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Background Escalation in the global rates of labour interventions, particularly cesarean section and oxytocin augmentation, has renewed interest in a better understanding of natural labour progression. Methodological advancements in statistical and computational techniques addressing the limitations of pioneer studies have led to novel findings and triggered a re-evaluation of current labour practices. As part of the World Health Organization's Better Outcomes in Labour Difficulty (BOLD) project, which aimed to develop a new labour monitoring-to-action tool, we examined the patterns of labour progression as depicted by cervical dilatation over time in a cohort of women in Nigeria and Uganda who gave birth vaginally following a spontaneous labour onset. Methods and findings This was a prospective, multicentre, cohort study of 5,606 women with singleton, vertex, term gestation who presented at [less than or equal to] 6 cm of cervical dilatation following a spontaneous labour onset that resulted in a vaginal birth with no adverse birth outcomes in 13 hospitals across Nigeria and Uganda. We independently applied survival analysis and multistate Markov models to estimate the duration of labour centimetre by centimetre until 10 cm and the cumulative duration of labour from the cervical dilatation at admission through 10 cm. Multistate Markov and nonlinear mixed models were separately used to construct average labour curves. All analyses were conducted according to three parity groups: parity = 0 (n = 2,166), parity = 1 (n = 1,488), and parity = 2+ (n = 1,952). We performed sensitivity analyses to assess the impact of oxytocin augmentation on labour progression by re-examining the progression patterns after excluding women with augmented labours. Labour was augmented with oxytocin in 40% of nulliparous and 28% of multiparous women. The median time to advance by 1 cm exceeded 1 hour until 5 cm was reached in both nulliparous and multiparous women. Based on a 95th percentile threshold, nulliparous women may take up to 7 hours to progress from 4 to 5 cm and over 3 hours to progress from 5 to 6 cm. Median cumulative duration of labour indicates that nulliparous women admitted at 4 cm, 5 cm, and 6 cm reached 10 cm within an expected time frame if the dilatation rate was [greater than or equal to] 1 cm/hour, but their corresponding 95th percentiles show that labour could last up to 14, 11, and 9 hours, respectively. Substantial differences exist between actual plots of labour progression of individual women and the 'average labour curves' derived from study population-level data. Exclusion of women with augmented labours from the study population resulted in slightly faster labour progression patterns. Conclusions Cervical dilatation during labour in the slowest-yet-normal women can progress more slowly than the widely accepted benchmark of 1 cm/hour, irrespective of parity. Interventions to expedite labour to conform to a cervical dilatation threshold of 1 cm/hour may be inappropriate, especially when applied before 5 cm in nulliparous and multiparous women. Averaged labour curves may not truly reflect the variability associated with labour progression, and their use for decision-making in labour management should be de-emphasized., Author(s): Olufemi T. Oladapo 1,*, Joao Paulo Souza 1, Bukola Fawole 2, Kidza Mugerwa 3, Gleici Perdoná 4, Domingos Alves 4, Hayala Souza 4, Rodrigo Reis 4, Livia Oliveira-Ciabati 4, [...]

Our objective in this trial was to assess the impact of daily zinc supplementation on growth in young children. A double-blind, randomized, placebo-controlled trial was conducted in New Delhi, India. We enrolled 2482 children aged 6-30 mo who were supplemented daily with placebo or zinc (10 mg elemental zinc to infants and 20 mg to older children) for 4 mo. At enrolment, all children also received a single dose of vitamin A (104.7 [micro]mol for infants and 209.4 [micro]mol for older children). Weight and length were measured at enrolment and 4 mo later. Weekly visits were conducted by field workers to ascertain morbidity in the previous 7 d. Change in length, weight, length-for-age Z-scores (LAZ), and weight-for- length Z-scores (WLZ) after 4 mo of supplementation were assessed in the zinc and placebo groups. After 4 mo of supplementation, the weight and length gains in the 2 groups did not differ and there was no impact on LAZ, weight- forage, and WLZ in the 2 groups. There was no substantial effect in any of the subgroups defined for age, income, gender, zinc levels in the crude analysis nor after adjusting for age, gender, income, breast-feeding status, and baseline anthropometric status. Despite successful zinc supplementation reflected in increased plasma zinc concentration and a substantially reduced incidence of diarrhea and pneumonia in zinc-supplemented children, the intervention did not have a beneficial effect on growth. doi: 10.3945/jn.109.115766.

