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Background: In many low- and middle-income countries, data on the prevalence of surgical diseases have been derived primarily from hospital-based studies, which may lead to an underestimation of disease burden within the community. Community-based prevalence studies may provide better estimates of surgical need to enable proper resource allocation and prioritization of needs. This study aims to assess the prevalence of common surgical conditions among children in a diverse rural and urban population in Nigeria. Methods: Descriptive cross-sectional, community-based study to determine the prevalence of congenital and acquired surgical conditions among children in a diverse rural-urban area of Nigeria was conducted. Households, defined as one or more persons 'who eat from the same pot' or slept under the same roof the night before the interview, were randomized for inclusion in the study. Data was collected using an adapted and modified version of the interviewer-administered questionnaire—Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey tool and analysed using the REDCap web-based analytic application. Main results: Eight-hundred-and-fifty-six households were surveyed, comprising 1,883 children. Eighty-one conditions were identified, the most common being umbilical hernias (20), inguinal hernias (13), and wound injuries to the extremities (9). The prevalence per 10,000 children was 85 for umbilical hernias (95% CI: 47, 123), and 61 for inguinal hernias (95% CI: 34, 88). The prevalence of hydroceles and undescended testes was comparable at 22 and 26 per 10,000 children, respectively. Children with surgical conditions had similar sociodemographic characteristics to healthy children in the study population. Conclusion: The most common congenital surgical conditions in our setting were umbilical hernias, while injuries were the most common acquired conditions. From our study, it is estimated that there will be about 2.9 million children with surgically correctable conditions in the nation. This suggests an acute need for training more paediatric surgeons. [ABSTRACT FROM AUTHOR]

Introduction: Nurses encounter children who report of pain of diverse and unknown causes in their professional work. The current study therefore assessed and compared nursing students and nurses' knowledge and attitudes pertaining to children's pain in the Ghanaian context. The goal of this was to have a baseline information to guide the development and implementation of the content for a sustainable educational programme (short-course) for nursing students and nurses in Ghana. Methods: Between October and December 2018, a cross-sectional study was carried out among 554 final year nursing students and 65 nurses in Ghana. The Pediatric Nurses Knowledge and Attitudes Survey Regarding Pain (PNKAS) was used to collect data from participants who were affiliated to four educational institutions and eight hospitals. Data were descriptively and inferentially analyzed using chi-square test of independence, independent samples t-test and one-way analysis of variance (ANOVA). Results: Our findings revealed that nursing students and nurses generally had unsatisfactory knowledge and attitudes towards pain management in children. Nursing students however, had significantly higher scores than nurses in the total PNKAS score and in 10 out of the 13 identified item-areas. Greater scores were obtained by nursing students in areas which were related to pain physiology, pharmacokinetics, pharmacology of analgesics and pain perceptions (p < .05). All the participating nurses could not accurately determine: the onset of action of orally administered analgesics, equianalgesia of orally administered morphine, and the right dosage of prescribed morphine for a child who consistently reported of moderate to severe pain. Conclusion: Final year nursing students and nurses have unsatisfactory knowledge and attitudes regarding children's pain; which reiterates the need for urgent and effective educational efforts in this area. Regular in-service training should be offered to post-registration nurses to enhance their pediatric pain knowledge and attitudes for improved pain care in children. [ABSTRACT FROM AUTHOR]

Breastfeeding has a wide range of benefits for both infants and mothers. The identification of factors associated with exclusive breastfeeding (EBF) are important to increase the prevalence of EBF. The study aimed to determine the prevalence of EBF within the first six months and its associated factors in Kaiyuan, Yunnan Province, Southwest China. This cross-sectional study was conducted in Kaiyuan, a middle-sized city of Yunnan Province, Southwest China. Mothers of infants under twelve months were randomly selected for a face to face interview in four towns (two in urban areas and two in rural areas) in Kaiyuan. A structured questionnaire was applied for collection of sociodemographic information, mothers’ and infants’ health, and breastfeeding information. A 24-hour food recall survey was used to collect infant feeding information. A logistic regression analysis was performed to identify the factors independently associated with exclusive breastfeeding for infants up to six months of age. The number of 417 mothers with infants under six months was interviewed. The prevalence of EBF at six months was 27.34%. Logistic regression indicated that EBF within six months was more likely to be practiced by mothers who had higher average household income per year (OR = 2.09, 95% CI: 1.05–4.17 p = 0.037; OR = 1.85, 95% CI: 1.04–3.28 p = 0.037), and mothers who received breastfeeding information (OR = 2.46, (95%CI: 1.45–4.18, p = 0.0009). The prevalence of EBF in Kaiyuan, Southwest China is considerably lower than national and international recommendations. Yearly household income, and mothers who received breastfeeding information are associated with higher EBF prevalence. Breastfeeding information should be given to mothers in order to increase the prevalence of EBF. [ABSTRACT FROM AUTHOR]

Background: Preterm infants are a group at high risk of having experienced placental insufficiency. It is unclear which growth charts perform best in identifying infants at increased risk of stillbirth and other adverse perinatal outcomes. We compared 2 birthweight charts (population centiles and INTERGROWTH-21st birthweight centiles) and 3 fetal growth charts (INTERGROWTH-21st fetal growth charts, World Health Organization fetal growth charts, and Gestation Related Optimal Weight [GROW] customised growth charts) to identify which chart performed best in identifying infants at increased risk of adverse perinatal outcome in a preterm population.Methods and Findings: We conducted a retrospective cohort study of all preterm infants born at 24.0 to 36.9 weeks gestation in Victoria, Australia, from 2005 to 2015 (28,968 records available for analysis). All above growth charts were applied to the population. Proportions classified as <5th centile and <10th centile by each chart were compared, as were proportions of stillborn infants considered small for gestational age (SGA, <10th centile) by each chart. We then compared the relative performance of non-overlapping SGA cohorts by each chart to our low-risk reference population (infants born appropriate size for gestational age [>10th and <90th centile] by all intrauterine charts [AGAall]) for the following perinatal outcomes: stillbirth, perinatal mortality (stillbirth or neonatal death), Apgar <4 or <7 at 5 minutes, neonatal intensive care unit admissions, suspicion of poor fetal growth leading to expedited delivery, and cesarean section. All intrauterine charts classified a greater proportion of infants as <5th or <10th centile than birthweight charts. The magnitude of the difference between birthweight and fetal charts was greater at more preterm gestations. Of the fetal charts, GROW customised charts classified the greatest number of infants as SGA (22.3%) and the greatest number of stillborn infants as SGA (57%). INTERGROWTH classified almost no additional infants as SGA that were not already considered SGA on GROW or WHO charts; however, those infants classified as SGA by INTERGROWTH had the greatest risk of both stillbirth and total perinatal mortality. GROW customised charts classified a larger proportion of infants as SGA, and these infants were still at increased risk of mortality and adverse perinatal outcomes compared to the AGAall population. Consistent with similar studies in this field, our study was limited in comparing growth charts by the degree of overlap, with many infants classified as SGA by multiple charts. We attempted to overcome this by examining and comparing sub-populations classified as SGA by only 1 growth chart.Conclusions: In this study, fetal charts classified greater proportions of preterm and stillborn infants as SGA, which more accurately reflected true fetal growth restriction. Of the intrauterine charts, INTERGROWTH classified the smallest number of preterm infants as SGA, although it identified a particularly high-risk cohort, and GROW customised charts classified the greatest number at increased risk of perinatal mortality. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) against women is a major global health issue, particularly in low- and middle-income countries (LMICs), that is associated with poor physical and mental health, but its association with breastfeeding practices is understudied. Both the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF) recommend that children initiate breastfeeding within the first hour of birth and be exclusively breastfed for the first 6 months of life. Breastfeeding within the first hour of birth is critical to newborn survival, and exclusive breastfeeding for 6 months is recognised to offer significant health benefits to mothers and their infants. We examined the association of maternal exposure to IPV with early initiation of breastfeeding (within 1 hour of birth) and exclusive breastfeeding in the first 6 months.Methods and Findings: We assessed population-based cross-sectional Demographic and Health Surveys (DHS) from 51 LMICs. Data from the most recent DHS in each country (conducted between January 2000 and January 2019) with data available on IPV and breastfeeding practices were used. By WHO region, 52.9% (27/51) were from Africa, 11.8% (6/51) from the Americas, 7.8% (4/51) from the Eastern Mediterranean, 11.8% (6/51) from Europe, 11.8% (6/51) from South-East Asia, and 3.9% (2/51) from the Western Pacific. We estimated multilevel logistic regression models for any IPV and each type of IPV separately (physical violence, sexual violence, and emotional violence), accounting for demographic and socioeconomic factors. Depending on specification, the sample size varied between 95,320 and 102,318 mother-infant dyads. The mean age of mothers was 27.5 years, and the prevalence of any lifetime exposure to IPV among mothers was 33.3% (27.6% for physical violence, 8.4% for sexual violence, and 16.4% for emotional violence). Mothers exposed to any IPV were less likely to initiate breastfeeding early (adjusted odds ratio [AOR]: 0.88 [95% CI 0.85-0.97], p < 0.001) and breastfeed exclusively in the first 6 months (AOR: 0.87 [95% CI 0.82-0.92], p < 0.001). The associations were similar for each type of IPV and were overall consistent across infant's sex and WHO regions. After simultaneously adjusting for all 3 types of IPV, all 3 types of IPV were independently associated with decreased likelihood of early breastfeeding initiation, but only exposure to physical violence was independently associated with a decreased likelihood of exclusively breastfeeding in the first 6 months. The main limitations of this study included the use of cross-sectional datasets, the possibility of residual confounding of the observed associations by household wealth, and the possibility of underreporting of IPV experiences attenuating the magnitude of observed associations.Conclusions: Our study indicates that mothers exposed to any form of IPV (physical, sexual, or emotional violence) were less likely to initiate breastfeeding early and breastfeed exclusively in the first 6 months. These findings may inform the argument for antenatal screening for IPV in LMICs and the provision of services to not only improve mothers' safety and well-being, but also support them in adopting recommended breastfeeding practices. [ABSTRACT FROM AUTHOR]

