Geographic targeting of nutrition programs can substantially affect the severity of stunting in Honduras.

The effect of nutrition intervention programs in developing countries is likely to vary with the degree to which the program can be successfully targeted at the most vulnerable. In Honduras, the existence of a recent census of the height of first-grade children makes it possible to assess a priori the effect of different targeting strategies, holding constant other features of a hypothetical program. We simulate a nutrition intervention with 20% national coverage and uniform gains of 0.5 Z-scores for all beneficiaries, with a number of different approaches to targeting. The VIIth National Census of First-Graders' Heights provides the baseline scenario and permits identification of priority departments, municipalities, schools and individuals, for a total of six alternative targeting mechanisms. Effect is assessed on the basis of changes in the prevalence of stunting (less than -2 Z-scores) and in two different measures of the severity of stunting adapted from the economics literature (the malnutrition gap and the quadratic malnutrition gap). We find that the simulated program has the potential to substantially improve the severity, but not the prevalence of stunting in Honduras. Household targeting with an imperfect indicator of vulnerability could reduce the malnutrition gap by >20% and the quadratic malnutrition gap by >30%, but would be very expensive to implement. "Broad stroke" geographic targeting could reduce the same measures by 15 and 20%, respectively, and would be much less expensive to implement. We conclude that geographic targeting has the potential to substantially enhance the effect of nutrition programs on the severity of stunting in Honduras.

Poor maternal schooling is the main constraint to good child care practices in Accra.

Life in urban areas presents special challenges for maternal child care practices. Data from a representative quantitative survey of households with children < 3 y of age in Accra, Ghana were used to test a number of hypothesized constraints to child care including various maternal (anthropometry, education, employment, marital status, age and ethnic group) and household-level factors (income, availability of food, quality of housing and asset ownership, availability of services, household size and crowding). Three care indices were created as follows: 1) a child feeding index; 2) a preventive health seeking index; and 3) a hygiene index. The first two indices were based on data from maternal recall; the hygiene index was based on spot-check observations of proxies of hygiene behaviors. Multivariate analyses (ordinary least-squares regression for the child feeding index and ordered probit for the two other indices) showed that maternal schooling was the most consistent constraint to all three categories of child care practices. None of the household-level characteristics were associated with child feeding practices, but household socioeconomic factors were associated with better preventive health seeking and hygiene behaviors. Thus, poor maternal schooling was a main constraint for child feeding, health seeking and hygiene practices in Accra, but the lack of household resources was a constraint only for health seeking and hygiene. The programmatic implications of these findings for interventions in nutrition education and behaviors in Accra are discussed.

Validity of rapid estimates of household wealth and income for health surveys in rural Africa.

STUDY OBJECTIVE: To test the validity of proxy measures of household wealth and income that can be readily implemented in health surveys in rural Africa. DESIGN: Data are drawn from four different integrated household surveys. The assumptions underlying the choice of wealth proxy are described, and correlations with the true value are assessed in two different settings. The expenditure proxy is developed and then tested for replicability in two independent datasets representing the same population. SETTING: Rural areas of Mali, Malawi, and Côte d'Ivoire (two national surveys). PARTICIPANTS: Random sample of rural households in each setting (n=275, 707, 910, and 856, respectively). MAIN RESULTS: In both Mali and Malawi, the wealth proxy correlated highly (r>/=0.74) with the more complex monetary value method. For rural areas of Côte d'Ivoire, it was possible to generate a list of just 10 expenditure items, the values of which when summed correlated highly with expenditures on all items combined (r=0.74, development dataset, r=0. 72, validation dataset). Total household expenditure is an accepted alternative to household income in developing country settings. CONCLUSIONS: It is feasible to approximate both household wealth and expenditures in rural African settings without dramatically lengthening questionnaires that have a primary focus on health outcomes.

Effect of breastfeeding and morbidity on the development of low birthweight term babies in Brazil.

