with higher under-5 mortality rates among Muslims only. The mortality rates of children born to Muslim mothers were 33%, 29%, and 22% higher when Ramadan occurred during conception, the first trimester, and the second trimester, respectively, compared with children of non-Muslim mothers born at the same time (P = 0.01, P < 0.001, and P = 0.007). Having a Muslim mother was not associated with mortality when the child was not exposed to Ramadan, born during Ramadan, or exposed during the third trimester. Observance of Ramadan during early pregnancy can have detrimental consequences for the future health of the unborn child.

In early 1987, immunizations were introduced to an isolated area of eastern Senegal where there had previously been no regular immunizations. Since immunizations were the only change introduced in the area during this period, this allowed the authors to study the impact of immunizations on mortality in different age groups and the possible interaction with sex differences in mortality. They compared mortality rates for the 6 years before and the 6 years after the introduction of immunization. Neonatal mortality declined 31% (95% confidence interval (Cl) 17 to 43) ; between 1 and 8 months of age, the reduction was 20% (95% Cl -2 to 37) ; and between 9 and 59 months of age, mortality declined 48% (95% Cl 39 to 56). Excluding acute measles deaths, the reduction was 16% (95% Cl -8 to 35) between 1 and 8 months of age and 32% (95% Cl 20 to 43) between 9 and 59 months of age. The decline was stronger in villages that maintained high coverage after the initial national campaign, whereas mortality increased again in the villages where the coverage declined. Since the reduction in mortality was most marked after 9 months of age, measles immunization is likely to have been the most important vaccination. Both female and male mortality declined but not equally quickly. The reduction in mortality in the neonatal period was significantly greater in males than in females, resulting in an increase in the female/male mortality ratio from 0.64 (95% Cl 0.50 to 0.83) to 0.96 (95% Cl 0.71 to 1.30), p = 0.04. After 9 months of age, the reduction in mortality was somewhat greater in females than in males, resulting in a decrease in the female/male mortality ratio from 1.04 (95% Cl 0.85 to 1.28) to 0.79 (95% Cl 0.62 to 1.02), p = 0.10. Am J Epidemiol 1995 ;142 :643-52.

The Old Order Amish are a distinct ethnic group with a very high birth rate and patterns of perinatal risk factors quite different from those of the general population. This study reports marital fertility and perinatal, infant, and child death rates for an entire Amish settlement of approximately 10,000 individuals, centered around Geauga County, Ohio. All 6,623 births from 1948 to 1988 listed in a directory of Geauga Settlement Amish households were studied. The childbearing experience of all 475 married women over the age of 44 years was also described. Women aged > 44 years had a median of 8.3 births; 24% of the births were to women aged > 34 years. Despite a higher prevalence of several risk factors for perinatal and infant death among the Amish, neonatal and infant death rates for Geauga Settlement Amish have been very similar to the corresponding rates for white children in rural Ohio and the state as a whole. The beneficial aspects of Amish society that may lessen the impact of perinatal risk factors on mortality merit further study.

This study aims to investigate the relation between distance to health facilities, measured as continuous travel time, and mortality among infants and children younger than 5 years of age in rural Burkina Faso, an area with low health facility density. The study included 24,555 children born between 1993 and 2005 in the Nouna Health and Demographic Surveillance System. The average walking time from each village to the closest health facility was obtained for both the dry and the rainy season, and its effect on infant (

In cross-sectional surveys, the sample of children with anthropometric measurements is not representative of all children in a birth cohort, since only children surviving to the survey date are measured. This survivor bias may have implications for studies of trends and differentials in anthropometric indicators. In this paper, the effects of the survivor bias on the estimates of child anthropometric indicators are assessed by 1) reviewing evidence from longitudinal studies on the prevalence of malnutrition among deceased children and among surviving children and by 2) analyzing retrospective data on child mortality and cross-sectional data on child anthropometry in 17 national surveys that are part of the Demographic and Health Surveys Program. It is concluded that comparisons of anthropometric data across geographic units, population subgroups, and calendar time are marginally affected by the survivor bias, unless mortality differences between the birth cohorts are very large (e.g., well over 50 per 1,000 births).The effects of survivor bias in cross-sectional surveys of anthropometric measurements of children, that is overestimates due to omission of children that died before the survey date, were estimated by reviewing longitudinal studies for prevalence of malnutrition in deceased and surviving children, and analyzing retrospective data on child mortality and cross-sectional data on child anthropometry. Data were taken from 17 Demographic and Health Surveys, collected from 1986-1989. The odds ratio of the prevalence of malnutrition in deceased to that of living children was computed to assess how much worse the nutritional status of deceased children is to surviving children. In most countries 50% of the dead children were malnourished. The ratios were higher if malnutrition was more severe, specifically if the differences were pronounced for weight for age, and weight for height, or for severe stunting, below -3 SD from the median height for age. The proportion dead among children 3-36 months ranged from 2.5% in Sri Lanka to 15% in Mali, and was higher in older children. The largest bias was seen in weight for age: e.g., in Mali, where mortality is highest, the proportion of underweight increased by 4.6%, and of severely underweight by 2.7%. There was a relationship between level of malnutrition and child mortality at the country level, with considerable variation between countries, and a few outstanding outliers, countries whose malnutrition was much higher than expected from mortality rates. The effects of mother's education and of length of preceding birth interval were computed, and the odds ratio rose only from 1.8 to 2.2. It was concluded that comparisons of anthropometric data across countries and time are only marginally affected by survivor bias, unless the mortality differences between birth cohorts are very large, over 50/1000 births.