Background/Objectives: This study examined the best practices with regard to infant and young child feeding in emergency (IYCF-E) program. This was done by observing a breastfeeding support scenario through wet nursing in Rohingya refugee camps in Cox’s Bazar, Bangladesh. Methods: Information on demographics, IYCF-E knowledge, wet nursing support, type of constraints faced, and possible ways to overcome such constraints was collected through face-to-face interviews with 24 conveniently selected wet nurses. Linear regression was used to analyze the associations. Results: Mean age of wet nurses was 21.6 years; 16.67% had adequate knowledge about IYCF-E; and 29.17% had prior knowledge about wet nursing. Mean age of supported infants was 1.29 months, and 58.33% had a familial relationship with the wet nurses. Duration of breastfeeding support was significantly associated with the wet nurse’s age, age of the wet nurses’ youngest children, familial relationship with infants, knowledge about IYCF-E, and follow-ups from community nutrition workers (Ps <0.05). The status of facing problems (58.33%) was negatively correlated with duration of wet nursing, although this association was not statistically significant. The most extensively reported problems were as follows: misunderstandings with the infant’s family (85.71%), family workload and time limitations (21.43%), household distance (42.86%), and family members’ poor compliance (21.43%). Counseling from community nutrition workers (64.29%) and mediation by community leaders (57.14%) played key roles in mitigating such problems. Self-satisfaction (37.50%), counseling (62.50%), and religious inspiration (58.33%) were key motivators behind dedicated breastfeeding support. Conclusion: Wet nursing in the Rohingya refugee camps in Cox’s Bazaar, Bangladesh, was associated with several factors involving both supply and demand. The present findings may help design better IYCF-E programs in similar context. [ABSTRACT FROM AUTHOR]

Background: Though exclusive breastfeeding (EBF) for the first six months is recommended, it remains a debatable issue in both developed and developing countries. Thus, this study investigated the effect of EBF cessation time on childhood morbidity and adverse nutritional outcome in Ethiopia. Methods: We used the 2011 and 2016 Ethiopian Demographic and Health Surveys. The study involved 2,433 children under six months of age. Logistic regression model was applied to determine the effect of EBF cessation time on outcome variables. Population Attributable Fraction was calculated to evaluate the public health impacts of EBF termination in the population. Results: Discontinuing EBF at 0–3 months (adjusted odds ratio (AOR): 1.95, 95% confidence interval (CI): 1.08, 3.53)) and 4–6 months (AOR: 3.57, 95% CI: 2.19, 5.83) increased diarrhea occurrence compared to children who continued EBF up to 6 months. Children who had terminated EBF at 4–6 months had increased odds of fever (AOR: 1.73, 95% CI: 1.11, 2.68) and acute respiratory illnesses (ARIs) (AOR: 2.74, 95% CI: 1.61, 4.65). Cessation of EBF earlier than 4 months or between 4–6 months was associated with increased odds of having at least one childhood morbidity. Termination of EBF at 0–3 months and at 4–6 months were associated with increased occurrence of wasting (AOR: 2.32, 95% CI: 1.45, 3.74) and underweight (AOR: 2.30, 95% CI: 1.36, 3.91), respectively. Exclusive breastfeeding can avert 42% of diarrhea, 27% of ARI, 21% of fever, 26% of wasting and 23% of underweight burden among children under six months of age. Conclusions: Termination of EBF before six months was associated with increased occurrence of diarrhea, fever and ARIs. It was also linked with increased occurrence of childhood wasting and underweight. The finding emphasized EBF for the first six months to reduce childhood morbidity and adverse nutritional outcomes. [ABSTRACT FROM AUTHOR]

Background: Approximately 250 million (43%) children under the age of 5 years in low- and middle-income countries (LMICs) are failing to meet their developmental potential. Risk factors are recognised to contribute to this loss of human potential. Expanding understanding of the risks that lead to poor outcomes and which protective factors contribute to resilience in children may be critical to improving disparities.Methods and Findings: The Drakenstein Child Health Study is a population-based birth cohort in the Western Cape, South Africa. Pregnant women were enrolled between 20 and 28 weeks' gestation from two community clinics from 2012 to 2015; sociodemographic and psychosocial data were collected antenatally. Mothers and children were followed through birth until 2 years of age. Developmental assessments were conducted by trained assessors blinded to background, using the Bayley-III Scales of Infant and Toddler Development (BSID-III), validated for use in South Africa, at 24 months of age. The study assessed all available children at 24 months; however, some children were not able to attend, because of loss to follow-up or unavailability of a caregiver or child at the correct age. Of 1,143 live births, 1,002 were in follow-up at 24 months, and a total of 734 children (73%) had developmental assessments, of which 354 (48.2%) were girls. This sample was characterised by low household employment (n = 183; 24.9%) and household income (n = 287; 39.1% earning 1 domain affected, and 75 (10.2%) had delay in all domains. Bivariate and multivariable analyses revealed several factors that were associated with developmental outcomes. These included protective factors (maternal education, higher birth weight, and socioeconomic status) and risk factors (maternal anaemia in pregnancy, depression or lifetime intimate partner violence, and maternal HIV infection). Boys consistently performed worse than girls (in cognition [β = -0.74; 95% CI -1.46 to -0.03, p = 0.042], receptive language [β = -1.10; 95% CI -1.70 to -0.49, p < 0.001], expressive language [β = -1.65; 95% CI -2.46 to -0.84, p < 0.001], and fine motor [β = -0.70; 95% CI -1.20 to -0.20, p = 0.006] scales). There was evidence that child sex interacted with risk and protective factors including birth weight, maternal anaemia in pregnancy, and socioeconomic factors. Important limitations of the study include attrition of sample from birth to assessment age and missing data in some exposure areas from those assessed.Conclusions: This study provides reliable developmental data from a sub-Saharan African setting in a well-characterised sample of mother-child dyads. Our findings highlight not only the important protective effects of maternal education, birth weight, and socioeconomic status for developmental outcomes but also sex differences in developmental outcomes and key risk and protective factors for each group. [ABSTRACT FROM AUTHOR]

Longitudinal designs provide a strong inferential basis for uncovering reciprocal effects or causality between variables. For this analytic purpose, a cross-lagged panel model (CLPM) has been widely used in medical research, but the use of the CLPM has recently been criticized in methodological literature because parameter estimates in the CLPM conflate between-person and within-person processes. The aim of this study is to present some alternative models of the CLPM that can be used to examine reciprocal effects, and to illustrate potential consequences of ignoring the issue. A literature search, case studies, and simulation studies are used for this purpose. We examined more than 300 medical papers published since 2009 that applied cross-lagged longitudinal models, finding that in all studies only a single model (typically the CLPM) was performed and potential alternative models were not considered to test reciprocal effects. In 49% of the studies, only two time points were used, which makes it impossible to test alternative models. Case studies and simulation studies showed that the CLPM and alternative models often produce different (or even inconsistent) parameter estimates for reciprocal effects, suggesting that research that relies only on the CLPM may draw erroneous conclusions about the presence, predominance, and sign of reciprocal effects. Simulation studies also showed that alternative models are sometimes susceptible to improper solutions, even when reseachers do not misspecify the model. [ABSTRACT FROM AUTHOR]

Objective: Pakistan has a high pediatric burden of tuberculosis, but few studies describe the treatment experience of children with tuberculosis in Pakistan. We sought to identify risk factors for unsuccessful treatment outcomes in children with drug-susceptible tuberculosis identified in eight hospitals in Karachi, Pakistan. Design: We conducted a retrospective cohort study among children (<15 years old) treated with first-line anti-tuberculosis drugs for presumed or confirmed drug-susceptible tuberculosis between 2016 and 2017. We assessed risk factors for experiencing an unsuccessful treatment outcome through multivariable logistic regression analysis. Results: In total, 1,665 children initiated tuberculosis treatment, including 916 (55.0%) identified through intensified case finding. Unsuccessful treatment outcomes were experienced by 197 (11.8%) children, comprising 27 (1.6%) deaths, 16 (1.0%) treatment failures, and 154 (9.3%) lost to follow-up. An additional 47 (2.8%) children had outcomes not evaluable. In multivariable analysis, children 0–4 years old (OR: 1.80, 95% CI: 1.07–3.04), males (OR: 1.48, 95% CI: 1.04, 2.11), and those with bacteriologic confirmation of disease (OR: 3.39, 95% CI: 1.98, 5.80) had increased odds of experiencing an unsuccessful treatment outcome. Conclusion: Our findings suggest a need to deploy strategies to identify children earlier in the disease process and point to the need for interventions tailored for young children once treatment is initiated. [ABSTRACT FROM AUTHOR]

Background and aim: Prevalence and motives for nipple shield use are not well studied in preterm infants and recommendations of nipple shield use in preterm infants are inconsistent. The aim of this study was to determine the prevalence of nipple shield use, explore the motives for nipple shield use and elucidate the association with exclusive breastfeeding in preterm infants. Methods: The study was part of a prospective survey of a Danish national cohort of preterm infants based on questionnaires answered by the 1221 mothers of 1488 preterm infants with gestational age of 24–36 weeks. Data on nipple shield use was available for 1407 infants. Results: Nipple shields were used by 54% of the mother-infant dyads for many different motives and was more often related to breastfeeding problems associated with the infant than with the mother. The most common motive for nipple shield use was “infant slipped the nipple” (52%). The lower the gestational age, the more frequently nipple shields were used for motives related to the infant. For those using a nipple shield, only the motive “infant fell asleep at the breast” was associated with a higher risk of not breastfeeding exclusively at discharge (OR 1.90 (95% CI 1.15; 3.13), p = 0.012), and “breast too engorged” with a lower risk of not breastfeeding exclusively (OR 0.32 (0.16; 0.63), p = 0.001), but overall nipple shield use was associated with failure of exclusive breastfeeding. Conclusion: The present study does not give justifiable motives for nipple shield use, except for “breast too engorged”. Nipple shields should not be recommended for infants falling asleep at the breast, instead, staff and mothers should be patient, allowing the dyad time skin-to-skin. The results indicate that the use of a nipple shield does not promote exclusive breastfeeding in preterm infants. [ABSTRACT FROM AUTHOR]

Background: Malaria and schistosomiasis represent two of the most prevalent and disabling parasitic infections in developing countries. Few studies have evaluated the effect of maternal schistosomiasis and malaria in the peri-conceptional period on infant’s risk of infection. Methods: In Benin, women were followed from the preconception period until delivery. Subsequently, their children were followed from birth to 3 months of age. Pre-pregnancy malaria, malaria in pregnancy (MiP)—determined monthly using a thick blood smear—and urinary schistosomiasis—determined once before pregnancy and once at delivery using urine filtration—were the main maternal exposures. Infant’s febrile infection (fever with respiratory, gastrointestinal and/or cutaneous clinical signs anytime during follow-up) was the main outcome. In a secondary analysis, we checked the relation of malaria and schistosomiasis with infant’s hemoglobin (Hb) concentration. Both effects were separately assessed using logistic/mixed linear regression models. Results: The prevalence of MiP was 35.7% with 10.8% occurring during the 1st trimester, and the prevalence of schistosomiasis was 21.8%. From birth to 3 months, 25.3% of infants had at least one episode of febrile infection. In multivariate analysis, MiP, particularly malaria in the 1st trimester, was significantly associated with a higher risk of infant’s febrile infection (aOR = 4.99 [1.1; 22.6], p = 0.03). In secondary results, pre-pregnancy malaria and schistosomiasis were significantly associated with a lower infant’s Hb concentration during the first 3 months. Conclusion: We evidenced the deleterious effect of maternal parasitic infections on infant’s health. Our results argue in favor of the implementation of preventive strategies as early as in the peri-conception. [ABSTRACT FROM AUTHOR]