Low birthweight (LBW) occurs in 17% of births in developing countries and many of them are full term. The subsequent development of LBW term infants is poorer than higher birthweight children and more likely to be affected by poor social circumstances. We investigated the effects of morbidity and breastfeeding on the development of these LBW term infants. Two parallel cohorts (n = 131 + 131) of LBW term (1500-2499 g) and higher birthweight (3000-3499 g) infants were recruited from six maternity centers in northeast Brazil. The longitudinal prevalence of morbidity and the frequency of breastfeeding over the first 6 mo of life were assessed. The infants' development was assessed on the Bayley Scales at 6 and 12 mo, and we previously reported that the low birthweight group had lower scores than the higher birthweight group. Hospitalizations in the first 6 mo were negatively associated with 6-mo and 12-mo Bayley scores in both groups. Among LBW infants, but not higher birthweight infants, there were significant associations between the prevalence of diarrhea and mental and motor development at 6 mo and mental development at 12 mo. Breastfeeding frequency in the first 4 wk of life was positively associated with mental development in both birthweight groups at 6 mo but not at 12 mo. Breastfeeding beyond 4 wk was not associated with the children's development. We conclude that low birthweight infants are especially vulnerable to the effects of diarrhea, and the greater frequency and differential effect of diarrhea partly explains their poorer development.

Influence of heavy agricultural work during pregnancy on birthweight in northeast Brazil.

BACKGROUND: Women in developing countries often continue their agricultural work during late pregnancy. Whether this adversely affects birthweight is not clear from previous studies as few controlled for confounding factors. This study seeks to clarify this issue. METHODS: This retrospective cohort study investigated 958 low-income women and their singleton newborn babies residing in a region of Northeast Brazil dependent on sugar-cane production. Women were recruited at maternity centres, when attending for delivery, and were allocated to one of two groups according to their exposure to heavy agricultural labour for at least 3 months during the second and third trimesters of pregnancy (n = 250), or to household activities only (n = 708). RESULTS: The mean birthweight of infants born to women who worked in agriculture during 9 months of pregnancy was 190 g lower than that of the non-exposed group (P = 0.02). After controlling for confounding factors, the adjusted effect was 117 g (P = 0.05). Heavy agricultural work for 6, 7 or 8 months had no significant effect. CONCLUSIONS: These findings suggest that working throughout pregnancy significantly reduces birthweight in this low-income population.

Precision, accuracy, and reliability of hemoglobin assessment with use of capillary blood.

BACKGROUND: Previous research has suggested that there may be significant within-subject variability, both site-to-site and over time, in hemoglobin concentrations in capillary blood. OBJECTIVE: This study examined the reliability of the portable hemoglobinometer (PHM) system with use of capillary blood and the implications of errors of the magnitude found for the classification of anemia status in individuals and population groups. The precision and accuracy of the method with use of venous blood were also tested. DESIGN: Three empirical data sets were used to measure reliability, precision, and accuracy of the PHM system [2 from Honduras (n = 87 and 141); 1 from Bangladesh (n = 73)]. Simulation data were used to assess the implications of errors for screening individuals for anemia and to estimate anemia prevalence. RESULTS: High within-subject variability (unreliability) was identified when capillary blood from the left hand was compared with that from the right hand (CV: 6.3%) and when measurements were taken on 4 consecutive days (CV: 7.0%). Reliability was only 69% and 50%, respectively. Precision and accuracy, however, were very high (concordance coefficients of 0.99 and 0.98 and CV < 1%). CONCLUSIONS: The simulation data showed that errors of the magnitude found due to unreliability can lead to misclassification of anemia status in individuals and small biases in anemia prevalence estimates. We recommend replicate sampling to reduce the influence of unreliability in the use of the PHM system with capillary blood.

[Rural development, household food safety, and nutrition in western Honduras]. / Desarrollo rural, seguridad alimentaria del hogar y nutrición en el oeste de Honduras.

The authors studied the impact of a rural development project on household food security and nutrition. A quasi-experimental study design was used to compare the experience of members of thirteen Honduran small-holder farmers groups which had already received a year of credit and technical assistance, with another thirteen groups which had just joined the project, and thirteen control communities. All these communities were followed-up for one year (March/April 1997-March/April 1998). Farmers participating in the project showed a greater increase in maize stores than farmers in the control communities (p = 0.01), but did not increase their dietary energy consumption. There was, however, a small improvement in their dietary diversity (p = 0.01). The impact of the project on the nutritional status of under 5's was complex. The study underlined the importance of monitoring the impact of programs which may affect food and nutrition.

