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The COVID-19 pandemic has caused a disruption in childhood immunization coverage around the world. This study aimed to determine the change in immunization coverage for children under 2 years old in Ontario, Canada, comparing time periods pre-pandemic to during the first year of the pandemic.Observational retrospective open cohort study, using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN) database, from January 2019 to December 2020. Children under 2 years old who had at least 2 visits recorded in UTOPIAN were included. We measured up-to-date (UTD) immunization coverage rates, overall and by type of vaccine (DTaP-IPV-Hib, PCV13, Rota, Men-C-C, MMR, Var), and on-time immunization coverage rates by age milestone (2, 4, 6, 12, 15, 18 months). We compared average coverage rates over 3 periods of time: January 2019-March 2020 (T1); March-July 2020 (T2); and August-December 2020 (T3).12,313 children were included. Overall UTD coverage for all children was 71.0% in T1, dropped by 5.7% (95% CI: -6.2, -5.1) in T2, slightly increased in T3 but remained lower than in T1. MMR vaccine UTD coverage slightly decreased in T2 and T3 by approximately 2%. The largest decreases were seen at ages 15-month and 18-month old, with drops in on-time coverage of 14.7% (95% CI: -18.7, -10.6) and 16.4% (95% CI: -20.0, -12.8) respectively during T2. When stratified by sociodemographic characteristics, no specific subgroup of children was found to have been differentially impacted by the pandemic.Childhood immunization coverage rates for children under 2 years in Ontario decreased significantly during the early period of the COVID-19 pandemic and only partially recovered during the rest of 2020. Public health and educational interventions for providers and parents are needed to ensure adequate catch-up of delayed/missed immunizations to prevent potential outbreaks of vaccine-preventable diseases.

The World Health Organization (WHO) has a mandate to promote maternal and child health and welfare through support to governments in the form of technical assistance, standards, epidemiological and statistical services, promoting teaching and training of healthcare professionals and providing direct aid in emergencies. The Strategic and Technical Advisory Group of Experts (STAGE) for maternal, newborn, child and adolescent health and nutrition (MNCAHN) was established in 2020 to advise the Director-General of WHO on issues relating to MNCAHN. STAGE comprises individuals from multiple low-income and middle-income and high-income countries, has representatives from many professional disciplines and with diverse experience and interests.Progress in MNCAHN requires improvements in quality of services, equity of access and the evolution of services as technical guidance, community needs and epidemiology changes. Knowledge translation of WHO guidance and other guidelines is an important part of this. Countries need effective and responsive structures for adaptation and implementation of evidence-based interventions, strategies to improve guideline uptake, education and training and mechanisms to monitor quality and safety. This paper summarises STAGE’s recommendations on how to improve knowledge translation in MNCAHN. They include support for national and regional technical advisory groups and subnational committees that coordinate maternal and child health; support for national plans for MNCAHN and their implementation and monitoring; the production of a small number of consolidated MNCAHN guidelines to promote integrated and holistic care; education and quality improvement strategies to support guidelines uptake; monitoring of gaps in knowledge translation and operational research in MNCAHN.

Adequate iron intake is essential for optimal child development, but iron deficiency and anemia among infants and young children are widespread in low- and middle-income countries. Large-scale food fortification strategies hold great promise for reducing micronutrient deficiencies; however, for children

Iron is an essential micronutrient for humans and their intestinal microbiota. Host intestinal cells and iron-dependent bacteria compete for intraluminal iron, so the composition and functions of the gut microbiota may influence iron availability. Studies of the effects of the microbiota or probiotic interventions on host iron absorption may be particularly relevant to settings with high burdens of iron deficiency and gastrointestinal infections, since inflammation reduces iron bioavailability and unabsorbed intraluminal iron may modify the composition of the microbiota. The quantification of stool iron content may serve as an indicator of the amount of intraluminal iron to which the intestinal microbiota is exposed, which is particularly relevant for studies of the effect of iron on the intestinal microbiome, where fecal samples collected for purposes of microbiome characterization can be leveraged for stool iron analysis. However, few studies are available to guide researchers in the selection and implementation of stool iron assays, particularly because cross-comparison of available methods is limited in literature. This review aims to describe the available stool iron quantification methods and highlight their potential application in studies of iron-microbiome relationships, with a focus on pediatric research. MS-based methods offer high sensitivity and precision, but the need for expensive equipment and the high per-sample and maintenance costs may limit their widespread use. Conversely, colorimetric assays offer lower cost, ease of use, and rapid turnaround times but have thus far been optimized primarily for blood-derived matrices rather than stool. Further research efforts are needed to validate and standardize methods for stool iron assessment and to determine if the incorporation of such analyses in human microbiome studies

Objective:The breadth of research on the impact of nutrition-specific policies to address child undernutrition is not well documented. This review maps the evidence base and identifies gaps on such policies.Design:We systematically searched Medline, Embase, PAIS Index for public policy, Scopus and Web of Science databases to identify eligible studies. Key study characteristics, including research design, type of policy, time span of policy before impact assessment, child age at outcome assessment and types of outcomes assessed, were abstracted in duplicate.Setting:Low-, middle- and high-income countries.Participants:Studies were eligible for inclusion if they aimed to assess the impact of population-level nutrition-specific policies on undernutrition among children under 10 years of age.Results:Of the 5646 abstracts screened, eighty-three studies were included. A range of policies to address child undernutrition were evaluated; the majority were related to micronutrient fortification. Most studies were observational, reported on mandatory regional or sub-national polices, were conducted in high-income countries and evaluated policies within 1 year of implementation. A narrow set of health outcomes were evaluated, most commonly iodine deficiency disorders and neural tube defects.Conclusions:Nutrition policies were commonly associated with improved child nutritional status and health. However, this evidence is primarily based on limited settings and on a limited number of outcomes. Further research is needed to assess the longer-term impact of a broader range of nutrition policies on child health, particularly in low- and middle-income countries.

Background: Anemia is highly prevalent particularly in low- and middle-income countries. Iron deficiency contributes to an estimated 50% of anemia cases. Iron interventions have become central to global anemia treatment and prevention; however, few iron interventions have been scaled up to the national level, despite their proven effectiveness. While both cross-sectional and interventional studies on the effect of anemia and iron supplementation on worker productivity have been conducted, there have been few systematic reviews conducted. As such, a synthesis of previously conducted primary research is warranted and may provide a more comprehensive overview of the strength of currently available evidence, potentially helping to inform national policy on matters relating to funding and legislation for population-level iron interventions. Objectives: The objective of this study was to synthesize available evidence on the effect of both anemia and therapeutic iron interventions on productivity in working adults. Methods: All relevant English language studies were systematically obtained from both MEDLINE and EMBASE and assessed for evidence of differing productivity levels across groups stratified by iron intervention or anemia status. Potential mediating variables were reported, and the results were narratively summarized. Results: The available data from 12 included studies provide strong evidence that anemia negatively impacts occupational performance and that therapeutic iron interventions can yield substantial productivity gains. Conclusions: Despite their limitations, these findings make an important contribution to the literature highlighting the impact of iron deficiency and population-wide iron interventions on work productivity and occupational performance.

