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INTRODUCTION: The aim of this analysis is to present initial contraceptive choices of women offered postpartum contraception in rural Guatemala. METHODS: We trained community nurses participating in the delivery of a home-based antepartum and postpartum care program in rural Guatemala in contraceptive implant placement and had them offer condoms, pills, an injection, or an implant at women’s home-based 40-day postpartum visit in intervention clusters of a non-blinded, cluster-randomized trial. Women who had already started postpartum contraception or were over the age of 35 were excluded from participation. The primary outcome of the trial was contraceptive use at 3 months postpartum, so this initial analysis describes immediate preferences in the population. RESULTS: Of 208 women enrolled in the study, 108 were in intervention clusters and 100 lived in control clusters. In the intervention group, 32 women declined contraception, 36 women received the injectable, 30 women had an implant placed, 5 women started pills, 2 women chose condoms, and data on 3 women were missing. In the control clusters, 43 women were planning on the injectable, 11 planned on the implant, 10 did not want to start a method, 5 planned on sterilization, 2 aimed for natural family planning, 2 wanted a copper IUD, 1 woman wanted condoms, 18 did not know, and data on 8 women were missing. DISCUSSION: The contraceptive implant, which was not previously available in this community, had high uptake at 27.8% in the intervention group. TRIAL REGISTRATION: Clinicaltrials.gov, NCT04005391; Retrospectively Registered 7/2/2019, https://clinicaltrials.gov/ct2/show/NCT04005391 PROTOCOL: https://doi.org/10.1186/s13063-019-3735-3

Each year in Latin America and the Caribbean, seasonal influenza is associated with an estimated 36,500 respiratory deaths and 400,000 hospitalizations. Since the 2009 influenza A(H1N1) pandemic, the Region has made significant advances in the prevention and control of seasonal influenza, including improved surveillance systems, burden estimates, and vaccination of at-risk groups. The Global Influenza Strategy 2019–2030 provides a framework to strengthen these advances. Against the backdrop of this new framework, the University of Colorado convened in October 2020 its Immunization Advisory Group of Experts to review and discuss current surveillance, prevention, and control strategies for seasonal influenza in Latin America and the Caribbean, also in the context of the COVID-19 pandemic. This review identified five areas for action and made recommendations specific to each area. The Region should continue its efforts to strengthen surveillance and impact evaluations. Existing data on disease burden, seasonality patterns, and vaccination effectiveness should be used to inform decision-making at the country level as well as advocacy efforts for programmatic resources. Regional and country strategic plans should be prepared and include specific targets for 2030. Existing investments in influenza prevention and control, including for immunization programs, should be optimized. Finally, regional partnerships, such as the regional networks for syndromic surveillance and vaccine effectiveness evaluation (SARInet and REVELAC-i), should continue to play a critical role in continuous learning and standardization by sharing experiences and best practices among countries.

This analysis describes the interpregnancy interval (time from livebirth to subsequent conception) in a convenience sample of women living in Southwest Guatemala and the association of antepartum characteristics and postpartum outcomes with a short interpregnancy interval (

The intention of our study was to establish the prevalence of low birth weight (LBW) as well as risk factors for LBW in infants born to a convenience sample of women enrolled in a home visitation maternal care program associated with the Center for Human Development in Southwest Trifinio, Guatemala.This is an observational study analyzing self-reported data from a quality improvement database. We recorded the distribution of birthweights of infants born to women enrolled in Madres Sanas that delivered between October 2018 and December 2019. We grouped women by LBW (2500g ) and adequate birthweight (≥2500g) infants, and performed bivariate comparisons using sociodemographic, obstetric, and intrapartum data. Using the independent variables shown to have an association with LBW, we then performed a multivariable analysis.There were 226 births among our program participants, 218 with recorded birthweights. The median birthweight was 3175g; 13.8% were LBW (2500g), higher than Guatemala's average of 10.9%. Through our bivariate analysis, we determined women with LBW infants were younger, with a median age of 20.8 (IQR [17.8-23.7]) compared to a median age of 23.2 (IQR [19.8-27.3]) among women with infants ≥2500g (Two significant findings emerged from our analysis: LBW infants were more commonly born to women who were younger in age and who had received fewer than 4 prenatal visits. These findings are consistent with existing literature on LBW in Latin America. Our study helps to strengthen the data around these associations and gives credence to programming and policy efforts in Latin America that support adequate prenatal care for all and youth education about reproductive health and contraceptive access.

Background: Victims of intimate partner violence (IPV) during pregnancy experience significant physical and mental health consequences and adverse birth outcomes. Our objective was to describe the prevalence of IPV, and risk factors associated with IPV in pregnant, rural Guatemalan women. Methods: This retrospective cohort study was complet- ed using quality improvement data gathered during routine prenatal health visits to women of Trifinio, Guatemala, by the Madres Sanas maternal health program from 2018 through 2020. Chi-square and t-tests were used to determine if there were differences in characteristics between women who self-reported experiencing IPV and those who did not. If differences occurred (p < 0.2), those covariates were included in a multivariable logistic regression to determine sociodem- ographic risk associated with IPV. Results: 583 women were enrolled with Madres Sanas between October 10, 2018, and October 1, 2020, and reported on IPV. Nineteen (3.26%) women reported experiencing IPV. The highest prevalence of IPV (7.6%) occurred in the sub-group of women who experienced food insecurity during the past year. The sole covariate of all sociodemographic and health characteristics which differed significantly between women who reported experiencing and not experiencing IPV was food insecurity. A regression model found that those who had worried about ability to buy food in the past year had a 3.19-fold increase in the odds that they experienced IPV (95% CI 1.072, 9.486, p-value 0.037). Conclusion: Among this convenience sample of women, the prevalence of IPV was 3.26%. Food insecurity was associated with increased odds of experiencing IPV, highlighting an opportunity for interventions.