People and eyes: statistical approaches in ophthalmology.

In conclusion, when an observation by its nature involves two eyes, as for blindness, statistical analyses should be conducted on individuals rather than eyes and between eye correlation is not a problem. In other circumstances, if information on only one eye per individual is used in the analysis there is a potential "waste" of information leading to less precise estimates of effect and less power. In addition, bias may be introduced into a study if there is non-random selection of the eye for inclusion in the analysis. The use of an overall summary of ocular findings for an individual may result in "wastage" of information in a similar fashion to the use of only one eye per individual. On the other hand, an analysis of individual eyes with no allowance made for between eye correlation may result in falsely narrow confidence intervals around estimates of effect. Between eyes correlation may be assessed empirically using the kappa statistic or similar means. If between eye correlation is substantial, statistical techniques exist which can utilise all available data while allowing for the correlation. In some circumstances a powerful design may be to use the fellow eye as a "control". Two conclusions may be drawn from this review of analytical approaches to the analysis of clinical data in the BJO. Firstly, the analytical approaches employed in many studies fail to use all the data available. In other words the analysis is less than "optimal". Secondly, in a proportion of studies, inappropriate statistical methods are used which may lead the investigator to draw inappropriate conclusions. In other words, the analysis is invalid. Ophthalmic data, by their very nature, present particular statistical challenges. We emphasise the need to involve appropriate statistical expertise in the design and analysis of ophthalmic studies.

The impact of vitamin A supplementation given during a pneumonia episode on the subsequent morbidity of children.

OBJECTIVE: To evaluate the impact of large-dose vitamin A supplementation given to infants > 6 months old (200000 IU) and to preschool children aged 1-4 years (400000 IU) during a pneumonia episode, on their subsequent morbidity and severe morbidity. METHOD: In a randomized, double-blind, placebo controlled trial, the children were followed-up with 2-weekly visits at home for 16 weeks, with the first visit 2 weeks after treatment for pneumonia was initiated. The field workers asked about the presence of morbidity on the day of the visit and in the previous two weeks and about the occurrence and number of clinic attendances and hospital admissions since the last visit. They also measured the patients respiratory rate and temperature and assessed the children for the presence of cyanosis, chest indrawing and wheezing. RESULTS: Except for the prevalence of diet refusal which was higher in the vitamin A group, no differences between the study groups were observed, either in the prevalence of morbidity or in the incidence of clinic attendances and hospital admissions. CONCLUSION: No evidence was found for a beneficial effect of vitamin A given during acute pneumonia on the subsequent morbidity and severe morbidity of children in a population with marginal vitamin A deficiency.

Effect of zinc supplementation on the morbidity, immune function, and growth of low-birth-weight, full-term infants in northeast Brazil.

In Brazil, the highest incidence of low birth weight (LBW) occurs in the northeast, and diarrhea and respiratory infections are the main causes of infant mortality and morbidity. We hypothesized that LBW infants may be zinc deficient, and that this might be adversely affecting their immune function, morbidity, and postnatal growth. We therefore examined the effect of zinc supplementation on these outcomes during the first 6 mo of life. LBW full-term infants (mean birth weight 2337 g) were given daily for 8 wk either 5 mg Zn (n = 71), 1 mg Zn (n = 68), or a placebo (n = 66). Morbidity was determined prospectively through daily home visits (except on Sunday) during weeks 0-8, then twice weekly in weeks 9-26. Anthropometric measurements were made at 0, 4, 8, 17, and 26 wk. Immune function was assessed at 8 wk by the phytohemagglutinin skin test. Supplementation (5 mg Zn) was associated with a 28% reduction in diarrhea prevalence over the 6-mo period [after adjustment for confounders (P = 0.043)], and a 33% reduction in the prevalence of cough (NS, adjusted prevalence P = 0.073). All infants had a positive immune response at 8 wk. Although supplementation had no significant effect on weight and length gains from 0 to 26 wk, infants given 5 mg Zn gained more weight than infants given placebo during weeks 17-26 (P = 0.024, analysis of variance). There was no effect on any outcome with 1 mg Zn. We conclude that 5 mg Zn/d is of benefit to LBW, full-term infants who only have a modest weight deficit.

