How do children with severe underweight and wasting respond to treatment? A pooled secondary data analysis to inform future intervention studies.

To characterize the relationship between child faeces disposal and child growth in low- and middle-income countries. We analysed caregiver responses and anthropometric data from Demographic and Health Surveys (2005-2014) for 202614 children under five and 82949 children under two to examine the association between child faeces disposal and child growth. Child faeces disposal in an improved toilet was associated with reduced stunting for children under five [adjusted prevalence ratio (aPR)=0.90, 95% confidence interval (CI) 0.89-0.92] and a 0.12 increase in height-for-age z-score (HAZ; 95% CI: 0.10-0.15) among all households. Among households with improved sanitation access, practicing improved child faeces disposal was still associated with a decrease in stunting (aPR=0.94, 95% CI: 0.91-0.96) and a 0.09 increase in HAZ (95% CI: 0.06-0.13). Improved child faeces disposal was also associated with reductions in underweight and wasting, and an increase in weight-for-age z-score (WAZ), but not an increase in weight-for-height z-score (WHZ). Community coverage level of improved child faeces disposal was also associated with stunting, with 75-100% coverage associated with the greatest reduction in stunting. Child faeces disposal in an unimproved toilet was associated with reductions in underweight and wasting, but not stunting. Improved child faeces disposal practices could achieve greater reductions in child undernutrition than improving toilet access alone. Additionally, the common classification of child faeces disposal as 'safe' regardless of the type of toilet used for disposal may underestimate the benefits of disposal in an improved toilet and overestimate the benefits of disposal in an unimproved toilet.

To compare the prognostic value of mid-upper arm circumference (MUAC), weight-for-height Z-score (WHZ) and weight-for-age Z-score (WAZ) for predicting death over periods of 1, 3 and 6 months follow-up in children. Pooled analysis of twelve prospective studies examining survival after anthropometric assessment. Sensitivity and false-positive ratios to predict death within 1, 3 and 6 months were compared for three individual anthropometric indices and their combinations. Community-based, prospective studies from twelve countries in Africa and Asia. Children aged 6-59 months living in the study areas. For all anthropometric indices, the receiver operating characteristic curves were higher for shorter than for longer durations of follow-up. Sensitivity was higher for death with 1-month follow-up compared with 6 months by 49 % (95 % CI (30, 69)) for MUAC < 115 mm (P < 0·001), 48 % (95 % CI (9·4, 87)) for WHZ < -3 (P < 0·01) and 28 % (95 % CI (7·6, 42)) for WAZ < -3 (P < 0·005). This was accompanied by an increase in false positives of only 3 % or less. For all durations of follow-up, WAZ < -3 identified more children who died and were not identified by WHZ < -3 or by MUAC < 115 mm, 120 mm or 125 mm, but the use of WAZ < -3 led to an increased false-positive ratio up to 16·4 % (95 % CI (12·0, 20·9)) compared with 3·5 % (95 % CI (0·4, 6·5)) for MUAC < 115 mm alone. Frequent anthropometric measurements significantly improve the identification of malnourished children with a high risk of death without markedly increasing false positives. Combining two indices increases sensitivity but also increases false positives among children meeting case definitions.

Objective: To establish the determinants of weight, length and head circumference changes during their initial hospitalization in very-low-birth-weight preterm infants. Subjects/Methods: A prospective cohort study was performed. Weight z-score and percentage of target dietary intakes (TDIs) were prospectively determined daily during the first 5 weeks of life in a group of preterm infants (n = 111, birth weight <1,500 g, gestational age <34 weeks). Weight, length and head circumference at 36 weeks' postmenstrual age (PMA) were recorded. A mixed effects regression model was used to evaluate changes in weight z-score during the first 5 weeks of life. Simple Pearson correlations and stepwise logistic regression were used to determine the relationship between fetal growth, illness severity, nutritional intake and growth at 36 weeks' PMA. Results: Weight z-score decreased significantly in all infants during the first 5 weeks of life from -0.92 ± 0.66 at birth to -1.89 ± 0.65 at 5 weeks. The variation of weight z-score during the first 5 weeks of life was influenced by weight z-score at birth, energy and protein intakes and gestational age. Mean energy and protein intakes were 95.5 and 86.4% of TDIs. Weight z-score fell to -2.05 ± 0.64 at 36 weeks' PMA. Birth weight z-score was significantly correlated with weight z-score at 36 weeks (R² = 0.71; p < 0.001). Severity of illness influenced the weight z-score at 36 weeks. Conclusion: Despite achieving a protein and energy intake close to the described target intake, the rate of growth in our infants was lower than indicated by the intrauterine growth curve. Lower gestational age, lower birth weight and severe illness had a negative effect on growth.

