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Objective To compare coverage of key child health policy indicators across provinces and to explore their association with under-five mortality and level of conflict in the Democratic Republic of the Congo. Methods We made a secondary analysis of nationally representative data from 1380 health facilities and 20 792 households in 2017--2018. We analysed provincial-level data on coverage of 23 different indicators for improving common causes of childhood mortality, combined into mean scores for: newborn health, pneumonia, diarrhoea, malaria and safe environment. Using negative binomial regression we compared the scores with provincial-level under-five mortality. With binary logistic regression at the individual level we compared indicators (outcome) with living in a conflict-affected province (exposure). Findings All grouped coverage scores demonstrated large ranges across the 26 provinces: newborn health: 20% to 61%; pneumonia: 26% to 86%; diarrhoea: 25% to 63%; malaria: 22% to 53%; and safe environment: 4% to 53%. The diarrhoea score demonstrated the strongest association with under-five mortality (adjusted coefficient: -0.026; 95% confidence interval: -0.045 to -0.007). Conflict-affected provinces had both the highest as well as the lowest mortality rates and indicator coverages. The odds of coverage were higher in conflict-affected provinces for 13 out of 23 indicators, whereas in provinces unaffected by conflict only one indicator had higher odds of coverage. Conclusion Conflict alone is a poor predictor for child health. Ensuring that children in unaffected provinces are not neglected while addressing the needs of the most vulnerable in conflict settings is important. Prevent, protect and treat strategies for diarrhoeal disease could help improve equity in child survival. [ABSTRACT FROM AUTHOR]

Background: Skilled birth attendants (SBAs) play a crucial role in reducing infant and maternal mortality. Although the ratio of skilled assistance at birth has increased in Bangladesh, factors associated with SBA use are unknown. The main goal of our study was to reveal the individual- and community-level factors associated with SBA use during childbirth in Bangladesh. We also showed the prevalence and trend of SBA use and related independent variables in Bangladesh over the past decade. Methods: This study utilized the Bangladesh Health and Demographic Survey (BDHS) 2017–2018, a cross-sectional study. We used binary logistic regression to examine the extent of variation in SBA use attributable to the individual- and community-level variables. Results: Overall, 53.35% of women received assistance from SBAs during childbirth. The average annual rate of increase (AARI) in the number of SBA-assisted births over the past 10 years was 8.88%. Respondents who gave birth at or above 19 years had 1.40 times (AOR = 1.40; 95% CI: 1.21–1.62) greater odds of having skilled delivery assistance than respondents aged 18 years old or less. Women and their husband's education levels were significantly associated with using skilled assistance during delivery, with odds of 1.60 (AOR = 1.60; 95% CI: 1.45–2.01) and 1.41 (AOR = 1.41; 95% CI: 1.21–1.66), respectively compared to those with education up to primary level. Women from rich families and those receiving better antenatal care (ANC) visits were more likely to have professional delivery assistance. Community-level factors also showed significance towards having professional assistance while giving birth. Women from urban communities and those who utilized more than four ANC visits and had completed secondary or higher education showed a greater tendency to use an SBA during childbirth than their counterparts. Conclusion: The use of SBAs during delivery was significantly associated with some individual- and community-level factors. To reduce maternal and child mortality, there is a need to focus on rural and uneducated people who are less likely to access these facilities. Special programs could increase awareness and help the poor community obtain the minimum facility in maternal care. [ABSTRACT FROM AUTHOR]

Background: The mortality pattern from birth to age five is known to vary by underlying cause of mortality, which has been documented in multiple instances. Many countries without high functioning vital registration systems could benefit from estimates of age- and cause-specific mortality to inform health programming, however, to date the causes of under-five death have only been described for broad age categories such as for neonates (0–27 days), infants (0–11 months), and children age 12–59 months. Methods: We adapt the log quadratic model to mortality patterns for children under five to all-cause child mortality and then to age- and cause-specific mortality (U5ACSM). We apply these methods to empirical sample registration system mortality data in China from 1996 to 2015. Based on these empirical data, we simulate probabilities of mortality in the case when the true relationships between age and mortality by cause are known. Results: We estimate U5ACSM within 0.1–0.7 deaths per 1000 livebirths in hold out strata for life tables constructed from the China sample registration system, representing considerable improvement compared to an error of 1.2 per 1000 livebirths using a standard approach. This improved prediction error for U5ACSM is consistently demonstrated for all-cause as well as pneumonia- and injury-specific mortality. We also consistently identified cause-specific mortality patterns in simulated mortality scenarios. Conclusion: The log quadratic model is a significant improvement over the standard approach for deriving U5ACSM based on both simulation and empirical results. [ABSTRACT FROM AUTHOR]

Childhood Immunization is one of the critical strategies to decrease infant morbidity and mortality due to infectious diseases, but primary immunization schedules for infants in most countries start at 2 months of age. Childhood vaccines therefore begin providing adequate protection later in life, leaving infants vulnerable to infectious diseases and creating an immunity gap that results in higher morbidity and mortality among younger infants. Maternal immunization, the practice of vaccinating individuals during pregnancy, reduces the risk of infant infection primarily through the transfer of protective maternal antibodies to the fetus during late pregnancy. Although much progress has been made in public health policies to support maternal immunization research, inclusion of pregnant individuals and children in clinical trials remains challenging. This has resulted in paucity of evidence regarding safety and effectiveness of vaccines to support licensure of products intended for use during pregnancy and lactation to prevent disease in the infant. In addition, although safeguards for clinical research in pregnancy are supportive, experimental vaccines, e.g., Respiratory Syncytial Viru s, are more complicated to study because data on safety, efficacy, and dosing are limited. This requires randomized controlled trials with safety monitoring for the mother, the fetus, and the infant with follow-up for at least 1 year or longer to assess long-term health outcomes that may be associated with peripartum vaccine exposure. The goal of this paper is to discuss the general regulatory considerations for clinical research to evaluate safety and effectiveness of vaccines administered during pregnancy to protect infants from disease. This could be useful to inform future vaccine trials. This discussion is not intended to provide agency guidance nor to articulate agency policy. [ABSTRACT FROM AUTHOR]

Gender still informs couple's choice in family planning decisions and has led to marital instabilities, child abuse, and increased maternal and infant mortality in Nigeria. Hence, this paper investigated gender implications in family planning decisions among couples in Nsukka urban, Enugu State, Nigeria. Six hundred married respondents were recruited through simple random sampling to respond to a survey questionnaire. Data were computed using Statistical Package for Social Sciences (SPSS), while descriptive statistics and chi-square were used to interpret the data. The findings show that women’s use of family planning is significantly related to men’s control of family planning decisions (p = 000). The consequences include increased maternal and child mortality, bearing children more than they can cater for economically and emotionally, unsatisfactory sexual life and family instability. Based on the findings, it is recommended that the government should develop and implement policies that will ensure the participation of both males and females in family planning programmes by inculcating it in the school curriculum. [ABSTRACT FROM AUTHOR]

This paper examines the effect of public and private health spending on health outcomes measured by infant and child mortality rate using a panel of 37 African countries over the period 1995–2018. Based on both system generalized method of moments and least squared dummy variable corrected bias estimators, we find that the level of public health expenditures has statistically significant positive effects on mortality reduction. However, private health spending has a statistically significant positive effect on infant and child mortality rates when it interacts with public health spending. This means that the health effect of private health expenditure is strengthened by public health spending. Conditioning on the level of private health expenditure, the total effect of public health expenditure on child mortality reduction is slightly higher in absolute value than that of private health expenditure. The main policy implication that emerges from our results is the need to increase public health expenditure and support the effectiveness of private health expenditure. This additional fund should be allocated to some specific expenditure categories which have a very direct link with child and infant mortality rates. [ABSTRACT FROM AUTHOR]

This paper examines the effect of maternal education on child mortality in Bangladesh by exploiting quasi‐experimental variations in the duration of exposure to a school stipend project for identification. Results from the instrumental variable estimation indicate that an additional year of maternal schooling reduces both under‐five and infant mortality by about 20 percent. The findings are statistically significant and robust to a number of model specifications, including survival models controlling for right censoring of child mortality. Analysis of potential mechanisms suggests that maternal education reduces child mortality through greater wealth and literacy, positive assortative mating, lower fertility, delayed marriage and childbearing, greater health‐related knowledge, better health‐seeking behaviors, and female empowerment, but not through female employment. [ABSTRACT FROM AUTHOR]

Aims: Mortality in children aged under two years is a severe public health problem in many developing countries. The aims of the study were to reveal the prevalence and factors associated with mortality in children under two years in Bangladesh. Methods: Data were analyzed using the Bangladesh Demographic and Health Survey 2014. A total of 7886 participant data used in this study. The chi-square test of association was performed with dependent and independent variables to measure the prevalence rate, while the final model binary logistic and log-binomial regressions were used to identify the potential risk factors for under-two mortalities. Results: The prevalence of under-2 mortalities in Bangladesh was 3.9%. Regression analysis revealed that a lower level of paternal education, succeeding birth interval less than 24 months, multiple birth babies, and smaller than the average size at birth were significantly associated with children's mortality under two years in Bangladesh. Conclusions: Despite improvements in the reduction of child mortality in Bangladesh, many children died within the first 24 months of life, mostly preventable. Programs towards increasing education levels and pregnancy intervals might help in preventing infant mortality in Bangladesh. [ABSTRACT FROM AUTHOR]