The NCHS reference and the growth of breast- and bottle-fed infants.

The current international growth reference, the National Center for Health Statistics (NCHS) reference, is widely used to compare the nutritional status of populations and to assess the growth of individual children throughout the world. Recently, concerns were raised regarding the adequacy of this reference for assessing the growth of breast-fed infants. We used the NCHS reference to evaluate infant growth in one of the most developed areas of Brazil. Infants who were exclusively or predominantly breast-fed for the first 4-6 mo, and partially breast-fed thereafter, grew more rapidly than the NCHS reference in weight and length during the first 3 mo, but appeared to falter thereafter. The average growth of all infants, regardless of feeding pattern, was faster than the NCHS reference until approximately 6 mo, after which their growth became slower than that of the NCHS sample. To substantiate this finding, the NCHS growth curves were then compared with growth data of breast-fed infants in developed countries from pooled published studies, formula-fed North American and European infants and predominantly bottle-fed U.S. infants monitored by the Centers for Disease Control and Prevention (CDC) Pediatric Surveillance System. In all three cases, weights showed the same pattern as the Brazilian infants-higher than NCHS in the early months but an apparent decline thereafter. The pattern for length gain was similar but less marked. Breast-fed infants showed more pronounced declines than those who were predominantly bottle-fed. These findings suggest that the infancy portion of the NCHS reference does not adequately reflect the growth of either breast-fed or artificially fed infants. This probably results from characteristics of the original sample and from inadequate curve-fitting procedures. The development of an improved international growth reference that reflects the normal infant growth pattern is indicated.

PIP: The National Center for Health Statistics (NCHS) reference is the international standard widely used to compare the nutritional status of populations and to assess the growth of individual children around the world. There has, however, recently been concern over the adequacy of this reference for assessing the growth of breast-fed infants. Findings are presented from an evaluation of infant growth using the NCHS reference in the city of Pelotas, Brazil, one of the most developed areas of the country. The 5304 children enrolled in the study comprised all but 0.3% of all hospital births occurring in the city in 1993. Infants who were either exclusively or mainly breast-fed for the first 4-6 months, and partially breast-fed thereafter, grew faster than the NCHS reference in weight and length during the first 3 months, but appeared to falter thereafter. The average growth of all infants, regardless of feeding pattern, was faster than the NCHS reference until approximately age 6 months, after which they grew slower than did the NCHS sample. A comparison of NCHS growth curves with growth data on breast-fed infants in developed countries from pooled published studies, formula-fed North American and European infants, and mainly bottle-fed US infants monitored by the Centers for Disease Control and Prevention (CDC) Pediatric Surveillance System found infant weights in all cases to exhibit the same pattern as that of the Brazilian infants. The pattern for length gain was similar, but less marked. Breast-fed infants showed more pronounced declines than those who were mainly bottle-fed. An improved international growth reference should be developed and used.

Measuring the burden of common morbidities: sampling disease experience versus continuous surveillance.

Longitudinal prevalence, the proportion of all days of observation that a given individual manifests symptoms of illness, is a measure of disease frequency that is easy to generate from daily morbidity data and has been shown to be strongly related to subsequent health outcome. It is hypothesized that this measure could be derived using a representative sample of days of observation rather than continuous surveillance. The authors use 1990-1991 data from a Brazilian supplementation trial comprising a year's daily records of the occurrence of diarrhea, fever, and cough in 906 children under 5 years of age to examine how many days of morbidity data need to be observed to rank subjects into quintiles of illness frequency. Systematic samples of the full data set, based on every 2nd, 3rd, 5th, 10th, 15th, 20th, and 30th day of data, are compared with the continuous record. For diarrhea and fever, estimates based on less than 72 days of observation result in over one fourth of individuals who should have been in the extreme quintiles of the morbidity distribution being misclassified, and over one fifth of all subjects appear (falsely) to suffer no morbidity. Estimates of longitudinal prevalence should be based on at least 72 days of observation.