Poor Weight Recovery Between Stage 1 Palliation and Hospital Discharge for Infants with Single Ventricle Physiology: An Analysis of the National Pediatric Cardiology Quality Improvement Collaborative Phase II Dataset

Associations Between Birthweight and Appetite Traits: Appetite Traits Partially Mediate the Link Between Birthweight and Later Child Weight in Low-Income Hispanic Families

We evaluated data on blacks and whites with acute ST-segment-elevation myocardial infarction treated with either fibrinolysis or primary percutaneous coronary intervention from the National Registry of Myocardial Infarction (NRMI)-4 and -5 participating centers between July 2000 and December 2006 to determine race-related differences in bleeding and outcomes. We found that among patients with ST-segment-elevation myocardial infarction receiving fibrinolysis, the bleeding rates were higher for blacks (n2283) than whites (n42 243; 10.9% versus 10.3%; adjusted odds ratio, 1.21; 95% confidence interval, 1.02-1.43). Similarly, in patients receiving primary percutaneous coronary intervention, the bleeding rates were higher in blacks (n2826) than whites (n46 332; 10.3% versus 7.8%; adjusted odds ratio, 1.33; 95% confidence interval, 1.13-1.56). Bleeding was associated with a higher risk of death in both ethnic groups. However, there was no overall racial difference in in-hospital mortality among those with bleeding or without bleeding treated with either fibrinolysis or primary percutaneous coronary intervention. We concluded that race-related differences existed in bleeding risk among patients with ST-segmentelevation myocardial infarction receiving reperfusion therapy that portend poor prognosis. Thus, the efficacy and safety of many new drugs or treatment strategies for any disease observed in clinical trials that enroll predominantly white patients may not be similar in other ethnic groups that are underrepresented in these trials.

Growth Trajectories Over the First Year of Life Among Early-Treated Infants with Human Immunodeficiency Virus and Infants Who are Human Immunodeficiency Virus-Exposed Uninfected

Background:Limited studies assess how infant dietary patterns impact child weight. The Starting Early Program (StEP) promotes healthy nutrition during pregnancy and infancy and leads to healthier child weight, but whether dietary patterns contribute to weight or mediate StEP weight outcomes has not been studied.Objectives:This secondary analysis identified infant dietary patterns in StEP, determined associations between dietary patterns and child weight outcomes, and examined whether dietary patterns mediated the relationship between StEP and child weight.Methods:Data were from 377 mother-infant dyads enrolled in a randomized trial testing the efficacy of StEP. Infant diet was assessed at 10 months using an interviewer-administered 24-hour recall, and dietary patterns were identified using latent class analysis. Child weights were abstracted from medical records at 12, 24, and 36 months. Associations between infant dietary patterns and weight-for-age z-score (WFAz) and likelihood of being classified as overweight (WFA ≥85th percentile) were assessed using multivariable linear and logistic regression models. Mediation analyses were used to assess intervention effects on WFAz via impacts on infant dietary patterns.Results:Four classes of infant dietary patterns were identified, characterized by differences in milk feeding and complementary food type and variety: Breastfed-High variety; Formula fed-High variety; Formula fed-Low variety; and Mixed fed-Low variety. Compared to the Breastfed-High variety class, infants in the Formula fed-Low variety class had higher WFAz and were more likely to be classified as overweight at 24 and 36 months. Participation in StEP increased membership in Breastfed-High variety, which mediated the association between StEP and lower WFAz at 24 months.Conclusions:Infant dietary patterns were identified and associated with child obesity risk. StEP promoted an infant dietary pattern that was most consistent with infant feeding guidelines, which mediated intervention effects on child weight.