• Post hoc analysis of the effect of introducing oral BCG in Northern Sweden, 1927–31. • BCG was voluntary and mostly not provided to sick or moribund neonates. • Receiving BCG was associated with a ~80% reduction in tuberculosis deaths. • BCG appeared to protect against death from other respiratory infections. Following the introduction of oral Bacille Calmette-Guérin (BCG) a century ago, Albert Calmette suggested that BCG both provided protection against death from tuberculosis (TB) and other causes. The findings were not pursued. Today, there is considerable evidence that intradermal BCG have beneficial non-specific effects (NSEs). We re-analyzed data from BCG's introduction 1927–1931 in Sweden hypothesizing that BCG reduced infectious deaths. In three papers published by Dr Carl Näslund, the progress of oral neonatal BCG rollout provided free-of-charge and the effects on child mortality in the highly TB-prevalent region Norrbotten was sequentially updated. We analyzed cause-specific post-neonatal mortality by vaccination status excluding deaths from congenital conditions. Due to apparent differences in effects during study years, effects were assessed overall and separately in two periods (1927–1929, 1930–1931). According to Näslund, TB households were slightly more likely to accept vaccination; fewer newborns that were sick or had congenital problems were vaccinated. BCG coverage was 28.3% (5659/20,012); 8.7% (1746/20,012) died. The BCG/unvaccinated Risk Ratio (RR) of post-neonatal childhood death was 0.53 (0.45–0.62). BCG was associated with 80% (49–92%) reduced mortality from TB. From 1927 to 29, BCG appeared to protect strongly against deaths from all diseases, including the non-infectious, RR = 0.09 (0.02–0.36), presumably reflecting selection bias. From 1930 to 1931, there was no protection against non-infectious deaths, RR = 0.92 (0.49–1.70) indicating less bias (p = 0.004 for same effect). During 1930–1931, BCG was associated with reductions in non-TB infectious deaths (RR = 0.75 (0.58–0.97)); 2/3 were caused by respiratory infections, against which the BCG/unvaccinated RR was 0.61 (0.43–0.84). Other causes of death were less frequent and provided no clear pattern, except that BCG was associated with more meningitis deaths, RR = 6.85 (2.20–21.4). Healthy vaccinee bias, particularly in 1927–1929, resulted in strongly beneficial overall BCG effects. However, the 1930–1931 data provided some support that BCG both protected against TB deaths and deaths from respiratory infections. [ABSTRACT FROM AUTHOR]

Introduction: Vital registration is an important element in health information systems which can inform policy and strengthen health systems. Mexico has a well-functioning vital registration system; however, there is still room for improvement, especially for deaths of children under 5. This study assesses the quality of the vital registration system in capturing deaths and evaluates the quality of cause of death certification in under-5 deaths in Yucatan, Mexico. Methods: We collected information on under-5 deaths that occurred in 2015 and 2016 in Yucatan, Mexico. We calculated the Vital Statistics Performance Index (VSPI) to have a general assessment of the vital registration performance. We examined the agreement between vital registration records and medical records at the individual and population levels using the chance-corrected concordance (CCC) and cause-specific mortality fraction (CSMF) accuracy as quality metrics. Results: We identified 966 records from the vital registry for all under-5 deaths, and 390 were linked to medical records of deaths occurring at public hospitals. The Yucatan vital registration system captured 94.8% of the expected under-5 deaths, with an overall VSPI score of 87.2%. Concordance between underlying cause of death listed in the vital registry and the cause determined by the medical record review varied substantially across causes, with a mean overall chance-corrected concordance across causes of 6.9% for neonates and 46.9% for children. Children had the highest concordance for digestive diseases, and neonates had the highest concordance for meningitis/sepsis. At the population level, the CSMF accuracy for identifying the underlying cause listed was 35.3% for neonates and 67.7% for children. Conclusions: Although the vital registration system has overall good performance, there are still problems in information about causes of death for children under 5 that are related mostly to certification of the causes of death. The accuracy of information can vary substantially across age groups and causes, with causes reported for neonates being generally less reliable than those for older children. Results highlight the need to implement strategies to improve the certification of causes of death in this population. [ABSTRACT FROM AUTHOR]

Introduction: Vital registration is an important element in health information systems which can inform policy and strengthen health systems. Mexico has a well-functioning vital registration system; however, there is still room for improvement, especially for deaths of children under 5. This study assesses the quality of the vital registration system in capturing deaths and evaluates the quality of cause of death certification in under-5 deaths in Yucatan, Mexico. Methods: We collected information on under-5 deaths that occurred in 2015 and 2016 in Yucatan, Mexico. We calculated the Vital Statistics Performance Index (VSPI) to have a general assessment of the vital registration performance. We examined the agreement between vital registration records and medical records at the individual and population levels using the chance-corrected concordance (CCC) and cause-specific mortality fraction (CSMF) accuracy as quality metrics. Results: We identified 966 records from the vital registry for all under-5 deaths, and 390 were linked to medical records of deaths occurring at public hospitals. The Yucatan vital registration system captured 94.8% of the expected under-5 deaths, with an overall VSPI score of 87.2%. Concordance between underlying cause of death listed in the vital registry and the cause determined by the medical record review varied substantially across causes, with a mean overall chance-corrected concordance across causes of 6.9% for neonates and 46.9% for children. Children had the highest concordance for digestive diseases, and neonates had the highest concordance for meningitis/sepsis. At the population level, the CSMF accuracy for identifying the underlying cause listed was 35.3% for neonates and 67.7% for children. Conclusions: Although the vital registration system has overall good performance, there are still problems in information about causes of death for children under 5 that are related mostly to certification of the causes of death. The accuracy of information can vary substantially across age groups and causes, with causes reported for neonates being generally less reliable than those for older children. Results highlight the need to implement strategies to improve the certification of causes of death in this population. [ABSTRACT FROM AUTHOR]

Background: Several clinical trials evaluated the effect of zinc supplementation on mortality in children, but the results were inconsistent. We aimed to conduct a systematic review and meta-analysis on the impact of zinc supplementation on mortality in under 5-year children. Methods: A comprehensive search was conducted using the electronic (PubMed, Scopus, Web of Science) databases, and Google Scholar, up to June 2020. Randomized clinical trials (RCTs) that reported the effect of zinc supplementation on death incidence in under 5-year children were included in the analysis. Screening was performed based on title/abstract and full-text. A random effects model was applied to calculate the summary relative risk (SRR). Risk of Bias 2.0 tool was used to rate the quality of trials. The body of evidence was assessed by the GRADE approach. Results: Combining 30 RRs from 28 RCTs including 237,068 participants revealed that zinc supplementation has significantly reduced the risk of all-causes mortality by 16% in children (SRR: 0.84, 95% CI: 0.74, 0.96). A follow-up duration of less than 1 year after supplementation resulted in 54% reduced risk of mortality (0.46; 0.33, 0.63) with no heterogeneity between investigations. Subgroup analysis by zinc dosage showed that assigning ≥ 10 mg/d zinc to under five children and duration of less than 11 months of intervention decreased the risk of all-cause mortality by 44% (0.56; 0.42, 0.75) and 48% (0.52; 0.38, 0.72), respectively. In low birth weight (LBW) infants, zinc supplementation was reduced all-cause mortality by 52% (0.48; 0.23, 1.00). Zinc supplementation significantly reduced the risk of death from pneumonia (0.70: 0.64, 0.98) and infection (0.54; 0.39, 0.76), also changed the risk of mortality from diarrhea by 15% (0.85; 0.70, 1.03) and sepsis by 57% (0.43; 0.18, 1.02). Conclusion: This meta-analysis on RCTs revealed that zinc supplementation in under 5-year children has significantly reduced the risk of all-cause mortality. Notable decreases were found in trials with a dose of 10 mg/d or more zinc supplementation, a maximum of 11 months of supplementation, a follow-up less than one year and especially in LBW infants. [ABSTRACT FROM AUTHOR]

In bioarchaeological contexts, a complex relationship exists between infant representation in the age‐at‐death distribution, gestational and young child mortality rates, and the total fertility rate. The representation of infants in a skeletal sample may be influenced by a range of social, biological, and archaeological factors. To better understand the interactions between representation, fertility, and mortality, this study evaluates the relationship between infant‐juvenile age‐at‐death proportions, fertility rates, and a range of gestational and early childhood mortality measures. The statistical component of this study found the correlation between fertility rates and infant‐juvenile proportions was stronger than with any mortality rate variable of interest. This suggests that the proportion of infants in a mortuary sample is a stronger indicator of fertility than it is of infant‐juvenile mortality. Social, biological, and archaeological variables potentially influencing infant representation in skeletal samples are discussed and a strongly contextualized and holistic approach to infant and juvenile mortality is recommended. [ABSTRACT FROM AUTHOR]