Background Inadequate health human resources is a key challenge to advancing child survival in Ghana. Nurses are an essential human resource to target because they represent the largest portion of the health workforce. Building on lessons learned from our pilot pediatric nurse training project and World Health Organization guidelines for transforming and scaling up health professional education, this project aimed to; train 500 pediatric nurse specialists through a one-year training program; develop and integrate a critical mass of pediatric nursing faculty and establish a national standardized pediatric nursing curriculum. This study aimed to evaluate the effectiveness of a national pediatric nurse training program in Ghana at the end of 4 years, including eight cohorts with 330 graduates. Methods This was a mixed-method evaluation with surveys, focus groups and a pre-test/post-test design. Before and after surveys were used to measure knowledge and confidence at baseline and graduation. Objective Structured Clinical Examinations (OSCE) were used to measure clinical skills at baseline, graduation, and 14 months follow-up. At the end of every module, surveys were used to measure students’ satisfaction. Focus groups at graduation qualitatively measured program outcomes. Repeat focus groups and surveys at 14 months after graduation captured the graduates’ career progress, experiences reintegrating into the health system and long-term program outcomes. Results Overall, the graduates completed the program with significantly increased knowledge, confidence, and clinical skills. They also had increased job satisfaction and were able to apply what they learned to their jobs, including leadership skills and gender-sensitive care. Data from 14-month follow-up OSCEs showed that all graduates remained competent in communication, physical assessment, and emergency care, although some obtained a lower mark compared to their performance at graduation. This finding is linked with the observation that the amount of mentorship, support from leadership and equipment that the graduates accessed from their respective facilities varied. Conclusions Mixed-methods evaluations demonstrated significant increases in knowledge confidence and skills by completing the program and maintenance of skills more than 1 year after graduation. Findings have implications for those working on the design, implementation, and evaluation of nursing education interventions in low- and middle-income countries.

With eight hundred million still living in extreme poverty and hunger, the Millennium Development Goals (MDGs) were created with a vision of a world with less poverty, hunger and disease; improved survival prospects for mothers and children; greater primary education; equal opportunities and empowerment for women; and a healthier environment. While several countries have progressed towards achieving the MDGs, many interventions have nonetheless failed to improve the quality of life in a large number of the world’s countries (Figure 1). To be sure, despite enormous in-country and international efforts to achieve the first MDG of ending extreme poverty and hunger, an estimated 800 million people still face these challenges daily. One in seven children under the age of fi ve years is still underweight (i.e., they weigh less than 2 standard deviations of the population average for their age and sex), and one in four children worldwide, or approximately 161 million children, are still stunted (i.e., they are below 2 standard deviations in height for age and sex).

In our original article in 2015, we focused on the process of scaling up micronutrient powders (MNPs). We defined scaling as a four-stage process that included: research and discovery; setting up a supply (value) chain; developing business models for implementation; and finally scaling up (original Figure 3). We defined scaling as the intentional process of taking an intervention that has been successful in one context, and expanding or replicating the relevant policies, programs, or projects to other locations so that the intervention can benefit more people in an equitable and sustainable way.

Child growth standards are commonly used to derive age- and sex-standardized anthropometric indices but are often inappropriately applied to preterm-born children (

Aim: To develop and perform an initial validation of a score to measure severity of illness in hospitalized children with severe acute malnutrition (SAM).Methods: A prospective study enrolled SAM children aged 6-59 months hospitalized in Borno State, Nigeria. Candidate items associated with inpatient mortality were combined and evaluated as candidate scores. Clinical and statistical methods were used to identify a preferred score.Results: The 513 children enrolled had a mean age of 15.6 months of whom 48 (9%) died. Seven of the ten evaluated items were significantly associated with mortality. Five different candidate scores were tested. The final score, Responses to Illness Severity Quantification (RISQ), included 7 items: heart rate, respiratory rate, respiratory effort, oxygen saturation, oxygen delivery, temperature and level of consciousness. The mean RISQ score on admission was 2.6 in hospital survivors and 7.3 for children dying Conclusion: The RISQ score can identify high risk malnourished children at and during hospital admission. Clinical application may help prioritize care and potentially improve survival.

BackgroundThe COVID-19 pandemic has caused a disruption in childhood immunization coverage around the world. This study aimed to determine the change in immunization coverage for children under 2 years old in Ontario, Canada, comparing time periods pre-pandemic to during the pandemic.MethodsWe conducted an observational retrospective open cohort study, using primary care electronic medical record data from the University of Toronto Practice-Based Research Network (UTOPIAN) database, from January 2019 to December 2020. Children under 2 years old who had at least 2 visits recorded in UTOPIAN were included. We measured up-to-date (UTD) immunization coverage rates, overall and by type of vaccine (DTaP-IPV-Hib, Pneu-C-13, Rot, Men-C-C, MMR, Var), and on-time immunization coverage rates by age milestone (2, 4, 6, 12, 15 and 18 months). We compared average coverage rates over 3 periods of time: January 2019-March 2020 (T1); March-July 2020 (T2); and August-December 2020 (T3).Results12,313 children were included. Overall UTD coverage for all children was 71.0% in T1, dropped by 5.7% (95% CI: -6.2, -5.1) in T2, slightly increased in T3 but remained lower than in T1. MMR vaccine UTD coverage slightly decreased in T2 and T3 by approximately 2%. The largest decreases were seen at ages 15-month and 18-month old, with drops in on-time coverage of 14.7% (95% CI: -18.7, -10.6) and 16.4% (95% CI: -20.0, -12.8) respectively during T2. When stratified by sociodemographic characteristics, no specific subgroup of children was found to have been differentially impacted by the pandemic.ConclusionChildhood immunization coverage rates for children under 2 years in Ontario decreased significantly during the early period of the COVID-19 pandemic and only partially recovered during the rest of 2020. Public health and educational interventions for providers and parents are needed to ensure adequate catch-up of delayed/missed immunizations to prevent potential outbreaks of vaccine-preventable diseases.