To determine the association between cord blood 25-hydroxyvitamin D (25(OH)D) concentration with growth, adiposity and neurodevelopment during infancy. Serum 25(OH)D was measured in cord blood by the liquid chromatography tandem mass spectrometry (LC-MS/MS) from the Shanghai's "Allergy and Obesity Cohort study" (n = 1244). Weight, length, head circumference, and body mass index (BMI) z-scores for age were calculated based on World Health Organization Standard (at 6 months, 1 years, and 2 years). Neurodevelopment was measured at 2 years using Ages and Stages Questionnaire. Generalized estimating equation and multivariable logistic regression model were exploited to examine associations between fetal 25(OH)D concentration and offspring outcomes. The median of the 25(OH)D concentration in cord blood was 22.4 ng/ml (interquartile range, 27.3-8.6). Infants born in winter had lower 25(OH)D concentration. 25(OH)D deficiency was not associated with weight z-score (mean difference, 0.07; 95% confidence internal (CI), -0.09 to 0.23), length z-score (mean difference, 0.01; 95% CI, -0.19 to 0.21), head circumference z-score (mean difference, -0.06; 95% CI, -0.27 to 0.15) and BMI z-score (mean difference, 0.09; 95% CI, -0.07 to 0.25) or neurodevelopment during infancy, adjusting for sex, socio-economic position, pre-pregnancy maternal BMI, and maternal and neonatal characteristics. The associations did not vary by gender. A sensitivity analysis of available case analysis showed virtually the same results. Fetal vitamin D concentration was not associated with growth, adiposity or neurodevelopment during infancy. The role of vitamin D concentration and its mechanistic pathway in the early origins of adiposity needs to be clarified.

Prenatal exposure to air pollutants and early childhood growth trajectories: A population-based prospective birth cohort study

Aims and Objectives: Malnutrition is common in children with congenital heart disease and may contribute to adverse outcomes. This study evaluates the impact of pre-operative nutritional status on outcomes after congenital heart surgery.Methods: We conducted a retrospective cohort study enrolling children under 10 years old who underwent congenital heart surgery at a tertiary children's hospital from 2012 to 2016. Patients who had patent ductus arteriosus ligation only, genetic syndromes, or global developmental delay were excluded. Outcome measures included 30-day mortality, intensive care unit (ICU) length of stay (LOS), hospital LOS, duration of mechanical ventilation, and number of inotropes used post-operatively. We performed univariate/multivariable logistic regression analysis, adjusting for age, cyanotic cardiac lesion, co-morbidity, and Risk Adjustment for Congenital Heart Surgery (RACHS-1) score.Results: Three hundred two children of median age 16.2 [interquartile range (IQR) 3.1, 51.4)] months were included. The most common cardiac lesions were ventricular septal defect (27.8%), atrial septal defect (17.9%), and Tetralogy of Fallot (16.6%). Median weight-for-age z-score (WAZ) was −1.46 (IQR −2.29, −0.61), height-for-age z-score (HAZ) was −0.94 (IQR −2.10, −0.10), and body mass index (BMI)-for-age z-score (BAZ) was −1.11 (IQR −2.19, −0.30). In multivariable analysis, there was an increased risk of 30-day mortality for WAZ ≤−2 vs. WAZ >−2 [adjusted odds ratio (aOR): 4.01, 95% CI: 1.22, 13.13; p = 0.022]. For HAZ ≤-2 vs. HAZ > −2, there was increased risk of hospital LOS ≥ 7 days (aOR: 2.08, 95% CI: 1.12, 3.89; p = 0.021), mechanical ventilation ≥48 h (aOR: 2.63, 95% CI: 1.32, 5.24; p = 0.006) and of requiring ≥3 inotropes post-operatively (aOR: 3.00, 95% CI: 1.37, 6.59; p = 0.006).Conclusion: In children undergoing congenital heart surgery, WAZ ≤ −2 is associated with higher 30-day mortality, while HAZ ≤ −2 is associated with longer durations of hospital LOS and mechanical ventilation, and increased risk of use of 3 or more inotropes post-operatively. Future studies are necessary to develop safe and efficacious peri-operative nutritional interventions, particularly in patients with WAZ and HAZ ≤ −2.