Background: The mortality pattern from birth to age five is known to vary by underlying cause of mortality, which has been documented in multiple instances. Many countries without high functioning vital registration systems could benefit from estimates of age- and cause-specific mortality to inform health programming, however, to date the causes of under-five death have only been described for broad age categories such as for neonates (0–27 days), infants (0–11 months), and children age 12–59 months. Methods: We adapt the log quadratic model to mortality patterns for children under five to all-cause child mortality and then to age- and cause-specific mortality (U5ACSM). We apply these methods to empirical sample registration system mortality data in China from 1996 to 2015. Based on these empirical data, we simulate probabilities of mortality in the case when the true relationships between age and mortality by cause are known. Results: We estimate U5ACSM within 0.1–0.7 deaths per 1000 livebirths in hold out strata for life tables constructed from the China sample registration system, representing considerable improvement compared to an error of 1.2 per 1000 livebirths using a standard approach. This improved prediction error for U5ACSM is consistently demonstrated for all-cause as well as pneumonia- and injury-specific mortality. We also consistently identified cause-specific mortality patterns in simulated mortality scenarios. Conclusion: The log quadratic model is a significant improvement over the standard approach for deriving U5ACSM based on both simulation and empirical results. [ABSTRACT FROM AUTHOR]

Objective: To describe the spatio-temporal distribution of infant mortality and its components in the city of Rio de Janeiro, Brazil, in 2010 and 2019. Methods: Infant mortality rate and the neonatal and postneonatal components were estimated. The standardized mortality rate was calculated to detect excess child mortality in the planning areas. Poisson regression was performed to estimate the effect of these planning areas on the years 2010 and 2019. Spatial analysis per neighborhoods was performed to identify the spatial autocorrelation rates, using the Moran's Index and local indicator of spatial association (LISA). Results: The planning areas are very heterogeneous, depending on the history and evolution of occupation. There is an excess of mortality in planning areas with greater social vulnerability. In the Poisson model, it was observed that in all components, the planning area (PA) of residence was statistically significant as well as the year. Moran's index did not show global spatial autocorrelation. However, when applying the LISA method, autocorrelation was observed at the local level and spatial clusters in the municipality of Rio de Janeiro. Conclusions: The spatial heterogeneity of the infant mortality rate in Rio de Janeiro suggests that local health policy strategies of each region consist in an efficient measure for reducing this rate. [ABSTRACT FROM AUTHOR]

The objective of this historical investigation is to discover if the Institution called "La Gota de Leche" existed in Toledo. Methodology by means of the heuristic method, the historical press is analyzed and other primary archival sources are reviewed. Results, although its creation was tedious and its operation was subject to criticism, its benefits were soon seen through the maternal and child health indicators. The institution between 1906 and 1966, was present in both the urban and rural areas of Toledo. Since the creation the mother received health care throughout the gestational period; she acquired habits on child hygiene and obtained health education to establish adequate breastfeeding. Conclusion La Gota de Leche Toledana was a School of Childcare and Maternology, a fact that allowed to carry out prevention, care and education activities throughout the gestational period. Thus, the results obtained were extremely satisfactory, since it was possible to reduce infant mortality during the first half of the 20th century, through the improvement of maternal and child health indicators. [ABSTRACT FROM AUTHOR]

BACKGROUND: Ambient fine particulate matter [PM ≤2.5 µm in aerodynamic diameter (PM2.5)] is a major health risk for children, particularly in South Asia, which currently experiences the highest PM2.5 levels globally. Nevertheless, there is comparatively little epidemiological evidence from this region to quantify the effects of PM2.5 on child survival. OBJECTIVES: We estimated the association between PM2.5 exposure and child survival in India. METHODS: We constructed a large, retrospective, and nationally representative cohort of children <5 years of age, born between 2009–2016, from the publicly available, cross-sectional 2015–2016 Demographic Health Surveys in India. In utero and post-delivery lifetime average ambient PM2.5 exposures were estimated with data from satellite remote sensing, meteorology, and land use information (model 푅² = 0.82). We used Cox proportional hazards regression to estimate the association between both average in utero and post-delivery lifetime PM2.5 and all-cause child mortality, controlling for individual- and household-level covariates, seasonality, location, and meteorology. RESULTS: Over 7,447,724 child-months of follow-up, there were 11,559 deaths at <5 years of age reported by the children's mothers. The mean concentrations of 9-month in utero and post-delivery lifetime average ambient PM2.5 exposure were 71.1 µg/m³ (range: 20.9-153.5 µg/m³) and 73.7 µg/m³ (range: 14.0-247.3 µg/m³), respectively. Estimated child mortality adjusted hazard ratios were 1.023 [95% confidence interval (CI): 1.008, 1.038] and 1.013 (95% CI: 1.001, 1.026) per 10-µg/m³ increase of in utero and post-delivery lifetime PM2.5, with both exposures in the model. DISCUSSION: This study adds to the growing body of evidence about the adverse health effects of PM2.5 by demonstrating the association between exposure, both in utero and post-delivery, on child survival at the national level in India. Strategies to reduce ambient air pollution levels, including steps to minimize in utero and early life exposures, are urgently needed in India and other countries where exposures are above recommended guideline value [ABSTRACT FROM AUTHOR]

Objective: To determine the factors related to the infant mortality rate (IMR) and under-five mortality rate (U5MR) in Turkey. Material and Methods: An ecological study was conducted using the provincial data of the Turkish Statistical Institute (TURKSTAT) and the Ministry of Health. Results: IMR and U5MR (r values for these two parameters are respectively mentioned in parenthesis) had a statistically significant relationship with total fertility rate (TFR) (r=0.661 and 0.718), ratio of adolescent births to total births (r=0.542 and 0.587), gross domestic product (GDP) per capita (r=-0.555 and -0.591), proportion of women aged =18 with high school or higher education (r=-0.434 and -0.470), number of physicians per 100,000 people (r=-0.352 and -0.398), number of hospital beds per 100,000 people (r=-0.244 and -0.286), and number of newborn intensive care beds per thousand births (r=-0.324 and -0.359). In bivariate models for IMR, the effect of all of the abovementioned parameters on the model was statistically significant, except for the number of hospital beds per 100,000 people. In bivariate models for U5MR, the effect of all the above-mentioned parameters on the model was statistically significant. TFR was the only variable with a statistically significant effect on the multivariate model for both IMR (standardized β=0.621, R2=0.385) and U5MR (standardized ß=0.667, R2=0.445). Conclusion: The results showed the presence of a weak correlation for the variables related to the numbers of healthcare professionals and hospital beds, thereby indicating that the effect of healthcare service provision is rather indirect. Health promotion programs can be developed for infant and child mortality with the aim of changing high fertility preferences and preventing adolescent pregnancies. Economic policies that improve income distribution and initiatives to increase education levels of girls can be life-saving for infants and children. [ABSTRACT FROM AUTHOR]

Within the UK, child mortality from all causes has declined for all ages over the last three decades. However, distinct inequality remains, as child mortality rates are generally found to be higher in males. A significant proportion of childhood deaths in the UK occur in Paediatric Intensive Care Units (PICU). We studied the association of sex with infant mortality in PICUs. We included all infants (0 to 12 months old) admitted to UK PICUs from 01/01/2005 to 31/12/2015 using the Paediatric Intensive Care Audit Network (PICANet) dataset. We considered first admissions to PICU and fitted a cause-specific-hazard-ratio (CSHR) model, and a logistic model to estimate the adjusted association between sex and mortality in PICU. Pre-defined subgroups were children less than 56-days old, and those with a primary diagnosis of infection. Of 71,243 cases, 1,411/29,520 (4.8%) of females, and 1,809/41,723 (4.3%) of males died. The adjusted male/female CSHR was 0.87 (95%-CI 0.81 to 0.92) representing a 13% higher risk of death for females. The adjusted OR for male to female mortality is 0.86 (95%-CI 0.80 to 0.93). Analyses in subgroups yielded similar findings. In our analysis, female infants have a higher rate of PICU mortality compared to male infants. [ABSTRACT FROM AUTHOR]

Under-five (U-5) mortality is a major public health problem in lower-middle income countries. The aim of this study is to examine the associations between maternal education and mortality of children below 5 years age in Indian context. We have used bi-variate and multivariate logistic regressions to assess the associations. Our study reveals that increasing level of education among women and in association with socio-economic and demographic factors significantly reduces the incidence of U-5 mortality. The findings suggest that increasing opportunities for female education and addressing socio-economic and demographic vulnerabilities could be effective strategies to combat the incidence of U-5 mortality. [ABSTRACT FROM AUTHOR]