Background Underweight occurs when caloric intake is insufficient to maintain growth. While it has long been assumed that underweight in the first 2 years of life is associated with lower growth potential in later childhood, longer term growth outcomes in high income countries are unclear. Objectives The primary objective was to evaluate the relationship between underweight in the first 2 years of life and body mass index z-score (zBMI) in later childhood. Secondly, we examined the relationship between underweight in the first 2 years of life and weight-for-age z-score (WAZ) and height-for-age z-score (HAZ) in later childhood, and how sex and the zBMI growth trajectory in the first 2 years of life modify these associations. Design/Methods This was a prospective cohort study conducted through The Applied Research Group for Kids (TARGetKids!) practice-based research network. Healthy children 0-10 years of age were included. The primary exposure was underweight in the first 2 years of life using zBMI Results Among the 5,803 children included in the primary analysis, the mean age was 4.07 months, and 52.2% were male at baseline. In adjusted models, underweight in the first 2 years of life was associated with lower zBMI, lower WAZ, and higher odds of underweight at 2, 5, and 10 years of age (p Conclusion Underweight in the first 2 years of life was associated with lower growth in later childhood. These relationships were amplified for females and children with underweight who had low growth trajectory in the first 2 years of life and were attenuated among children with underweight who had high growth trajectory in the first 2 years of life.

Background Adolescents are especially vulnerable due to increased biological, social and economic risks associated with early pregnancy and childbirth, yet most pregnancy and childbirth-related complications are preventable through a combination of proven, cost-effective clinical interventions including timely antenatal care (ANC). The voices and specific needs of adolescents are currently underrepresented in the literature on antenatal and maternity care. Objectives were to a) increase our understanding of adolescents’ experiences with, and perceptions of, ANC and b) explore how these perspectives might be applied towards future initiatives to enhance adolescent care-seeking behaviour. Methods This cross-sectional qualitative study employed 14 focus group discussions with 112 adolescents aged 15–20 years in Singida Region in Tanzania and Volta and Eastern Regions in Ghana who had accessed ANC during their most recent pregnancy. We were particularly interested in what these young women valued and understood about their ANC experience, as this would provide insights into what factors motivated them to seek care. Transcripts were analyzed using conventional content analysis. Based on emergent themes and drawing on the Health Belief Model (HBM) as an analytical tool, a conceptual framework was developed to illustrate the myriad factors influencing adolescents’ decision to attend ANC. Results Interpreting results through an adapted HBM demonstrates that adolescent health-seeking behaviour can vary widely among individuals and within communities, is shaped by the opinions of family members and peers, and is intrinsically influenced by broader health systems-level factors. Conclusions The results led to our development of an adapted theory-based framework to illustrate the complexity of adolescent care-seeking during pregnancy in resource-poor settings. We demonstrate that while an adolescent mother is capable of exercising her own agency, she is also developmentally vulnerable to external influences and must be supported in her ability to make autonomous decisions. While the model presented here focuses specifically on ANC utilization, it may have applications for understanding how adolescents engage with health services more broadly. Electronic supplementary material The online version of this article (10.1186/s12884-019-2326-3) contains supplementary material, which is available to authorized users.

Background Causes of infant linear growth faltering in low-income settings remain poorly understood. Identifying age-specific risk factors in observational studies might be influenced by statistical model selection. Objectives To estimate associations of selected household factors and infant feeding behaviors within discrete age intervals with interval-specific changes in length-for-age z-scores (LAZs) or attained LAZ, using 5 statistical approaches. Methods Data from a birth cohort in Dhaka, Bangladesh (n = 1157) were analyzed. Multivariable-adjusted associations of infant feeding patterns or household factors with conditional LAZ (cLAZ) were estimated for 5 intervals in infancy. Two alternative approaches were used to estimate differences in interval changes in LAZ, and differences in end-interval attained LAZ and RRs of stunting (LAZ

In resource limited settings accurate respiratory rate (RR) measurement directly informs medical decision-making for children with respiratory problems.1 Counting RR remains a challenge: it may not be done 2 or gives rise to highly disparate values despite the use of RR counters.3 Technological solutions may permit more children to have assessments and may alter clinical decisions. A hand-held pulse oximeter with integrated RR measurement (Rad-G, Masimo, Irvine California) in 97 children reported good agreement between measurements of the device and pediatricians.

Background We examined the effect of maternal vitamin D supplementation during pregnancy and lactation on risk of acute respiratory infection (ARI) in infants up to 6 months of age in Bangladesh. Methods This study was nested in a randomized, double-blind, placebo-controlled, 5-arm dose-ranging trial of prenatal and postpartum vitamin D supplementation. One group of women received 0 IU vitamin D per week during pregnancy and for 26 weeks post delivery (“placebo” group), one group received high-dose prenatal vitamin D supplementation of 28 000 IU per week and 26 weeks post delivery, and there were 3 additional dose-ranging groups receiving vitamin D supplementation during pregnancy only (4200, 16 800, and 28 000 IU per week, respectively). Episodes of ARI were identified by active and passive surveillance. The primary outcome was microbiologically confirmed ARI, and the primary analysis compared the high-dose prenatal plus postpartum vitamin D vs placebo groups. Results In total, 1174 mother-infant pairs were included. Among infants born to mothers in the placebo group, 98% had a venous umbilical cord 25(OH)D level below 30 nmol/L compared with none in the high-dose prenatal plus postdelivery vitamin D group. Incidence of microbiologically confirmed ARI in the high-dose prenatal plus postpartum vitamin D (1.21 episodes per 6 person-months; N = 235) and placebo groups (1.07 episodes per 6 person-months; N = 234) was not significantly different (hazard ratio of 1.12 [95% confidence intervals: 0.90-1.40]). There were no differences in the incidence of microbiologically confirmed or clinical ARI, upper, lower, or hospitalized lower respiratory tract infection between high-dose prenatal plus postpartum vitamin D and placebo groups. Conclusions Despite a high prevalence of maternal baseline vitamin D deficiency and significant effects of maternal vitamin D supplementation on infant vitamin D status, the intervention did not reduce the risk of microbiologically confirmed ARI in infants up to 6 months of age.