Maternal/caregivers’ mental health (MMH) and child nutrition are both poor in low- and middle-income countries. Links between the two are plausible but poorly researched. Our aim was to inform future malnutrition management programmes by better understanding associations between MMH and nutritional status of infants aged under six month (u6m). We conducted a health facility-based cross-sectional survey of 1060 infants in rural Ethiopia, between October 2020 and January 2021. We collected data on: MMH status (main exposure) measured using the Patient Health Questionnaire (PHQ-9) and infant anthropometry indicators (outcome); length for age Z-score (LAZ), weight for age Z-score (WAZ), weight for length Z-score (WLZ), mid upper arm circumference (MUAC), head circumference for age Z-score (HCAZ) and lower leg length (LLL). Analysis of secondary data using linear regression was employed to determine associations between the main exposure and outcome variables. The result showed infants’ mean (SD) age was 13.4 (6.2) weeks. The median score for MMH problem was 0 (inter quartile range 0–2) points, and 29.5% and 11.2% reported minimal and mild to severe depression score of 1–4 and 5–27 points, respectively. Mean (SD) LAZ was -0.4 (1.4), WAZ -0.7 (1.3), WLZ -0.5 (1.2), MUAC 12.4 (1.3) cm, HCAZ 0.4 (1.3) and LLL 148 (13.9) mm. In adjusted linear regression analysis, minimal MMH problem was negatively associated with infant LAZ marginally (β = -0.2; 95% CI: -0.4, 0.00; p = 0.05) and LLL (β = -2.0; 95% CI: -3.8, -0.1; p = 0.04), but not with other anthropometric indicators. Statistically significant associations were not found between mild to severe depressive symptoms and infant anthropometric outcomes. In conclusion, only minimal, but not mild, moderate or severe, maternal/caregivers’ depressive symptoms are associated with infant anthropometry outcomes in this data set. Whilst there is a plausible relationship between maternal mental health problems and offspring nutritional status, we did not observed this. Possible reasons include: PHQ-9 not suited to our population; and only a small number of participants reporting moderate to severe level of depression. Further research to investigate and understand the relationship and pathways between maternal mental health and offspring nutritional status is required.

BackgroundAlthough dialysis patients are at a high risk of death, it is difficult for medical practitioners to simultaneously evaluate many inter-related risk factors. In this study, we evaluated the characteristics of hemodialysis patients using machine learning model, and its usefulness for screening hemodialysis patients at a high risk of one-year death using the nation-wide database of the Japanese Society for Dialysis Therapy.Materials and methodsThe patients were separated into two datasets (n = 39,930, 39,930, respectively). We categorized hemodialysis patients in Japan into new clusters generated by the K-means clustering method using the development dataset. The association between a cluster and the risk of death was evaluated using multivariate Cox proportional hazards models. Then, we developed an ensemble model composed of the clusters and support vector machine models in the model development phase, and compared the accuracy of the prediction of mortality between the machine learning models in the model validation phase.ResultsAverage age of the subjects was 65.7±12.2 years; 32.7% had diabetes mellitus. The five clusters clearly distinguished the groups on the basis of their characteristics: Cluster 1, young male, and chronic glomerulonephritis; Cluster 2, female, and chronic glomerulonephritis; Cluster 3, diabetes mellitus; Cluster 4, elderly and nephrosclerosis; Cluster 5, elderly and protein energy wasting. These clusters were associated with the risk of death; Cluster 5 compared with Cluster 1, hazard ratio 8.86 (95% CI 7.68, 10.21). The accuracy of the ensemble model for the prediction of 1-year death was 0.948 and higher than those of logistic regression model (0.938), support vector machine model (0.937), and deep learning model (0.936).ConclusionsThe clusters clearly categorized patient on their characteristics, and reflected their prognosis. Our real-world-data-based machine learning system is applicable to identifying high-risk hemodialysis patients in clinical settings, and has a strong potential to guide treatments and improve their prognosis.

