Risk factors for cerebral palsy.

Cerebral palsy is a major cause of crippling in children, but it's etiology is poorly understood. This case control study was done to assess some of the identified risk factors for cerebral palsy, 125 cerebral palsy cases selected from hospital clinic and 125 age and sex matched neighbourhood controls, all aged less than 5 years and residing in Delhi (India) were studied. Information regarding antenatal, natal and postnatal period was collected by mother's interview, and wherever available, from hospital records with the study subjects. Most common type of cerebral palsy was spastic (88%). Quadriplegia was the commonest topographical subtype (86.4%). Birth asphyxia was found to be present in only 25.6% of cases. The commonest risk factor amongst cases was low birth weight (28.8%). The multivariate odds ratios (confidence limits) for the risk factors found to be significantly associated with cerebral palsy were 36.1 (7.76-160) for birth asphyxia, 13.8 (4.95-38.3) for low birth weight, 37.4 (4.47-313) for neonatal convulsion, 23 (4.7-112) for neonatal jaundice, 14.4 (3.69-56.4) for neonatal infection, 24.9 (2.78-223) for instrument assisted delivery and 15.4 (1.57-152) for antepartum hemorrhage. Precipitate labour, caesarean section, twins, toxemia, breech delivery and head injury were not found to be significantly associated with cerebral palsy. Thus birth asphyxia, low birth weight, neonatal convulsions, neonatal jaundice, neonatal infection, instrument assisted delivery and antepartum hemorrhage are significant risk factors for cerebral palsy.

Epidemiological characteristics of new borns in a rural community.

All births (1211) were recorded in a rural area for 1985 by monthly domiciliary visits and the sociological characteristics were collected from mothers within a month. The analysis of 1201 births is presented: 52.7% were male births, 95.7% were delivered in village itself, 80.4% were delivered by trained dais, 99.5% were live born, 12.9% were born before 37 weeks of gestation, 61.5% were put to breast feed within 6 hours, 35% were of gravida 4 and above, 68.9% did not receive any antenatal care, 67.1% had not received any tetanus toxoid, 70.8% did not receive any folifer tablet, 0.8% had abortion and another 0.8% had still birth in preceding outcome, 1.58% had lost a live born dead in preceding out come, 89.6% stopped breast feeding at conception, 31.7% had birth interval less than 2 years, but 2.2% had less than one year, 2/3rd were born in second half of the year, 17.8% had taken extra food during pregnancy, 21.2% reduced the work after becoming pregnant, 9.5% were born to mothers of less than 20 years age, 98.5% of mothers were housewives and 95.9% mothers were illiterate, 33.5% were born in nuclear family, 22.3% were living in 'Kacha' house, 34.8% had no electricity connection, 37.0% were born to land less, 42.2% had no radio in the house, 7.1% had no conveyance, 52.0% families had piped water supply. These findings have been discussed here.

Management of ARI for control of mortality in underfives.

WHO advocated a standard case management for control of ARI related mortality. India has started an ARI control programme in 15 districts. Conflicting reports appeared regarding the effectiveness of case management strategy. Authors reported earlier that it was not effective. The coverage was only about 57% in pneumonias, and 23% in severe pneumonias. Health agencies & health workers have a low utilization (13.7%), and RMPs were used in large numbers (36.9%). Most of the deaths were in those treated by RMPs (75%). The efficacy of standard case management (88%) is highlighted. The problem of coverage and assumptions behind the strategy were discussed and recommendations for improvement were suggested.

Socio-biological factors in underfive deaths in a rural area.