OBJECTIVES: Vitamin D may have an adjunctive role in the prevention and treatment of iron deficiency (ID) through its proposed role in the regulation of erythropoiesis and circulating hepcidin concentrations. Observational studies have shown associations between low vitamin D and iron status; however, there are few data from intervention trials. In participants of the Maternal Vitamin D for Infant Growth Trial (MDIG; NCT01924013), among whom the baseline prevalence of vitamin D deficiency was 64%, we examined the effect of prenatal vitamin D supplementation on iron status during pregnancy by testing the effect of vitamin D supplementation on serum ferritin concentrations. METHODS: In this double-blind, dose-response, randomized trial in Dhaka, Bangladesh, women were recruited at 17–24 weeks’ gestation and randomly assigned to receive a prenatal vitamin D(3) dose of 4200, 16,800, 28,000 IU/week or placebo. Serum ferritin was quantified using an electro-chemiluminescence immunoassay. Plasma C-reactive protein (CRP) was analysed by enzyme-linked immunoassay. Linear regression was used to test the hypothesized effect of vitamin D supplementation on serum ferritin (n = 1011 of 1300 enrolled). In a sensitivity analysis, we adjusted for concurrent CRP to correct for inflammation (n = 920). Regression correction was used to generate an inflammation-corrected estimate of the prevalence of ID (n = 920). RESULTS: Prevalence of ID (serum ferritin

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows: We aim to assess the effect of double‐fortified salt (DFS) compared to iodized salt (IS) on measures of iron and iodine status across the life course.

It is unclear whether maternal vitamin D supplementation during pregnancy and lactation improves fetal and infant growth in regions where vitamin D deficiency is common.We conducted a randomized, double-blind, placebo-controlled trial in Bangladesh to assess the effects of weekly prenatal vitamin D supplementation (from 17 to 24 weeks of gestation until birth) and postpartum vitamin D supplementation on the primary outcome of infants' length-for-age z scores at 1 year according to World Health Organization (WHO) child growth standards. One group received neither prenatal nor postpartum vitamin D (placebo group). Three groups received prenatal supplementation only, in doses of 4200 IU (prenatal 4200 group), 16,800 IU (prenatal 16,800 group), and 28,000 IU (prenatal 28,000 group). The fifth group received prenatal supplementation as well as 26 weeks of postpartum supplementation in the amount of 28,000 IU (prenatal and postpartum 28,000 group).Among 1164 infants assessed at 1 year of age (89.5% of 1300 pregnancies), there were no significant differences across groups in the mean (±SD) length-for-age z scores. Scores were as follows: placebo, -0.93±1.05; prenatal 4200, -1.11±1.12; prenatal 16,800, -0.97±0.97; prenatal 28,000, -1.06±1.07; and prenatal and postpartum 28,000, -0.94±1.00 (P=0.23 for a global test of differences across groups). Other anthropometric measures, birth outcomes, and morbidity did not differ significantly across groups. Vitamin D supplementation had expected effects on maternal and infant serum 25-hydroxyvitamin D and calcium concentrations, maternal urinary calcium excretion, and maternal parathyroid hormone concentrations. There were no significant differences in the frequencies of adverse events across groups, with the exception of a higher rate of possible hypercalciuria among the women receiving the highest dose.In a population with widespread prenatal vitamin D deficiency and fetal and infant growth restriction, maternal vitamin D supplementation from midpregnancy until birth or until 6 months post partum did not improve fetal or infant growth. (Funded by the Bill and Melinda Gates Foundation; ClinicalTrials.gov number, NCT01924013 .).

OBJECTIVES: To estimate the dose-dependent effects of maternal vitamin D3 (VD) supplementation during pregnancy and lactation on the risk of first nasal pneumococcal colonization (PnC) and the dynamics of nasal pneumococcal (Pn) carriage in infants from birth to 6 months (mos) of age in Dhaka, Bangladesh. METHODS: Infants born to mothers who received weekly VD doses in one of 4 pre/post-partum dose combinations or placebo as part of the Maternal Vitamin D Supplementation during Pregnancy and Lactation to Prevent Acute Respiratory Illness (MDARI) study, were monitored from 0–6 mos for signs of an acute respiratory infection (ARI). A nasal swab was performed to obtain a sample of nasal epithelial tissue if the infant met pre-set ARI criteria. Nasal PnC was detected by qPCR. The effect of VD on the risk of first observed PnC was estimated by an interval-censored survival model. A multi-state model was used to characterize the dynamics of Pn carriage using transition probabilities of state changes. RESULTS: Of 1060 infants in MDARI, PnC was observed in 90% during the first 6 mos of life with 69% of swabs being positive (n = 3792). There was no significant difference between any VD group and placebo on the risk of initial nasal PnC (Table 1). Overall, the predicted median time to colonization was 7 weeks. Transitioning between positive and negative episodes was common: among 949 infants who were ever positive, 238 (25%) were observed to revert to negative during the first 6 mos of life, of whom 99 (40%) had at least one additional positive swab. Across all groups, an infant was predicted to spend 69 days negative and 120 days positive during the first 6 mos; yet, no Pn dynamics differed significantly across treatment groups (P >0.05). PnC and Pn dynamics were associated with season of birth, parental education and number of siblings, but were not associated with infant characteristics including anthropometric parameters. CONCLUSIONS: These results do not provide evidence supporting an effect of VD on infants’ risk of first nasal PnC nor the dynamics of carriage in a setting where early infant PnC is highly probable. In contrast to in vitro data that demonstrated that VD promoted immune responses against pneumococcus, the present study does not support the hypothesis that improvements in VD status in early infancy reduces the risk of Pn colonization. FUNDING SOURCES: Bill & Melinda Gates Foundation. SUPPORTING TABLES, IMAGES AND/OR GRAPHS

This is the first systematic review to examine the global prevalence of catch-up growth (CUG) in small for gestational age (SGA) infants who were born at full term (FT). Size at birth and subsequent growth is an important indicator of neonatal and adult health. Globally, 16% of infants are SGA at birth, ranging from 7% in industrialized countries to 41.5% in South Asia. SGA infants are at increased risk for negative developmental and adult health outcomes. Some achieve CUG but others do not. CUG has immediate and late health implications especially in low- and middle-income countries. This systematic review sought to determine the global prevalence of CUG among FT-SGA infants. We performed a literature search of MEDLINE, Pubmed, Embase, Web of Science, and Scopus, as well as grey literature databases, and identified 3137 studies. The final analysis included 11 studies. The median prevalence of CUG was 87.4% across all definitions of SGA and CUG. However, multiple definitions were used to classify SGA and CUG. Nine unique reference populations were used to classify SGA, and 6 to approximate CUG. Due to this heterogeneity, a meta-analysis could not be conducted. Program implementation for this vulnerable group of infants is dependent on proper classification. Given the wide range of definitions and reference standards used in the past, it is not possible to determine the global need for programs to address CUG for FT-SGA infants or to rationally plan any such programs. We highlight the need and propose standard definitions and references for SGA and CUG.