Length and ponderal index at birth: associations with mortality, hospitalizations, development and post-natal growth in Brazilian infants.

BACKGROUND: Low birthweight infants suffer greater mortality and neonatal morbidity, grow less well in infancy and show poorer psycho-motor development. However, this simple categorization may obscure important differences in aetiology and prognosis between infants born stunted, thin, or both. METHODS: In 1993, all births in Pelotas, Brazil, were enrolled into a prospective study of health and development in infancy. Of 5249 live births, 5160 had length and weight measures at birth, and were classified into tertiles of length and ponderal index. All deaths and hospitalizations were monitored, and suspected developmental delay and attained growth at 12 months were assessed on a subsample of 1364 infants. Logistic regression was used to control for gestational age and socioeconomic status. RESULTS: There was no association between birth length and ponderal index tertiles. After adjusting for gestational age, infants in the lower tertiles of both length and ponderal index presented a 3.8-times higher risk of mortality from day 8 to day 365, and a 2.5-times higher risk of hospitalization compared to infants with greater birth lengths and/or ponderal indices. Suspected developmental delay was associated with length and, less strongly, with ponderal index, but there was no synergism between the two. Infants in the middle and upper tertiles of ponderal index at birth became thinner. CONCLUSIONS: Birth length was strongly associated with development at 12 months, but only infants born both short and thin were at increased risk of mortality and hospitalizations. The combination of the two measures provides a useful classification of the anthropometric status of the newborn.

PIP: A prospective study of all 5249 live births in Pelotas, Brazil, in 1993 examined interactions between health and development in infancy. The 5160 infants who had length and weight measurements taken at birth were classified into tertiles of length-for-age Z score and ponderal index--a measure of soft tissue growth. There was no association between these two measures. After adjustments for gestational age, infants in the lower tertiles of both length and ponderal index had a 3.8 times greater risk of mortality from day 8 to 365 and a 2.5 times higher risk of hospitalization than infants in the high tertile. However, infants born short but not thin, or thin but not short, were not at increased risk of either mortality or hospitalization. Suspected developmental delay at 12 months was associated with shorter stature at birth and, less strongly, with a lower ponderal index, but there was no synergism between the two measures. Infants in the middle and upper tertiles of ponderal index at birth became markedly thinner in the first year of life, while length changes were less strongly associated with initial status. Overall, these findings suggest that the combination of length and ponderal index at birth may provide a functionally relevant means of classifying the newborn's anthropometric status since the two measures are relatively independent of each other at the level of the individual and appear to affect different aspects of the infant's subsequent health and development.

The development of low birth weight term infants and the effects of the environment in northeast Brazil.

OBJECTIVES: (1) To compare the mental and psychomotor development of low birth weight term (LBW-T) infants with that of appropriate birth weight (ABW) infants at 6 and 12 months of age. (2) To examine the relationship between developmental levels and social background. METHODS: A cohort of 131 LBW-T infants (1500 to 2499 gm) and 131 ABW infants (3000 to 3499 gm) matched for sex and time of birth, recruited from six maternity centers in Northeast Brazil were followed for 1 year. Their development was assessed with the Bayley Scales at 6 and 12 months of age, and at 12 months their behavior during the test was rated on five scales. Details of their families' socioeconomic status were recorded and the degree of stimulation in their homes was assessed. RESULTS: At 6 months of age the LBW-T infants had significantly lower scores than the ABW infants on the mental development index (MDI; 4.2 points lower, p < 0.001) and on the psychomotor development index (PDI; 7.3 points lower, p < 0.001). The difference had increased by 12 months of age (MDI 7.0 points lower, p < 0.001; PDI 9.9 points lower, p < 0.001). Socioeconomic variables were related to development at both ages in both groups. Maternal literacy was significantly related to the PDI in LBW-T infants at 12 months but not in ABW infants. Similarly, stimulation in the home was related to the MDI in LBW-T infants at 6 and 12 months but not in ABW infants. LBW-T infants were less active, cooperative, vocal, and happy, and were more inhibited than ABW infants. CONCLUSIONS: LBW-T infants had poorer development than ABW infants and differed in their behavior. There was an interaction between birth weight and the environment. LBW-T infants, but not ABW infants, were affected by the quality of stimulation in the home and maternal illiteracy.