Sleep quality is vital for healthy development in children. Sleep disorders are prevalent and negatively affect sleep quality. Early identification and appropriate intervention can improve children’s health and quality of life. The current reference standard, polysomnography (PSG) has limitations regarding availability, cost, and access and may not replicate normal sleep patterns in the home. Simple, accurate sleep tests, available for repeated testing should be beneficial in management of sleep disorders. Secondary analysis of PSG data from the prospective multicenter Childhood Adenotonsillectomy Trial (CHAT) to evaluate FDA-cleared cloud-based software (Software-as-a-Medical-Device), which is based on analysis of photoplethysmogram data (PPG; plethysmogram-signal (PLETH) and oxygen saturation data (SpO2)), to automatically generate a novel apnea-hypopnea index (sAHI). sAHI is compared to manually scored AHI from PSG. Significant correlation is observed comparing the software-generated sAHI and manually derived AHI from the in-laboratory PSG-studies (Pearson correlation = 0.954, p

OBJECTIVE: The use of traditional birth attendants (TBAs) in low- and middle-income countries remains controversial. The aim of this secondary analysis was to observe factors associated with visiting a TBA in addition to a skilled nurse for antepartum care, and how this additional care was associated with birth characteristics and outcomes. METHODS: The study included a convenience sample of women living in Southwestern Guatemala enrolled in a community nursing program between October 1, 2018 and December 3, 2019. This analysis describes the sociodemographic characteristics, antepartum care, birth outcomes, and post-partum behaviors of women who received antepartum care with skilled nurses only compared to women who received antepartum care with skilled nurses and a TBA. RESULTS: Of the 316 enrollees, 259 had given birth and completed their postpartum visit at the time of analysis. Three women were excluded due to missing data. The majority of women in the study sample reported visiting aTBA over the course of their pregnancies (80.9%). Women who saw a TBA in addition to the nurse were similar to the comparator sample except that they were almost three times more likely to have 8 or more prenatal contacts with the nurse. In separate multivariable logistic regression models adjusted for number of prenatal visits, women who saw a TBA in addition to nurses had a reduced likelihood of cesarean birth, increased likelihood of birth with a TBA, and increased likelihood of breastfeeding within one hour of birth, compared to women who only received antenatal care from nurses. Patient-reported adverse outcomes were not included in the analysis due to low prevalence and concern about data quality and missing data. CONCLUSION: Among a convenience sample of women in the Trifinio community in rural Guatemala, a large proportion of women continued to seek the care of a TBA in pregnancy while utilizing a skilled nursing program for antenatal care. Intentionally integrating the TBA into the maternity care workforce may be beneficial for improving pregnancy care quality measures.

Design: We conducted a secondary analysis of a cluster-randomized trial to observe characteristics associated with women who chose to use long-acting reversible contraceptives (LARC) compared to those who chose a short-acting method 12 months after enrollment. Methods: The trial studied four control and four intervention clusters where the intervention clusters were offered contraception at their 40-day routine postpartum visit; control clusters received standard care, which included comprehensive postpartum contraceptive counseling. Women were followed through twelve months postpartum. Results: The study enrolled 208 women; 94 (87.0%) were in the intervention group and 91 (91.0%) were in the control group. At twelve months, with 130 (70.3%) women using contraception at that time. 94 women (50.8%) were using a short acting method compared to 33 (17.9%) who chose a long-acting method, irrespective of cluster. In mixed effect regression modeling adjusted for cluster, characteristics associated with a reduced likelihood of choosing long-acting contraception in multivariate modeling included age (aRR 0.98 [0.96,0.99], p = 0.008) and any education (compared to no education; aRR 0.76 [0.60,0.95], p = 0.02). Women who were sexually active by their enrollment visit (40 days postpartum) were 30% more likely to opt for a long-acting method (aRR 1.30 [1.03,1.63], p = 0.03). Conclusion: Older and more educated women were less likely to be using LARC a year after enrollment, while women with a history of early postpartum sexual activity were more likely to choose LARC.

Design: We executed a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with three and 12-month contraceptive utilization, satisfaction, and pregnancy rates.Methods: Eight clusters were randomized to receive either the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit in addition to routine care, or routine care alone, which included comprehensive contraceptive counseling throughout antepartum care. Results: 208 women were enrolled in the study, 108 in the intervention clusters and 100 in control clusters. 94 (87.0%) women in the intervention group and 91 (91%) of women in control clusters were evaluated 12 months post-enrollment. Likelihood of using contraception at that time was borderline increased in intervention clusters (RR 1.1 [1.0,1.3], p = 0.05) with an increased likelihood of long-acting contraceptive use (the implant; RR 1.6 [1.3,1.9], p < 0.001). Pregnancy rates were also borderline reduced in the intervention clusters (RR 1.0 [1.0,1.1], p = 0.07). There was no difference in satisfaction of women with contraceptive use between arms with about 95% of women very satisfied or a little satisfied in each arm. Continuation rates at twelve months of contraceptives in the intervention group were 0.0% for condom users, 80.0% for contraceptive pill users, 57% for injectable users, and 83% for implant users. Most women who discontinued their initial method chose a more long-term or permanent method. There was a trend toward a significant association with reduced short interval pregnancy.Conclusion: Our study had a borderline increase in overall use of contraception by 12 months, did have an increased likelihood of long-acting contraceptive use of the implant by 12 months, and resulted in a trend toward reduced short interval pregnancy in the intervention clusters as compared to control clusters. Registration: clinicaltrials.gov, NCT04005391; Retrospectively Registered 7/2/2019, https://clinicaltrials.gov/ct2/show/NCT04005391Protocol: https://doi.org/10.1186/s13063-019-3735-3

