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BackgroundIn Pakistan, the prevalence of stunting in children younger than 5 years has remained above global critical levels over the past two decades, with the stunting rate being 40.2% in 2018. Children living in rural areas and in the poorest households suffer the most from stunting across the country—43.2% in rural areas and 51.4% in the lowest wealth quintile. As a continuing public health concern, it is essential that stunting prevention is a national priority in order to ensure human capital development, especially among the poorest households. ObjectiveThe primary objective of this study is to determine the effect of a medium quantity of a lipid-based nutrient supplement (LNS) combined with unconditional cash transfers and social and behavior change communication (SBCC) on reduction of stunting in children aged 6 to 23 months. MethodsA 5-arm cluster randomized controlled trial will be conducted in the district of Rahim Yar Khan in Punjab, Pakistan. The intervention packages will be (1) cash only, (2) cash with LNS, (3) cash with SBCC, and (4) cash with SBCC and LNS. The control arm will receive routine standard of care. We will enroll children at 6 months of age and follow up on a monthly basis up to 24 months of age. A total of 2000 children, 400 in each arm, will be enrolled to detect a 20% reduction in the prevalence of stunting among children aged 24 months. Length, weight, food intake, compliance to interventions, morbidities, and other relevant data will be collected at enrollment and on a monthly basis over the period of 18 months. The process evaluation will assess acceptability of the interventions and potential barriers to implementation through focus group discussions and in-depth interviews with the target population and relevant stakeholders. Furthermore, a cost analysis will be conducted to assess the cost-effectiveness of each intervention package. ResultsThe study protocol was approved by the Ethics Review Committee of Aga Khan University in Pakistan on January 4, 2017. Data collection began in May 2017 and was completed in July 2019. Data analyses are yet to be completed. This study will explore the effectiveness of intervention packages comprised of cash transfers from Benazir Income Support Programme with or without additional LNS and SBCC in preventing childhood stunting. We expect the results to be published in peer-reviewed journals by autumn of 2020. ConclusionsThe findings of this trial will provide robust evidence as to which intervention packages can have significant effects on linear growth of children and design effective intervention packages to prevent stunting in children aged 6 to 23 months. Trial RegistrationClinicalTrials.gov NCT03299218; https://clinicaltrials.gov/ct2/show/NCT03299218 International Registered Report Identifier (IRRID)DERR1-10.2196/19001

In Pakistan, the 2018 National Nutrition Survey reported that 40% of children under five years old were stunted. This study assessed the effectiveness of nutritional supplementation in reducing stunting among children under five years old in two rural districts in Sindh, Pakistan. This was a mixed-method quasi-experimental study comprising intervention and control populations, with 3397 and 3277 children under five years old participating in the baseline and end-line surveys, respectively. The study areas were similar in terms of demographic and economic circumstances. In the intervention group, pregnant and lactating women (first six months post-partum) received wheat soy blend, children 6–23 months old received Wawamum (lipid-based supplement), and children 24–59 months old received micronutrient powders, all through lady health workers. This was underpinned by nutrition behaviour change communication for appropriate complementary feeding practices and hygiene promotion targeted at primary caregivers. The control group received no intervention. The impact was assessed using the difference-in-difference analysis with kernel propensity score matching to adjust the differences among the control and intervention populations. The overall DID analysis indicated that the intervention did not significantly reduce the prevalence of stunting (under 5 years) [DID = −5.1, p = 0.079]. The adjusted DID indicated a significant decrease of 13% [DID = −13.0, p = 0.001] in the number of stunted children 24–59 months of age at the endline survey. A significant reduction in underweight among children 24–59 months old was also observed (DID = −9.4%, p = 0.014). In conclusion, this evidence further establishes that nutrient uptake through an intervention for a short duration cannot effectively reduce stunting. It requires continuous nutritional supplementation for mothers during the pregnancy and an initial six months of lactation and then nutritional supplementation for children 6–59 months of age underpinned by effective behaviour change communication targeting mothers and other caregivers for improving complementary feeding practices and hygiene promotion. [ABSTRACT FROM AUTHOR]