Zinc supplementation, mental development and behaviour in low birth weight term infants in northeast Brazil.

OBJECTIVE: To test whether zinc supplementation reduces the deficits in mental development and behaviour that are found in term infants of low birth weight in the study population. DESIGN: A prospective double-blind, part-randomised efficacy trial. SETTING: A low-income population in Pernambuco, northeast Brazil, where the economy is largely dependent on sugar-cane production, and where over 90% of deliveries occur in health facilities. SUBJECTS: During a 20-month period, all singleton, term infants weighing 1500-2499 g born to families of low income ( < US $280/month) were enrolled at birth (n = 205). At 6 and 12-months, the numbers tested were 163 and 138 respectively. INTERVENTION: Infants born from January 1993-January 1994 were randomly assigned to receive daily, except Sundays, a placebo (n = 66) or 1 mg zinc (n = 68). Those born February-August 1994 were given 5 mg zinc (n = 71). Supplementation was for eight weeks, starting at birth. Field workers visited each infant at home to administer the supplement. RESULTS: At 6 and 12-months, mental and psychomotor development was assessed with the Bayley Scales of Infant Development and no significant differences in the scores of the three groups were found. At 12-months, behaviour was also assessed on 5 ratings. Ratings were highest in infants given 5 mg zinc (P = 0.042). CONCLUSIONS: Zinc supplementation (5 mg/d) for eight weeks may reverse some of the poor behaviours, particularly responsiveness, exhibited by low birth weight infants. No amelioration of their mental and psychomotor deficits was found.

PIP: Severe zinc deficiency, widespread in developing countries, has been associated with cognitive and psychomotor impairment in animal studies. The capability of zinc supplementation, to reduce the deficits in mental development and behavior found in low-birth-weight term infants, was assessed in a prospective study conducted in a low-income community in Pernambuco, Brazil. All 205 singleton, term infants, delivered at the local hospital in a 20-month period and weighing 1500-2499 g at birth, were enrolled. Infants born from January 1993 to January 1994, were randomly assigned to receive either a placebo (n = 66) or 1 mg of zinc (n = 68) 6 days a week. The 71 low-birth-weight infants delivered from February to August 1994, were given 5 mg of zinc 6 days a week. Supplementation administered by local health workers was initiated at birth and lasted for 8 weeks. Mental and psychomotor development was measured at 6 and 12 months of age by the Bayley Scales of Infant Development. There were no significant differences between infants in the 3 study groups on this test. Also at 12 months, infant behavior was assessed on 5 scales. Ratings for one of these scales (responsiveness to tester) were significantly higher in infants who received 5 mg of zinc than in the 2 other groups, and the 5 mg zinc group also had the highest scores on the 4 other scales. Further studies are urged to investigate the effect of zinc provided later in life, and for longer periods of time, on the development of low-birth-weight infants.

Breast-feeding and growth in Brazilian infants.

A new international growth reference is being prepared based on children who are fed according to World Health Organization recommendations, which entail exclusive breast-feeding for the first 4-6 mo of life. However, the number of exclusively breast-fed infants in most societies is small, so that selection biases may result from using such a population. We examined the variability in linear and soft tissue growth of infants according to their feeding patterns, emphasizing differences between exclusively and predominantly (breast milk plus fluids) breast-fed infants. About 650 infants from a relatively developed urban area in southern Brazil were examined at the ages of 1, 3, 6, and 12 mo, and an additional 800 infants at 6 and 12 mo. At each visit, infants were weighed and measured and a 24-h dietary recall was completed with the infants' caretakers. In the analyses of growth, care was taken to address the biases of reverse causality, regression to the mean, and confounding. There was little association between feeding pattern and growth in the first month. From 1 to 3 mo, partially breast-fed infants tended to gain more weight, followed by those who were completely weaned. From 3 to 6 mo, fully weaned infants grew fastest in weight and length and exclusively breast-fed infants grew slowest. After 6 mo of age, the growth in length of partially breast-fed and fully weaned infants was similar, but the latter gained more weight. There were virtually no differences between exclusively and predominantly breast-fed infants in the first 6 mo of life. There results suggest that both of these groups may be pooled for the purpose of constructing growth references.