Personal motivation is a key factor in the service of foster care, impending both on the welfare of the child and on the satisfaction of the carer. This paper explores the benefits, challenges and dilemmas involved in the job of professional (i.e. state-supported) foster carer in Romania–a country where the issue of child protection has drawn a great deal of international attention over the last thirty years. The principal hypothesis concerns whether the benefits, challenges and dilemmas identified by foster carers are influenced by the factors that led to their taking up this kind of work. Quantitative research was conducted using a questionnaire as the main tool. The paper takes a descriptive, cross-sectional and multifactorial approach. Sampling was carried out by self-selecting method, and the study involved 51 participants. The research project identified a statistically significant variation in the challenges and dilemmas reported by foster carers. Thus, the results of the study show that the majority of the carers indicate a primarily intrinsic motivation for their work. By way of conclusion, it is argued that social workers, operating in collaboration with multidisciplinary teams, can offer carers support in managing more difficult periods in the child–carer relationship, thus enhancing the sustainability of the foster care service. [ABSTRACT FROM AUTHOR]

Reward delay impulsivity is a feature of attention deficit/hyperactivity disorder (ADHD) and a likely feature of loss of control eating (LOC-E), which might explain the higher risk of children with ADHD or LOC-E to become obese. The goal of this study was to investigate reward delay impulsivity in children with LOC-E, ADHD, or a double diagnosis, in contrast to healthy children. Children (8 to 13 years) with LOC-E (n = 24), ADHD (n = 33), a double diagnosis (n = 9), and healthy children (n = 34) performed a computer game (door opening task [DOT]) and the delay of gratification task (DoGT) to assess food related facets of reward delay impulsivity. In addition, children reported whether they worried to lose control over eating during the DoGT. There were no group differences in the DOT. However, children with ADHD or a double diagnosis had a significantly higher risk to eat prematurely during the DoGT than children with LOC-E, who were not significantly different from healthy children. Children with a double diagnosis were most likely to worry about losing control over eating during the DoGT, followed by children with LOC-E, and both had a significantly higher probability to worry than healthy children. For children with a double diagnosis the probability to worry was significantly higher than for children with ADHD. If replicated, these findings point to a special relevance of reward delay impulsivity in children with ADHD or a double diagnosis, compared to children with LOC-E. ADHD should be regularly assessed in children with LOC-E. [ABSTRACT FROM AUTHOR]

Background: Encephalitis, characterised as inflammation of the brain tissue, is an important cause of acquired brain injury in children. Objective clinical outcomes vary significantly between affected patients, however they do not always correlate with quality of life as reported by parents. The aim of this study was to explore how parents experience and interpret outcomes in relation to their child who has been affected by encephalitis. Methods: Data were derived from in-depth, semi-structured interviews, with 15 parents of 12 children and young people affected by encephalitis. Paediatric cases were identified from the retrospective arm of the research programme ‘ENCEPH-UK-Understanding and Improving the Outcome of Encephalitis’, and from the prospective UK childhood meningitis and encephalitis cohort study (UK-ChiMES, 2012 to 2016). Data were analysed thematically. Results: Parents’ perspectives on important outcomes for their child and family changed during the different stages of the encephalitis illness trajectory: from acute illness, recovery and rehabilitation, then reintegration into everyday life. Parents’ understanding of their children’s overall outcome was informed by their own experiences, involving comparisons with other children and reflections on their child’s problems before, during and after the acute illness. Conclusion: Outcomes in paediatric encephalitis need to be understood in terms of the context of the patient and family experience as well as the timeframe of recovery. The research highlights the need to include more patient, parent and/or carer reported outcome measures during patient assessment, and that assessment should be repeated during recovery as family concerns change. In the longer term, these parameters could be included in clinical and rehabilitation practice to further support child recovery. [ABSTRACT FROM AUTHOR]

Introduction: Auditory processing disorders can negatively affect academic performance in children. They can result from a number of aetiologies, including the human immunodeficiency virus (HIV). Although studies in paediatrics are limited, research suggests that HIV-infected children display poorer auditory processing skills than uninfected children. Methods: The aims of this study were to scan the peer-reviewed literature on auditory processing skills in HIV-infected children, to describe how auditory processing was tested, how auditory processing skills were reported, and to identify gaps in current evidence. This systematic scoping review was conducted using a modified version of Arksey and O’Malley’s framework. Key words comprised ‘HIV’, ‘auditory processing’, ‘hearing’ and ‘child’. Electronic databases were searched for relevant articles published from 1 January 2000 to 30 April 2018, and reference lists of included studies were pearled. Two researchers reviewed the articles and extracted data on sample descriptors, auditory processing testing procedures, and auditory processing skills. A third author collated the results and resolved discrepancies. The American Speech-Language-Hearing Association description of auditory processing skills framed the analysis. Results: Five articles were included in this review (three from Brazil, one each from Mexico and Tanzania). Samples, and methods of testing were heterogeneous. Three studies reported on localization abilities, while gap detection thresholds, performance on dichotic tasks and speech discrimination scores were reported in one article each. No one study tested all areas of auditory processing skills and there was limited information about the auditory processing skills required for learning. Conclusion: This review highlighted the current sparse evidence-base for auditory processing in HIV-infected children. It identified the need to standardise testing procedures, measures of auditory processing skills, and sample selection. [ABSTRACT FROM AUTHOR]

Introduction: While parents’ construction of and actions around child growth are embedded in their cultural framework, the discourse on child growth monitoring (CGM) has been using indicators grounded in the biomedical model. We believe that for CGM to be effective, it should also incorporate other relevant socio-cultural constructs. To contribute to the further development of CGM to ensure that it reflects the local context, we report on the cultural conceptualization of healthy child growth in rural Tanzania. Specifically, we examine how caregivers describe and recognize healthy growth in young children, and the meanings they attach to these cultural markers of healthy growth. Methods: Caregivers of under-five children, including mothers, fathers, elderly women, and community health workers, were recruited from a rural community in Kilosa District, Southeastern Tanzania. Using an ethnographic approach and the cultural schemas theory, data for the study were collected through 19 focus group discussions, 30 in-depth interviews, and five key informant interviews. Both inductive and deductive approaches were used in the data analysis. Results: Participants reported using multiple markers for ascertaining healthy growth. These include ‘being bonge’ (chubby), ‘being free of illness’, ‘eating well’, ‘growing in height’, as well as ‘having good kilos’ (weight). Despite the integration of some biomedical concepts into the local conceptualization of growth, the meanings attached to these concepts are largely rooted in the participants’ cultural framework. For instance, a child’s weight is ascribed to the parents’ adherence to postpartum sex taboos and to the nature of a child’s bones. The study noted conceptual differences between the meanings attached to height from a biomedical and a local perspective. Whereas from a biomedical perspective the height increment is considered an outcome of growth, the participants did not see height as linked to nutrition, and did not believe that they have control over their child’s height. Conclusions: To provide context-sensitive advice to mothers during CGM appointments, health workers should use a tool that takes into account the mothers’ constructs derived from their cultural framework of healthy growth. The use of this approach should facilitate communication between health professionals and caregivers during CGM activities, increase the uptake and utilization of CGM services, and, eventually, contribute to reduced levels of childhood malnutrition in the community. [ABSTRACT FROM AUTHOR]

Background: This study sought understand how the 2014–2016 EVD Virus Disease (EVD) outbreak impacted the nutrition sector in Sierra Leone and use findings for improving nutrition responses during future outbreaks of this magnitude. Methodology: This qualitative study was iterative and emergent. In-depth interviews (n = 42) were conducted over two phases by purposively sampling both key informants (n = 21; government stakeholders, management staff from United Nations (UN) agencies and non-governmental organizations (NGO)), as well as community informants (n = 21; EVD survivors, health workers, community leaders) until data saturation. Multiple analysts collaborated in a team-based coding approach to identify key themes using Dedoose software. Findings are presented as both quotations and tables/figures. Results: The EVD outbreak effects and the related response strategies, especially movement restriction policies including 21-day quarantines, contributed to disruptions across the food value-chain in Sierra Leone. System-wide impacts were similar to those typically seen in large-scale disasters such as earthquakes. Participants described an array of direct and indirect effects on agricultural production and food storage and processing, as well as on distribution, transport, trade, and retailing. Secondary data were triangulated by interviews which described the aggregate negative effect of this outbreak on key pillars of food security, infant and young child feeding practices, and nutrition. During the humanitarian response, nutrition-specific interventions, including food assistance, were highly accepted, although sharing was reported. Despite EVD impacts across the entire food value-chain, nutrition-sensitive interventions were not central to the initial response as EVD containment and survival took priority. Culturally-appropriate social and behavior change communications were a critical response component for improving health, nutrition, and hygiene-related behaviors through community engagement. Conclusions: Infectious diseases such as EVD have far-reaching effects that impact health and nutrition through interrelated pathways. In Sierra Leone, the entire food value-chain was broken to the extent that the system-wide damage was on par with that typically resulting from large natural disasters. A food value-chain approach, at minimum, offers a foundational framework from which to position nutrition preparedness and response efforts for outbreaks in similar resource constrained settings. [ABSTRACT FROM AUTHOR]

Social stress and inflammatory processes are strong regulators of one another. Considerable evidence shows that social threats trigger inflammatory responses that increase infection susceptibility in both humans and animals, while infectious disease triggers inflammation that in turn regulates social behaviours. However, no previous study has examined whether young children’s popularity and their rate of infectious disease are associated. We investigated the longitudinal bidirectional links between children’s popularity status as perceived by peers, and parent reports of a variety of infectious diseases that are common in early childhood (i.e. common cold as well as eye, ear, throat, lung and gastric infections). We used data from the ‘Matter of the First Friendship Study’ (MOFF), a longitudinal prospective multi-informant study, following 579 Norwegian pre-schoolers (292 girls, median age at baseline = six years) with annual assessments over a period of three years. Social network analysis was used to estimate each child’s level of popularity. Cross-lagged autoregressive analyses revealed negative dose–response relations between children’s popularity scores and subsequent infection (b = –0.18, CI = –0.29, –0.06, and b = –0.13, CI = –0.23, –0.03). In conclusion, the results suggest that children who are unpopular in early childhood are at increased risk of contracting infection the following year. [ABSTRACT FROM AUTHOR]