Background: Child mortality is a key indicator of the performance of the health system of a nation. Impressive progress in the reduction of under-five mortality has been made in Ethiopia. However, still there are some regions where the under-five mortality rates are high. Southern Nations, Nationalities, and Peoples' Region (SNNPR) is among those regions in Ethiopia with high under-five mortality rates. This study aimed to identify the determinant factors of under-five mortality in SNNPR. Methods: Data used for the study were drawn from the 2016 EDHS. A total of 1277 under-five children were included in the study. A multivariable logistic regression model was fitted to identify determinant factors associated with under-five mortality. Results: Children with second or third birth order (OR = 1.316, 95% CI: (1.097, 2.343)), fourth or fifth birth order (OR = 1.934, 95% CI: (1.678, 3.822)), sixth or above birth order (OR = 3.980, 95% CI: (2.352, 6.734)) were significantly associated with increased risk of under-five mortality as compared to those with first birth order. Increased risk of under-five mortality was also significantly associated with a family size of five or more (OR = 3.397, 95% CI: (1.702, 6.782)) as compared to the family size of less than five; smaller size at birth (OR = 1.714, 95% CI: (1.120, 2.623)) as compared to larger size at birth; multiple births (OR = 1.472, 95% CI: (1.289, 2.746)) as compared to singletons. On the other hand, female children (OR = 0.552, 95% CI: (0.327, 0.932)), children born at health institutions (OR = 0.449, 95% CI: (0.228, 0.681)) and children who were breastfed (OR = 0.657, 95% CI: (0.393, 0.864)) were significantly associated with decreased risk of under-five mortality as compared to male children, those born at home and those who were not breastfed respectively. Conclusions: Sex of a child, birth order, size of a child at birth, place of delivery, birth type, breastfeeding status, and family size were significant factors associated with under-five mortality in SNNPR, Ethiopia. Thus, planning and implementing relevant strategies that focus on those identified determinant factors of under-five mortality is required for the improvement of child survival in SNNPR, Ethiopia. [ABSTRACT FROM AUTHOR]

Background: Armed conflicts have major indirect health impacts in addition to the direct harms from violence. They create enduring political instability, destabilise health systems, and foster negative socioeconomic and environmental conditions-all of which constrain efforts to reduce maternal and child mortality. The detrimental impacts of conflict on global maternal and child health are not robustly quantified. This study assesses the association between conflict and maternal and child health globally.Methods and Findings: Data for 181 countries (2000-2019) from the Uppsala Conflict Data Program and World Bank were analysed using panel regression models. Primary outcomes were maternal, under-5, infant, and neonatal mortality rates. Secondary outcomes were delivery by a skilled birth attendant and diphtheria, pertussis, and tetanus (DPT) and measles vaccination coverage. Models were adjusted for 10 confounders, country and year fixed effects, and conflict lagged by 1 year. Further lagged associations up to 10 years post-conflict were tested. The number of excess deaths due to conflict was estimated. Out of 3,718 country-year observations, 522 (14.0%) had minor conflicts and 148 (4.0%) had wars. In adjusted models, conflicts classified as wars were associated with an increase in maternal mortality of 36.9 maternal deaths per 100,000 live births (95% CI 1.9-72.0; 0.3 million excess deaths [95% CI 0.2 million-0.4 million] over the study period), an increase in infant mortality of 2.8 per 1,000 live births (95% CI 0.1-5.5; 2.0 million excess deaths [95% CI 1.6 million-2.5 million]), a decrease in DPT vaccination coverage of 4.9% (95% CI 1.5%-8.3%), and a decrease in measles vaccination coverage of 7.3% (95% CI 2.7%-11.8%). The long-term impacts of war were demonstrated by associated increases in maternal mortality observed for up to 7 years, in under-5 mortality for 3-5 years, in infant mortality for up to 8 years, in DPT vaccination coverage for up to 3 years, and in measles vaccination coverage for up to 2 years. No evidence of association between armed conflict and neonatal mortality or delivery by a skilled birth attendant was found. Study limitations include the ecological study design, which may mask sub-national variation in conflict intensity, and the quality of the underlying data.Conclusions: Our analysis indicates that armed conflict is associated with substantial and persistent excess maternal and child deaths globally, and with reductions in key measures that indicate reduced availability of organised healthcare. These findings highlight the importance of protecting women and children from the indirect harms of conflict, including those relating to health system deterioration and worsening socioeconomic conditions. [ABSTRACT FROM AUTHOR]

Each year, > 3 million children die in sub-Saharan Africa before their fifth birthday. Most deaths are preventable or avoidable through interventions delivered in the primary healthcare system. However, evidence regarding the impact of health system characteristics on child survival is sparse. We assembled a retrospective cohort of > 250,000 children in seven countries in sub-Saharan Africa. We described their health service context at the subnational level using standardized surveys and employed parametric survival models to estimate the effect of three major domains of health services—quality, access, and cost—on infant and child survival, after adjusting for child, maternal, and household characteristics. Between 1995 and 2015 we observed 13,629 deaths in infants and 5149 in children. In fully-adjusted models, the largest effect sizes were related to fees for services. Immunization fees were correlated with poor child survival (HR = 1.20, 95% CI 1.12–1.28) while delivery fees were correlated with poor infant survival (HR = 1.11, 95% CI 1.01–1.21). Accessibility of facilities and greater concentrations of private facilities were associated with improved infant and child survival. The proportion of facilities with a doctor was correlated with increased risk of death in children and infants. We quantify the impact of health service environment on survival up to five years of age. Reducing health care costs and improving the accessibility of health facilities should remain a priority for improving infant and child survival. In the absence of these fundamental investments, more specialized interventions may not achieve their desired impact. [ABSTRACT FROM AUTHOR]

With improved surgical outcomes, infants and children with congenital heart disease (CHD) may die from other causes of death (COD) other than CHD. We sought to describe the COD in youth with CHD in North Carolina (NC). Patients from birth to 20 years of age with a healthcare encounter between 2008 and 2013 in NC were identified by ICD-9 code. Patients who could be linked to a NC death certificate between 2008 and 2016 were included. Patients were divided by CHD subtypes (severe, shunt, valve, other). COD was compared between groups. Records of 35,542 patients < 20 years old were evaluated. There were 15,277 infants with an annual mortality rate of 3.5 deaths per 100 live births. The most frequent COD in infants (age < 1 year) were CHD (31.7%), lung disease (16.1%), and infection (11.4%). In 20,265 children (age 1 to < 20 years), there was annual mortality rate of 9.7 deaths per 1000 at risk. The most frequent COD in children were CHD (34.2%), neurologic disease (10.2%), and infection (9.5%). In the severe subtype, CHD was the most common COD. In infants with shunt-type CHD disease, lung disease (19.5%) was the most common COD. The mortality rate in infants was three times higher when compared to children. CHD is the most common underlying COD, but in those with shunt-type lesions, extra-cardiac COD is more common. A multidisciplinary approach in CHD patients, where development of best practice models regarding comorbid conditions such as lung disease and neurologic disease could improve outcomes in this patient population. [ABSTRACT FROM AUTHOR]

Purpose: Studies have been conducted on the prevalence and infant mortality rate of congenital anomalies; however, studies on child mortality are rare. Therefore, we evaluated the characteristics of deaths associated with congenital anomalies among children born in Korea who died within 5 years of age. Methods: Birth-to-death cohort linked data of children under the age of 5 years from 2010 to 2013, and statistical data on the cause of death by age from 1999 to 2019, both provided by the Korea National Statistical Office's Microdata Integrated Service, were retrospectively investigated. We investigated the trends and characteristics of mortality associated with congenital anomalies. Results: Among 1,858,945 children, 6,510 children who died were under 5 years of age, and among them, 1,229 deaths were associated with congenital anomalies, while 5,281 deaths were due to other causes. Deaths associated with congenital anomalies accounted for 18.9% of all deaths. When comparing congenital anomalies by systems, anomalies of the cardiovascular system (52.6%) were the most common. The mortality rate associated with congenital anomalies and those of other causes showed similar declining trends in 21 years. Conclusion: The mortality rate of congenital anomalies during the first 5 years of life did not increase differently from the prevalence of congenital anomalies but rather decreased. Deaths associated with congenital anomalies accounted for 20.5% of all infant deaths and 12.1% of child deaths, since the major causes of death in infants and children are slightly different, continuous and careful monitoring is required. [ABSTRACT FROM AUTHOR]

Background: With 8,82,000 deaths in the under-five period, India observed varied intra-state and inter-regional differences across infant and child mortality in 2018. However, scarce literature is present to capture this unusual concentration of mortality in certain families by examining the association of the mortality risks among the siblings of those families along with various unobserved characteristics of the mother. Looking towards the regional and age differential in mortality, this paper attempts to provide evidence for the differential in mortality clustering among infants (aged 0-11 months), children (12-59 months) and under-five (0-59 months) period among mothers from the Empowered Action Group (EAG) and non-EAG regions of India.Methods: The study used data from the National Family Health Survey (2015-16) which includes all the birth histories of 475,457 women aged 15-49 years. Bivariate and multivariate analyses were used to fulfil the objectives of the study. A two-level random intercept Weibull regression model was used to account for the unexplained mother (family) level heterogeneity.Results: About 3.3% and 5.9% of infant deaths and 0.8% and 1.6% of childhood deaths were observed in non-EAG and EAG regions respectively. Among them, a higher percentage of infant and child death was observed due to the death of a previous sibling. There were 1.67 times [95% CI: 1.55-1.80] and 1.46 times [CI: 1.37-1.56] higher odds of infant and under-five mortality of index child respectively when the previous sibling at the time of conception of the index child was dead in the non-EAG regions. In contrast, the odds of death scarring (death of previous sibling scars the survival of index child) were 1.38 times [CI: 1.32-1.44] and 1.24 times [CI: 1.20-1.29] higher for infant and under-five mortality respectively in the EAG regions.Conclusion: The extent of infant and child mortality clustering and unobserved heterogeneity was higher among mothers in the non-EAG regions in comparison to their EAG region counterparts. With the growing situation of under-five mortality clustering in non-EAG states, region-wise interventions are recommended. Additionally, proper care is needed to ameliorate the inter-family variation in mortality risk among the children of both EAG and non-EAG regions throughout their childhood. [ABSTRACT FROM AUTHOR]