Objective To describe the frequency and factors associated with antibiotic use in early childhood, and estimate the proportion of diarrhoea and respiratory illnesses episodes treated with antibiotics. Methods Between 2009 and 2014, we followed 2134 children from eight sites in Bangladesh, Brazil, India, Nepal, Pakistan, Peru, South Africa and the United Republic of Tanzania, enrolled in the MAL-ED birth cohort study. We documented all antibiotic use from mothers' reports at twice-weekly visits over the children's first two years of life. We estimated the incidence of antibiotic use and the associations of antibiotic use with child and household characteristics. We described treatment patterns for diarrhoea and respiratory illnesses, and identified factors associated with treatment and antibiotic class. Findings Over 1 346 388 total days of observation, 16 913 courses of antibiotics were recorded (an Incidence of 4.9 courses per child per year), with the highest use in South Asia. Antibiotic treatment was given for 375/499 (75.2%) episodes of bloody diarrhoea and for 4274/9661 (44.2%) episodes of diarrhoea without bloody stools. Antibiotics were used in 2384/3943 (60.5%) episodes of fieldworker-confirmed acute lower respiratory tract illness as well as in 6608/16742 (39.5%) episodes of upper respiratory illness. Penicillins were used most frequently for respiratory illness, while antibiotic classes for diarrhoea treatment varied within and between sites. Conclusion Repeated antibiotic exposure was common early in life, and treatment of non-bloody diarrhoea and non- specific respiratory illnesses was not consistent with international recommendations. Rational antibiotic use programmes may have the most impact in South Asia, where antibiotic use was highest. Objectif Decrire la frequence et les facteurs associes a l'utilisation d'antibiotiques chez les jeunes enfants et estimer la proportion d'episodes de diarrhee et de maladies respiratoires traites avec des antibiotiques. Methodes De 2009 a 2014, nous avons suivi 2134 enfants qui participaient a l'etude de cohorte de naissance MAL-ED sur huit sites en Afrique du Sud, au Bangladesh, au Bresil, en Inde, au Nepal, au Pakistan, au Perou et en Republique-Unie de Tanzanie. Nous avons note l'utilisation de tous les antibiotiques declares par les meres lors de consultations bi-hebdomadalres pendant les deux premieres annees de vie des enfants. Nous avons estime l'Incidence du recours aux antibiotiques ainsi que les associations entre utilisation d'antibiotiques et caracteristiques des enfants et des foyers. Nous avons decrit les habitudes de traitement de la diarrhee et des maladies respiratoires et avons Identifie les facteurs associes aux traitements et aux classes d'antibiotiques. Resultats Sur 1 346 388 jours d'observation au total, 16 913 traitements aux antibiotiques ont ete enregistres (Incidence de 4,9 traitements par enfant et par an), la plus forte utilisation ayant ete observee en Asie du Sud. Un traitement antibiotique a ete administre pour 375/499 (75,2%) episodes de diarrhee sanglante et pour 4274/9661 (44,2%) episodes de diarrhee sans presence de sang dans les selles. Des antibiotiques ont ete utilises pour 2384/3943 (60,5%) episodes de maladie aigue des voies respiratoires inferieures confirmee par un professionnel sur le terrain ainsi que pour 6608/16 742 (39,5%) episodes de maladie des voies respiratoires superieures. Les penicillines etaient les plus frequemment utilisees pour combattre les maladies respiratoires, tandis que les classes d'antibiotiques utilisees pour traiter la diarrhee variaient selon les sites et au sein d'un meme site. Conclusion L'exposition repetee aux antibiotiques a un jeune age etait courante et le traitement de la diarrhee sans presence de sang dans les selles et de maladies respiratoires non specifiques ne respectait pas les recommandations internationales. C'est en Asie du Sud, oU l'usage des antibiotiques etait le plus important, que les programmes d'utilisation rationnelle des antibiotiques pourraient avoir le plus fort impact. Objetivo Describir la frecuencia y los-factores relacionados con el uso de antibioticos en la primera infancia y estimar la proporcion de los episodios de diarrea y enfermedades respiratorias tratados con antibioticos. Metodos Entre 2009 y 2014, se realizo el seguimiento de 2 134 ninos de ocho lugares en Bangladesh, Brasil, India, Nepal, Pakistan, Peru, la Republica Unida de Tanzania y Sudafrica inscritos en el estudio de cohortes en el nacimiento MAL-ED. Se documento el uso de todos los antibioticos de los informes de las madres en las visitas dos veces por semana a lo largo de los dos primeros anos de vida de los ninos. Se estimo la incidencia del uso de antibioticos y las asociaciones del uso de antibioticos con caracteristicas familiares y con ninos. Se describieron los patrones de tratamiento para la diarrea y las enfermedades respiratorias, y se identificaron los factores relacionados con las clases de tratamientos y de antibioticos. Resultados De un total de 1 346 388 dias de observacion, se registraron 16 913 tratamientos con antibioticos (una incidencia de 4,9 tratamientos por nino al ano), siendo el mayor uso en el sur de Asia. Se empleo tratamiento con antibioticos en 375/499 (75,2%) episodios de diarrea hemorragica y en 4 274/9 661 (44,2%) episodios de diarrea sin deposiciones hemorragicas. Se usaron antibioticos en 2 384/3 943 (60,5%) episodios de enfermedad respiratoria aguda de las vias bajas confirmadas por los investigadores, asi como en 6 608/16 742 (39,5%) episodios de enfermedad respiratoria de las vias altas. Las penicilinas se usaron mas frecuentemente para las enfermedades respiratorias, mientras que los antibioticos para el tratamiento de la diarrea variaron entre los distintos lugares. Conclusion La exposicion repetida a antibioticos fue comun en los primeros anos de vida, y el tratamiento de diarrea no hemorragica y de enfermedades respiratorias no especificas no fue coherente con las recomendaciones internacionales. Los programas de uso racional de antibioticos pueden tener el mayor efecto en el sur de Asia, donde el uso de antibioticos fue el mas alto., Introduction Antibiotics can be a lifesaving treatment for children with bacterial infections and are the most commonly prescribed therapy among all medications given to children. (1) However, antibiotics can also [...]