In an urban area of Guinea-Bissau, 71 children exposed to measles before age 6 months had a mortality risk of 34% (95% confidence interval (Cl) 24-47) between 6 and 60 months of age. The mortality risk for the 205 other children of the same birth cohort who had not been exposed to or developed measles was 11% (95% Cl 9-15), a significant difference compared with exposed children. With a version of the Cox regression model, maternal education was found to be the only background factor with a significant effect on mortality. When background factors were controlled for, the mortality of children exposed to measles was significantly higher than that of controls in each of the age intervals 6-11, 12-23, and 24-35 months. For the large subgroup of children of mothers without any formal education, exposed children had 5.7 times (95% Cl 2.7-12.0) higher mortality than did the control children in the age interval 6-35 months. Diarrhea deaths were particularly common among exposed children. Of 22 children who had been exposed before age 6 months during a subsequent epidemic and had a blood test taken, there was a significantly higher mortality risk (27%) between 6 months and 5 years than in the 26 controls who had a blood test (0%). Children who had elevated antibody titers to measles after exposure had a particularly high mortality compared with controls. These results suggest that later childhood mortality may be related to infectious experiences during the first months of life. The possible long-term health consequences of exposure to measles virus should be considered when assessing the value of measles control programs.

In this study, the authors identified maternal and child characteristics that were independent predictors of death from infectious diseases acquired in the community and determined if these factors could be used to identify groups of children with excess risk of mortality from infection. A historical cohort study was conducted of children less than 5 years of age between 1985 and 1994 (the study period), who were born in Tennessee, and had complete information on their birth certificates. The primary outcome was death from infection identified from death certificates and confirmed through medical record review. Among the 1,014,976 children less than 5 years of age, who contributed 3,351,568 child-years of follow-up, there were 247 deaths from infections (7.4 deaths from infections per 100,000 child-years). Respiratory infections accounted for approximately one half of the deaths. Children having three or more older siblings or birth weight of less than 1,500 g had a 3-fold and 10-fold increased risk of death from infection, respectively, while children with both characteristics had a nearly 20-fold increased risk that persisted beyond the first year of life. Interventions should be focused on prevention of these infections in vulnerable children. At-risk children should be targeted for careful follow-up and early hospitalization when signs of infection develop.

Previous studies have associated overcrowding at the household level with increased mortality, especially from airborne diseases. This association may be confounded by associations with adverse socioeconomic conditions or low age at infection. This study investigated the effect of crowding on the risk of measles death. Individual entries in a population-based register and on death certificates for children aged 0-15 years living in one parish in Stockholm in 1885, 1891, and 1910 (n = 36,718) were used to analyze cause-specific and overall death rates in relation to household size and the number of children in the household, using Cox regression analysis. Bivariate analysis identified significant relations between crowding and the cause-specific risk of death, which were subsequently tested while controlling for other known risk factors for childhood death. Significant negative associations between crowding and the risk of death from pneumonia and bronchitis disappeared when controlling for other risk factors. A negative association between the risk of overall death and large household size became significantly positive when controlling for other risk factors. The increased risk of death from measles associated with proxies for crowding remained after controlling for other risk factors. In conclusion, crowding may have a statistically independent effect on the risk of death from measles.

The female/male mortality ratio among unimmunized children and children vaccinated with standard or high-titer measles vaccines was examined for all children born in the period 1985-1991 in a rural area of Senegal. The female/male mortality ratio from 9 months to 5 years of age for unvaccinated children was 0.94 (95% confidence interval (CI) 0.75-1.19), significantly different from the ratio of 0.64 (95% CI 0.48-0.85) for recipients of the Schwarz standard measles vaccine (p = 0.040). In the 4-year period, where high-titer measles vaccines were used in the study area, the female/male mortality ratio was 1.33 (95% CI 1.00-1.78) for recipients of high-titer Edmonston-Zagreb or Schwarz vaccines compared with 0.67 (95% CI 0.42-1.07) for recipients of the Schwarz standard vaccine (p = 0.013). Hence, the Schwarz standard and high-titer measles vaccines have divergent sex-specific effects on mortality throughout childhood. Further studies of the underlying mechanisms are needed.The female/male mortality ratio among unimmunized children and children vaccinated with the Schwarz standard or Edmonston-Zagreb high-titer measles vaccine was examined for all children born in period 1985-1991. The cohort included all children born between February 1, 1987, and January 31, 1989. From 1983 to 1987, annual censuses (and after 1987, weekly surveillance visits) of the Sereer population of Niakhar yielded data on migration, marriages, births, mortality, vaccinations, breast feedings, and infections. Mortality was examined from 9 months, the recommended age for immunization with the Schwarz standard measles vaccine. Children were followed until death, migration, 5 years of age, or the annual census in February 1992. At 5 months of age (or when they were 10 months old), children were randomized to receive a placebo or a high-titer dose of Edmonston-Zagreb or Schwartz standard measles vaccine. All 2467 children born in the period were included, of whom 2118 lived in the study area after the age of 9 months. 11% of the Schwarz standard-vaccinated children received their vaccination after 12 months of age (92 and 810). After 9 months of age, there were 29 boys and 26 girls who had measles among unvaccinated (22 boys, 21 girls), Schwarz standard-vaccinated (1 boy, 2 girls), and high-titer-vaccinated children (6 boys, 3 girls). The female/male mortality ratio from 9 months to 5 years of age for unvaccinated children was 0.94, significantly different from the ratio of 0.64 for recipients of the Schwarz standard measles vaccine (p = 0.040). In the 4-year period, the female/male mortality ratio was 1.33 for recipients of high-titer Edmonston-Zagreb or Schwarz vaccines, compared with 0.67 for recipients of the Schwarz standard vaccine (p = 0.013). The Schwarz standard and high-titer measles vaccines had divergent sex-specific effects on mortality throughout childhood to be taken into consideration in future studies of measles vaccination.