BACKGROUND AND OBJECTIVE Previous studies have described the effect of sociodemographic factors on early development. We describe development of a simple cumulative risk index (CRI) based on four sociodemographic factors and explore the concurrent and predictive relationship of this index to a measure of the cognitive home environment in early childhood and to later school functioning. METHODS This was a secondary data analysis of children from an urban pediatrics clinic. Baseline data were collected at 10-23 months (n = 324) with primary follow-up 6 months later at 18-35 months (n = 179) and secondary follow-up at 8-10 years (n = 68). A CRI score was derived at baseline using maternal education, marital status, race/ethnicity and child insurance. Baseline and primary follow-up included three subscales of the STIMQ, a measure of the cognitive home environment. Effectiveness of CRI was examined using analysis of variance (ANOVA) with linear contrasts. Chi-square examined differences in school function between children from CRI high-risk (CRI 3-4) and low-risk (CRI 0-2) families. RESULTS CRI had a negative impact in early childhood on STIMQ subscale scores (p

IntroductionEarly childhood development (ECD) is a critical component for building the foundation of future physical and emotional health and subsequent academic success. The quality of the home environment to promote development is an important factor in ECD. Since large rural–urban disparities in the home environment exist in China, there is a critical need to develop and evaluate interventions to promote ECD in rural areas. Individual center-based or home-based interventions dominate the current ECD programmes in rural China. However, group-based interventions offer potential advantages in terms of both effectiveness and cost. Thus, we aim to: (1) evaluate the effectiveness of an integrated group-based intervention, the Care Group Intervention, in enhancing ECD among children age 6–18 months and (2) conduct a cost-effectiveness analysis.Methods and analysisThe Care Group Intervention uses a cluster (by township) randomised controlled trial conducted in Fenxi county, Shanxi province, China, from July 2019, for 1 year. The intervention focuses on five key components of nurturing care including good health, adequate nutrition, responsive caregiving, security and safety, and opportunities for early learning. The intervention comprises small groups of 3–10 children within a certain age range and their primary caregivers that are led by well-trained local facilitators. Outcomes includes infants’ developmental quotient (Bayley Scales of Infant Development III, Ages & Stages Questionnaire: Social–Emotional, second edition); anaemia (HemoCue Hb 301+); nurturing environment (Infant/Toddler Home Observation for Measurement of the Environment), parent-child interaction (Teaching Scale) and caregiver depression (Center for Epidemiological Studies Depression). Cost data are collected throughout the entire study to carry out a cost-effectiveness analysis.Ethics and disseminationThis study was approved by the Ethical Committee of Capital Institute of Pediatrics, Beijing, China on 10 July 2018 (SHERLL2018014). Findings and results from this project will be disseminated via publications and presentations.Trial registration numberChinese Clinical Trials Registry: ChiCTR1900022894. Registered on 30 April 2019.

* Abbreviations: COVID-19 — : coronavirus disease 2019 PART — : Pediatricians Against Racism and Trauma We have seen the horrifying cell phone and surveillance video footage of the murder of George Floyd replay again and again in the last few weeks. The aftermath begs the question why this particular murder of a Black man by a police officer has sparked the international response so few have received.1 Scores of other Black men, women, and children have been killed by police since the 2014 murder of Eric Garner in New York City, in which he suffered an illegal chokehold and uttered the devastating refrain “I can’t breathe,” and countless others have been murdered over generations. These cases represent just the tip of the iceberg because these murders happened to be recorded on bystander cell phone video or police webcam capture. Moreover, it is the tip of another iceberg because these cases represent modern-day lynchings. The lynching of Black people in the United States was routine before the “civil rights era,” when there were major legal advances to change the treatment of Black Americans in this country. However, it was not until February 2020 that federal legislation, the Emmett Till Antilynching Act, was passed by the House of Representatives but is still … Address correspondence to Benard P. Dreyer, MD, FAAP, Division of Developmental and Behavioral Pediatrics, Department of Pediatrics, New York University Grossman School of Medicine and Department of Pediatrics, Bellevue Hospital Center, 550 First Ave, New York, NY 10016. E-mail: benard.dreyer{at}nyulangone.org

Design: This a cluster-randomized parallel arm pragmatic trial to observe the association of home-based postpartum contraceptive provision, including the contraceptive implant, with implant utilization rates at 3 months post-enrollment.Methods: In a region of rural Guatemala referred to as the Southwest Trifinio, twelve communities are served by a community-based antenatal and postnatal care program. The communities were combined into eight clusters based on 2017 birth rates and randomized to receive the home-based contraceptive delivery (condoms, pills, injection, implant) during the routine 40-day postpartum visit. All participants receive comprehensive contraceptive counseling beginning at the first antenatal visit, so control clusters received this as part of routine care; this education preceded the study intervention. Results: Once the 12 communities were combined into 8 clusters by expected birth volume and nurse team, which we expected to translate to eventual postpartum visits, the allocation sequence was generated in SAS. Of 208 women enrolled in the study, 108 were in four intervention and 100 in four control clusters. We used descriptive statistics to produce counts and percentages of characteristics of the study population overall and by intervention arm followed by univariate modeling using a mixed effects regression adjusted for cluster. Three-month contraceptive initiation rates were 56.0% in the control clusters compared to 76.8% in the intervention clusters, p < 0.001. Women in control clusters overwhelmingly opted for the injectable contraceptive (94.6%) while women in intervention clusters chose both the injection (61.5%) and the implant (33.7%), p < 0.001. Implant use by 3 months, the primary outcome of the study, was significantly higher in the intervention arm (25.9%) compared to the control arm (3.6%), p < 0.001, RR 1.3 CI [1.2, 1.4]. Conclusion: Our study was designed to respond to previously identified barriers to contraceptive uptake, and it was successful. Not only did it increase overall use of contraception by 3 months, but it shifted that contraceptive use away from short-acting methods in favor of longer-acting methods, with high continuation and satisfaction rates and no adverse outcomes reported.Registration: clinicaltrials.gov, NCT04005391; Retrospectively Registered 7/2/2019, https://clinicaltrials.gov/ct2/show/NCT04005391Protocol: https://doi.org/10.1186/s13063-019-3735-3