Objective To compare the estimated prevalence of malnutrition using the World Health Organization's (WHO) child growth standards versus the National Center for Health Statistics' (NCHS) growth reference, to examine the relationship between exclusive breastfeeding and malnutrition, and to determine the sensitivity and specificity of nutritional status indicators for predicting death during infancy. Methods A secondary analysis of data on 9424 mother-infant pairs in Ghana, India and Peru was conducted. Mothers and infants were enrolled in a trial of vitamin A supplementation during which the infants' weight; length and feeding practices were assessed regularly. Malnutrition indicators were determined using WHO and NCHS growth standards. Findings The prevalence of stunting, wasting and underweight in infants aged < 6 months was higher with WHO than NCHS standards. However, the prevalence of underweight in infants aged 6-12 months was much lower with WHO standards. The duration of exclusive breastfeeding was not associated with malnutrition in the first 6 months of life. In infants aged < 6 months, severe underweight at the first immunization visit as determined using WHO standards had the highest sensitivity (70:2%) and specificity (85.8%) for predicting mortality in India. No indicator was a good predictor in Ghana or Peru. In infants aged 6-12 months, underweight at 6 months had the highest sensitivity and specificity for predicting mortality in Ghana (37.0% and 82.2%, respectively) and Peru (33.3% and 97.9% respectively), while wasting was the best predictor in India (sensitivity: 54.6%; specificity: 85.5%). Conclusion Malnutrition indicators determined using WHO standards were better predictors of mortality than those determined using NCHS standards. No association was found between breastfeeding duration and malnutrition at 6 months. Use of WHO child growth standards highlighted the importance Of malnutrition in the first 6 months of life. Objectif Comparer l'estimation de la prevalence de la malnutrition obtenue a partir des normes OMS de croissance de l'enfant avec celle determinee a partir des valeurs de reference du National Center for Health Statistics (NCHS) en vue d'etudier la relation entre l'allaitement maternel exclusif et la malnutrition et de determiner la sensibilite et la specificite des indicateurs d'etat nutritionnel dans la prediction de la mortalite pendant la petite enfance. Methodes Une analyse secondaire des donnees relatives a 9424 couples mere-enfant a ete realisee au Ghana, en Inde et au Perou. Des nourrissons et leurs meres ont ete recrutes pour participer a un essai de supplementation en vitamine A, dans le cadre duquel ona evalue regulierement leur poids, leur taille et leur mode d'alimentation. Les indicateurs de malnutrition ont ete determines a l'aide des normes de croissance OMS et NCHS. Resultats La prevalence du retard de croissance, de l'emaciation et du deficit ponderal chez les nourrissons de moins de 6 mois obtenue avec les normes OMS etait superieure a celle fournie par les normes NCHS. Toutefois, les normes OMS donnaient une valeur nettement pius faible de la prevalence du deficit ponderal chez les enfants de 6 a 12 mois. On n'a pas releve d'association entre la duree de l'allaitement maternel exclusif et la malnutrition pendant les 6 premiers mois de vie. Chez les nourrissons de moins de 6 mois, la presence d'un deficit ponderal severe selon les normes OMS lors de la premiere visite de vaccination etait l'indicateur le plus sensible (70,2 %) et le plus specifique (85,8 %) pour predire la mortalite en Inde. Aucun indicateur n'a presente une grande valeur predictive au Ghana et au Perou. C'est le deficit ponderal a 6 mois chez les nourrissons de 6 a 12 mois, qui offrait les plus grandes sensibilite et specificite dans la prediction de la mortalite au Ghana (37,0 % et 82,2 %, respectivement) et au Perou (33,3 % et 97,9 %, respectivement), tandis que I'emaciation constituait le meilleur facteur de prediction en Inde (sensibilite : 54,6 %, specificite : 85,5 %). Conclusion Les indicateurs de malnutrition determines en utilisant les normes OMS presentent une meilleure valeur predictive pour la mortalite que ceux obtenus avec les normes NCHS. Aucune association n'a ete relevee entre la duree de l'allaitement au sein et la malnutrition a 6 mois. L'application des normes OMS de croissance de renfant fait ressortir l'importance de la malnutrition pendant les 6 premiers mois de vie. Objetivo Comparar la prevalencia estimada de malnutricion basada en los patrones de crecimiento infantil de la OMS con la basada en los patrones de crecimiento dei National Center for Health Statistics (NCHS), estudiar la relacion entre lactancia materna exclusiva y malnutricion y determinar la sensibilidad y especificidad de los indicadores dei estado nutricional para predecir la mortalidad durante la lactancia. Metodos Se Ilevo a cabo un analisis secundario de datos relativos a 9424 pares de madre y lactante de Ghana, la India y el Peru. Madres y lactantes participaron en un ensayo de administracion de