Vitamin A supplementation (VAS), started as a short‐term strategy pending dietary improvements, has been implemented in Ethiopia for the last 15 years. We aimed to describe the trends in VAS coverage and estimated the associated reductions in child mortality. VAS coverage data obtained from the District Health Information System and the Demographic and Health Surveys were linked to child mortality data from the United Nations Interagency Group for Child Mortality Estimation (UN IGME). The number of child deaths averted was modelled assuming 12% and 24% reductions in all‐cause mortality. From 2006 to 2011, VAS was delivered through campaigns, and coverage was above 85%. However, from 2011 onwards, VAS delivery was integrated to the routine health system, and the coverage declined to <60% with significant disparities by wealth quintile and rural–urban residence. VAS has saved between 167,563 to 376,030 child lives (2005–2019), but additional lives (>42,000) could have been saved with a universal coverage (95%). Inconsistent supply of vitamin A capsules, but more importantly, low access to health care, and the limited contact opportunities for children after 24 months may have contributed to the declining VAS coverage. Any changes in target or scale‐up should thus consider these spatial and socioeconomic variations. Increasing the coverage of VAS and closing the equity gap in access to nutrition services is critical. However, with alternative programmes like vitamin A fortification being set‐up, the benefits and safety of VAS need to be closely monitored, particularly in areas where there will be overlap. [ABSTRACT FROM AUTHOR]

Extant humans are currently increasing their genetic load, which is informing present and future human microevolution. This has been a gradual process that has been rising over the last centuries as a consequence of improved sanitation, nutritional improvements, advancements in microbiology and medical interventions, which have relaxed natural selection. Moreover, a reduction in infant and child mortality and changing societal attitudes towards fertility have led to a decrease in total fertility rates (TFRs) since the 19th century. Generally speaking, decreases in differential fertility and mortality have meant that there is less opportunity for natural selection to eliminate deleterious mutations from the human gene pool. It has been argued that the average human may carry ~250-300 mutations that are mostly deleterious, as well as several hundred less-deleterious variants. These deleterious alleles in extant humans mean that our fitness is being constrained. While such alleles are viewed as reducing human fitness, they may also have had an adaptive function in the past, such as assisting in genetic complexity, sexual recombination and diploidy. Saying this, our current knowledge on these fitness compromising alleles is still lacking. [ABSTRACT FROM AUTHOR]

In sub-Saharan Africa (SSA), every 1 in 12 children under five dies every year compared with 1 in 147 children in the high-income regions. Studies have shown an association between birth intervals and pregnancy outcomes such as low birth weight, preterm birth, and intrauterine growth restriction. In this study, we examined the association between birth interval and under-five mortality in eight countries in West Africa. A secondary analysis of the Demographic and Health Survey (DHS) data from eight West African countries was carried out. The sample size for this study comprised 52,877 childbearing women (15-49 years). A bivariate logistic regression analysis was carried out and the results were presented as crude odds ratio (cOR) and adjusted odds ratios (aOR) at 95% confidence interval (CI). Birth interval had a statistically significant independent association with under-five mortality, with children born to mothers who had >2 years birth interval less likely to die before their fifth birthday compared to mothers with ≤2 years birth interval [ cOR = 0.56 ; CI = 0.51 − 0.62 ], and this persisted after controlling for the covariates [ aOR = 0.55 ; CI = 0.50 − 0.61 ]. The country-specific results showed that children born to mothers who had >2 years birth interval were less likely to die before the age of five compared to mothers with ≤2 years birth interval in all the eight countries. In terms of the covariates, wealth quintile, mother's age, mother's age at first birth, partner's age, employment status, current pregnancy intention, sex of child, size of child at birth, birth order, type of birth, and contraceptive use also had associations with under-five mortality. We conclude that shorter birth intervals are associated with higher under-five mortality. Other maternal and child characteristics also have associations with under-five mortality. Reproductive health interventions aimed at reducing under-five mortality should focus on lengthening birth intervals. Such interventions should be implemented, taking into consideration the characteristics of women and their children. [ABSTRACT FROM AUTHOR]

Background: Previous research on the association between maternal HIV status and child mortality in sub–Saharan Africa was published between 2005–2011. Findings from these studies showed a higher child mortality risk among children born to HIV–positive mothers. While the population of women with disabilities is growing in developing countries, we found no research that examined the association between maternal disability in HIV–positive mothers, and child mortality in sub–Saharan Africa. This study examined the potential compounding effect of maternal disability and HIV status on child mortality in South Africa. Methods: We analyzed data for women age 15–49 years from South Africa, using the nationally representative 2016 South Africa Demographic and Health Survey. We estimated unadjusted and adjusted risk ratios of child mortality indicators by maternal disability and maternal HIV using modified Poisson regressions. Results: Children born to disabled mothers compared to their peers born to non-disabled mothers were at a higher risk for neonatal mortality (RR = 1.80, 95% CI:1.31–2.49), infant mortality (RR = 1.69, 95% CI:1.19–2.41), and under-five mortality (RR = 1.78, 95% CI:1.05–3.01). The joint risk of maternal disability and HIV-positive status on the selected child mortality indicators is compounded such that it is more than the sum of the risks from maternal disability or maternal HIV-positive status alone (RR = 3.97 vs. joint RR = 3.67 for neonatal mortality; RR = 3.57 vs. joint RR = 3.25 for infant mortality; RR = 6.44 vs. joint RR = 3.75 for under-five mortality). Conclusions: The findings suggest that children born to HIV-positive women with disabilities are at an exceptionally high risk of premature mortality. Established inequalities faced by women with disabilities may account for this increased risk. Given that maternal HIV and disability amplify each other's impact on child mortality, addressing disabled women's HIV-related needs and understanding the pathways and mechanisms contributing to these disparities is crucial. [ABSTRACT FROM AUTHOR]

Background: As under-5 mortality rates declined all over the world, the relative distribution of under-5 deaths during different periods of life changed. To provide information for policymakers to plan for multi-layer health strategies targeting child health, it is essential to quantify the distribution of under-5 deaths by age groups. Methods: Using 245 Demographic and Health Surveys from 64 low- and middle-income countries conducted between 1986 and 2018, we compiled a database of 2,437,718 children under-5 years old with 173,493 deaths. We examined the share of deaths that occurred in the neonatal (< 1 month), postneonatal (1 month to 1 year old), and childhood (1 to 5 years old) periods to the total number of under-5 deaths at both aggregate- and country-level. We estimated the annual change in share of deaths to track the changes over time. We also assessed the association between share of deaths and Gross Domestic Product (GDP) per capita. Results: Neonatal deaths accounted for 53.1% (95% confidence interval [CI]: 52.7, 53.4) of the total under-5 deaths. The neonatal share of deaths was lower in low-income countries at 44.0% (43.5, 44.5), and higher in lower-middle-income and upper-middle income countries at 57.2% (56.8, 57.6) and 54.7% (53.8, 55.5) respectively. There was substantial heterogeneity in share of deaths across countries; for example, the share of neonatal to total under-5 deaths ranged from 20.9% (14.1, 27.6) in Eswatini to 82.8% (73.0, 92.6) in Dominican Republic. The shares of deaths in all three periods were significantly associated with GDP per capita, but in different directions—as GDP per capita increased by 10%, the neonatal share of deaths would significantly increase by 0.78 percentage points [PPs] (0.43, 1.13), and the postneonatal and childhood shares of deaths would significantly decrease by 0.29 PPs (0.04, 0.54) and 0.49 PPs (0.24, 0.74) respectively. Conclusions: Along with the countries' economic development, an increasing proportion of under-5 deaths occurs in the neonatal period, suggesting a need for multi-layer health strategies with potentially heavier investment in newborn health. [ABSTRACT FROM AUTHOR]

Context: Most pediatric deaths occur in an intensive care unit, and treatment specific predictors of mortality could help clinicians and families make informed decisions.Objective: To investigate whether the intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, predicts in-hospital mortality.Methods: Single-center, retrospective medical chart review of children aged 0-17 who were admitted between 2005 and 2015 at a pediatric tertiary care center in the U.S. and received any vasopressor medication-dopamine, dobutamine, epinephrine, vasopressin, norepinephrine, or hydrocortisone.Results: During the 10-year period, 1654 patients received at least one vasopressor medication during a hospitalization. Median age at the time of hospitalization was three months, and the median duration of hospitalization was 23 days; 8% of patients had two to five hospitalizations in which they received vasopressors. There were 176 total patients who died while receiving vasopressors; most (93%) died during their first hospitalization. The most common diagnosis was sepsis (34%), followed by congenital heart disease (17%). Dopamine was the most commonly prescribed first-line vasopressor (70%), and hydrocortisone was the most commonly prescribed second-line vasopressor (49%) for all pediatric patients. The incidence of mortality rose sequentially with escalating vasopressor support, increasing from under 10% with the first vasopressor to 48% at the maximum number of agents. The odds of death almost doubled with the addition of each new vasopressor.Conclusions: The intensity of vasopressor therapy for pediatric patients, regardless of diagnosis, is associated with in-hospital mortality; vasopressor escalation should trigger intensive palliative care supports. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to estimate the association between Protestantism and child mortality for Brazil. This paper employs data from the 1991, 2000, and 2010 Brazilian censuses. The association between Protestantism and child mortality was estimated using a conventional negative binomial regression model for women between the age of 20 and 34 years. This paper finds that the death rate of children born to Protestant mothers is around 5% lower compared to non-Protestant mothers, even after controlling for an extensive array of demographic and social characteristics. When Protestants are split into 'Traditional' and 'Pentecostal' groups, we find that the child mortality rate is substantially lower for Traditional Protestants. Our study contributes to the literature by providing recent empirical results on the association between child mortality and Protestantism in Brazil. [ABSTRACT FROM AUTHOR]