PIP: Under the auspices of the World Health Organization, a new international growth reference is being developed to reflect the growth of breast-fed infants and their tendency to falter from 3-4 months onward. Of concern, however, is the small number of exclusively breast-fed infants in most societies and the potential for selection bias. A study conducted in Brazil in 1993 found no significant differences between exclusively and predominantly breast-fed infants in the first 6 months of life, suggesting that both these groups can be pooled for the purpose of growth reference construction. 650 infants from a relatively developed urban area in southern Brazil (Pelotas) were examined at 1, 3, 6, and 12 months of age and an additional 800 infants were enrolled at 6 and 12 months. There was little association between growth and feeding pattern in the first month of life. Slower growth in the first month increased the risk of subsequent weaning. From months 1-3, partially breast-fed infants tended to gain more weight, followed by those who were completely weaned. During months 3-6, fully weaned infants grew fastest in terms of both weight and length and exclusively breast-fed infants grew slowest. After 6 months of age, the growth in length of partially breast-fed and fully weaned infants was similar, but the latter group gained more weight. The tendency for breast-fed infants to grow more slowly should be considered in view of the many benefits of breast feeding, including protection against infections and diseases of the immune system, psychological advantages, and birth spacing.

Measles incidence, case fatality, and delayed mortality in children with or without vitamin A supplementation in rural Ghana.

Data on measles incidence, acute case fatality, and delayed mortality were collected on 25,443 children aged 0-95 months during the course of a community-based, double-blind, placebo-controlled, randomized trial of vitamin A supplementation in rural, northern Ghana between 1989 and 1991. Measles vaccine coverage in these children was 48%. The overall estimated measles incidence rate was 24.3 per 1,000 child-years, and acute case fatality was 15.7%. There was not significantly increased mortality in survivors of the acute phase of measles compared with controls (rate ratio = 1.22, 95% confidence interval (CI) 0.65-2.30). Reported incidence rates and case fatality were higher in families with low paternal education, in the dry season, and in unvaccinated children, and case fatality was higher in malnourished children. There was no sex difference in incidence, but acute case fatality was somewhat higher in girls than boys (adjusted odds ratio = 1.3, 95% CI 0.9-2.1). Measles incidence was lower in vitamin A-supplemented groups (23.6 per 1,000 child-years) than in placebo groups (28.9 per 1,000 child-years), but this difference was not statistically significant (p = 0.33). Among 946 measles cases in clusters randomized to receive vitamin A or placebo, there was no marked difference in acute measles case fatality between vitamin A-supplemented and placebo groups (15.4% vs. 14.5%, respectively). The biologic effects of vitamin A supplemented on the subsequent clinical manifestations and severity of measles need further elucidation.

PIP: As part of a community-based, placebo-controlled trial of vitamin A supplementation in rural northern Ghana in 1989-91, data were collected on measles incidence and mortality among 25,433 children 0-95 months of age. Measles vaccination coverage was 48%. A total of 961 measles cases were identified, with a median age at onset of 41 months. The overall measles incidence rate was estimated at 24.3/1000 child-years and the acute case fatality rate was 15.7%. Both measles incidence and fatality were higher in families with low paternal education, in the dry season, and in unvaccinated children. Case fatality was also higher in malnourished children. There was a lower, although nonsignificant, measles incidence in vitamin-A supplemented groups (23.6/1000 child-years) than in placebo groups (28.9/1000 child-years). Among 946 measles cases in clusters randomized to receive vitamin A or placebo, there was no marked difference in acute measles case fatality (15.4% and 14.5%, respectively). These findings confirm the importance of sustained measles vaccination in Africa.