After the Rwandan genocide in 1994, vaccine coverage was close to zero. Several factors, including extreme poverty, rural populations and mountainous geography affect Rwandans’ access to immunizations. Post-conflict, various other factors were identified, including the lack of immunization program infrastructure, and lack of population-level knowledge and demand. In recent years, Rwanda is one of few countries that has demonstrated a sustained increase to near universal vaccination coverage, with a current rate of 98%. Our aim was to ask why and how Rwanda achieved this success so that it could potentially be replicated in other countries.Literature searches of scientific and grey literature, as well as other background research, was conducted from September 2016 through August 2017, including primary fieldwork in Rwanda. We determined that four factors have had a major influence on the Rwandan vaccine program, including strong central government leadership (political will), a culture of accountability, local ownership and a strong health value chain. Rwanda’s national immunization program is rooted in a political landscape shaped by unique aspects of Rwandan history and culture. Rwanda has a strong central government and a hierarchical chain of command supported by decentralized implementation bodies. A culture of accountability transcends the entire health system and there is local-level ownership of the immunization program, including the role of engaged community health workers and a strong health information system. Together, these four factors likely account for Rwanda’s vaccination coverage success.

Excessive micronutrient intake causes a variety of adverse health effects, depending on dose and duration. The risk of excess intake carries significant implications for micronutrient delivery interventions, particularly when such programs are overlapping. To minimize risk and provide public health guidance, several countries and the Food and Agriculture Organization of the United Nations/World Health Organization have set upper intake levels (ULs) for various life-stage populations using the risk assessment framework. However, there is a lack of international consensus on the actual ULs due to variability in application of this framework and a scarcity of evidence from which to draw upon, especially for children. Often ULs for children are established through a downward weight-based extrapolation from adult ULs, which is not always appropriate. The published ULs of nine organizations are compared, recent population nutrient intake evidence is presented, and the toxic effects of key minerals and vitamins are reviewed. Finally, the evidence for toxicity and setting of ULs for each nutrient is discussed including a comment on our degree of confidence in the strength of existing individual ULs. Challenges with risk assessment and opportunities for strengthening the definition of ULs are discussed.

ObjectiveMillions of children suffer from severe acute malnutrition (SAM) in low- and middle- income countries. Much is known about the effectiveness of community treatment programmes (CMAM) but little is known about post-discharge outcomes after successful treatment. The present study aimed to evaluate post-discharge outcomes of children cured of SAM.DesignProspective, observational cohort study. Children with SAM who were discharged as cured were followed monthly for 6 months or until they experienced relapse to SAM. ‘Cure’ was defined as a child achieving a mid-upper arm circumference (MUAC) of ≥115 mm with ≥15 % weight gain after loss of oedema. Relapse was defined as a child with MUACSettingSave the Children CMAM programme in Swabi, Pakistan, from January 2012 to December 2014.SubjectsChildren aged 6–59 months (n117) discharged as cured from the CMAM programme were eligible for the study and followed for 6 months.ResultsOne hundred children (92·6 %) remained free of SAM, eight (7·4 %) relapsed to SAM, nine (8·3 %) were lost to follow-up and none died. Most relapses occurred within 3 months of discharge (mean time to relapse 73·4 (sd36·2) d). At enrolment, 90 % had moderate acute malnutrition (MAM) and 10 % were not malnourished. By the end of 6 months, 35 % persisted with MAM and the remaining were not malnourished.ConclusionsIn rural Pakistan, fewer than 10 % of children cured of SAM relapsed. The first 3 months is the most vulnerable time.

Micronutrient powders (MNP) are an efficacious intervention in terms of reducing anaemia among young children, yet challenges remain regarding implementation at scale. Research that can guide effective implementation of nutrition interventions and facilitate integration into existing health care platforms is needed. This paper seeks to advance the implementation science knowledge base by presenting our multiphased strategy and findings for scaling-up MNP in Rwanda. The multiphased implementation strategy, spanning a 5-year period (2011-2016), included (a) a feasibility study involving formative research, (b) a 30-day trial of improved practices (n = 60 households), (c) a 12-month pilot that included an effectiveness study (n = 1,066 caregiver/child pairs), and (d) a staggered approach to national scale-up. At the end of Phase 4, the programme had been implemented in 19 of Rwanda's 30 districts with the scale-up in the final 11 districts completed in the following year. The caregivers of over 270,000 eligible children 6-23 months of age received a box of 30 MNP sachets in the final 3-month assessment period, representing a coverage rate of 87%. Initial problems with the supply chain and distribution and ongoing challenges to monitoring and reporting have been the largest obstacles. Continued success will be dependent on adequate resources for capacity development, refresher training, and responsive monitoring. Rwanda is one of the first countries to successfully scale-up home fortification subnationally with MNP. Lessons learned have implications for other countries.

The objective of this article is to evaluate food sharing practices in households receiving corn–soya blend (CSB) and ready-to-use supplementary food (RUSF) in southern Ethiopia. Ethiopian children with moderate acute malnutrition from 10 supplementary feeding sites received CSB (1413 kcal/day) or RUSF (500 kcal/day). Data on food sharing and consumption practices were collected from 1125 households via structured questionnaires administered by trained local health professionals after 6 weeks of treatment. CSB was shared among a significantly higher number of family members (1.9 ± 1.0) compared to RUSF (0.1 ± 0.4; P < .001). In only 14% of CSB households, children consumed equal or more than three quarters of the ration, compared to 98% of RUSF households. Only 9% of RUSF households reported food sharing, the majority (86%) of whom were children in the same household under 5 years of age. Comparatively, CSB was shared within the household with a greater number of family members and in greater quantities c...

ObjectivesFe-deficiency anaemia (IDA) occurs in 1–2 % of infants in developed countries, peaks at 1–3 years of age and is associated with later cognitive deficits. The objectives of the present study were to describe the characteristics of young children with severe IDA and examine modifiable risk factors in a developed-country setting.DesignTwo prospective samples: a national surveillance programme sample and a regional longitudinal study sample.SettingCanada, 2009–2011.SubjectsTwo samples of young children recruited from community-based health-care practices: a national sample with severe anaemia (HbResultsChildren with severe IDA (n201, mean Hb 55·1 g/l) experienced substantial morbidity (including developmental delay, heart failure, cerebral thrombosis) and health-care utilization (including a 42 % hospitalization rate). Compared with children with Fe sufficiency (n597, mean Hb 122·4 g/l), children with severe IDA consumed a larger volume of cow’s milk daily (median 1065 mlv. 500 ml,Pv. 43 %, OR=6·0; 95 % CI 4·0, 8·9) and also in bed (60 %v. 21 %, OR=6·5; 95 % CI 4·4, 9·5).ConclusionsSevere IDA is associated with substantial morbidity and may be preventable. Three potentially modifiable feeding practices are associated with IDA: (i) cow’s milk consumption greater than 500 ml/d; (ii) daytime bottle use beyond 12 months of age; and (iii) bottle use in bed. These feeding practices should be highlighted in future recommendations for public health and primary-care practitioners.