Previous studies of an urban and a rural epidemic in Guinea-Bissau have shown perinatal mortality to be statistically significantly higher among children whose mothers have been exposed to measles during pregnancy. After the epidemic in 1970 in Bandim, a district in the capital of Guinea-Bissau, such children also had a postperinatal childhood mortality risk (7 days to 5 years of age) of 0.229, compared with 0.134 for other children in the community. None of the mothers had developed clinical measles. In a Cox regression analysis adjusting for known background factors, the mortality hazard ratio between the exposed and the controls was found to be 2.0 (95% confidence interval 1.1-3.8). After a small rural measles epidemic in Quinhamel in 1983, the mortality hazard ratio for children of mothers exposed during pregnancy compared with controls was 1.7 (95% confidence interval 0.6-4.6). Exposure to measles or some concomitantly transmitted pathogen during fetal life may contribute to the high childhood mortality found in many developing countries.

Few studies have determined risk factors for diarrheal deaths in developing areas. The Ministry of Health of Lesotho, southern Africa, reported that 9.5% of children under five years of age who were hospitalized for diarrhea in 1984 died. Of 104 children under five years of age who died during hospitalization for diarrhea, 85% were aged 24 months or younger and had nonbloody diarrhea during the warm season. We conducted two retrospective case-control studies of children aged 24 months or younger admitted for diarrhea at two hospitals in 1983 and 1984, comparing 44 who died with 89 who survived. Eight factors were significantly associated (p less than 0.05) with death at one or both hospitals by univariate analysis: diagnosis of a major infection, age under six months, illness for seven days or more before admission, thrush or stomatitis on admission, severe dehydration, history of vomiting, dehydration that had not improved after 12 hours in the hospital, and fever or subnormal temperature. Multivariate analysis of data from one hospital showed the first three factors to be significantly associated with death. Cases and controls were similar in sex and in degree of malnutrition. This study identified children at high risk for death from diarrhea.

Weights and heights were obtained on approximately 4,000 preschool-aged children in six rural villages of West Java between 1977 and 1978. Deaths occurring in the ensuing 18 months were ascertained at three-month intervals. The abilities of relative weight for height and height for age to discriminate children at greatest risk of dying were compared. Younger children (less than or equal to two years) with low height for age (less than 95% of the reference median) were at greater risk of dying than children of the same age who were not stunted. This risk declined with increasing age, and among children aged 3-5 years, those who were stunted were at no greater risk than those of normal height for age. The mortality risk associated with mild wasting (80-90% of the reference median) also declined with increasing age. However, the risk of dying among moderately to severely wasted (less than 80% of the reference median) children increased with increasing age. These results suggest that stunting, rather than wasting, puts younger children at greater risk of death, but among older children, wasting carries a greater relative mortality risk over an 18-month period.

The study is based on 440,452 single births occurring in Norway, 1967--1973, with known gestational age. The information was collected through a notification system known as "Medical Registration of Births," covering all births occurring in Norway, and the data are made available through the Medical Birth Registry of Norway, which allows for linkage between births and infant deaths. The life table describes the experience of women still pregnant at a gestational age of 16 completed weeks, and states for each subsequent week the number of pregnancy terminations, the outcome, and the number of women still pregnant. Seven outcomes of pregnancy are considered: fetal death prior to labor, fetal death during labor, death within 24 hours, death 1--6 days, death 7--27 days, death 28 days--1 year, and survival of one year or more. The data in the life table provide information on the probability of pregnancy termination in each week of gestation (after 16 completed weeks), and the probabilities of the various outcomes. The fetal-infant life table is considered as an extension of descriptive perinatal statistics and is of value in monitoring health changes and in comparing perinatal mortality between populations. It also provides information on time of pregnancy termination and outcome, which has some clinical applications.