To describe perinatal and neonatal outcomes in newborns exposed to SARS-CoV-2.A systematic review was conducted by searching PubMed Central, LILACS, and Google Scholar using the keywords 'covid ' AND 'newborn' OR 'child' OR 'infant,' on 18 March 2020, and again on 17 April 2020. One researcher conducted the search and extracted data on demographics, maternal outcomes, diagnostic tests, imaging, and neonatal outcomes.Of 256 publications identified, 20 met inclusion criteria and comprised neonatal outcome data for 222 newborns whose mothers were suspected or confirmed to be SARS-CoV-2 positive perinatally (17 studies) or of newborns referred to hospital with infection/pneumonia (3 studies). Most (12 studies) were case-series reports; all were from China, except three (Australia, Iran, and Spain). Of the 222 newborns, 13 were reported as positive for SARS-CoV-2; most of the studies reported no or mild symptoms and no adverse perinatal outcomes. Two papers among those from newborns who tested positive reported moderate or severe clinical characteristics. Five studies using data on umbilical cord blood, placenta, and/or amniotic fluid reported no positive results. Nine studies reported radiographic imaging, including 5 with images of pneumonia, increased lung marking, thickened texture, or high-density nodular shadow. Minor, non-specific changes in biochemical variables were reported. Studies that tested breast milk reported negative SARS-CoV-2 results.Given the paucity of studies at this time, vertical transmission cannot be confirmed or denied. Current literature does not support abstaining from breastfeeding nor separating mothers and newborns. Further evidence and data collection networks, particularly in the Americas, are needed for establishing definitive guidelines and recommendations.Describir los resultados perinatales y neonatales de los recién nacidos expuestos al SARS-CoV-2.Se realizó una revisión sistemática con búsqueda bibliográfica en PubMed Central, LILACS, y Google Scholar usando las palabras clave ‘covid’ Y ‘newborn’ O ‘child’ O ‘infant’, el 18 de marzo de 2020, y de nuevo el 17 de abril de 2020. Un investigador llevó a cabo la búsqueda y extrajo datos sobre demografía, resultados maternos, pruebas de diagnóstico, imágenes y resultados neonatales.De las 256 publicaciones identificadas, 20 cumplieron los criterios de inclusión y comprendían datos de resultados neonatales de 222 recién nacidos cuyas madres eran casos sospechosos o positivos confirmados de SARS-CoV-2 en el período perinatal (17 estudios) o bien recién nacidos internados en el hospital con infección/neumonía (3 estudios). La mayoría (12 estudios) eran informes de series de casos; todos procedían de China, excepto tres (de Australia, España e Irán). De los 222 recién nacidos, 13 tenían resultados positivos para SARS-CoV-2; en la mayoría de los estudios se informó que los recién nacidos eran asintomáticos o tenían síntomas leves y que no se habían producido resultados perinatales adversos. Entre los estudios con recién nacidos positivos, en dos se informaron características clínicas moderadas o graves. En cinco estudios se analizó la sangre del cordón umbilical, la placenta o el líquido amniótico y no se informaron resultados positivos. En nueve estudios se reportaron imágenes radiográficas, entre ellos cinco con imágenes de neumonía, aumento de la trama pulmonar, textura engrosada u opacidades nodulares de alta densidad. Se informaron alteraciones menores e inespecíficas de los parámetros bioquímicos. En los estudios en que se analizó la leche materna se informaron resultados negativos para el SARS-CoV-2.Dada la escasez de estudios, en este momento no es posible confirmar ni descartar la transmisión vertical. La bibliografía actual no apoya la abstención de la lactancia materna ni la separación de los recién nacidos de sus madres. Se necesitan más evidencia y redes de recolección de datos, en particular en la Región de las América, para establecer directrices y recomendaciones definitivas.Descrever os resultados perinatais e neonatais dos recém-nascidos expostos à SARS-CoV-2.Uma revisão sistemática com pesquisa bibliográfica em PubMed Central, LILACS e Google Scholar foi realizada utilizando as palavras-chave ‘covid’ E (‘newborn’ OU ‘child’ OU ‘infant’) em 18 de março de 2020, e novamente em 17 de abril de 2020 por um pesquisador. Foram analisados dados sobre demografia, resultados maternos, testes de diagnóstico, técnicas de imagem e resultados neonatais.Das 256 publicações identificadas, 20 preenchiam os critérios de inclusão e incluíam dados de resultados neonatais de 222 recém-nascidos cujas mães eram suspeitas ou positivas para a SARS-CoV-2 no período perinatal (17 estudos) ou recém-nascidos internados no hospital com infecção/pneumonia (3 estudos). A maioria (12 estudos) eram relatos de séries de casos; todos, exceto três (Austrália, Irão e Espanha), eram provenientes da China. Dos 222 recém-nascidos, 13 eram positivos para SARS-CoV-2; a maioria dos estudos relatou que os recém-nascidos eram assintomáticos ou tinham sintomas leves e que não foram observados resultados perinatais adversos. Entre os estudos com recém-nascidos positivos, dois descreviam características clínicas moderadas ou graves. O sangue do cordão umbilical, a placenta ou o líquido amniótico foram analisados em cinco estudos, não tendo sido relatados resultados positivos. Imagens radiográficas foram descritas em nove estudos, incluindo cinco com imagens de pneumonia, aumento da trama pulmonar, espessamento da textura ou opacidades nodulares de alta densidade. Foram relatadas alterações menores e não específicas dos parâmetros bioquímicos. Estudos que analisaram leite materno mostraram resultados negativos para SARS-CoV-2.Dada a escassez de estudos, neste momento a transmissão vertical não pode ser confirmada ou excluída. A literatura atual não apoia a abstenção da amamentação ou a separação dos recém-nascidos das suas mães. São necessárias mais provas e mais dados, especialmente na Região das Américas, para estabelecer orientações e recomendações definitivas.