Realistic planning for a nutrition intervention is a critical component of implementation, yet effective approaches have been poorly documented. Under the auspices of “The Micronutrient Powders Consultation: Lessons Learned for Operational Guidance,” 3 working groups were formed to summarize experiences and lessons across countries regarding micronutrient powders (MNP) interventions for young children. This paper focuses on programmatic experiences in the planning stages of an MNP intervention, encompassing assessment, enabling environment and adaptation, as well as considerations for supply. Methods included a review of published and grey literature, key informant interviews, and deliberations throughout the consultation process. We found that assessments helped justify adopting an MNP intervention, but these assessments were often limited by their narrow scope and inadequate data. Establishing coordinating bodies and integrating MNP into existing policies and programmes have helped foster an enabling environment and support programme stability. Formative research and pilots have been used to adapt MNP interventions to specific contexts, but they have been insufficient to inform scale‐up. In terms of supply, most countries have opted to procure MNP through international suppliers, but this still requires understanding and navigating the local regulatory environment at the earliest stages of an intervention. Overall, these findings indicate that although some key planning and supply activities are generally undertaken, improvements are needed to plan for effective scale‐up. Much still needs to be learned on MNP planning, and we propose a set of research questions that require further investigation.

Objectives Patterns of infection among children with varying levels of iron status in a malaria endemic area may vary spatially in ways requiring integrated infection and iron deficiency control programmes. The objective of this secondary analysis was to determine the geospatial factors associated with malaria and non-malaria infection status among young Ghanaian children at the end of a 5-month iron intervention trial. Design Cluster-randomised controlled trial. Setting Rural Ghana Participants 1943 children (6–35 months of age) with geocoded compounds. Interventions Point-of-use fortification with micronutrient powders containing vitamins and minerals with or without iron. Primary and secondary outcome measures Generalised linear geostatistical models with a Matern spatial correlation function were used to analyse four infection response variables, defined using different combinations of inflammation (C-reactive protein, CRP >5 mg/L) and malaria parasitaemia. Analyses were also stratified by treatment group to assess the independent effects of the iron intervention. Results The by-group and combined-group analyses both showed that baseline infection status was the most consistent predictor of endline infection risk, particularly when infection was defined using parasitaemia. In the No-iron group, age above 24 months and weight-for-length z-score at baseline were associated with high CRP at endline. Higher asset score was associated with a 12% decreased odds of endline infection, defined as CRP >5 mg/L and/or parasitaemia (OR 0.88, 95% credible interval 0.78 to 0.98), regardless of group. Maps of the predicted risk and spatial random effects showed a defined low-risk area around the District centre, regardless of how infection was defined. Conclusion In a clinical trial setting of iron fortification, where all children receive treated bed nets and access to malaria treatment, there may be geographical variation in the risk of infection with distinct high-risk and low-risk areas, particularly around municipal centres. Trial registration number clinicaltrials.gov, NCT01001871.

Background Leading children’s hospitals in high-income settings have become heavily engaged in international child health research and educational activities. These programs aim to provide benefit to the institutions, children and families in the overseas locations where they are implemented. Few studies have measured the actual reciprocal value of this work for the home institutions and for individual staff who participate in these overseas activities. Our objective was to estimate the perceived reciprocal value of health professionals’ participation in global child health-related work. Benefits were measured in the form of skills, knowledge and attitude strengthening as estimated by an adapted Global Health Competency Model. Methods A survey questionnaire was developed following a comprehensive review of literature and key competency models. It was distributed to all health professionals at the Hospital for Sick Children with prior international work experience (n = 478). Results One hundred fifty six health professionals completed the survey (34%). A score of 0 represented negligible value gained and a score of 100 indicated significant capacity improvement. The mean respondent improvement score was 57 (95% CI 53–62) suggesting improved overall competency resulting from their international experiences. Mean scores were >50% in 8 of 10 domains. Overall scores suggest that international work brought value to the hospital and over half responded that their international experience would influence their decision to stay on at the hospital. Conclusions The findings offer tangible examples of how global child health work conducted outside of one’s home institution impacts staff and health systems locally. Electronic supplementary material The online version of this article (doi:10.1186/s12992-017-0250-8) contains supplementary material, which is available to authorized users.

BACKGROUND Low-birth-weight children are known to be at risk of both anemia and cognitive/language deficits in their early years. OBJECTIVE The aim of the current study was to examine the effects of a 22-element multiple micronutrient powder (MNP) on the cognitive and language development of full-term low-birth-weight (LBW-T) children in Bangladesh. METHODS The current study was a follow-up of children who were enrolled in a randomized cluster trial at 7-12 mo of age. Children in 12 intervention clusters (communities) were administered a daily 22-element MNP sachet with their food for 5 mo, and both intervention and control groups (also 12 clusters) received nutrition, health, and hygiene education. The current study involved the assessment of children at 16-22 mo of age (22-element MNP group: n = 96; control group: n = 82) on 3 subtests of the Bayley Scales of Infant and Toddler Development III test to measure cognitive, receptive language, and expressive language development. RESULTS There was a significant effect of the 22-element MNP on children's expressive language scores (d = 0.39), and stunting moderated the effect on receptive language scores; there was no effect on cognitive development (d = 0.08). CONCLUSION An MNP may thus offer one feasible solution to improve language development of LBW-T children in low-resource community settings. This trial was registered at clinicaltrials.gov as NCT01455636.