Globally, public health expenditure (PHE) is closely associated with Reproductive, Maternal, Newborn, Child Health, and Nutrition (RMNCHN) and Family Planning (FP) outcomes. In India, the role of PHE in shaping the progress towards the attainment of RMNCHN and FP-related Sustainable Development Goals (SDGs) is not widely documented. Using the four consecutive rounds of National Family Health Survey (NFHS), we have investigated the progress in RMNCHN and FP indicators and their association with PHE by applying robust econometric modelling. The findings suggest that although there is noticeable progress in the RMNCHN indicators from 1992–93–2015–16, India has failed to achieve RMNCHN targets related to Millennium Development Goals (MDGs). Lack of noteworthy correlation between FP indicators and PHE supports the argument that post National Rural Health Mission (2005), the core family welfare expenditure suffered a setback despite the absolute rise in PHE. However, correlation plots and the multivariate panel data regression analyses affirm that even with a moderate rise, PHE emerges as an important predictor of RMNCHN outcomes in the country. Thus, the road to achieving RMNCHN and FP-related SDGs demands to avoid austerity on PHE and strengthen the integration of RMNCHN and FP programmes at the operational level. [ABSTRACT FROM AUTHOR]

Purpose: This article examines whether increasing the income of the poor – measured as the income of the lowest quintile – is more beneficial in reducing infant and child mortality rates compared with increases in average income. Given the global importance in reducing infant mortality, the value of this research is important to academics, policymakers and practitioners alike. Design/methodology/approach: Using a sample of 86 countries from 1995–2014 inclusive, our preferred estimation strategy uses an instrumental variable fixed-effects estimator. Findings: Our results propose that the elasticity of the income of the lowest quintile never exceeds that of average income. Therefore, if reducing infant and child mortality is a key policy goal, then boosting average income may be preferable to raising incomes at the lower end of the distribution. Originality/value: Given these findings, we open a gateway for new literature to add to this unexplored area of research in the income and health relationship. [ABSTRACT FROM AUTHOR]

Infant and maternal mortality are important indicators for assessing the quality of healthcare systems. The World Health Organization underscores the importance of proper health care system in reducing preventable mortality through early intervention. Early intervention includes availability, accessibility and affordability of health care systems for children and mothers. While there are several studies that assess the immediate and underlying drivers of child mortality, literature on the role of policy measures are limited and inconsistent. Thus, robust empirical analysis of the determinants of maternal and infant mortality remains inconclusive in the era of achieving the Sustainable Development Goals (SDG). Here, we examined the influence of health expenditure on infant and maternal deaths for the period 2000–2015 across 177 countries. Using panel Quantile Regression with bootstrapping, this study accounted for the 2007–2008 financial crisis in an empirical relationship between health outcome and health expenditure. We found a negative effect of health expenditure on mortality across all percentiles. Infant mortality rate declines between 0.19% - 1.45% while maternal mortality rate declines ranging from 0.09% - 1.91%. To attain the goal of ensuring healthy lives and wellbeing of all people (SDG 3), this study infers that health expenditure potentially reduces maternal and infant mortality across lower and middle income countries. We highlight the need for an enhanced health care expenditure, especially in developing countries to curb the levels of infant and maternal deaths. [ABSTRACT FROM AUTHOR]

Background: Humans life histories have been described as "slow", patterned by slow growth, delayed maturity, and long life span. While it is known that human life history diverged from that of a recent common chimpanzee-human ancestor some ~4–8 mya, it is unclear how selection pressures led to these distinct traits. To provide insight, we compare wild chimpanzees and human subsistence societies in order to identify the age-specific vital rates that best explain fitness variation, selection pressures and species divergence. Methods: We employ Life Table Response Experiments to quantify vital rate contributions to population growth rate differences. Although widespread in ecology, these methods have not been applied to human populations or to inform differences between humans and chimpanzees. We also estimate correlations between vital rate elasticities and life history traits to investigate differences in selection pressures and test several predictions based on life history theory. Results: Chimpanzees' earlier maturity and higher adult mortality drive species differences in population growth, whereas infant mortality and fertility variation explain differences between human populations. Human fitness is decoupled from longevity by postreproductive survival, while chimpanzees forfeit higher potential lifetime fertility due to adult mortality attrition. Infant survival is often lower among humans, but lost fitness is recouped via short birth spacing and high peak fertility, thereby reducing selection on infant survival. Lastly, longevity and delayed maturity reduce selection on child survival, but among humans, recruitment selection is unexpectedly highest in longer-lived populations, which are also faster-growing due to high fertility. Conclusion: Humans differ from chimpanzees more because of delayed maturity and lower adult mortality than from differences in juvenile mortality or fertility. In both species, high child mortality reflects bet-hedging costs of quality/quantity tradeoffs borne by offspring, with high and variable child mortality likely regulating human population growth over evolutionary history. Positive correlations between survival and fertility among human subsistence populations leads to selection pressures in human subsistence societies that differ from those in modern populations undergoing demographic transition. [ABSTRACT FROM AUTHOR]

Background: Malnutrition and low birth weight (LBW) are two common causes of morbidity and mortality among children in sub-Saharan Africa. Both malnutrition and LBW affect early childhood development with long term consequences that may vary in their degree depending on the geographical setting. This study evaluates growth, nutritional status and mortality of infants from Lambaréné and Fougamou in Gabon from a birth cohort of a malaria in pregnancy clinical trial (NCT00811421). Method: A prospective longitudinal birth cohort conducted between 2009 and 2012, included infants that were followed up from birth until their first-year anniversary. The exposure of interest was low birth weight and the outcomes explored were growth represented by weight gain, the nutritional status including stunting, wasting and underweight, and the mortality. Scheduled follow-up visits were at one, nine and 12 months of age. Logistic regression was used to assess the association between low birth weight and growth and nutritional outcomes, and cox regression was used for mortality. Result: A total of 907 live-born infants were included in the analysis. The prevalence of LBW was 13% (115). At one month of life, out of 743 infants 10% and 4% presented with stunting and underweight, respectively, while these proportions increased at 12 months of life to 17% and 21%, respectively, out of 530 infants. The proportion of infants with wasting remained constant at 7% throughout the follow-up period. Stunting and underweight were associated with LBW, adjusted odds ratio (aOR): 2.6, 95% confidence interval (95%CI): 1.4–4.9 and aOR: 4.5, 95%CI: 2.5–8.1, respectively. Preterm birth was associated with stunting, aOR: 2.7, 95%CI: 1.2–6.3 and underweight, aOR: 5.4, 95%CI: 1.7–16.1 at one month of life. Infants with LBW were at higher hazard of death during the first year of life, adjusted hazard ratio 4.6, 95%CI: 1.2–17.0. Conclusion: Low birthweight infants in Gabon are at higher risks of growth and nutritional deficits and mortality during the first year of life. Tailored interventions aiming at preventing adverse pregnancy outcomes including LBW, early detection and appropriate management of growth, and nutritional deficits in infants are necessary in Gabon. [ABSTRACT FROM AUTHOR]

Background: Global mortality estimates remain heavily dependent on household surveys in low- and middle-income countries, where most under-five deaths occur. Few studies have assessed the accuracy of mortality data or determinants of capturing births in surveys. Methods: The Every Newborn-INDEPTH study (EN-INDEPTH) included a large, multi-country survey of women aged 15–49 interviewed about livebirths and their survival status in five Health and Demographic Surveillance Systems (HDSSs). The HDSSs undertake regular household visits to register births and deaths for a given population. We analysed EN-INDEPTH survey data to assess background factors associated with not recalling a complete date-of-birth. We calculated Kaplan-Meier survival estimates for both survey and HDSS data and describe age-at-death distributions during the past 5 years for children born to the same women. We assessed the proportion of HDSS-births that could be matched on month-of-birth to survey-births and used regression models to identify factors associated with matching. Results: 69,176 women interviewed in the survey reported 109,817 births and 3064 deaths in children under 5 years in the 5 years prior to the survey. In the HDSS data, the same women had 83,768 registered births and 2335 under-five deaths in the same period. A complete date-of-birth was not reported for 1–7% of survey-births. Birthdates were less likely to be complete for dead children and children born to women of higher parity or with little/no education. Distributions of reported age-at-death indicated heaping at full weeks (neonatal period) and at 12 months. Heaping was more pronounced in the survey data. Survey estimates of under-five mortality rates were similar to HDSS estimates of under-five mortality in two of five sites, higher in the survey in two sites (15%, 41%) and lower (24%) in one site. The proportion of HDSS-births matched to survey-births ranged from 51 to 89% across HDSSs and births of children who had died were less likely to be matched. Conclusions: Mortality estimates in the survey and HDSS were not markedly different for most sites. However, neither source is a "gold standard" and both sources miss some events. Research is required to improve capture and accuracy to better track newborn and child survival targets. [ABSTRACT FROM AUTHOR]