Background: Preterm infants are at increased risk of infections including vaccine preventable diseases. Therefore, timely vaccination is crucial to ensure adequate disease protection. Information on whether preterm infants are vaccinated according to chronological age as recommended is limited in low-income countries. Objectives: We evaluated the timeliness of vaccination and associated factors among preterm infants at Mulago hospital, Uganda. Methods: We conducted a mixed methods study between July 2016 and April 2017. Vaccination dates of preterm infants aged 6–24 months were obtained from child health cards. Additional data were collected using a questionnaire. Five key informant interviews with health workers and two focus group discussions with caregivers were conducted. Cox regression analysis was used to identify factors associated with vaccination timeliness. Qualitative data was transcribed and analysed manually using content thematic approach. Results: We enrolled 350 preterm infants, with a median age of 8.4 months (IQR 6.8–10.8). Less than half, 149/350 (42.6%) of infants received all vaccines within the recommended time range. Timely vaccination was highest for BCG (92%) and lowest for OPV (45.4%). Untimely vaccination was highest for vaccines administered at 6 weeks (DPT 1, PCV 1 and OPV 1) compared to other vaccines in the EPI schedule. Delivering from home or private clinics and vaccine stock-out were significantly associated with untimely BCG and OPV 0 vaccination. Low maternal education level and being very preterm were associated with untimely DPT 1 and DPT 3 receipt. Admission and long stay in the neonatal unit were associated with untimely DPT 1 receipt while extreme low birth weight was associated with untimely DPT 3 vaccination. Increasing parity was associated with untimely measles vaccination. Qualitative findings revealed that lack of knowledge and poor attitudes of health workers and caregivers, gaps in documentation of vaccination status and inadequate communication by health workers hindered timely vaccination. Conclusion: More than half of preterm infants attending a specialised clinic at Mulago National Referral hospital in Uganda did not receive vaccines within the recommended time range. Specific strategies to improve vaccination timeliness in preterm infants are needed especially among the extremely low birth weight, very preterm and those with prolonged hospitalisation. [ABSTRACT FROM AUTHOR]

Choosing a valid and feasible method to measure child developmental outcomes is key to addressing developmental delays, which have been shown to be associated with high levels of unemployment, participation in crime, and teen pregnancies. However, measuring early childhood development (ECD) with multi-dimensional diagnostic tests such as the Bayley Scales of Infant and Toddler Development III (Bayley-III) can be time-consuming and expensive; therefore, parental screening tools such as the Ages and Stages Questionnaire (ASQ-3) are frequently an alternative measure of early childhood development in large-scale research. The ASQ is also becoming more frequently used as the first step to identify children at risk for developmental delays before conducting a diagnostic test to confirm. However, the effectiveness of the ASQ-3 is uncertain. In this study, we evaluate the accuracy of the ASQ-3 as a screening measure for children at risk of developmental delay in rural China by age group. To do so, we administered the Bayley-III, widely considered to be the “gold standard” of ECD diagnostic tests, to a sample of 1,831 five to twenty-four month-old children and also administered the ASQ-3 to their caregivers. We then compared the outcomes of the ASQ-3 test to those of the Bayley-III. We find that the ASQ-3 was significantly though weakly correlated with the Bayley-III and that the strength of this correlation increased with child age and was stronger when the mother was the primary caregiver (as compared to the grandmother). We also find that the sensitivity and specificity of ASQ-3 ranged widely. The overall findings suggest that the ASQ-3 may not be a very accurate screening tool for identifying developmentally delayed children, especially for children under 13 months of age or children whose primary caregiver is not the mother. [ABSTRACT FROM AUTHOR]

Background: True burden of tuberculosis (TB) in children is unknown. Hospitalised children are low-hanging fruit for TB case detection as they are within the system. We aimed to explore the process of recognition and investigation for childhood TB using a guideline-linked cascade of care. Methods: This was an observational study of 42,107 children admitted to 13 county hospitals in Kenya from 01Nov 15-31Oct 16, and 01Nov 17-31Oct 18. We estimated those that met each step of the cascade, those with an apparent (or “Working”) TB diagnosis and modelled associations with TB tests amongst guideline-eligible children. Results: 23,741/42,107 (56.4%) met step 1 of the cascade (≥2 signs and symptoms suggestive of TB). Step 2(further screening of history of TB contact/full respiratory exam) was documented in 14,873/23,741 (62.6%) who met Step 1. Step 3(chest x-ray or Mantoux test) was requested in 2,451/14,873 (16.5%) who met Step 2. Step 4(≥1 bacteriological test) was requested in 392/2,451 (15.9%) who met Step 3. Step 5(“Working TB” diagnosis) was documented in 175/392 (44.6%) who met Step 4. Factors associated with request of TB tests in patients who met Step 1 included: i) older children [AOR 1.19(CI 1.09–1.31)]; ii) co-morbidities of HIV, malnutrition or pneumonia [AOR 3.81(CI 3.05–4.75), 2.98(CI 2.69–3.31) and 2.98(CI 2.60–3.40) respectively]; iii) sicker children, readmitted/referred [AOR 1.24(CI 1.08–1.42) and 1.15(CI 1.04–1.28) respectively]. “Working TB” diagnosis was made in 2.9%(1,202/42,107) of all admissions and 0.2%(89/42,107) were bacteriologically-confirmed. Conclusions: More than half of all paediatric admissions had symptoms associated with TB and nearly two-thirds had more specific history documented. Only a few amongst them got TB tests requested. TB was diagnosed in 2.9% of all admissions but most were inadequately investigated. Major challenges remain in identifying and investigating TB in children in hospitals with access to Xpert MTB/RIF and a review is needed of existing guidelines. [ABSTRACT FROM AUTHOR]

Background: In Bangladesh, neonatal sepsis is the cause of 24% of neonatal deaths, over 65% of which occur in the early-newborn stage (0-6 days). Only 50% of newborns in Bangladesh initiated breastfeeding within 1 hour of birth. The mechanism by which early initiation of breastfeeding reduces neonatal deaths is unclear, although the most likely pathway is by decreasing severe illnesses leading to sepsis. This study explores the effect of breastfeeding initiation time on early newborn danger signs and severe illness.Methods and Findings: We used data from a community-based trial in Bangladesh in which we enrolled pregnant women from 2013 through 2015 covering 30,646 newborns. Severe illness was defined using newborn danger signs reported by The Young Infants Clinical Science Study Group. We categorized the timing of initiation as within 1 hour, 1 to 24 hours, 24 to 48 hours, ≥48 hours of birth, and never breastfed. The analysis includes descriptive statistics, risk attribution, and multivariable mixed-effects logistic regression while adjusting for the clustering effects of the trial design, and maternal/infant characteristics. In total, 29,873 live births had information on breastfeeding among whom 19,914 (66.7%) initiated within 1 hour of birth, and 4,437 (14.8%) neonates had a severe illness by the seventh day after birth. The mean time to initiation was 3.8 hours (SD 16.6 hours). The proportion of children with severe illness increased as the delay in initiation increased from 1 hour (12.0%), 24 hours (15.7%), 48 hours (27.7%), and more than 48 hours (36.7%) after birth. These observations would correspond to a possible reduction by 15.9% (95% CI 13.2-25.9, p < 0.001) of severe illness in a real world population in which all newborns had breastfeeding initiated within 1 hour of birth. Children who initiated after 48 hours (odds ratio [OR] 4.13, 95% CI 3.48-4.89, p < 0.001) and children who never initiated (OR 4.77, 95% CI 3.52-6.47, p < 0.001) had the highest odds of having severe illness. The main limitation of this study is the potential for misclassification because of using mothers' report of newborn danger signs. There could be a potential for recall bias for mothers of newborns who died after being born alive.Conclusions: Breastfeeding initiation within the first hour of birth is significantly associated with severe illness in the early newborn period. Interventions to promote early breastfeeding initiation should be tailored for populations in which newborns are delivered at home by unskilled attendants, the rate of low birth weight (LBW) is high, and postnatal care is limited.Trial Registration: Trial Registration number: anzctr.org.au ID ACTRN12612000588897. [ABSTRACT FROM AUTHOR]

Background: Evidence on the association between breastfeeding and later childhood obesity and blood pressure (BP) is inconsistent, especially in HIV-prevalent areas where, until recently, HIV-infected women were discouraged from breastfeeding, but obesity is increasingly prevalent.Methods and Findings: The Siyakhula cohort (2012-2014), a population-based prospective cohort study, collected data over 3 visits on HIV-negative children ages 7 to 11 years in rural South Africa. We used weight (body mass index [BMI]), fat, and BP as outcome variables and incorporated early life (including mother's age at delivery and HIV status) and current life factors (including maternal education and current BMI). Our primary exposure was breastfeeding duration. We dichotomized 3 outcome measures using pre-established thresholds for clinical interpretability: (1) overfat: ≥85th percentile of body fat; (2) overweight: >1 SD BMI z score; and (3) prehypertension: ≥90th percentile for systolic BP (SBP) or diastolic BP (DBP). We modelled each outcome using multivariable logistic regression, including stopping breastfeeding, then early life, and finally current life factors. Of 1,536 children (mean age = 9.3 years; 872 girls; 664 boys), 7% were overfat, 13.2% overweight, and 9.1% prehypertensive. Over half (60%) of the mothers reported continued breastfeeding for 12+ months. In multivariable analyses, continued breastfeeding between 6 and 11 months was associated with approximately halved odds of both being overfat (adjusted odds ratio [aOR] = 0.43, 95% confidence interval [CI] 0.21-0.91, P = 0.027) and overweight (aOR = 0.46, CI 0.26-0.82, P = 0.0083), but the association with prehypertension did not reach statistical significance (aOR = 0.72, CI 0.38-1.37, P = 0.32). Children with a mother who was currently obese were 5 times more likely (aOR = 5.02, CI 2.47-10.20, P < 0.001) to be overfat and over 4 times more likely to be overweight (aOR = 4.33, CI 2.65-7.09, P < 0.001) than children with normal weight mothers. Differences between HIV-exposed and unexposed children on any of the outcomes were minimal and not significant. The main study limitation was that duration of breastfeeding was based on maternal recall.Conclusions: To our knowledge, this is the first study examining and quantifying the association between breastfeeding and childhood obesity in an African setting with high HIV prevalence. We observed that breastfeeding was independently associated with reduced childhood obesity for both HIV-exposed and unexposed children, suggesting that promoting optimal nutrition throughout the life course, starting with continued breastfeeding, may be critical to tackling the growing obesity epidemic. In the era of widespread effective antiretroviral treatment for HIV-infected women for life, these data further support the recommendation of breastfeeding for all women. [ABSTRACT FROM AUTHOR]

The Guest Editors for the PLOS Medicine Special Issue on Maternal and Child Health & Nutrition discuss the published research in the context of global priorities for women's and children's health. [ABSTRACT FROM AUTHOR]