Malnutrition among hospitalized children is known to negatively influence their response to therapy and to prolong their admission. It also has short- and long-term consequences for growth, development and well-being. It is commonly regarded as a condition affecting children in low-income countries; however, malnutrition has been found to be variably prevalent among hospitalized children in higher-income countries. At the time the present study was conducted, it had been30 years since the nutritional status of Canadian hospitalized children was last published.To determine and communicate the prevalence of malnutrition among children in a Canadian tertiary-care paediatric hospital at the time of their admission.In the present cross-sectional study, anthropometric measures were obtained from 322 children admitted to The Hospital for Sick Children in Toronto, Ontario. Nutritional indexes (BMI for age, weight for age, weight for length/height and length/height for age) were generated from anthropometric measures using the WHO igrowup software, and summarized according to WHO definitions.The overall prevalence of malnutrition using BMI for age was 39.6% (95% CI 33% to 46%), of which 8.8% and 30.8% of participants were under- and overnourished, respectively. Furthermore, 6.9% (95% CI 3% to 13%) were determined to be acutely malnourished (weight for length/height-2 SD) and 13.4% (95% CI 10% to 18%) chronically malnourished (length/height for age-2 SD).The high prevalence of overall malnutrition observed among study participants suggests that initial screening using simple anthropometric measures should be conducted on hospital admission so that patients can receive appropriate nutrition-specific care.On sait que la malnutrition chez les enfants hospitalisés nuit à leur réponse au traitement et prolonge leur hospitalisation. Elle a également des conséquences à court et à long terme sur la croissance, le développement et le bien-être. Elle est souvent considérée comme un problème chez les enfants de pays à faible revenu, mais sa prévalence est variable chez les enfants hospitalisés dans les pays à revenu élevé. Au moment de la présente étude, les dernières publications sur l’état nutritionnel des enfants canadiens hospitalisés remontaient à plus de 30 ans.Déterminer et communiquer la prévalence de malnutrition chez les enfants au moment de leur admission dans un hôpital pédiatrique canadien de soins tertiaires.Dans la présente étude transversale, les mesures anthropométriques ont été recensées auprès de 322 enfants admis àD’après l’IMC en fonction de l’âge, la prévalence globale de malnutrition s’élevait à 39,6 % (95 % IC 33 % à 46 %). Ainsi, 8,8 % et 30,8 % des participants étaient sous-alimentés et suralimentés, respectivement. De plus, il a été établi que 6,9 % (95 % IC 3 % à 13 %) souffraient de malnutrition aiguë (poids par rapport à la taille−2 ÉT), et 13,4 % (95 % IC 10 % à 18 %), de malnutrition chronique (taille par rapport à l’âge−2 ÉT).D’après la forte prévalence de malnutrition globale chez les participants à l’étude, le dépistage initial faisant appel à des mesures anthropométriques simples devrait être effectué au moment de l’admission à l’hôpital, afin que les patients puissent recevoir des soins pertinents en matière de nutrition.

Background Hypertensive diseases of pregnancy are important causes of maternal and perinatal mortality. Based on meta-analyses of efficacy trials of prenatal cal- cium supplementation to reduce the risk of hypertensive diseases of pregnancy, the World Health Organization recommends 1.5 to 2.0 g of elemental calcium per day for pregnant women with low dietary calcium intakes (as well as 60 mg of iron and 400 μg of folic acid). However, implementation of this recommendation is challenged by the size and number of calcium tablets required and the need to avoid concurrent ingestion of calcium and iron due to intraintestinal interactions. Objective We developed a novel micronutrient powder containing microencapsulated pH-sensitive calcium in addition to iron and folic acid, designed to facilitate early intestinal iron release and delayed calcium release. Methods Two pharmaceutical companies were con- tracted to develop a prototype, one of which was chosen for clinical testing. Calcium carbonate granules were coated with a trilayer pH-sensitive enteric coating using a fluid-bed spray coater. Iron and folic acid granules were encapsulated with a time-release coating. Iron and cal- cium dissolution profiles were assessed during exposure to acidic (pH 1.2) and/or basic (pH 5.8) media using a modified USP apparatus 1 (basket) method. Results At pH 1.2, calcium and iron release was ≤ 10% and > 90% after 120 minutes, respectively. At pH 5.8, > 80% of total calcium was released after 90 minutes. Conclusions Based on in vitro criteria, the sup- plement may be a promising approach for delivering calcium, iron, and folic acid as a single daily dose to preg- nant women in settings of low dietary intake of calcium.

OBJECTIVES: To summarize the evidence on the impact of nutrition policies on improving health among children in low-, middle- and high-income countries (LMHICs). METHODS: A scoping review was conducted to map and describe peer-reviewed studies evaluating the impact of population-level nutrition policies on child health and undernutrition (using primary data) in LMHICs. We systematically searched Medline, Embase, Web of Science, Scopus, and PAIS Index for public policy, to identify eligible studies. Data on key study characteristics, including research design, type of nutrition policy, time span of policy, child's age at outcome assessment, and types of outcomes assessed, were abstracted. Abstract screening and data abstraction were conducted in duplicate and reconciled. RESULTS: Of the 5646 abstracts screened, 83 studies were included. The majority of studies were conducted in upper-middle or high-income settings (66%, 54/83 studies) (Figure 1). Most studies were observational study design (49%, 41/83 studies), evaluated regional/sub-national policies (68%, 56/83 studies), reported on mandatory policies (71%, 59/83 studies), were related to micronutrient food fortification and/or supplementation (70%, 58/83 studies), and assessed outcomes among children

Policymaking that is informed by cost-effectiveness analysis (CEA) is increasing, thanks to the growing influence of evidence-based medicine and a universal need to make the best use of scarce resources for rising health care demands. In developing countries, the relatively greater scarcity of resources, coupled with relatively greater health needs, suggests that the efficient use of those same resources is even more critical than in industrialized countries. And it is most critical for those with great health needs: children. Worldwide, of the 11.4 million deaths in children under age ten in 2002, 90 percent occurred in those under five years old, and of these, children from developing countries accounted for 99 percent (Mathers 2009). In recognition of the scale and disparity of this problem, the international community pledged to achieve Millennium Development Goal (MDG) 4, aimed at reducing under-5 mortality by two-thirds between 1990 and 2015. Despite important gains, with global under-5 mortality dropping from one hundred to seventy-two deaths per 1,000 live births from 1990 to 2008 (United Nations Development Program 2011), the current rate of annual decline at 2.2 percent (UNICEF 2011) is too slow to meet the 2015 target. CEA may well be important to making health care investment decisions about interventions that can contribute to achieving MDG4. For example, Tan-Torres Edejer and colleagues (2005) identified strategies for implementing bundled regional child survival interventions (combinations of micronutrient fortification, measles immunization, and pneumonia case management) that are both effective and cost-effective. With substantially more funding focused on accelerating gains in child survival and health, particularly from international donors (Ravishankar et al. 2009), CEA has a role in illuminating how those extra resources might be best allocated. Yet it is unclear to what extent CEA evidence is used or, indeed, is useful in developing countries where relevant economic and effectiveness data are limited and where theoretical underpinnings (such as the concept of opportunity cost) might not be congruent with economic systems. In addition, methodological issues unique to pediatric economic evaluations, especially of preventive measures, can compromise results (Ungar 2010). Finally, donor funding as a source of health care financing is an unscrutinized entity in CEA methodology and application, as it is nonexistent in industrialized countries where the CEA technique has its roots. With new vaccines, on the one hand, promising to dramatically reduce much of the heaviest burdens of disease borne by children in developing countries (e.g., rotavirus and pneumococcal vaccines) but, on the other hand, costing several times more than older vaccines, a fuller understanding of the limitations of CEA methodology and the role of donor funding could enhance the ability of policymakers to use economic evidence to improve child health programming. In this context, we explored how CEA might be enhanced for use in developing countries. Our specific objectives were (1) to summarize the application of CEA in industrialized and developing countries; (2) to identify the methodological limitations of conventional CEA when used in developing countries, focusing on pediatric interventions; and (3) to determine the impacts of donor funding on the conduct and use of CEA. In this article we present an overview of the results of our thematic document analysis. First we outline our methods. Then, as an introduction, we describe the standard use of the CEA in industrialized countries and, next, its use in developing countries. We discuss some of the main issues concerning the CEA of pediatric interventions and their specific relevance to developing countries, as well as the significance of donor funding to the adoption of CEA evidence in developing nations. Finally, we summarize our conclusions and outline the policy implications.