suplementos de vitamina A en el que se evaluaron periodicamente el peso, la talla y las practicas de alimentacion de los lactantes. Los indicadores de malnutricion se determinaron aplicando los patrones de crecimiento de la OMS y del NCHS. Resultados La prevalencia de retraso dei crecimiento, emaciacion e insuficiencia ponderal en lactantes de menos de 6 meses fue mayor con los patrones de la OMS que con Ios dei NCHS; sin embargo, la prevalencia de peso inferior al normal en los lactantes de 6 a 12 meses fue mucho menor al aplicar los patrones de la OMS. La duracion de la lactancia materna exclusiva no se asocio a malnutricion en los seis primeros meses de vida. En los lactantes de menos de 6 meses, la deteccion de insuficiencia ponderal grave con los patrones de la OMS en la primera visita de inmunizacion fue la variable con mayor sensibilidad (70,2%) y especificidad (85,8%) para predecir la mortalidad en la India. Ningun indicador fue un buen factor predictivo en Ghana o el Peru. En los lactantes de 6 a 12 meses, el peso inferior al normal a los 6 meses mostro la maxima sensibilidad y especificidad para predecir la mortalidad en Ghana (37,0% y 82,2%, respectivamente) y el Peru (33,3% y 97,9% respectivamente), mientras que la emaciacion fue el mejor factor predictivo en la India (sensibilidad: 54,6%; especificidad: 85,5%). Conclusion Los indicadores de malnutricion determinados mediante los patrones de la OMS fueron mejores factores predictivos de la mortalidad que los determinados mediante los patrones dei NCHS. No se hallo ninguna relacion entre la duracion de la lactancia materna y la malnutricion a los 6 meses. El uso de los patrones de crecimiento infantil de la OMS puso de relieve la importancia de la malnutricion en los 6 primeros meses de vida., Introduction Malnutrition contributes to about one-third of the 9.7 million child deaths that occur each year. (1,2) Recently, the World Health Organization (WHO) introduced new child growth standards for use [...]

Abstract Studies have found a substantial reduction in diarrhea and respiratory morbidity in young children receiving zinc supplementation. The impact of daily zinc supplementation administered with iron plus folic acid (IFA) in young children on all-cause hospitalizations and mortarity in comparison with IFA alone was evaluated. In a double blind cluster-randomized controlled trial, 94,359 subjects aged 1-23 mo were administered a daily dose of zinc plus IFA or IFA alone for a duration of 12 mo after enrollment. The intervention group tablet contained 10 mg of elemental zinc, 12.5 mg of iron, and 50 [micro]g of folic acid. The control group tablets were similar except that they contained a placebo for zinc. Infants aged

Objective To determine the association of different feeding patterns for infants (exclusive breastfeeding, predominant breastfeeding, partial breastfeeding and no breastfeeding) with mortality and hospital admissions during the first half of infancy. Methods This paper is based on a secondary analysis of data from a multicentre randomized controlled trial on immunization-linked vitamin A supplementation. Altogether, 9424 infants and their mothers (2919 in Ghana, 4000 in India and 2505 in Peru) were enrolled when infants were 18-42 days old in two urban slums in New Delhi, India, a periurban shanty town in Lima, Peru, and 37 villages in the Kintampo district of Ghana. Mother-infant pairs were visited at home every 4 weeks from the time the infant received the first dose of oral polio vaccine and diphtheria-pertussis-tetanus at the age of 6 weeks in Ghana and India and at the age of 10 weeks in Peru. At each visit, mothers were queried about what they had offered their infant to eat of drink during the past week. Information was also collected on hospital admissions and deaths occurring between the ages of 6 weeks and 6 months. The main outcome measures were all-cause mortality, diarrhoea-specific mortality, mortality caused by acute lower respiratory infections, and hospital admissions. Findings There was no significant difference in the risk of death between children who were exclusively breastfed and those who were predominantly breastfed (adjusted hazard ratio (HR) = 1.46; 95% confidence interval (CI) = 0.75-2.86). Non-breastfed infants had a higher risk of dying when compared with those who had been predominantly breastfed (HR = 10.5; 95% CI = 5.0-22.0; P< 0.001) as did partially breastfed infants (HR = 2.46; 95% CI = 1.44-4.18; P= 0.001). Conclusion There are two major implications of these findings. First, the extremely high risks of infant mortality associated with not being breastfed need to be taken into account when informing HIV-infected mothers about options for feeding their infants. Second, our finding that the risks of death are similar for infants who are predominantly breastfed and those who are exclusively breastfed suggests that in settings where rates of predominant breastfeeding are already high, promotion efforts should focus on sustaining these high rates rather than on attempting to achieve a shift from predominant