Background: Community management of acute malnutrition (CMAM) is a highly efficacious approach for treating acute malnutrition (AM) in children who would otherwise be at significantly increased risk of mortality. In program settings, however, CMAM's effectiveness is limited because of low screening coverage of AM, in part because of the lack of perceived benefits for caregivers. In Burkina Faso, monthly screening for AM of children <2 years of age is conducted during well-baby consultations (consultation du nourrisson sain [CNS]) at health centers. We hypothesized that the integration of a preventive package including age-appropriate behavior change communication (BCC) on nutrition, health, and hygiene practices and a monthly supply of small-quantity lipid-based nutrient supplements (SQ-LNSs) to the monthly screening would increase AM screening and treatment coverage and decrease the incidence and prevalence of AM.Methods and Findings: We used a cluster-randomized controlled trial and allocated 16 health centers to the intervention group and 16 to a comparison group. Both groups had access to standard CMAM and CNS services; caregivers in the intervention group also received age-appropriate monthly BCC and SQ-LNS for children >6 months of age. We used two study designs: (1) a repeated cross-sectional study of children 0-17 months old (n = 2,318 and 2,317 at baseline and endline 2 years later) to assess impacts on AM screening coverage, treatment coverage, and prevalence; (2) a longitudinal study of 2,113 children enrolled soon after birth and followed up monthly for 18 months to assess impacts on AM screening coverage, treatment coverage, and incidence. Data were analyzed as intent to treat. Level of significance for primary outcomes was α = 0.016 after adjustment for multiple testing. Children's average age was 8.8 ± 4.9 months in the intervention group and 8.9 ± 5.0 months in the comparison group at baseline and, respectively, 0.66 ± 0.32 and 0.67 ± 0.33 months at enrollment in the longitudinal study. Relative to the comparison group, the intervention group had significantly higher monthly AM screening coverage (cross-sectional study: +18 percentage points [pp], 95% CI 10-26, P < 0.001; longitudinal study: +23 pp, 95% CI 17-29, P < 0.001). There were no impacts on either AM treatment coverage (cross-sectional study: +8.0 pp, 95% CI 0.09-16, P = 0.047; longitudinal study: +7.7 pp, 95% CI -1.2 to 17, P = 0.090), AM incidence (longitudinal study: incidence rate ratio = 0.98, 95% CI 0.75-1.3, P = 0.88), or AM prevalence (cross-sectional study: -0.46 pp, 95% CI -4.4 to 3.5, P = 0.82). A study limitation is the referral of AM cases (for ethical reasons) by study enumerators as part of the monthly measurement in the longitudinal study that may have attenuated the detectable impact on AM treatment coverage.Conclusions: Adding a preventive package to CMAM delivered at health facilities in Burkina Faso increased participation in monthly AM screening, thus overcoming a major impediment to CMAM effectiveness. The lack of impact on AM treatment coverage and on AM prevalence and incidence calls for research to address the remaining barriers to uptake of preventive and treatment services at the health center and to identify and test complementary approaches to bring integrated preventive and CMAM services closer to the community while ensuring high-quality implementation and service delivery.Trial Registration: ClinicalTrials.gov NCT02245152. [ABSTRACT FROM AUTHOR]

Background: Children with uncomplicated severe acute malnutrition (SAM) are treated at home with ready-to-use therapeutic foods (RUTFs). The current RUTF dose is prescribed according to the weight of the child to fulfil 100% of their nutritional needs until discharge. However, there is doubt concerning the dose, as it seems to be shared, resulting in suboptimal cost-efficiency of SAM treatment. We investigated the efficacy of a reduced RUTF dose in community-based treatment of uncomplicated SAM.Methods and Findings: We undertook a randomised trial testing the non-inferiority of weight gain velocity of children with SAM receiving (a) a standard RUTF dose for two weeks, followed by a reduced dose thereafter (reduced), compared with (b) a standard RUTF dose throughout the treatment (standard). A mean difference of 0.0 g/kg/day was expected, with a non-inferiority margin fixed at -0.5 g/kg/day. Linear and logistic mixed regression analyses were performed, with study site and team as random effects. Between October 2016 and July 2018, 801 children with uncomplicated SAM aged 6-59 months were enrolled from 10 community health centres in Burkina Faso. At admission, the mean age (± standard deviation [SD]) was 13.4 months (±8.7), 49% were male, and the mean weight was 6.2 kg (±1.3). The mean weight gain velocity from admission to discharge was 3.4 g/kg/day and did not differ between study arms (Δ 0.0 g/kg/day; 95% CI -0.4 to 0.4; p = 0.92) confirming non-inferiority (p = 0.013). However, after two weeks, the weight gain velocity was significantly lower in the reduced dose with a mean of 2.3 g/kg/day compared with 2.7 g/kg/day in the standard dose (Δ -0.4 g/kg/day; 95% CI -0.8 to -0.02; p = 0.041). The length of stay (LoS) was not different (p = 0.73) between groups with a median of 56 days (interquartile range [IQR] 35-91) in both arms. No differences were found between reduced and standard arm in recovery (52.7% and 55.4%; p = 0.45), referral (19.2% and 20.1%; p = 0.80), defaulter (12.2% and 8.5%; p = 0.088), non-response (12.7% and 12.5%; p = 0.95), and relapse (2.4% and 1.8%; p = 0.69) rates, respectively. However, the reduced RUTF dose had a small 0.2 mm/week (95% CI 0.04 to 0.4; p = 0.015) negative effect on height gain velocity with a mean height gain of 2.6 mm/week with reduced and 2.8 mm/week with standard RUTF dose. The impact was more pronounced in children under 12 months of age (interaction, p = 0.019) who gained 2.8 mm/week with reduced and 3.1 mm/week with standard dose (Δ -0.4 mm/week; 95% CI -0.6 to -0.2; p < 0.001). Limitations include not blinding participants to the RUTF dose received and excluding all children with negative appetite test. The results are generalisable for relatively food secure contexts with a young SAM population.Conclusions: Reducing the RUTF dose provided to children with SAM after two weeks of treatment did not reduce overall weight or mid-upper arm circumference (MUAC) gain velocity nor affect recovery or lengthen treatment time. However, it led to a small but significant negative effect on linear growth, especially among the youngest. The potential effect of reducing the RUTF dose in a routine program on treatment outcomes should be evaluated before scaling up.Trial Registration: ISRCTN registry ISRCTN50039021. [ABSTRACT FROM AUTHOR]

Objective: Our main objective was to examine if parental prenatal preferences predict delivery-room management of extremely preterm periviable infants. The secondary objectives were to describe parental involvement and the content of prenatal counseling given to parents for this prenatal decision. Design: Prospective study of neonates liveborn between 22 and 26 weeks of gestation in France in 2011 among the neonates included in the EPIPAGE-2 study Setting: 18 centers participating in the “Extreme Prematurity Group” substudy of the EPIPAGE-2 study. Patients: 302 neonates liveborn between 22–26 weeks among which 113 with known parental preferences while parental preferences were unknown or unavailable for 186 and delivery room management was missing for 3. Results: Data on prenatal counseling and parental preferences were collected by a questionnaire completed by professionals who cared for the baby at birth; delivery room (DR) management, classified as stabilization or initiation of resuscitation (SIR) vs comfort care (CC). The 113 neonates studied had a mean (SD) gestational age of 24 (0.1) weeks. Parents of neonates in the CC group preferred SIR less frequently than those with neonates in the SIR group (16% vs 88%, p < .001). After multivariate analysis, preference for SIR was an independent factor associated with this management. Professionals qualified decisions as shared (81%), exclusively medical (16%) or parental (3%). Information was described as medical with no personal opinion (71%), complete (75%) and generally pessimistic (54%). Conclusion: Parental involvement in prenatal decision-making did not reach satisfying rates in the studied setting. When available, prenatal parental preference was a determining factor for DR management of extremely preterm neonates. Potential biases in the content of prenatal counselling given to parents need to be evaluated. [ABSTRACT FROM AUTHOR]

Background: Prenatal antibiotic exposure induces changes in infants’ gut microbiota composition and is suggested as a possible contributor in the development of autism spectrum disorders (ASD). In this study, we examined the association between prenatal antibiotic exposure and the risk of ASD. Methods: This was a population-based cohort study utilizing the Manitoba Population Research Data Repository. The cohort included 214 834 children born in Manitoba, Canada between April 1, 1998 and March 31, 2016. Exposure was defined as having filled one or more antibiotic prescription during pregnancy. The outcome was autism spectrum disorder diagnosis. Multivariable Cox proportional hazards regression was used to estimate the risk of developing ASD in the overall cohort and in a sibling cohort. Results: Of all subjects, 80 750 (37.6%) were exposed to antibiotics prenatally. During follow-up, 2965 children received an ASD diagnosis. Compared to children who were not exposed to antibiotics prenatally, those who were exposed had a higher risk of ASD: (adjusted HR 1.10 [95% CI 1.01, 1.19]). The association was observed in those exposed to antibiotics in the second or third trimester (HR 1.11 [95% CI 1.01, 1.23] and 1.17 [95% CI 1.06, 1.30], respectively). In the siblings’ cohort, ASD risk estimate remained unchanged (adjusted HR 1.08 [95% CI 0.90, 1.30], although it was not statistically significant. Conclusions: Prenatal antibiotic exposure is associated with a small increase in the risk of ASD. Given the potential of residual confounding beyond what it was controlled through our study design and because of possible confounding by indication, such a small risk increase in the population is not expected to be clinically significant. [ABSTRACT FROM AUTHOR]

Background: Although the perinatal mortality rate (PNMR) has been reduced over time in Bangladesh, the rate is still very high. Only a few studies explored the determinants of high PNMR in Bangladesh, yet most of them were small-scale or conducted for stillbirths and early neonatal deaths separately. The objective of this study was to explore the trends in and determinants of perinatal deaths in Bangladesh which would be an advanced step in effective policies to tackle the issue. Methods: The data used for this study was extracted from four rounds of Bangladesh Demographic and Health Surveys (BDHSs) 2004, 2007, 2011 and 2014. We considered the outcome of the 26604 pregnancies reaching seven months of their gestation. The trends of perinatal mortality was assessed using the Cochran–Armitage test, while the logistic regression with generalized estimating equation (GEE) to account for the clustering effect was implemented to explore the association between perinatal mortality and its risk factors. Results: The PNMR was significantly reduced from 64 (95% CI: 57–73) to 41 (95% CI: 35–48) per 1000 pregnancies between 2004 and 2014 (stillbirths: 34 to 19 and early neonatal deaths: 30 to 22). After adjusting for potential covariates in the model, we found that administrative division, type of cooking fuel, child’s gender, maternal occupation, body mass index, birth interval, history of miscarriage, previous deaths of children, total number of under 5 children, mode of delivery, type of delivery, access to participation in decision making, paternal education and occupation were significantly associated with perinatal deaths. Conclusion: The study highlights the importance of strengthening proper postnatal care services in the healthcare facilities. Alongside this, effort should also be stressed to ensure proper pregnancy care and to improve the socio-economic condition of the households to address the issue. [ABSTRACT FROM AUTHOR]