OBJECTIVES: To evaluate trends and factors associated with mode of delivery in the rural Southwest Trifinio region of Guatemala. METHODS: We conducted a retrospective analysis of self-reported antepartum factors and postpartum outcomes recorded in a quality improvement database among 430 women enrolled in a home-based maternal healthcare program between June 1, 2015 and August 1, 2017. RESULTS: Over the study period, the rates of cesarean delivery (CD) increased (from 30% to 45%) and rates of vaginal delivery (VD) decreased (70% to 55%) while facility-based delivery attendance remained stable around 70%. Younger age (23.5 years for VD versus 21.6 years for CD, p < 0.001), nulliparity (25.1% for VD versus 45.0% for CD, p < 0.001), prolonged/obstructed labor (2.4% for VD versus 55.6% for CD, p < 0.001), and fetal malpresentation (0% for VD versus 16.3% CD, p < 0.001) significantly influenced mode of delivery in univariate analysis. The leading indications for CD were labor dysfunction (47.5%), malpresentation (14.5%), and prior cesarean delivery (19.8%). The CD rate among the subpopulation of term, nulliparous women with singleton pregnancies in vertex presentation also increased from 20% of all CD in 2015, to 38% in 2017. CONCLUSIONS: Among low-income women from rural Guatemala, the CD rate has increased above the World Health Organization (WHO) recommendations in a period of 3 years. Additional research on the factors affecting this trend are essential to guide interventions that might improve the appropriateness of CD, and to determine if reducing or stabilizing rates is necessary.

In this narrative review, we first present a brief overview of known disparities in children's language development based on socioeconomic status and efforts in the primary care setting to promote children's language development. Next, we define mobile health (m-health) and review the limited, published literature regarding the effectiveness of m-health interventions in promoting children's health, in general, and language development, in particular. Finally, we discuss the potential role of smartphone applications to increase parental behaviors that promote their children's language development, as well as challenges that should be addressed as the field of m-health continues to grow.

A variety of microcephaly case definitions detect high background prevalence in rural Guatemala, which complicates congenital Zika screening efforts. In addition, gestational age is needed for most screening tools but is usually unknown in low-resource settings. Fenton growth curves, originally designed for use in preterm infants, offer a standardized approach to adjust for unknown gestational age and may improve screening efforts., Background: Congenital microcephaly is the result of a disturbance in early brain development and can have multiple etiologies. Establishing background prevalence of microcephaly in Zika virus (ZIKV)-affected areas is important for improving identification of ZIKV-affected newborns. However, to date, there is limited consistent guidance for the accurate identification of microcephaly in infants of unknown gestational age, a common concern in low- and middle-income countries. Methods: Occipital frontal head circumference (OFC) obtained from infants (0–13 days) of unknown gestational age at enrollment in a pregnancy registry in rural Guatemala from August 2014 to March 2016 were retrospectively reviewed. Trained community health nurses recorded anthropometry in an online database. In April 2015, ZIKV was identified in this population. Gestational age was approximated in 2 ways: presumed term and estimated using z-score of zero for height on modified Fenton growth curves. After which, z-scores for OFC and weight were obtained. Microcephaly and microcephaly background prevalence were estimated using 7 established microcephaly case definitions from national and international organizations and 3 proposed definitions using Fenton growth curves. Independent associations with microcephaly and OFC, including relationship with date of birth, were assessed with prevalence ratios and linear regression. Results: For 296 infants, the mean OFC was 33.1 cm (range, 29.5 to 37 cm) and the mean OFC z-score was −0.68. Depending on case definition, 13 to 125 infants were classified as having microcephaly (background prevalence 439 to 4,223 per 10,000 live births), and 1 to 9 infants were classified as having severe microcephaly (

Objective Vaccines represent a significant portion of primary care practice expenses. Our objectives were to determine among pediatric (Ped) and family medicine (FM) practices: 1) relative payment for vaccine purchase and administration and estimated profit margin according to payer type, 2) strategies used to reduce vaccine purchase costs and increase payment, and 3) whether practices have stopped providing vaccines because of finances. Methods A national survey conducted from April through September 2011 among Ped and FM practitioners in private, single-specialty practices. Results The response rate was 51% (221 of 430). Depending on payer type, 61% to 79% of practices reported that payment for vaccine purchase was at least 100% of purchase price and 34% to 74% reported that payment for vaccine administration was at least $11. Reported strategies to reduce vaccine purchase cost were online purchasing (81% Ped, 36% FM), prompt pay (78% Ped, 49% FM), and bulk order (65% Ped, 49% FM) discounts. Fewer than half of practices used strategies to increase payment; in a multivariable analysis, practices with ≥5 providers were more likely to use strategies compared with practices with fewer providers (adjusted odds ratio, 2.65; 95% confidence interval, 1.51–4.62). When asked if they had stopped purchasing vaccines because of financial concerns, 12% of Ped practices and 23% of FM practices responded ‘yes,' and 24% of Ped and 26% of FM practices responded ‘no, but have seriously considered.' Conclusions Practices report variable payment for vaccination services from different payer types. Practices might benefit from increased use of strategies to reduce vaccine purchase costs and increase payment for vaccine delivery.

Disadvantaged children often show disparities in early language development. We tested the feasibility, acceptability, and preliminary efficacy of introducing finger puppets in the primary care setting at the 2-month well visit to support caregivers talking with their infants. Caregivers completed a sociodemographic survey and were contacted by phone 2 weeks later to assess initial usage and satisfaction. Ages & Stages Questionnaires (ASQ-3) were independently recorded at well visits. A family cumulative risk score was calculated from the sociodemographic survey. Thirty-four caregiver-child pairs were enrolled. Caregivers reported high satisfaction with the intervention. ASQ-3 Communication and Total scores at 6, 12, and 18 months were significantly higher for high puppet users across all age levels with no significant interactions with age or cumulative risk. Finger puppets provide a low-cost way to promote language-rich interactions. Preliminary evidence suggests that high puppet usage may have long-lasting effects on child development and should be further evaluated.