Early infancy is a high-risk period for severe acute respiratory infection (ARI), particularly in low-income countries with resource-limited health systems. Lower respiratory tract infection (LRTI) is commonly preceded by upper respiratory infection (URTI), and often caused by respiratory syncytial virus (RSV), influenza and other common community-acquired viral pathogens. Vitamin D status is a candidate modifiable early-life determinant of the host antiviral immune response and thus may influence the risk of ARI-associated morbidity in high-risk populations. In the Maternal Vitamin D for Infant Growth (MDIG) study in Dhaka, Bangladesh (NCT01924013), 1300 pregnant women are randomized to one of five groups: placebo, 4200 IU/week, 16,800 IU/week, or 28,000 IU/week from 2nd trimester to delivery plus placebo from 0–6 months postpartum; or, 28,000 IU/week prenatal and until 6-months postpartum. In the Maternal Vitamin D for ARI in Infancy (MDARI) sub-study nested within the MDIG trial, trained personnel conduct weekly postnatal home visits to inquire about ARI symptoms and conduct a standardized clinical assessment. Supplementary home visits between surveillance visits are conducted when caregivers make phone notifications of new infant symptoms. Mid-turbinate nasal swab samples are obtained from infants who meet standardized clinical ARI criteria. Specimens are tested by polymerase chain reaction (PCR) for 8 viruses (influenza A/B, parainfluenza 1/2/3, RSV, adenovirus, and human metapneumovirus), and nasal carriage density of Streptococcus pneumoniae. The primary outcome is the incidence rate of microbiologically-positive viral ARI, using incidence rate ratios to estimate between-group differences. We hypothesize that among infants 0–6 months of age, the incidence of microbiologically-confirmed viral ARI will be significantly lower in infants whose mothers received high-dose prenatal/postpartum vitamin D supplements versus placebo. Secondary outcomes include incidence of ARI associated with specific pathogens (influenza A or B, RSV), clinical ARI, and density of pneumococcal carriage. If shown to reduce the risk of viral ARI in infancy, integration of maternal prenatal/postpartum vitamin D supplementation into antenatal care programs in South Asia may be a feasible primary preventive strategy to reduce the burden of ARI-associated morbidity and mortality in young infants. NCT02388516 , registered March 9, 2015.

Background Determining the spatial patterns of infection among young children living in a malaria-endemic area may provide a means of locating high-risk populations who could benefit from additional resources for treatment and improved access to healthcare. The objective of this secondary analysis of baseline data from a cluster-randomized trial among 1943 young Ghanaian children (6–35 months of age) was to determine the geo-spatial factors associated with malaria and non-malaria infection status. Methods Spatial analyses were conducted using a generalized linear geostatistical model with a Matern spatial correlation function and four definitions of infection status using different combinations of inflammation (C-reactive protein, CRP > 5 mg/L) and malaria parasitaemia (with or without fever). Potentially informative variables were included in a final model through a series of modelling steps, including: individual-level variables (Model 1); household-level variables (Model 2); and, satellite-derived spatial variables (Model 3). A final (Model 4) and maximal model (Model 5) included a set of selected covariates from Models 1 to 3. Results The final models indicated that children with inflammation (CRP > 5 mg/L) and/or any evidence of malaria parasitaemia at baseline were more likely to be under 2 years of age, stunted, wasted, live further from a health facility, live at a lower elevation, have less educated mothers, and higher ferritin concentrations (corrected for inflammation) compared to children without inflammation or parasitaemia. Similar results were found when infection was defined as clinical malaria or parasitaemia with/without fever (definitions 3 and 4). Conversely, when infection was defined using CRP only, all covariates were non-significant with the exception of baseline ferritin concentration. In Model 5, all infection definitions that included parasitaemia demonstrated a significant interaction between normalized difference vegetation index and land cover type. Maps of the predicted infection probabilities and spatial random effect showed defined high- and low-risk areas that tended to coincide with elevation and cluster around villages. Conclusions The risk of infection among young children in a malaria-endemic area may have a predictable spatial pattern which is associated with geographical characteristics, such as elevation and distance to a health facility. Original trial registration clinicaltrials.gov (NCT01001871) Electronic supplementary material The online version of this article (doi:10.1186/s12936-016-1388-1) contains supplementary material, which is available to authorized users.

Background Low- and middle-income countries (LMICs) are developing novel approaches to healthcare that may be relevant to high-income countries (HICs). These include products, services, organizational processes, or policies that improve access, cost, or efficiency of healthcare. However, given the challenge of replication, it is difficult to identify innovations that could be successfully adapted to high-income settings. We present a set of criteria for evaluating the potential impact of LMIC innovations in HIC settings. Methods An initial framework was drafted based on a literature review, and revised iteratively by applying it to LMIC examples from the Center for Health Market Innovations (CHMI) program database. The resulting criteria were then reviewed using a modified Delphi process by the Reverse Innovation Working Group, consisting of 31 experts in medicine, engineering, management and political science, as well as representatives from industry and government, all with an expressed interest in reverse innovation. Results The resulting 8 criteria are divided into two steps with a simple scoring system. First, innovations are assessed according to their success within the LMIC context according to metrics of improving accessibility, cost-effectiveness, scalability, and overall effectiveness. Next, they are scored for their potential for spread to HICs, according to their ability to address an HIC healthcare challenge, compatibility with infrastructure and regulatory requirements, degree of novelty, and degree of current collaboration with HICs. We use examples to illustrate where programs which appear initially promising may be unlikely to succeed in a HIC setting due to feasibility concerns. Conclusions This study presents a framework for identifying reverse innovations that may be useful to policymakers and funding agencies interested in identifying novel approaches to addressing cost and access to care in HICs. We solicited expert feedback and consensus on an empirically-derived set of criteria to create a practical tool for funders that can be used directly and tested prospectively using current databases of LMIC programs.