In 1985-86, 286 underfive deaths occurred among a population of 30,000 in a rural area of Haryana. Two hundred and eighty one were analysed for socio-biological factors related to under five mortality. Females had a higher mortality. About 2/3 of the deaths were in infants, and 90% in first 3 years. Most of the deaths (94%) occurred in the village itself, 58.4% did not seek any medical care during the terminal illness, 80-90% did not receive even a single dose of BCG, DPT or O.P.V., and 36.7% died in the first attack of illness. Though 68% had at least one episode earlier, 31.0% had been admitted in hospitals for an earlier episode of illness. In 42.8% of deaths, the birth order was IV or above. Deaths in socially and economically disadvantaged cases constituted 77.6%. The triad of diarrhea, ARI and malnutrition claimed 56% deaths. In 93% of the deaths, the mothers were illiterate and 96.4% were house wives. There was a sibling death earlier in the family in 78.3%, and 60.1% deaths were of those living in poor housing conditions. About 50% had radio for communication, 85.8% had bicycle for conveyance, and in 66.9% the family had piped water supply. All these findings have been discussed in the study.

Effectiveness of measles immunization on diarrhea and malnutrition related mortality in 1-4 year olds.

All the children between 1-4 year old were followed from January 1985 to December 1987 and all eligible children 9-24 months were given measles vaccine using annual pulse method in November-December 1985 and 86 in the study area. The children in C.R.H.S. Project area were used as controls for comparison. At the end of 2 years and 2 rounds of immunization with measles, significant reductions were observed in 1-4 year old mortality due to diarrhea and malnutrition in the study area in contrast to control area. Using epidemiological data and method of pulse immunization with measles vaccine can bring considerable benefit to this age group.

Control of tetanus neonatorum in a rural area.

Experience in the control of tetanus neonatorum (TN) in a rural area is presented. TN was reduced by training of dais, increasing the coverage of tetanus toxoid to pregnant women and distribution of presterilized delivery kits to pregnant ladies for use by birth attendants. The problems of untrained birth attendants, effectiveness of tetanus toxoid coverage and place of delivery are discussed.

Epidemiology of diarrhea and its implications for providing services.

This study was conducted in children under the age of four years for a period of one year. By domiciliary visits the diarrheal episodes were recorded, analysed and presented. The findings are based on the diarrheal experience of 4860 children. The attack rate was 2.6/child/year. Family with more than one child had more attacks. Mean duration was 5.76 days and 11.2% had lasted more than 7 days. All the age groups are similarly affected. 75.6% were just plain loose motions and only 4.9% had blood, mucus or fever associated with loose motions. Case fatality was 0.6%. Attack rate was more in June-August and December-February than the other quarters. 42.2% were shown to R.M.P.s. and 33.6% consulted friends or relatives. More than 2/3 gave mainly home made ORS. 69.9% restricted food during attack.

Effectiveness of ARI control strategy on underfive mortality.

A prospective intervention study was conducted in Ballabgarh block of Haryana. The study area has a population of about 30,000 under a state run P.H.C. area. The control area has a population of about 60,000 under Comprehensive Rural Health Services Project of All India Institute of Medical Sciences. ARI control strategies as advocated by WHO was instituted in the study area. Measles and DPT immunization was strengthened. The ARI cases detected or reported to Health Workers were managed as per the standard case management procedure. The underfives mortality, infant and 1-4 years mortality rates were initially higher in study area and differences were statistically significant. After 2 years, the reductions in study area were substantial and differences were not statistically significant. The ARI mortality in underfives, and 1-4 years were higher in study area at the beginning compared to control area. Though they were less than in control area after 2 years of intervention the observed differences were not statistically significant in both periods. The reduction of 37% in underfives mortality and 26% due ARI mortality is substantial. More benefit was attained with measles immunization than with standard case management. ARI control programme is advocated for application on national level vigourously covering with measles immunization and to include the village based private practitioners in the strategy for effective case management.

Epidemiology of pneumonia in rural underfives.