Breast feeding, pacifier use and infant development at 12 months of age: a birth cohort study in Brazil.

Many studies suggest that breast feeding confers developmental and intellectual advantages on children. In a recent study, however, no association was found between breast feeding and intelligence in adult life after adjustment for other variables, and the use of pacifier in infancy was the most important predictor of intelligence. We analysed the associations between breast-feeding duration, pacifier use and suspected developmental delay at 12 months of age in a birth cohort in Pelotas, southern Brazil. All 5304 hospital births occurring during 1993 were studied and a sample was followed up at 1, 3, 6 and 12 months of age. Breast-feeding practices and use of pacifiers were assessed at each visit, as well as suspected developmental delay, measured by the Denver II test. The prevalence of developmental delay was analysed, through logistic regression, according to breast-feeding status and pacifier use, accounting for the possible confounding effect of other variables. The prevalence of suspected developmental delay at 12 months was 34.1%, being slightly higher among children who used pacifiers at 6 months than among non-users (35.3% and 28.7% respectively). There was a marked negative association between breast-feeding duration and developmental delay, with children breast fed for 9 months or more presenting significantly less suspected developmental delay (25.5%) than those breast fed for less than 1 month (42.4%). The effects of multiple variables were tested, and only high parity, smoking during pregnancy, birthweight, gestational age, pacifier use and breast-feeding duration remained significantly associated with suspected developmental delay. The effect of pacifier use, however, disappeared after adjusting for breast-feeding duration, suggesting that breast feeding, and not pacifiers, affects child development.

Postnatal growth patterns of full-term low birth weight infants in Northeast Brazil are related to socioeconomic status.

Low birth weight has many adverse consequences, some of which might be ameliorated if there is good postnatal compensatory, or catch-up, growth. We monitored growth, morbidity and feeding patterns in a cohort of 133 full-term, low birth weight infants from poor families in Pernambuco, Brazil, and investigated the relative contributions of a number of socioeconomic, maternal and infant variables to postnatal growth. Growth was measured at 4, 8, 17, 26 and 52 wk of age. Differential growth patterns were most marked during the first 8 wk of life, and the gains in z-score during this interval were strongly associated with attained z-scores at 12 months (r = 0.62 for weight and 0.64 for length). In a multivariate model, socioeconomic variables explained 21.4% of the variation in maximum gain in weight-for-age z-score achieved during the 12-month period, maternal weight explained a further 4.4%, infant birth length 4.7% and neonatal illness 5.4%. For maximum gain in length-for-age z-score, socioeconomic variables accounted for 24.4% of the variance, maternal height 4.9%, maternal smoking 3.3% and neonatal illness 3.1%. We surmise that the early differential growth patterns are set in utero and are indirectly affected prenatally by socioeconomic status.

Randomised, double blind, placebo controlled clinical trial of efficacy of vitamin A treatment in non-measles childhood pneumonia.

OBJECTIVE: To evaluate the impact on clinical recovery and severity of the addition of large doses of vitamin A to the standard treatment for childhood pneumonia. DESIGN: A randomised, double blind, placebo controlled trial. SETTING: Study children were recruited at a public hospital in Recife, north east Brazil, an area of marginal vitamin A deficiency. SUBJECTS: 472 children aged 6 to 59 months with clinical diagnosis of pneumonia. INTERVENTIONS: 200,000 IU (infants) or 400,000 IU (1-4 year olds) of vitamin A in oil or similar capsules of placebo divided into two daily oral doses, in addition to the standard treatment. MAIN OUTCOME MEASURES: Duration of the episode and incidence of adverse outcomes. RESULTS: The groups were similar with respect to overall duration of pneumonia and incidence of adverse outcomes. Children who received vitamin A, however, were less likely to have fever by day 3 (P = 0.008) and were 29% less likely to fail to respond to the first line antibiotic (P = 0.054). CONCLUSION: There was little evidence for an effect of vitamin A treatment on the immediate outcome of the pneumonia episode.