Multiplex polymerase chain reaction (PCR) platforms have enhanced understanding of intestinal pathogens in low- and middle-income countries (LMICs). However, few such studies have been performed in Latin America, where poverty, poor sanitation, and undernutrition persist. Multiplex PCR (BioFire, Salt Lake City, UT) was used to identify viral, bacterial, and parasitic pathogens in stool collected on day 1 and 31 from children aged 6 to 35 months with acute, non-bloody diarrhea in two locations (rural and urban) in Guatemala. We analyzed correlation between pathogens and clinical, demographic, and socioeconomic variables; described patterns of pathogen acquisition, persistence, and clearance over the 30-day period; and calculated population attributable fractions (PAFs) for diarrheal causation for individual pathogens. We analyzed 316 subjects (144 urban; 172 rural) enrolled between March 2015 and January 2016. Rural subjects had significantly more malnutrition, animal exposure, and unimproved water/sanitation infrastructure. The majority of subjects had multiple pathogens/sample (4.8 rural and 2.7 urban). Few meaningful correlates were identified between individual pathogens and clinical, demographic, or environmental variables. Escherichia coli pathotypes, Shigella, Campylobacter, and Giardia had high rates of persistence between initial and 30-day follow-up. Statistically significant adjusted PAFs were identified for Campylobacter (14.9%, 95% CI: 3.2-23.1), norovirus (10.2%, 95% CI: 0.4-17.1), sapovirus (7.6%, 95% CI: 2.3-10.9), and adenovirus 40/41 (5.6%, 95% CI: 0.3-8.7). These observations further characterize the diversity and complexity of enteric pathogens in children in LMICs. Patterns of chronic symptomatic and asymptomatic infection among Latin American children are similar to those observed in other LMIC regions. Findings have direct implications for practitioners treating individuals with acute infectious diarrhea and should inform regional public health strategies.

Background Postpartum contraception is important to prevent unintended and closely spaced pregnancies following childbirth. Methods This study is a cluster-randomized trial of communities in rural Guatemala where women receive ante- and postnatal care through a community-based nursing program. When nurses visit women for their postpartum visit in the intervention clusters, instead of providing only routine care that includes postpartum contraceptive education and counseling, the nurses will also bring a range of barrier, short-acting, and long-acting contraceptives that will be offered and administered in the home setting, after routine clinical care is provided. Discussion A barrier to postpartum contraception is access to medications and devices. Our study removes some access barriers (distance, time, cost) by providing contraception in the home. We also trained community nurses to place implants, which are a type of long-acting reversible contraceptive method that was previously only available in the closest town which is about an hour away by vehicular travel. Therefore, our study examines how home-based delivery of routinely available contraceptives and the less routinely available implant may be associated with increased uptake of postpartum contraception within 3 months of childbirth. The potential implications of this study include that nurses may be able to be trained to safely provide contraceptives, including placing implants, in the home setting, and provision of home-based contraception may be an effective way of delivering an evidence-based intervention for preventing unintended and closely spaced pregnancies in the postpartum period. Trial registration Clinicaltrials.gov, NCT04005391. Retrospectively registered on 1 July 2019.

Background Few cluster-randomized trials have been performed in rural Guatemala. Our objective was to describe the feasibility, recruitment and retention in our cluster-randomized trial. Methods In our cluster-randomized trial, a range of contraceptives were brought to mothers’ homes in rural Guatemala. Results Of 173 women approached, 33 were excluded. Of the 140 eligible women, 127 (91%) consented to participate. Of the 87 women who should have been assessed for the primary outcome, three were lost to follow-up, which represents a retention rate of 97%. Conclusions Nurses who are both clinical providers and study staff can feasibly conduct research, which leads to high enrollment and retention rates.

INTRODUCTION Early home support for language development is critical for later developmental progress. Paediatricians have the opportunity to identify families at risk of failing to provide this support in infancy but often lack simple tools to do so. This study explores the potential of a simple count of sociodemographic risk factors, a cumulative risk (CR) index, to identify families likely to need help in providing literacy support from an early age. METHODS CR scores were calculated for 308 families who completed the STIMQ and MacArthur Communicative Development Inventory (MCDI) at 11-15 months) and 197 (64%) again at 23-37 months. Analysis of variance with linear contrasts examined the effect of CR on the STIMQ and the MCDI at baseline and follow-up. Correlation analysis explored the relationship between STIMQ and MCDI. RESULTS At both baseline and follow-up, CR index showed a significant effect (p

Background: Determine the usefulness of ear pain anticipatory counseling for young children with public health plans to reduce visits for acute otitis media (AOM) and shift visits from urgent care/emergency department (UC/ED) settings to primary care clinic (PCC) settings. Methods: We documented the AOM visit distribution and incidence rates by setting according to race/ethnicity from the EPIC electronic medical record system for 12 months following the enrollment of eligible 12-15 month old children in a single blind randomized control trial of ear pain counseling. Results: Among the 310 children enrolled in the study, 30.6% of participants had at least 1 AOM visit and 4.5% had 3 or more AOM visits. The overall incidence was 490 AOM visit episodes per 1000 child years with rates of 232 in PCC and 226 in UC/ED settings. The difference in the proportion of Hispanic children with at least 1 AOM visit (33.5% 52/155) compared to Non-Hispanic children (24% 25/106) approached significance (p=0.08). The counseling intervention did not reduce the proportion of children with at least 1 AOM visit (counseling: 29.0%: 45/155; control: 32.3% 50/155 p=0.54); the proportion of children with 3 or more AOM visits (counseling: 5.8%: 9/155; control: 3.2% 5/155 p=0.41); or the AOM visit incidence rates (counseling: 471; control: 510) and did not shift AOM visits from the UC/ED to PCC setting. Conclusions: Anticipatory ear pain counseling in a hospital based PCC serving children enrolled in public plans does not reduce PCC or UC/ED AOM visit incidence rates.