Objectives: The Norwegian randomized controlled trial Early Food for Future Health provided parental anticipatory guidance on early protective feeding practices from child age 6 to 12 months through an eHealth intervention. Previously published outcomes at child age 12 months indicated that the eHealth intervention increased daily vegetable/fruit intake and promoted more beneficial mealtime routines. The objective of the current paper is to evaluate the effects of the intervention at child age 24 months, one year after cessation. Methods: Parents of infants aged 3–5 months were recruited via social media and child health clinics during spring 2016. At child age 5.5 months, 715 mothers were randomized to either control (n = 358) or intervention (n = 360) arm. Primary study-outcomes were child eating behaviors, dietary intake, mealtime routines and maternal feeding practices and feeding styles. Secondary outcome was child anthropometry. Results: In total 295 mothers (41%) completed the follow-up questionnaire at child age 24 months. Regarding fruit intake, 54.3% in the intervention group had a high score compared with 48.3% of the control group (p = 0.29). For intake of vegetables, 54.5% in the intervention group had a high score compared with 50.7% in the control group (p = 0.49). A total of 65.7% of the children in the intervention group were eating breakfast together with family ≥ 4 times per week, compared with 57.3% of the children in the control group (p = 0.12). There was no difference between the groups for child anthropometric outcomes at child age 24 months. Conclusions: At child age 24 months, we found no evidence of sustained intervention-effects. Although dietary patterns and mealtime routines at child age 24 months were reasonably consistent and in the same directions as at child age 12 months, the between-group differences were not significant. The large loss to follow-up may have limited power and validity and makes it difficult to draw overall conclusions. Future research is needed to improve knowledge of how short-time effects could be retained over longer term, taking into account that larger samples are necessary when planning longer-term follow-up studies. Trial registration: ISRCTN, . [ABSTRACT FROM AUTHOR]

China relaxed its family planning policy and adopted a universal two-child policy on January 1, 2016 to actively address the country’s aging trend. However, the policy has failed to have any significant effect on the fertility rate of many provinces. In light of the country having the highest sex ratio at birth in the world and the huge burden of the aging population, improving the fertility rate is an urgent priority in China. This facility-based cross-sectional survey aimed to study determinants of fertility decision-making among couples based on the Theory of Planned Behavior. The study was conducted in Inner Mongolia Autonomous Region of China. A structured self-administered questionnaire was completed by 1,399 couples, consisting of wives aged 20–49 years and their husbands. Based on the structural equation modeling method of analysis, determinants of fertility decision-making were perceived behavior control (perceived importance of having a stable income and cost of raising a child), subjective norms (perceived social pressure about “sex preference of the newborn by themselves and their partner”) and attitudes (only healthy parents can have a child). Other significant factors influencing fertility decision were ethnicity and education level, with ethnic minority couples having less perception of social norm towards fertility and those with higher education having higher perceived control toward having a (further) child. The study reveals the importance of the China’s infrastructure and public facilities to support child-rearing to increase the fertility rate among couples of child-bearing age, which in turn will reduce the burden associated with an aging society. [ABSTRACT FROM AUTHOR]

Different guidelines are adopted in clinics and countries to assess pure tone hearing sensitivity in children with otitis media with effusion (OME). Some guidelines specify a broad range of audiometric frequencies that must be tested and from which average thresholds determined, while others leave test frequencies unspecified. For guidelines that suggest specific frequencies there are various pure tone frequencies and frequency ranges given. The present study investigated whether (1) a full range of audiometric frequencies is required to evaluate hearing loss caused by OME in children, or if neighboring frequencies provide essentially the same threshold information, and (2) if different combinations of test frequency pure tone averaging calculations may affect decision criteria for surgical treatment. In a retrospective cohort study, right and left ear air conduction pure tone threshold data were obtained, from 125 Hz to 8 kHz, for 96 children with OME aged 4 to 12 years. Paired t-tests, correlation tests (Pearson’s r, Cronbach’s alpha, intraclass correlation) and absolute differences were used to examine the relationships among pure tone audiometric (PTA) frequencies for all ears with hearing loss. 168 ears were found to have OME-related hearing loss. Only the 125 Hz—250 Hz comparison showed no statistically significant difference between neighboring thresholds. However, only the 4 kHz and 8 kHz comparison showed a clinically significant mean difference of ≥ 10 dB. When viewing individual differences, comparison between 250 Hz and 500 Hz, 125 Hz and 500 Hz, and 4 kHz and 8 kHz, showed a large number of ears with clinically significant differences between test frequencies. Comparisons among low frequency 3 PTA average (500 Hz, 1 kHz, 2 kHz), high frequency 3 PTA average (1 kHz, 2 kHz, 4 kHz), and 4 frequency PTA average (500 Hz, 1 kHz, 2 kHz, 4 kHz) showed no statistically significant differences, with very strong correlations for all comparisons. In addition, for all the combinations of PTA averages, no clinically significant differences were found for the various comparisons or among individual results. Clinically, testing hearing sensitivity in the 125 Hz to 8 kHz range is worthwhile in evaluating hearing sensitivity in children with OME due to large individual variability across audiometric frequencies. However, frequencies tested for criterion averages for surgical treatments of children with OME may be restricted to 3 frequency PTA averages, either an average of 500 Hz, 1 kHz, 2 kHz or an average of 1 kHz, 2 kHz, 4 kHz, as no clinically significant differences were found using these or a 4 frequency averaging technique. For research purposes, 250 Hz can proxy for hearing thresholds at 125 Hz; and the low frequency 3 PTA average, high frequency 3 PTA average and 4 frequency PTA average may be used interchangeably, as no statistically significant differences were found among these measures. [ABSTRACT FROM AUTHOR]

Background: Accelerated growth in early childhood is an established risk factor for later obesity and cardiometabolic disease, but the relative importance of fat mass (FM) and fat-free mass (FFM) accretion is not well understood. We aimed to study how FM and FFM at birth and their accretion during infancy were associated with body composition and cardiometabolic risk markers at 5 years.Methods and Findings: Healthy children born at term were enrolled in the Infant Anthropometry and Body Composition (iABC) birth cohort between December 2008 and October 2012 at Jimma University Specialized Hospital in the city of Jimma, Ethiopia. FM and FFM were assessed using air displacement plethysmography a median of 6 times between birth and 6 months of age. In 507 children, we estimated individual FM and FFM at birth and their accretion over 0-3 and 3-6 months of age using linear-spline mixed-effects modelling. We analysed associations of FM and FFM at birth and their accretion in infancy with height, waist circumference, FM, FFM, and cardiometabolic risk markers at 5 years using multiple linear regression analysis. A total of 340 children were studied at the 5-year follow-up (mean age: 60.0 months; girls: 50.3%; mean wealth index: 45.5 out of 100; breastfeeding status at 4.5 to 6 months post-partum: 12.5% exclusive, 21.4% almost exclusive, 60.6% predominant, 5.5% partial/none). Higher FM accretion in infancy was associated with higher FM and waist circumference at 5 years. For instance, 100-g/month higher FM accretion in the periods 0-3 and 3-6 months was associated with 339 g (95% CI: 243-435 g, p < 0.001) and 367 g (95% CI: 250-484 g, p < 0.001) greater FM at 5 years, respectively. Higher FM at birth and FM accretion from 0 to 3 months were associated with higher FFM and cholesterol concentrations at 5 years. Associations for cholesterol were strongest for low-density lipoprotein (LDL)-cholesterol, and remained significant after adjusting for current FM. A 100-g higher FM at birth and 100-g/month higher FM accretion from 0 to 3 months were associated with 0.16 mmol/l (95% CI: 0.05-0.26 mmol/l, p = 0.005) and 0.06 mmol/l (95% CI: 0.01-0.12 mmol/l, p = 0.016) higher LDL-cholesterol at 5 years, respectively. Higher FFM at birth and FFM accretion in infancy were associated with higher FM, FFM, waist circumference, and height at 5 years. For instance, 100-g/month higher FFM accretion in the periods 0-3 and 3-6 months was associated with 1,002 g (95% CI: 815-1,189 g, p < 0.001) and 624 g (95% CI: 419-829 g, p < 0.001) greater FFM at 5 years, respectively. We found no associations of FM and FFM growth with any of the other studied cardiometabolic markers including glucose, HbA1c, insulin, C-peptide, HOMA-IR, triglycerides, and blood pressure. Non-attendance at the 5-year follow-up visit was the main limitation of this study, which may have introduced selection bias and limited the power of the regression analyses.Conclusions: FM accretion in early life was positively associated with markers of adiposity and lipid metabolism, but not with blood pressure and cardiometabolic markers related to glucose homeostasis. FFM accretion was primarily related to linear growth and FFM at 5 years. [ABSTRACT FROM AUTHOR]

Background: Improving access to paediatric HIV treatment requires large-scale antiretroviral treatment programmes and medication adapted to infants and children’s needs. The World Health Organisation recommends lopinavir/ritonavir plus two nucleoside reverse transcriptase inhibitors as first-line treatment for all HIV-infected children younger than three years, usually given as a syrup. A pellet formulation (i.e. tiny cylinders of compressed medication put in capsules) was developed to overcome the syrup formulation’s disadvantages such as bitterness, toxicity and cold storage. This study assessed multi-level factors influencing caregivers’ acceptance of and adherence to lopinavir/ritonavir pellets as well as their underlying mechanisms. Methods: A realist evaluation (a theory-driven evaluation method considering the social context and mechanisms of change), embedded in a clinical trial was carried out in three hospital settings in Kenya. Data were collected through document review, observations (n = 34) in home and clinic settings and semi-structured interviews (n = 44) with caregivers and providers. Data analysis was based on realist principles. Results: High levels of treatment initiation and adherence were observed. Taste masking, neutral packaging and easy storage made the new formulation highly acceptable. Caregivers developed individual strategies to deliver the treatment, particularly to overcome specific problems e.g. in case of just-weaned babies or food shortage. A refined program theory emerged from the triangulated findings showing that ease of administration combined with increased self-efficacy and competences of the caregivers, and effective provider support contributed to high levels of adherence. Conclusions: Formulating combined antiretroviral treatment in the form of pellets is clearly a more acceptable solution for infants and children and their caregivers compared to the syrup. Further research in non-trial settings may shed light on factors related to providers, services and the health system that contribute to better adherence of such formulations. [ABSTRACT FROM AUTHOR]