Rural underfives (5335) were followed for a period of one year from January to December 1987 for acute respiratory infections (ARI). Those affected with pneumonias were studied in detail to know the epidemiology. The children reported an attack rate of 0.29/child/year. Severe cases constitute 0.5%. Infants had higher attack rate (0.59/child/year), 47.7% of episodes occurred in infants and 87.7% occurred in children below 3 years. Males had a higher attack rate (0.32 vs 0.27). Mean duration of attack was 5.45 +/- 1.95 days. The attack rate was higher in winter. The case fatality rate was 1.26%. It was highest in neonates (10.7%) Females had higher case fatality rate than males (1.5% Vs 1.1%). Mortality was very high in severe cases. Case fatalities were high in seasons when the climatic change occurred, the highest being in autumn.

Knowledge, attitude and practices regarding acute respiratory infections.

One hundred and six mothers in a rural area were interviewed to determine as to how they recognise pneumonia in children, what therapies they practice with mild acute respiratory illnesses and pneumonias and the feeding practices they adopt. Most mothers recognised pneumonia by noticing fast respiratory rate and difficulty in breathing. More severe cases were recognised by these signs among a higher percentage of mothers. As regards management of mild ARI episodes, more than half the mothers preferred not to give any treatment or use only home remedies. In pneumonias, a majority of them preferred to consult a qualified doctor. Nearly a third of them were of the opinion that they would take the child to hospital if the disease was severe. Regarding feeding practices, most of them stated that they would continue feeding, fluids and breast feeds. Only 10% desired to stop and another 15% would decrease the amounts.

Factors influencing prevalence of breastfeeding in a resettlement colony of New Delhi.

Influence of some family and maternal characteristics on prevalence of breastfeeding was studied in a cross sectional study using WHO suggested methodology. 547 mothers with children less than three years of age were interviewed with the help of a schedule. Age and parity of the mother, sex of the child, length of urban stay, mother's going for work did not influence the prevalence of breastfeeding. Prevalence was higher among illiterate mothers and mothers belonging to lower socio-economic status. The mothers from higher socio-economic status initiated breastfeeding earlier. More mothers from higher socio-economic status and those with better education thought that supplementation was needed before the child was 4 months old and felt that breastfeeding was needed for less than two years.

Breast feeding practices in a resettlement colony and its implications for promotional activities.

The mothers of 547 children less than three years of age were interviewed for breastfeeding practices using WHO suggested methodology in a resettlement colony of South Delhi. Only 1.8% of children were never breastfed. Prelacteal feeds were given in 90.9% of infants. More than half received their first breastfeed on 3rd day or later. Among children under three months of age, one third were already receiving top milk. 68.4% of mothers felt that the child should be breastfed for as long as possible. Demand feeding was practised by 95% of the mothers. Most of the mothers did not seek privacy to breastfeed their children. The need to identify desirable and undesirable infant feeding practices prevalent in an area has been stressed so that appropriate promotional activities can be carried out more effectively.

Supplementary iron dose in pregnancy anemia prophylaxis.

This study was conducted to determine the optimum dose of supplemental iron for prophylaxis against pregnancy anemia. One hundred and ten pregnant women were randomly allocated to three groups: Group A receiving equivalent of 60 mg, group B 120 mg and Group C 240 mg, elemental iron as ferrous sulphate daily; the content of folic acid was constant in all the three groups (0.5 mg). These women had at least consumed 90 tablets in 100 +/- 10 days. Blood was drawn at the beginning and at the end of the treatment. Fifty percent were anemic (less than 11 g/100 ml). The hemoglobin levels rose similarly in all groups and the differences were statistically not significant. Fifty-six percent had depleted iron stores (serum ferritin value less than 12 micrograms/l) at the beginning of the study. Following therapy a statistically significant increase in iron stores was observed in group B and C as compared to group A. The difference between group B and C was not significant. The side effects increased with increasing doses of iron; 32.4%, 40.3% and 72% in group A, B and C respectively. Based on these findings, the authors advocate that optimum dose of iron should be 120 mg instead of 60 mg as is currently being used in the National Nutritional Anemia Prophylaxis Programme.