Background: Bright by Three (BB3), a non-profitorganization that promotes caregiver behaviors to support language developmentin young children was augmented with a text-messaging program, Bright by Text(BBT), in 2015. While some evidence suggests that text-messaging can promoteearly development, it is unknown if these interventions are reaching childrenat increased sociodemographic risk for developmental delay. The purpose of thisstudy is to compare socio-demographic characteristics of caregivers who did anddid not enroll in BBT. Methods: Retrospective analysis of caregiverswho received BB3 written materials and were eligible to sign up for BBT in2016. Outcomes: (I) provision of a mobile phone number; (II) enrollment in BBT(receipt of 3+ messages). Predictors: education, marital status,race/ethnicity, insurance, language, and urban vs. rural residence. Amultivariable generalized linear model was used to determine characteristics ofcaregivers more likely to sign up for BBT. Results: A total of 18,145 caregivers receivedBB3 written materials; 10,843 (60%) provided a mobile phone number and 2,314(21%) enrolled in BBT. The relative risk (RR) of enrollment was higher forcaregivers who were non-minority (RR 1.15, 95% CI, 1.04–1.28), had higher education(1.60, 1.35–1.89), had private insurance (1.15, 1.15–1.28) and lived in urbanareas (1.21, 1.06–1.37). Non-English speaking caregivers were less likely toenroll (0.73, 0.59–0.90). Conclusions: Caregivers withlower incomes and education, minorities and non-English speakers were lesslikely to enroll in BBT. Future research could identify ways to increaseengagement among these populations and determine if BBT is effective inchanging parent behavior and improving children’s development.

* Abbreviations: EB — : epidermolysis bullosa RDEB — : recessive dystrophic epidermolysis bullosa In my career as a pediatrician, I have gone to many funerals. I have cared for 28 children with recessive dystrophic epidermolysis bullosa (RDEB) in both primary care and hospital inpatient settings and attended 12 of their funerals. These funerals celebrated lives that had meaning, that brought great joy as well as heartache to their friends and families, and that made the world a better, more tolerant and understanding place. At 2 funerals, almost everyone wore pink, the girls’ favorite color. At another, almost everyone wore T-shirts with Batman, the boy’s favorite superhero. At another, the church was a sea of Bronco orange because of the boy’s football passion. At others, we learned about a boy’s well-delivered comedy routines, a girl’s love of horseback riding (her horse was outside greeting people as they came to the service), and a girl’s love of making lasagna. Attending these funerals provided us with a valuable perspective on the lives of chronically ill children with a terminal illness. They also helped us cope with our frustration. Why could we not have done more to alleviate our patients’ suffering and delay the deaths of these children? We gained a deeper understanding that these children, despite their terrible disease and suffering, brought enormous joy to their parents and friends. Our entire team had the satisfaction that our care and support helped to maximize … Address correspondence to Stephen Berman, MD, FAAP, 13199 E. Montview Blvd, Suite 310, A090, Aurora, CO 80045. E-mail: stephen.berman{at}childrenscolorado.org

* Abbreviations: AAP — : American Academy of Pediatrics CI — : confidence interval ppt — : percentage point How well does having a Medicaid card translate into getting needed care in a private-practice pediatrician’s office? For many years, families with children enrolled in Medicaid have experienced difficulties finding private-practice pediatricians and family physicians willing to accept them into their practice panels.1–6 And, for many years, private-practice pediatricians and physicians have cited reasons for limiting or not accepting children with Medicaid. Consistently, inadequate payment for services has been the dominant factor.1–6 As a result, many children were forced to use emergency departments for their primary care. In addition, children enrolled in Medicaid who needed specialty and/or subspecialty care often experienced a much longer waiting period to get an appointment than did children with commercial insurance.7,8 Pediatricians indicated their willingness to care for more children with Medicaid if payment rates were raised to reasonable levels.1–6 On the basis of data from these surveys and state early and periodic screening, diagnosis and treatment data, class action lawsuits were filed in Illinois (2003), Florida (2007), and Oklahoma (2005) alleging a failure to adhere to the equal access provision as codified in Title XIX of the Social Security Act (42 U.S.C. §1396 et seq). This section of federal statute requires states “to assure that payments are consistent with efficiency, … Address correspondence to Stephen Berman, MD, FAAP, Center for Global Health, 13199 E Montview Blvd, Suite 310, A090 Aurora, CO 80045. E-mail: stephen.berman{at}childrenscolorado.org

Background Treatments for paediatric diarrhoeal disease are limited. We assessed the impact of a bovine colostrum and egg-based treatment designed to reduce diarrhoea duration through non-specific and pathogen-directed mechanisms in children. Methods Randomised, double-blind, placebo-controlled trial of PTM202, derived from bovine colostrum and hyperimmune hen’s egg on the duration of acute diarrhoeal disease in Guatemalan children. PTM202 contains specific immunoglobulins that target rotavirus, enterotoxigenic Escherichia coli , Shiga toxin-producing E. coli and Salmonella. Children aged 6–35 months presenting to three sites (one rural and two urban) with acute non-bloody diarrhoea were computer randomised to receive three daily doses of PTM202 or placebo. The primary outcome was the post-treatment duration of diarrhoea assessed in the per protocol population. Diarrhoeal pathogens were identified in stool by multiplex PCR (FilmArray Gastrointestinal-Panel, BioFire, Salt Lake City, Utah, USA). Key secondary outcomes included postdiarrhoeal weight gain and impact on diarrhoeal duration stratified by study site and presence of PTM202-targeted organisms in stool at enrolment. Safety was assessed in all participants. Results From 9 March 2015 to 25 January 2016, 325 children were enrolled, and 301 (154 intervention and 147 placebo) were analysed for the primary outcome. No difference in diarrhoea duration was observed between intervention and placebo in the total population, but a significant reduction was observed in the treatment group among children with at least one targeted pathogen in stool (HR=1.46, P=0.02), an effect most pronounced in urban subjects (HR 2.20, P=0.007) who had fewer stool pathogens and better nutritional status. No impact on 2-week or 4-week weight gain was noted. No adverse events attributed to PTM202 occurred. Conclusion Results demonstrate the potential to target specific pathogens occurring in children with acute non-bloody diarrhoea and shorten illness duration using a novel, safe, nutrition-based intervention. PTM202 may represent a new tool to ameliorate the effects of acute diarrhoeal disease in low/middle-income populations. Trial registration number NCT02385773; Results.