Objective: Although under-five mortality rate (U5MR) is declining in India, it is still high in a few selected states and among the scheduled caste (SC) and scheduled tribe (ST) population of the country. This study re-examines the association between caste and under-five deaths in high focus Indian states following the implementation of the country's National Rural Health Mission (NRHM) program. In addition, we aim to quantify the contribution of socioeconomic determinants in explaining the gap in under-five death risk between the SC/ST population and non-SC/ST population in high focus states in India. Data and method: Using data from the National Family Health Survey (NFHS), we calculated the U5MR by applying a synthetic cohort probability approach. We applied a binary logistic regression model to examine the association of under-five deaths with the selected covariates. Further, we used Fairlie's decomposition technique to understand the relative contribution of socioeconomic variables on under-five death risk between the caste groups. Findings: In high focus Indian states, the under-five mortality risk between well-off and deprived caste children has declined in the post-NRHM period, indicating a positive impact in terms of reducing caste-based inequalities in the high focus states. Despite the reduction in under-five death risk, children belonging to the SC population experience higher mortality rates than children belonging to the non-SC/ST population from 1992 to 2016. Both macro level (district level mortality rates) and individual (regression analysis) analyses showed that children belonging to SCs experience the highest likelihood of dying before their fifth birthday. A decomposition analysis revealed that 83% of the caste-based gap in the under-five deaths is due to the distribution of women's level of educational attainment and household wealth between the SC/ST and non-SC/ST population. Program indicators such as place of birth and number of antenatal care (ANC) visit also contributed significantly to widening caste-based gaps in U5MR. Conclusion: The study indicates that there is still room to improve access to health facilities for mothers and children belonging to deprived caste groups in India. Continuous efforts to raise the level of maternal education and the economic status of people belonging to deprived caste groups should be pursued simultaneously. [ABSTRACT FROM AUTHOR]

Background: Treatment with nifurtimox (NF) for Chagas disease is discouraged during breast-feeding because no information on NF transfer into breast milk is available. NF is safe and effective for paediatric and adult Chagas disease. We evaluated the degree of NF transfer into breast milk in lactating women with Chagas disease. Patients and methods: Prospective study of a cohort of lactating women with Chagas disease. Patients were treated with NF for 1 month. NF was measured in plasma and milk by high performance liquid chromatography (HPLC). Breastfed infants were evaluated at admission, 7th and 30th day of treatment (and monthly thereafter, for 6 months). Results: Lactating women with chronic Chagas disease (N = 10) were enrolled (median age 28 years, range 17–36). Median NF dose was 9.75 mg/kg/day three times a day (TID). Six mothers had mild adverse drug reactions (ADRs), but no ADRs were observed in any of the breastfed infants. No interruption of breastfeeding was observed. Median NF concentrations were 2.15 mg/L (Inter quartil range (IQR) 1.32–4.55) in milk and 0.30 mg/L (IQR 0.20–0.95) in plasma. Median NF milk/plasma ratio was 16 (range 8.75–30.25). Median relative infant NF dose (assuming a daily breastmilk intake of 150 mL/kg/day) was 6.7% of the maternal dose/kg/day (IQR 2.35–7.19%). Conclusions: The low concentrations of NF in breast milk and the normal clinical evaluation of the breastfed babies imply that maternal NF treatment for Chagas disease during breastfeeding is unlikely to lead to clinically relevant exposures in the breastfed infants. Trial registration: Clinical trial registry name and registration number: ClinicalTrials.gov . [ABSTRACT FROM AUTHOR]

Amita Gupta and colleagues discuss priorities in clinical research aimed at improving tuberculosis prevention and treatment in pregnant women, children, and people with HIV. [ABSTRACT FROM AUTHOR]

Background: This study initiated the validation process of a translated and adapted version of the Malawi Developmental Assessment Tool (MDAT) for children in the Dominican Republic (DR). Like Malawi before the development of the MDAT, the DR did not have early childhood development (ECD) tools explicitly designed for low-resource areas that are also valid assessments of child development. We chose MDAT because it underwent a rigorous validation process and retained measurements of test items that were culturally adaptable from the Denver Developmental Screening Test II. We aimed to test the internal consistency and inter-rater reliability of the MDAT in children under the age of two years living in low-income neighborhoods in Santo Domingo in 2017. Methods and findings: Forty-two children from 2 to 24 months of age (mean = 11.26, SD = 6.37, boys = 22, girls = 20) and their corresponding caregiver participated in the study. We conducted a cross-sectional, pre-experimental study. The primary outcome measure was an index of ECD, as assessed by the Dominican adaptation of the MDAT. The tool evaluates children in four domains: social, fine motor, language, and gross motor. To determine internal consistency, we obtained Spearman-Brown split-half reliability for each sub-scale. The results showed a good consistency (>.6) for social, fine motor, and gross motor, and an acceptable consistency (>.5) for language. Second, to test the inter-rater reliability, we conducted a Kendall’s Taub test of independence for both the general scale and each sub-scale. Significant rτ scores ranged from .923 to .966, indicating appropriate inter-rater reliability. Third, we correlated the age variable with each subscale to determine if the development scale followed a progression of abilities that are expected to increase with maturation. The age variable correlated positively with all the subscales (social r = .887, p < .001; fine motor r = .799, p < .001; language r = .834, p < .001; gross motor r = .805, p < .001), indicating that the older the child, the better scores in the development measurements, as expected. There were no adverse events. This study, however, has multiple limitations. We did not gather information about socioeconomic position, which is an important variable when assessing child development; however, all participants lived in a low-income neighborhood. Given that this is the first ECD tool specific to the Dominican Republic, norm-referenced scores for the Dominican population do not yet exist. This study sample size is insufficient to make inferences about the national population. Conclusions: This study represents the first attempt to obtain a valid tool to screen for development milestones in children living in poverty in the DR. More research is needed to refine the instrument. The availability of the tool will enable impact evaluations of ECD intervention programs and the development of evidence-based public policies in the DR. [ABSTRACT FROM AUTHOR]

Background: Chronic systemic inflammation accelerates early vascular ageing. Atopic sensitization and allergic diseases may involve increased inflammatory activity. This study aimed to assess whether atopic sensitization and allergic diseases were associated with altered vascular biomarkers in Norwegian adolescents. Methods: Distensibility coefficient of the common carotid arteries, carotid intima-media thickness and atopic sensitization (serum total and specific IgEs) were assessed in 95 Norwegian adolescents, who participated in the RHINESSA generation study. Symptoms of allergic disease were assessed by an interviewer-led questionnaire. Results: Atopic sensitization was found in 33 (34.7%) of the adolescents. Symptomatic allergic disease was found in 11 (33.3%) of those with atopic sensitization. Distensibility coefficient of the common carotid arteries appeared to be lower in participants with atopic sensitization than in those without (46.99±8.07*10−3/kPa versus 51.50±11.46*10−3/kPa; p>0.05), while carotid intima-media thickness did not differ between these groups (0.50±0.04mm versus 0.50±0.04mm; p>0.05). Crude, as well as age- and sex-adjusted multiple regression, revealed no significant association, neither of atopic sensitization nor of allergic disease, with distensibility coefficient of the common carotid arteries and carotid intima-media thickness. Conclusions: Our results do not support the assumption of an adverse impact of atopic sensitization and/or allergic disease on distensibility coefficient of the common carotid arteries and carotid intima-media thickness in Norwegian adolescents. Further research is necessary to study whether the clinical severity of allergic diseases might be more important than the status of allergic disease or atopic sensitization. [ABSTRACT FROM AUTHOR]

Children whose parents have mental health disorders are at increased risk for deliberate self-harm (DSH). However, the effect of timing of parental mental health disorders on adolescent DSH risk remains under-researched. The aim of this study was to investigate how parental hospital admissions for mental health disorders and/or DSH in different developmental periods impact on the child’s DSH risk in adolescence. A nested case-control sample was compiled from a total population cohort sample drawn from administrative health records in Western Australia. The sample comprised 7,151 adolescents who had a DSH-related hospital admission (cases), and 143,020 matched controls who hadn’t had a DSH-related hospital admission. The occurrence of parental hospital admissions related to mental health disorders and/or DSH behaviours was then analysed for the cases and controls. The timing of the parental hospital admissions was partitioned into four stages in the child’s life course: (1) pre-pregnancy, (2) pregnancy and infancy, (3) childhood, and (4) adolescence. We found that adolescents of a parent with mental health and/or DSH-related hospital admissions in all developmental periods except pregnancy and infancy were significantly more likely than controls to have a DSH-related hospital admission. Compared to parental hospital admissions that occurred during childhood and adolescence, those that occurred before pregnancy conferred a higher risk for adolescent DSH: adjusted odds ratio (aOR) = 1.25 for having only one parent hospitalised and 1.66 for having both parents hospitalised for mental health disorders; aOR = 1.97 for having any parent hospitalised for DSH, all being significant at the level of p < .001. This study shows that timing is important for understanding intergenerational transmission of DSH risk. The pre-pregnancy period is as critical as period after childbirth for effective intervention targeting adult mental health disorders and DSH, highlighting the important role of adult mental health services in preventing DSH risk in future generations. [ABSTRACT FROM AUTHOR]

Rarebit is a simple and user-friendly perimetry that tests the visual field by using tiny supra-threshold dot stimuli. It appears to be especially useful for examining the visual field of children who are under 12 years of age. However, previous data showed that the number of errors was higher in children than adults. We ask whether the different number of errors in these two groups depended on task learning and whether it may be accounted for by sensitivity differences or a response bias. Thirty-one children between 9 and 12 years of age and thirty-nine adults were tested three times with Rarebit perimetry. A bias-free sensitivity index, d’, rather than the simple hit rate, revealed a group difference that remained after extensive task repetition. Indeed, d’ increased with task learning in a similar way in the two groups so that group difference remained after practice. The response bias differed in the two groups, being conservative in the older group (criterion C >0) and liberal in the younger (criterion C < 0). Both biases disappeared with task learning in the third session, suggesting that response bias cannot account for the group difference in sensitivity after practice. When bias-free measures of sensitivity are used and task learning effects are minimized, Rarebit perimetry may be a more valuable method than simple mean hit rate (MHR) to enlighten sensitivity differences in the visual field assessment within the pediatric population. [ABSTRACT FROM AUTHOR]

We investigated the incidences and characteristics of pediatric traumatic injuries requiring emergency department visits, through a complementary approach using both nationwide-sample and single-institutional data. Data for children (aged <15 years) identified with traumatic injuries during a 10-year period from the Korean National Health Insurance Sharing Service (n = 35,064 among 10,114,909 randomly sampled cases from the claim records of the National Health Insurance) and the authors' institute (n = 39,228) were retrospectively reviewed. The incidences and characteristics of the injuries were investigated using both datasets; additionally, detailed information regarding the injury environments was investigated using the single-institutional data. The findings were similar across both datasets. The incidence of injuries increased during the study period; the head was most commonly injured, whereas the trunk or proximal extremities were rarely injured; low-energy head injuries accounted for >50% of the cases in children aged <5 years, although the incidences of lower-extremity injuries and fractures increased in older children. Single-institutional data demonstrated that the proportion of indoor playground and trampoline-related injuries increased rapidly during the study period, and outdoor injuries and seasonal variation (with peak incidences in May and June) were more prominent in older children. Based on similarities between both datasets, the detailed results regarding pediatric traumatic injuries obtained from the single-institutional data could be generalized nationally with adequate external validity. To prevent traumatic injuries, it may be more effective to wear protective equipment covering the head and distal extremities rather than the trunk or proximal extremities; simple clothing, such as caps, could prevent many injuries in preschoolers. Among older children, safety guidelines for outdoor sports/leisure activities are needed. The increase in pediatric traumatic injuries may be partially explained by the increased availability of indoor playgrounds and installation of trampolines. Stricter adherence to the preventive guidelines is needed. [ABSTRACT FROM AUTHOR]