Background There is limited evidence between contraceptive use, availability of commodities and distance to the facility in developing countries. Distance to the facility is an essential determinant of contraceptive use. Still, women may not seek family planning services from the nearest facility and may be prepared to travel the farthest distance to receive quality family planning services. Methods We analyzed women's survey data linked to health facility data and applied an alternate specific conditional logit model to examine the distance a woman is prepared to travel and the quality of services offered by facilities in urban areas in Karachi, Pakistan. Results This study analyzed data from 336 women and 28 facilities and identified that the mean distance to the nearest facility was 0.44 km; the chosen facility was, on average, 5 km away. Women preferred facilities that offered a range of contraceptive methods and additional services provided by female healthcare providers only. Furthermore, on average, women are willing to travel a further 1.7 km for a facility that offers more family planning methods, 1.4 km for a facility that offers additional health services and 11 km for a facility that offers services delivered by female healthcare providers. Conclusions The findings highlight the quality measures women prioritize over distance and consider essential when choosing a family planning facility. [ABSTRACT FROM AUTHOR]

Background Diarrhoea is a leading cause of preventable childhood morbidity and mortality worldwide. Unfortunately, Pakistan has the third-highest burden of diarrhoea-related deaths in children <5 y of age. Therefore we aimed to evaluate factors associated with diarrhoea among Pakistani children. Methods A retrospective 1:2 matched case–control study nested in a baseline cross-sectional survey was conducted from October to December 2018 in Taluka Kotri, a two-thirds urban locality in the Jamshoro district. Children between the ages of 0 and 23 months with a history of diarrhoea in the 2 weeks preceding the survey were labelled as cases. Age-matched controls were children without symptoms of diarrhoea. Univariate and multivariable conditional logistic regression was performed to identify diarrhoea-related factors. Results A total of 1558 cases were matched with 3116 controls. Factors significantly associated with lower odds of diarrhoea in the multivariate analysis included increasing maternal age (odds ratio [OR] 0.78 [95% confidence interval {CI} 0.67 to 0.90]), breastfeeding (OR 0.77 [95% CI 0.66 to 0.90]), higher paternal education (OR 0.79 [95% CI 0.65 to 0.97]) and belonging to the rich (OR 0.66 [95% CI 0.54 to 0.80]) and richest quintiles (OR 0.54 [95% CI 0.44 to 0.66]). Conclusions This study identifies risk factors associated with diarrhoea in children <23 months of age, including younger maternal age, higher paternal education, not breastfeeding and poverty, which has implications for developing preventive programs and strategies that target populations with a higher risk of diarrhoea. [ABSTRACT FROM AUTHOR]

Background The objective was to achieve high coverage of possible serious bacterial infections (PSBI) treatment using the World Health Organization (WHO) guideline for managing it on an outpatient basis when referral to a hospital is not feasible. Methods We implemented this guideline in the programme settings at 10 Basic Health Units (BHU) in two rural districts of Sindh in Pakistan using implementation research. A Technical Support Unit supported the programme to operationalize guidelines, built capacity of health workers through training, monitored their clinical skills, mentored them and assured quality. The community-based health workers visited households to identify sick infants and referred them to the nearest BHU for further management. The research team collected data. Results Of 17 600 identified livebirths, 1860 young infants with any sign of PSBI sought care at BHUs and 1113 (59.8%) were brought by families. We achieved treatment coverage of 95%, assuming an estimated 10% incidence of PSBI in the first 2 months of life and that 10% of young infants came from outside the study catchment area. All 923 infants (49%; 923/1860) 7–59 days old with only fast breathing (pneumonia) treated with outpatient oral amoxicillin were cured. Hospital referral was refused by 83.4% (781/937) families who accepted outpatient treatment; 92.2% (720/781) were cured and 0.8% (6/781) died. Twelve (7.6%; 12/156) died among those treated in a hospital. Conclusion It is feasible to achieve high coverage by implementing WHO PSBI management guidelines in a programmatic setting when a referral is not feasible. [ABSTRACT FROM AUTHOR]