breastfeeding to exclusive breastfeeding. Keywords Infant nutrition; Feeding behavior; Breast feeding; Infant mortality; Cause of death; Diarrhea/mortality; Respiratory tract infections/mortality; Hospitalization; Infant; Cohort studies; Multicenter studies; Ghana; India; Peru (source: MeSH, NLM). Mots cles Nutrition nourrisson; Comportement alimentaire; Allaitement au sein; Mortalite nourrisson; Cause deces; Diarrhee/mortalite; Voies aeriennes superieures, Infection/mortalite; Hospitalisation; Nourrisson; Etude cohorte; Etude multicentrique, Ghana; Inde; Perou (source: MeSH, INSERM). Palabras clave Nutricion infantil; Alimentos infantiles: Conducta alimentaria; Lactancia materna; Mortalidad infantil; Causa de muerte; Diarrea/mortalidad; Infecciones del tracto respiratorio/mortalidad; Hospitalizacion; Lactante; Estudios de cohortes; Estudios multicentricos; Ghana; India; Peru (fuente: DeCS, BIREME). Bulletin of the World Health Organization 2005;83:418-426. Voir page 424 le resume en francais. En la pagina 425 figura un resumen en espanol., Introduction The recognition that human immunodeficiency virus (HIV) is transmitted through breast milk has resulted in the need to inform all Tomen infected with HIV about this risk and to [...]

This paper assessed gender bias within hospitalisation rates to ascertain whether differential care-seeking practices significantly contribute to excess female mortality. It then examined the impact of socio-economic factors, particularly maternal education and economic status, on gender bias. The results find both the clear and significant impact of gender on hospitalisation rates, as well as the simultaneous inability of rising education and economic status to alleviate this bias. A secondary analysis was conducted within a uniquely large and ongoing randomised control trial that sought to measure the impact of Zinc supplementation on hospitalisations and deaths in low-income communities in New Delhi, India. During the course of the study, 85,633 children were enrolled and monitored over one year of follow-up. Of the 430 deaths that occurred, 230 were female (0.57% of total females), while 200 were male (0.43% of all males). Despite this higher mortality amongst females (p Curiously, our results show that gender bias is highest amongst highly educated mothers, and decreases steadily for children of mothers with a middle school education, a primary school education, and is lowest amongst mothers with no formal education. Put differently, female children of mothers with no formal education were significantly more likely to be hospitalised than children of mothers with several years of formal education, even after adjusting for all other factors. Economic status was not found to affect the association of gender and hospitalisation, though overall odds of hospitalisation rose with increasing economic status. Paternal education was found not to be significantly related to hospitalisation. Keywords: Gender; Care-seeking; Excess female mortality; Maternal education; Socio-economic development; India

Complementary feeding practices are often inadequate in developing countries, resulting in a significant nutritional decline between 6 and 18 mo of age. We assessed the effectiveness of an educational intervention to promote adequate complementary feeding practices that would be feasible to sustain with existing resources. The study was a cluster randomized controlled trial in communities in the state of Haryana in India. We developed the intervention through formative research. Eight communities were pair matched on their baseline characteristics; one of each pair was randomly assigned to receive the intervention and the other to no specific feeding intervention. Health and nutrition workers in the intervention communities were trained to counsel on locally developed feeding recommendations. Newborns were enrolled in all of the communities (552 in the intervention and 473 in the control) and followed up every 3 mo to the age of 18 mo. The main outcome measures were weights and lengths at 6, 9, 12, and 18 mo and complementary feeding practices at 9 and 18 mo. All analyses were by intent to treat. In the overall analyses, there was a small but significant effect on length gain in the intervention group (difference in means 0.32 cm, 95% CI, 0.03, 0.61). The effect was greater in the subgroup of male infants (difference in mean length gain 0.51 cm, 95% CI 0.03, 0.98). Weight gain was not affected. Energy intakes from complementary foods overall were significantly higher in the intervention group children at 9 mo (mean [+ or -] SD: 1556 [+ or -] 1109 vs. 1025 [+ or -] 866 kJ; P < 0.001) and 18 mo (3807 [+ or -] 1527 vs. 2577 [+ or -] 1058 kJ; P < 0.001). Improving complementary feeding practices through existing services is feasible but the effect on physical growth is limited. Factors that limit physical growth in such settings must be better understood to plan more effective nutrition programs. KEY WORDS: * complementary feeding * educational intervention * child growth * gender * cluster randomization