Background:The first three years of a child’s life are a critical period for brain growth and development. Caregiver interventions during this period that improve early childhood health and development have the potential to enhance a child’s physical, mental, and social well-being.Methods:This was a pretest/posttest quasi experimental program evaluation. Early childhood education materials were adapted to create two separate interventions consisting of 30-page interactive flipchart talks to educate mothers on health and development topics relevant to 0–6 and 6–12 month old children. Three community health workers performed the talks with groups of 5–8 mothers. Short learning assessments were given individually to each mother pre-intervention (pretest), immediately post-intervention (posttest 1), and two weeks post-intervention (posttest 2). Demographic surveys and focus group discussions were conducted with all participants.Results:Mothers ( n = 77) had an average age of 33.6 years and had an average of 3.6 living children. Most of the mothers (71%) had received some primary education, but 23% had received no formal schooling. For the 0–6 months flipchart learning assessment ( n = 38), the mean pretest score was 77% correct. The mean posttest 1 score improved to 87% ( p < 0.0001), and the mean posttest 2 score improved further from the mean posttest 1 score to 90% ( p = 0.01). For the 6–12 months flipchart learning assessment ( n = 39), the mean pretest score was 78%. The mean posttest 1 score improved to 89% ( p < 0.0001), and the mean posttest 2 score improved further from the mean posttest 1 score to 92% ( p = 0.03).Conclusions:Mothers in an impoverished region of southwestern Guatemala significantly increased their knowledge about child health topics following a short interactive group talk. Mothers further increased their knowledge two weeks after the intervention, without specific re-exposure to the intervention materials, suggesting assimilation and informal reinforcement through group based learning with other mothers in their community.

Health plans try to maintain profit margins and limit rising premiums as escalating drug prices, expensive new technologies, and higher physician and hospital expenditures increase health care costs. Rural areas have the additional issue of adverse risk because young, healthier people often move to live in urban areas, leaving an older, sicker population in these communities. Health plan cost-containment strategies include having a narrow network that excludes primary care, specialty, and pediatric subspecialty physicians whose practice patterns and/or high payment rates result in higher costs. When a health plan’s physician network is restricted (narrow), the plan has more leverage to negotiate favorable payments because a high proportion of the patients in a participating physician’s practice are enrolled in the plan. Having a network that has fewer specialists and pediatric subspecialists may also discourage the enrollment of children and adults with chronic and complex conditions when they recognize that their physician does not participate in the plan. When a plan has fewer sick enrollees, it can have lower premium costs, which also encourages enrollment of lower … Address correspondence to Stephen Berman, MD, FAAP, 13199 E Montview Blvd, Suite 310, A090, Aurora, CO 80045. E-mail: stephen.berman{at}childrenscolorado.org

The findings of this evaluation document partial success for the PEDS training program to achieve its 3 aims. It will take several years for the dissemination of this program to reach a critical mass of pediatricians and other physicians in many LMICs. Obtaining stronger support from MOHs and other governmental agencies is necessary to achieve this goal. Another additional approach would be to integrate the training into medical school and residency programs.

Entamoeba histolytica is believed to be a ubiquitous cause of pediatric non-bloody diarrhea. Using a multiplex polymerase chain reaction assay, we identified stool pathogens in 298 Guatemalan children presenting with acute, non-bloody diarrhea. Despite a high overall pathogen burden, we identified no cases of E. histolytica. Knowledge of local epidemiology is important to inform E. histolytica therapeutic strategies in low-income settings.

OBJECTIVES: Because of high purchase costs of newer vaccines, financial risk to private vaccination providers has increased. We assessed among pediatricians and family physicians satisfaction with insurance payment for vaccine purchase and administration by payer type, the proportion who have considered discontinuing provision of all childhood vaccines for financial reasons, and strategies used for handling uncertainty about insurance coverage when new vaccines first become available. METHODS: A national survey among private pediatricians and family physicians April to September 2011. RESULTS: Response rates were 69% (190/277) for pediatricians and 70% (181/260) for family physicians. Level of dissatisfaction varied significantly by payer type for payment for vaccine administration (Medicaid, 63%; Children’s Health Insurance Program, 56%; managed care organizations, 48%; preferred provider organizations, 38%; fee for service, 37%; P < .001), but not for payment for vaccine purchase (health maintenance organization or managed care organization, 52%; Child Health Insurance Program, 47%; preferred provider organization, 45%; fee for service, 41%; P = .11). Ten percent of physicians had seriously considered discontinuing providing all childhood vaccines to privately insured patients because of cost issues. The most commonly used strategy for handling uncertainty about insurance coverage for new vaccines was to inform parents that they may be billed for the vaccine; 67% of physicians reported using 3 or more strategies to handle this uncertainty. CONCLUSIONS: Many primary care physicians are dissatisfied with payment for vaccine purchase and administration from third-party payers, particularly public insurance for vaccine administration. Physicians report a variety of strategies for dealing with the uncertainty of insurance coverage for new vaccines.