Neonates and pediatric populations are vulnerable subjects in terms of health. Proper screening and early optimal treatment would reduce infant and child mortality, improving the quality of life. Researchers and clinicians all over the world are in pursuit of innovations to improve the medical care delivery system. Infant morphometrics changes drastically due to the rapid somatic growth in infancy and childhood, demanding for patient-specific customization of treatment intervention accordingly. 3D printing is a radical technology that allows the generation of physical 3D products from digital images and addresses the patient-specific requirement. The combination of cost-effective and on-demand customization offers a boundless opportunity for the enhancement of neonates and pediatric health. Conclusion: The advanced technology of 3D printing proposes a pioneering breakthrough in bringing physiologically and anatomically appropriate treatment strategies addressing the unmet needs of child health problems. What is Known: • The potential application of 3D printing is observed across a multitude of fields within medicine and surgery. • The unprecedented effect of this technology on pediatric healthcare is still very much a work in progress. What is New: • The recent clinical applications of 3D printing provide better treatment modalities to infants and children. • The review provides an overview of the comparison between conventional treatment methods and 3DP regarding specific applications [ABSTRACT FROM AUTHOR]

Estimating the potential impact on infant mortality of increasing Bacille Calmette-Guérin (BCG) vaccination coverage and BCG scar prevalence. Guinea-Bissau Health and Demographic Surveillance System data on BCG vaccination coverage, scar status, and all-cause mortality were used for this study. Mortality risk (MR) by scar status was assessed in Cox models providing adjusted mortality rate ratios (aMRRs). Distributions were fitted for survival, vaccination coverage, and scar prevalence. Models for 12-month mortality were calculated. We utilized World Bank data on birth rates and mortality rates to assess the potential global impact of optimizing BCG vaccination programs. BCG coverage was 81% and scar prevalence 42% among 2-month-old infants, and the 1- to 12-month scar/no scar aMRR was 0.40 (0.22, 0.76). Modeling 2-month 99% vaccination coverage with 95% developing scars would change the 1- to 12-month MR by −8% (−21%, +12%). Globally, the reduction in the MR between 1- and 12-month would be −14% (−14%, −15%), corresponding to −208,075 (−214,453, −204,023) fewer infant deaths/year. We confirmed previous observations: having a BCG scar markedly reduces infant MR. Increasing current global 2-month BCG vaccination coverage from 76% to 99%, and scar prevalence among vaccinated infants from 52% to 95% might reduce global infant mortality by >200,000 deaths/year. Thus, optimizing BCG vaccination programs to focus on increasing early BCG vaccination coverage and the overall scar prevalence would have major public health benefits. • Developing a scar after Bacille Calmette-Guérin (BCG) vaccination reduces mortality. • Increasing vaccination coverage and scar prevalence reduces 1- to 12-month mortality. • Optimizing BCG programs might result in >200,000 fewer infant deaths/year. [ABSTRACT FROM AUTHOR]

Aim: This ecological study was carried out to determine the cyclic trends in the rate of perinatal and infant mortality and among children aged under 15 years who died in traffic accidents or from drowning, respiratory disease or cancer.Methods: Monthly data on the numbers of live births, perinatal and infant deaths, and deaths from respiratory disease, cancer, traffic accidents, accidental drowning, and submersion in children aged under 15 years were obtained from the Hungarian nationwide population register. The data were aggregated over the study period and cyclic trends were investigated using the Walter-Elwood and negative binomial regression methods.Results: Significant double-peak (May and November) trends were found in mortality rates for perinatal and infant deaths, respectively. Additionally, significant (p-value < .001) seasonal variation in monthly mortality rates for deaths from respiratory diseases was observed with a peak in February, and a significant single peak was observed in mortality rates in July in both deaths from traffic accidents and drowning among children aged 0-14 years. However, there was no seasonal variation in monthly mortality rates for deaths from childhood cancer.Conclusions: Since cyclic trends in mortality suggest some effect of environmental factors in etiology, we might speculate that perinatal mortality may have been related to respiratory infections. A significant single peak was observed in mortality rates in July in both deaths from traffic accidents and drowning among children aged 0-14 years which could be related to environmental factors, such as temperature, air masses, and fronts. However, there was no seasonal variation in monthly mortality rates for deaths from childhood cancer. All of these novel findings could prove useful in preventive strategies, but further cohort studies are needed to investigate this hypothesis.What is knownSeasonality in infant mortality is known.What is newA significant cyclic trend was found in infants' mortality, with a peak in deaths in winter during the post-perinatal period and double peaks in May and November during the perinatal period, which might be associated with respiratory syncytial virus infections.Winter-peak cyclic trends were observed in both preterm and low birthweight mortality.A significant cyclic trend was observed in mortality, with a peak in deaths from traffic accidents and drowning in July for children aged 0-14 years, but seasonal variation was not found in monthly deaths from childhood cancer. [ABSTRACT FROM AUTHOR]

The world is today a healthier and safer place than ever, and children have the chance to become responsible adults and to enjoy their lives. Romania has made unquestionable progress, especially in the last two decades, with infant mortality rates increasingly approaching the European average. However, our country still occupies leading places across the European continent on child deaths, with children remaining in our society, the most vulnerable social category. Strong territorial and social disparities mark this positive development. In our study we intend to identify the particularities (ethnic and confessional) that influence, in some cases, child mortality in Iași county (four types of communes with distinct ethnic and confessional). Whereas a clearing-up is taking place in Iași county between vulnerable socio-economic communities and those with higher levels of development. The results of the study show a stronger correlation between the ethnic factor and the level of infant mortality as opposed to the confessional factor, closely linked to the incidence of educational, economic or demographic factors. [ABSTRACT FROM AUTHOR]

Present study examine the effect of public healthcare expenditure on health outcome in Arab Golf region by using World Bank world development indicators data. This study found that health expenditure had a significant effect in improving health outcome in this region. The effects of health expenditures on infant mortality rate, child mortality rate and maternal mortality rate are negative and statistically significant implying that the public health expenditures is essential for improving population's health. However, the present study shows that public health expenditure has no significant effect in reducing death due to non‐communicable diseases. The study also found that per capita GDP had significant positive effects in increasing life expectancy rate and reducing infant mortality rate in this region. Availability of safe drinking water also played a significant positive role in increasing life expectancy and decreasing infant and child mortality rate. [ABSTRACT FROM AUTHOR]

Maternal immunization with tetanus, diphtheria, and acellular pertussis (Tdap) vaccine confers protection to young infants. We aimed to describe trends in pertussis incidence and associated mortality in children aged <12 months before and after introduction of maternal Tdap immunization in Bogotá, Colombia. Data on pertussis-related cases/deaths in infants aged <12 months were collected from SIVIGILA for the period 2005–2016, and compared incidence for the pre-vaccine introduction (2005–2012) and post-maternal Tdap vaccination (2014–2016) periods in infants aged <12 months and in three distinct age-strata; ≤6 weeks, 7–<28 weeks, and 28–52 weeks. Mortality comparisons were performed in all infants <12 months. From 2005 to 2016, 2315 laboratory or clinically-confirmed pertussis cases were reported in infants <12 months of age (278 cases in young infants aged ≤6 weeks); 55 pertussis deaths were reported in children aged <12 months. No pertussis deaths were reported in the 2014–2016 period. Since maternal Tdap introduction in 2013, a consistent decline in pertussis incidence and mortality was observed. In the time-series analysis, incidence declined from 209.4/100,000 persons (2005–2012) to 49.1/100,000 persons (2014–2016) in all children <12 months; a 87.5% (95%CI: 77.2-93.2%) reduction. For these same period's incidence in young infants ≤6 weeks declined from 196.7 to 89.6/100,000 person-years (an 54.4% [95% CI: 35.4–67.9%] reduction). Greater incidence reductions were observed in older infants; 73.4% (95% CI: 68.4–77.6%) in those aged 7–<28 weeks, and 100% in those aged 28–52 weeks. A 100% reduction in Pertussis mortality in infants <12 months was observed. Since Tdap introduction, maternal vaccine coverage rose from <60% in 2013–2015 to 80% in 2016. Implementation of maternal immunization in Bogotá may have contributed to the reduction in pertussis incidence and mortality among infants <12 months of age (ClinicalTrials.gov: NCT02569879). An Audio Summary linked to this article that can be found on Figshare https://doi.org/10.6084/m9.figshare.12943316 [ABSTRACT FROM AUTHOR]