Background: This study aims to explore the characteristics and risk factors of inadvertent intraoperative hypothermia (IIH) in pediatric surgical patients. Methods: Data from 291 pediatric surgical patients were retrospectively analyzed. Demographic and surgical data were collected. Intraoperative nasopharyngeal temperature was recorded as the core temperature. Patients were divided into two groups: The hypothermic group (core temperature &lt; 36℃) and the normothermic group (core temperature ≥ 36℃). This study included 291 pediatric patients who underwent pediatric surgery at our center between January 2020 and June 2020. A logistic regression model was used to compare 17 parameters between the two groups. Subgroup analyses were conducted for neonates and infants (0 - 1 year) and older children (&gt; 1 year). Results: Among 291 pediatric patients, 73.5% experienced intraoperative hypothermia, mostly mild. In neonates and infants, younger age (OR = 0.88, P = 0.031) and longer preoperative preparation (OR = 1.03, P = 0.050) were associated with a higher risk. In older children, male sex (OR = 7.06, P = 0.001), supine (OR = 5.53, P = 0.017) or lateral position (OR = 5.94, P = 0.033), level 4 surgery (OR = 12.15, P = 0.001), laparotomy (OR = 5.71, P = 0.037), and lower weight for age Z-score (WAZ) (OR = 0.48, P = 0.008) were significant risk factors. Conclusions: Pediatric surgical patients are at high risk of IIH. Factors such as gender, age, WAZ, surgical position, surgical levels, surgical types, and preparation duration were related to IIH. Risk factors of IIH varied by age groups. Targeted interventions are needed to reduce the incidence of IIH among pediatric patients.

South Asia has >50% of the global burden of low birth weight (LBW). The objective was to determine the extent to which maternal nutrition interventions commenced before conception or in the 1st trimester improved fetal growth in this region. This was a secondary analysis of combined newborn anthropometric data for the South Asian sites (India and Pakistan) in the Women First Preconception Maternal Nutrition Trial. Participants were 972 newborn of mothers who were poor, rural, unselected on basis of nutritional status, and had been randomized to receive a daily lipid-based micronutrient supplement commencing ≥3 months prior to conception (Arm 1), in the 1st trimester (Arm 2), or not at all (Arm 3). An additional protein-energy supplement was provided if BMI <20 kg/m2 or gestational weight gain was less than guidelines. Gestational age was established in the 1st trimester and newborn anthropometry obtained <48-hours post-delivery. Mean differences at birth between Arm 1 vs. 3 were length +5.3mm and weight +89g. Effect sizes (ES) and relative risks (RR) with 95% CI for Arm 1 vs. 3 were: length-for-age Z-score (LAZ) +0.29 (0.11–0.46, p = 0.0011); weight-for-age Z-score (WAZ) +0.22 (0.07–0.37, p = 0.0043); weight-to-length-ratio-for-age Z-score (WLRAZ) +0.27 (0.06–0.48, p = 0.0133); LAZ<-2, 0.56 (0.38–0.82, p = 0.0032); WAZ <-2, 0.68 (0.53–0.88, p = 0.0028); WLRAZ <-2, 0.76 (0.64–0.89, p = 0.0011); small-for-gestational-age (SGA), 0.74 (0.66–0.83, p<0.0001); low birth weight 0.81 (0.66–1.00, p = 0.0461). For Arm 2 vs. 3, LAZ, 0.21 (0.04–0.38); WAZ <-2, 0.70 (0.53–0.92); and SGA, 0.88 (0.79–0.97) were only marginally different. ES or RR did not differ for preterm birth for either Arm 1 vs. 3 or 2 vs. 3. In conclusion, point estimates for both continuous and binary anthropometric outcomes were consistently more favorable when maternal nutrition supplements were commenced ≥3 months prior to conception indicating benefits to fetal growth of improving women’s nutrition in this population.