Background and objective: Health status in childhood is correlated with educational outcomes. Emergency hospital admissions during childhood are common but it is not known how these unplanned breaks from schooling impact on education outcomes. We hypothesised that children who had emergency hospital admissions had an increased risk of lower educational attainment, in addition to the increased risks associated with other health, social and school factors. Methods: This record-linked electronic birth cohort, included children born in Wales between 1 January 1998 and 31 August 2001. We fitted multilevel logistic regression models grouped by schools, to determine whether emergency hospital inpatient admission before age 7 years was associated with the educational outcome of not attaining the expected level in a teacher-based assessment at age 7 years (KS1). We adjusted for pregnancy, perinatal, socio-economic, neighbourhood, pupil mobility and school-level factors. Results: The cohort comprised 64 934 children. Overall, 4680 (7.2%) did not attain the expected educational level. Emergency admission to hospital was associated with poor educational attainment (OR 1.12 95% Credible Interval (CI) 1.05, 1.20 for all causes during childhood, OR 1.19 95%CI 1.07, 1.32 for injuries and external causes and OR 1.31 95%CI 1.04, 1.22 for admissions during infancy), after adjusting for known determinants of education outcomes such as extreme prematurity, being small for gestational age and socio-economic indicators, such as eligibility for free school meals. Conclusion: Emergency inpatient hospital admission during childhood, particularly during infancy or for injuries and external causes was associated with an increased risk of lower education attainment at age 7 years, in addition to the effects of pregnancy factors (gestational age, birthweight) and social deprivation. These findings support the need for injury prevention measures and additional support in school for affected children to help them to achieve their potential. [ABSTRACT FROM AUTHOR]

Background: Undernutrition, an important indicator for monitoring progress of development goals, is a matter of concern in many developing countries, including Bangladesh. Despite regional differences in chronic undernutrition in Bangladesh, regional determinants among children under the age of five were not extensively explored. Data and methods: Using combined repeated cross-sectional nationwide Bangladesh Demographic and Health Surveys (BDHS 2011 and 2014) and employing bivariate and logistic regression analyses, we estimated prevalence, changes and variations in regional determinants of stunting among children aged 6–59 months over two time periods 2011 and 2014. Results: Our benchmark results suggested that the children from Rajshahi, Khulna, Rangpur, Chittagong and Dhaka tend to be significantly less stunted by 51% (p = 0.000; CI = [0.38, 0.63]), 44% (p = 0.000; CI = [0.44, 0.71]), 26% (p = 0.012; CI = [0.58, 0.93]), 23% (p = 0.012; CI = [0.62, 0.95]) and 22% (p = 0.033; [0.63, 0.97]) respectively, against Sylhet in 2011. With the exception of Dhaka, no region showed significant differences in the odds of stunting over two time periods 2011 and 2014, i.e. only Dhaka revealed significant difference by 30% reductions in the odds of stunting in 2014. Also, rural children were less likely to be stunted (by 19%) of the urban counterparts. Regional covariates of stunting differ. However, children’s age, household wealth, mother’s height, and parental education were important determinants of stunting in Bangladesh. Conclusion: Dhaka made an impressive improvement in child nutrition, thus contributed largely to the reduction of stunting levels in Bangladesh for 2014 over 2011. Sylhet and Barisal require strong push to improve nutritional status of children. Further decline is possible through region-specific multipronged interventions that can address area-specific covariates to break the cycle of undernutrition like strengthening economic and educational status, emphasizing the role of father to augment their knowledge in varying aspects like family planning, reduction of fertility and by improving mother’s health. [ABSTRACT FROM AUTHOR]

Studies from the social and health sciences have tended to view the household as the locus of access to and distribution of care, resources, monitoring and modeling for children’s wellbeing. Obesity may present a special case for the study of investments in children, being a component of health for which more of certain inputs may not lead to better outcomes. We expanded on common measures of household structure in the child health literature by considering co-residence and relatedness of parents, grandparents, other relatives, and other children. Data were from a longitudinal sample of 6,700 children participating in the Early Childhood Longitudinal Study Kindergarten Class of 1998–99 (ECLS-K), the largest U.S. national dataset with measures of child anthropometrics and household structure at seven time-points over nine years. We used lagged survey-adjusted regressions to estimate associations between household structure and subsequent changes in children’s weight between ages 5 and 14 years in terms of BMI gain and incident obesity. Adjusting for household structure more thoroughly, children living in households with two parents rather than one parent did not experience advantages in terms of less excess weight gain or lower incidence of obesity during elementary and middle school. Children living with a grandmother gained more weight than children not living with a grandmother. Living with siblings and with non-related adults was associated with less weight gain. These findings corroborate a scenario in which, for health problems associated with caloric surplus, classic household factors have more complex associations with child wellbeing. [ABSTRACT FROM AUTHOR]

Background: Combination antiretroviral therapy (cART) is associated with marked immune reconstitution. Although a long term viral suppression is achievable, not all children however, attain complete immunological recovery due to persistent immune activation. We use CD4/CD8 ratio like a marker of immune reconstitution. Methods: Perinatal HIV-infected children who underwent a first-line cART, achieved viral suppression in the first year and maintained it for more than 5 years, with no viral rebound were included. Logistic models were applied to estimate the prognostic factors, clinical characteristics at cART start, of a lower CD4/CD8 ratio at the last visit. Results: 146 HIV-infected children were included: 77% Caucasian, 45% male and 28% CDC C. Median age at cART initiation was 2.3 years (IQR: 0.5–6.2). 42 (30%) children received mono-dual therapy previously to cART. Time of undetectable viral load was 9.5 years (IQR: 7.8, 12.5). 33% of the children not achieved CD4/CD8 ratio >1. Univariate analysis showed an association between CD4/CD8 <1 with lower CD4 nadir and baseline CD4; older age at diagnosis and at cART initiation; and a previous exposure to mono-dual therapy. Multivariate analysis also revealed relationship between CD4/CD8 <1 and lower CD4 nadir (OR: 1.002, CI 95% 1.000–1.004) as well as previous exposure to mono-dual therapy (OR: 0.16, CI 95% 0.003–0.720). Conclusions: CD4/CD8 >1 was not achieved in 33% of the children. Lower CD4 nadir and previous exposure to suboptimal therapy, before initiating cART, are factors showing independently association with a worse immune recovery (CD4/CD8 < 1). [ABSTRACT FROM AUTHOR]

Human adenovirus (HAdV) is known to be a common cause of diarrhea in children worldwide. Infection with adenovirus is responsible for 2–10% of diarrheic cases. To increase a better understanding of the prevalence and epidemiology of HAdV infection, a large scale and long-term study was needed. We implemented a multi-year molecular detection and characterization study of HAdV in association with acute gastroenteritis in Chiang Mai, Thailand from 2011 to 2017. Out of 2,312 patients, HAdV was detected in 165 cases (7.2%). The positive rate for HAdV infection was highest in children of 1 and 2 years of age compared to other age groups. HAdV subgroup C (40.6%) was the most prevalent, followed by subgroups F (28.5%), B (20.6%), A and D (4.8% each), and E (0.6%). Of these, HAdV-F41 (22.4%), HAdV-C2 (18.2%), HAdV-B3 (15.2%), and HAdV-C1 (13.3%) were the most common genotypes detected. HAdV infection occurred throughout the year with a higher detection rate between May and July. In conclusion, our study demonstrated the infection rate, seasonal distribution and genotype diversity of HAdV infection in children with diarrhea in Chiang Mai, Thailand over a period of 7 year. Not only enteric adenovirus (F40 and F41) but also non-enteric adenovirus (B3, C1, C2) may play an important role in gastroenteritis in this area. The information will be beneficial for the prevention and control of HAdV outbreaks in the future. [ABSTRACT FROM AUTHOR]

Previous studies have reported an association between family relationships and suicidal behavior, and found that people with high suicidal ideation are not likely to consult with others about their distress. An effective consulting service is therefore necessary for such individuals. Crisis hotlines are effective for reducing suicide risk, but their associated suicide ideation rate and odds ratio of family problems children remain unclear. The present study investigated the suicidal ideation rate and odds ratio of callers under 20 years of age (N = 24,333) with family problems to the Japanese crisis hotline in 2012. There were 5,242 (21.5%), 18,061 (74.2%), and 1,030 (4.2%) calls related to family problems, other problems, and both, respectively. The suicidal ideation rate and odds ratio of callers with family problems were 2.2% and 0.426, respectively. This result suggested that callers with family problems have a significantly lower rate and odds ratio for suicidal ideation compared with others. However, some associations with a high suicide ideation rate were found for individual items among callers with family problems such as abuse (20.4%), family breakdown (16.1%), and domestic violence (10.6%). Further studies are needed to understand the suicidal ideation of callers with family problems and develop more effective preventive strategies. [ABSTRACT FROM AUTHOR]

Background: There is increasing evidence that childhood socioeconomic position and childhood adversities influence adult health. However, the potential contribution of these factors to disability retirement is poorly understood. This study aimed to examine the associations between childhood adversities, parental education and disability retirement. Methods: Data on parental education and childhood adversities were derived from the Helsinki Health Study baseline survey, conducted in 2000–02 among 40- to 60-year old employees of the City of Helsinki, Finland. Data on disability retirement and their diagnoses were obtained from the Finnish Centre of Pensions and followed until the end of 2016. The analyses included 5992 employees. The associations of parental education and childhood adversities with disability retirement due to any cause, musculoskeletal diseases and mental disorders were analysed using Cox regression analysis. Results: Low parental education was associated with an increased risk of disability retirement due to any cause (maternal education: HR 1.74, 95% CI 1.16–2.62; paternal education: 1.86, 1.38–2.51) and due to musculoskeletal diseases (maternal education: 4.44, 1.66–11.92; paternal education: 3.81, 2.02–7.17). However, adjustment for own education mainly abolished the associations. Economic difficulties in the childhood family, parental alcohol problems and having been bullied at school or by peers increased the risk of disability retirement due to all studied diagnostic groups, whereas parental death or divorce had no effect. Childhood illness (1.53, 1.20–1.95) and parental mental illness (1.68, 1.28–2.20) were associated with disability retirement due to any cause and due to mental disorders (1.65, 1.05–2.59; 3.60, 2.46–5.26). The associations between childhood adversities and disability retirement remained after adjustment for own education, whereas working conditions, and weight and health behaviours somewhat attenuated the associations. Conclusions: Parental education and childhood adversities contributed to disability retirement even in midlife. Policy actions investing in children’s well-being might promote work ability in midlife. [ABSTRACT FROM AUTHOR]