Introduction: Within country inequality in infant mortality poses a big challenge for countries moving towards the internationally agreed upon targets on child mortality by 2030. There is a lack of high-quality evidence on infant mortality measured through different dimensions of social inequality in Angola. Thus, this paper was carried out to address the knowledge gap by conducting in-depth examination of infant mortality rate (IMR) inequality among population subgroups to provide more nuanced evidence to help end IMR disparity in the country. Methods: The World Health Organization's (WHO) Health Equity Assessment Toolkit (HEAT) was used to analyze IMR inequality. HEAT is a software application that facilitates examination of disparities in reproductive, maternal, neonatal and child health indicators using the WHO Health Equity Monitor (HEM) database. Inequality of IMR was analyzed through disaggregation by five equity stratifiers: education, wealth, gender, subnational region and residence. These were analyzed through three inequality measures: Population Attributable Risk, Ratio and Slope Index of Inequality. A 95% confidence Interval (CI) was built around point estimates to determine statistical significance. Results: A notable disadvantage was found for children born to poor (Population Attributable Risk (PAR): -27.0; -28.4, -26.0) and uneducated (PAR: -17.0; -17.9, -16.0), women who live in rural areas (PAR: -7.3;-7.8, -6.7) and those residing in certain regions of the country (PAR: -43.0; 45.3, -4). Male infants had a higher risk of death than female infants (PAR: -6.8;-7.5, -6.2). The subnational regional variation of IMR had been the most evident when compared with the disparities in the other equity stratifers. Conclusions: Policymakers and planners need to address the disproportionately higher clustering of IMR among infants born to disadvantaged subpopulations through interventions that benefit such subgroups. [ABSTRACT FROM AUTHOR]

Background: The mortality impact of pulse oximetry use during infant and childhood pneumonia management at the primary healthcare level in low-income countries is unknown. We sought to determine mortality outcomes of infants and children diagnosed and referred using clinical guidelines with or without pulse oximetry in Malawi.Methods and Findings: We conducted a data linkage study of prospective health facility and community case and mortality data. We matched prospectively collected community health worker (CHW) and health centre (HC) outpatient data to prospectively collected hospital and community-based mortality surveillance outcome data, including episodes followed up to and deaths within 30 days of pneumonia diagnosis amongst children 0-59 months old. All data were collected in Lilongwe and Mchinji districts, Malawi, from January 2012 to June 2014. We determined differences in mortality rates using <90% and <93% oxygen saturation (SpO2) thresholds and World Health Organization (WHO) and Malawi clinical guidelines for referral. We used unadjusted and adjusted (for age, sex, respiratory rate, and, in analyses of HC data only, Weight for Age Z-score [WAZ]) regression to account for interaction between SpO2 threshold (pulse oximetry) and clinical guidelines, clustering by child, and CHW or HC catchment area. We matched CHW and HC outpatient data to hospital inpatient records to explore roles of pulse oximetry and clinical guidelines on hospital attendance after referral. From 7,358 CHW and 6,546 HC pneumonia episodes, we linked 417 CHW and 695 HC pneumonia episodes to 30-day mortality outcomes: 16 (3.8%) CHW and 13 (1.9%) HC patients died. SpO2 thresholds of <90% and <93% identified 1 (6%) of the 16 CHW deaths that were unidentified by integrated community case management (iCCM) WHO referral protocol and 3 (23%) and 4 (31%) of the 13 HC deaths, respectively, that were unidentified by the integrated management of childhood illness (IMCI) WHO protocol. Malawi IMCI referral protocol, which differs from WHO protocol at the HC level and includes chest indrawing, identified all but one of these deaths. SpO2 < 90% predicted death independently of WHO danger signs compared with SpO2 ≥ 90%: HC Risk Ratio (RR), 9.37 (95% CI: 2.17-40.4, p = 0.003); CHW RR, 6.85 (1.15-40.9, p = 0.035). SpO2 < 93% was also predictive versus SpO2 ≥ 93% at HC level: RR, 6.68 (1.52-29.4, p = 0.012). Hospital referrals and outpatient episodes with referral decision indications were associated with mortality. A substantial proportion of those referred were not found admitted in the inpatients within 7 days of referral advice. All 12 deaths in 73 hospitalised children occurred within 24 hours of arrival in the hospital, which highlights delay in appropriate care seeking. The main limitation of our study was our ability to only match 6% of CHW episodes and 11% of HC episodes to mortality outcome data.Conclusions: Pulse oximetry identified fatal pneumonia episodes at HCs in Malawi that would otherwise have been missed by WHO referral guidelines alone. Our findings suggest that pulse oximetry could be beneficial in supplementing clinical signs to identify children with pneumonia at high risk of mortality in the outpatient setting in health centres for referral to a hospital for appropriate management. [ABSTRACT FROM AUTHOR]

Background: Child health has been a health policy priority for more than a century in Chile. Since 2000, new health and intersectoral interventions have been implemented. However, no recent analyses have explored child mortality and equity in Chile, an indispensable input to guide policies towards the achievement of the Sustainable Development Goals, specially, in the context of a deeply unequal country such as many other Latin American countries. Thus, the objectives of this study are to analyze the variations in the risk and the causes of death among Chilean children aged <5 years, to identify the determinants, and to measure inequality of infant mortality from 1990 to 2016. Materials and methods: An observational study was conducted to analyze the Chilean children's mortality from 1990 to 2016 using under five deaths and live births data from the Vital Statistics System. To describe the variation in the risk of death, a time series analysis was performed for each of the under five mortality rate components. A comparative cause of death analysis was developed for Neonatal and 1–59 months' age groups. The determinants of infant mortality were studied with a descriptive analysis of yearly rates according to mother's and child factors and bivariate logistic regression models at the individual level. Finally, simple and complex measures of inequality at individual level were estimated considering three-year periods. Results: Regarding under 5 mortality: (i) Child survival has improved substantially in the last three decades, with a rapid decline in under five mortality rate between 1990 and 2001, followed by a slower reduction; (ii) early neonatal mortality has become the main component of the under five mortality rate (50.6%); (iii) congenital abnormalities have positioned as the leading cause of death; (iv) an important increase in live births below 1,000 grs. Regarding infant mortality: (i) birth weight and gestational age are the two most relevant risk factors in the neonatal period, while social variables are more significant for post-neonatal mortality and, (ii) the inequality according to mother's education has shown a steady decline, with persistent inequalities in post-neonatal period. Conclusions: The Chilean experience illustrates child health achievements and challenges in a country that transitioned from middle-to high-income in recent decades. Although inequity is one of the main challenges for the country, the health sector by granting universal access was able to reduce disparities. However, closing the gap in post-neonatal mortality is still challenging. To overcome stagnation in neonatal mortality, new and specific strategies must address current priorities, emphasizing the access of vulnerable groups. [ABSTRACT FROM AUTHOR]

Background: Biannual azithromycin distribution has been shown to reduce child mortality as well as increase antimicrobial resistance. Targeting distributions to vulnerable subgroups such as malnourished children is one approach to reaching those at the highest risk of mortality while limiting selection for resistance. The objective of this analysis was to assess whether the effect of azithromycin on mortality differs by nutritional status.Methods and Findings: A large simple trial randomized communities in Niger to receive biannual distributions of azithromycin or placebo to children 1-59 months old over a 2-year timeframe. In exploratory subgroup analyses, the effect of azithromycin distribution on child mortality was assessed for underweight subgroups using weight-for-age Z-score (WAZ) thresholds of -2 and -3. Modification of the effect of azithromycin on mortality by underweight status was examined on the additive and multiplicative scale. Between December 2014 and August 2017, 27,222 children 1-11 months of age from 593 communities had weight measured at their first study visit. Overall, the average age among included children was 4.7 months (interquartile range [IQR] 3-6), 49.5% were female, 23% had a WAZ < -2, and 10% had a WAZ < -3. This analysis included 523 deaths in communities assigned to azithromycin and 661 deaths in communities assigned to placebo. The mortality rate was lower in communities assigned to azithromycin than placebo overall, with larger reductions among children with lower WAZ: -12.6 deaths per 1,000 person-years (95% CI -18.5 to -6.9, P < 0.001) overall, -17.0 (95% CI -28.0 to -7.0, P = 0.001) among children with WAZ < -2, and -25.6 (95% CI -42.6 to -9.6, P = 0.003) among children with WAZ < -3. No statistically significant evidence of effect modification was demonstrated by WAZ subgroup on either the additive or multiplicative scale (WAZ < -2, additive: 95% CI -6.4 to 16.8, P = 0.34; WAZ < -2, multiplicative: 95% CI 0.8 to 1.4, P = 0.50, WAZ < -3, additive: 95% CI -2.2 to 31.1, P = 0.14; WAZ < -3, multiplicative: 95% CI 0.9 to 1.7, P = 0.26). The estimated number of deaths averted with azithromycin was 388 (95% CI 214 to 574) overall, 116 (95% CI 48 to 192) among children with WAZ < -2, and 76 (95% CI 27 to 127) among children with WAZ < -3. Limitations include the availability of a single weight measurement on only the youngest children and the lack of power to detect small effect sizes with this rare outcome. Despite the trial's large size, formal tests for effect modification did not reach statistical significance at the 95% confidence level.Conclusions: Although mortality rates were higher in the underweight subgroups, this study was unable to demonstrate that nutritional status modified the effect of biannual azithromycin distribution on mortality. Even if the effect were greater among underweight children, a nontargeted intervention would result in the greatest absolute number of deaths averted.Trial Registration: The MORDOR trial is registered at clinicaltrials.gov NCT02047981. [ABSTRACT FROM AUTHOR]