A Study on Development of Pediatric Reference Charts

RATIONALE: Pediatric growth pattern differences continue even after controlling for various factors such as nutrition, income distribution, environment, maternal/child health care and availability of health care infrastructures. Therefore it is recommended that every country should use reference height and weight curves based on measurements on their own children. AIM OF THE STUDY: To construct pediatric reference centile charts for weight, height and body mass index using maximum penalized likelihood LMS method for boys and girls separately from ages 6 -12 years. STUDY OBJECTIVES: The Primary outcome measures were; 1. Construction of percentile charts using LMS method, 2. Calculation of Z- score using LMS method. Secondary outcome measures were; 1. Making Weight-for- age centile chart for boys and girls separately. 2. Making Height-for-age centile chart for boys and girls separately. 3. Making weight-for-height centile chart for boys and girls separately. 4. Making Body Mass Index centile chart for boys and girls separately. 5. Calculation of WAZ, WHZ ,HAZ and BMI Z score for boys and girls separately. 6. Comparison of American National Center for Health Statistics/ Center for Disease Control (NCHS/CDC2000/WHO2007) references with locally weighted. 7. Estimation of prevalence of malnutrition, overweight and obesity among Tamil Nadu children. STUDY DESIGN: Population based cross-sectional multi-site (various schools) study design. SETTING: The study was conducted at the Institute of Child Health and Hospital for children, Egmore, Chennai-8. STUDY POPULATION: The study population consisted of 6-12 years children from all social groups and from families of high, moderate and low income. TARGET POPULATION: The target population consisted of 6-12 years children in the selected urban–rural middle schools based on a representative sample of 2520 boys and 2520 girls. SAMPLE SIZE: Sample size was estimated using previous studies prevalence of normal children in the population 48%, with 5% relative precision and 95% of confidence. The calculated sample size was 1665.This was multiplied by 3 (bringing the sample size up to 4995) to allow for design effect due to application of cluster sampling method. For equal distribution of sample in clusters the ultimate sample size required for the study was determined to 5040 children. Tools used: Part I: Socio-demographic data tool, Part II: Anthropometric measurement tool. Outcome variables: 1. Percentile charts. 2. Z- score. 3. Comparison with NCHS/WHO2007/CDC2000 charts. 4. Prevalence of wasted ,stunted, underweight, overweight, obesity. METHODOLOGY: A total of 5040 apparently healthy boys and girls aged 6 to 12 years were recruited using population based cross-sectional multi-site (various schools) study design. Anthropometric measurements were collected as per WHO standards. To construct smoothened percentile reference charts, the lamda-mu-sigma-additional parameter (LMSP) method using Box-Cox power exponential (BCPE) distribution model was adopted. LMSP summarizes the changing distribution with age according to 4 curves representing the median (M), the coefficient of variation (S), skewness (L), and kurtosis (P). BCPE distribution takes the idea of having a range of power transformations (rather than the traditional square root, log, and inverse) available to improve the efficacy of normalizing and variance equalizing for both positively and negatively skewed, and for both leptokurtic-platykurtic variables. Maximum penalized likelihood, the Generalized Additive Models were used. The centile curves of height, weight and BMI were fitted by BCPE (μ, _, _, _ ) models, and the parameters, μ, _, _ and _, were smoothened by cubic smoothing splines. The goodness-of-fit of BCPE models were assessed by worm plot and Q-test. The degrees of freedom, with respect to the parameter curves of μ, _, _ and _ from BCPE distribution, were selected according as the smallest AIC and GAIC(3), and the centile curves were fitted by BCPE distribution. RESULTS: Comparing present study charts with those of NCHS/WHO2007/CDC2000 chart showed significant differences between growth patterns of our children and other populations. Estimated median 50th percentile shows Tamil Nadu children anthropometric measurements are lower than NCHS/WHO2007/CDC2000 standard children. The study revealed that total prevalence of overweight was 10.6% (9.8%- 11.5%) and obesity was 3.0% (2.6%- 3.5%) when considering Body Mass Index of children between 6-12 years. Boys are having more overweight and obese than girls based on CDC2000 reference distributions of Z-scores for BMI. Present study shows prevalence of underweight is 31.7%, stunting is 19.7% and wasting is 24% among 6-12 years children. The boys had a risk of 1.23 (95%CI: 1.09-1.39) times greater to be underweight, 1.05 (95%CI: 0.92- 1.20) times greater to be stunting, and 1.03 (95%CI: 0.88- 1.20) times greater to be wasting than the girls. CONCLUSION: Since there is a secular trend in upward increase both in height and weight, a comparison of growth curves requires both methodological and secular similarity to determine similarity or difference. Local references would then provide a useful tool for health planning and screening inter-population differences. The results of the current study demonstrate the possibility of preparation of local growth charts and their importance in evaluating children's growth. Also their differences, relative to those prepared by global references, reflect the necessity of preparing local charts in future studies using longitudinal data

Socioeconomic determinants of breastfeeding practices in South India - A hospital-based cross-sectional study

Background: Breastfeeding is an unparalleled universally recommended intervention for the promotion of health and nutrition of children and reduction of mortality. In spite of the WHO recommendations and baby-friendly hospital initiative, breastfeeding practices are inappropriate due to maternal, infant, socioeconomic, and cultural factors. Objective: The objective of this study was to determine the socioeconomic factors associated with inappropriate breastfeeding practices. Secondary objective was to determine the knowledge level of mothers on ideal breastfeeding recommendations. Materials and Methods: This cross-sectional study was conducted in pediatric wards of a tertiary care teaching institution from January 2017 to July 2017. Mothers having children aged 7–60 months were included in the study. A sample size of one thousand was planned. After obtaining informed consent from mother, detailed feeding history including the timing of initiation of breastfeeding following childbirth, duration of exclusive breastfeeding, and age at which breastfeeding was discontinued was noted. Possible determinants considered were gender of the child, place of residence, maternal age, maternal education, maternal employment, number of children at home, type of family, whether mother was counseled during antenatal period, mode of delivery, and hospitalization in newborn period. Knowledge of mother on breastfeeding was probed and the response recorded. Univariate analysis followed by regression was performed to determine the significant factors. Results: 59% (95% confidence interval 55.9–62.1) of mothers initiated breastfeeding within 1 h of childbirth. 70.2% (95% CI - 67.3–73) exclusively breastfed their babies for 6 months and above. 43.6% (95% CI - 39.2–48.1) of mothers with children of age 25–60 months breastfed their babies up to 2 years and beyond. On univariate analysis, female gender, maternal employment, operative delivery, and hospitalization in the newborn period were identified as risk factors for inappropriate breastfeeding practices, which were confirmed by regression. Overall, only 26.6% (95% CI - 23.9–29.5) of mothers had appropriate knowledge about ideal breastfeeding recommendations. Conclusion: Female gender, maternal employment, operative delivery, and hospitalization in newborn period are significant independent risk factors for inappropriate breastfeeding practices. Only a quarter of mothers had adequate knowledge of breastfeeding recommendations

TENSILE TEST ANALYSIS OF NATURAL FIBER REINFORCED COMPOSITE

This project mainly deals with analysis of tensile properties of Palmyra fiber Reinforced Epoxy Composite that is suitable for automobile application. First, the property of material was obtained on the basis of some assumptions (i.e., Rule of Mixture) and was modeled with reference to ASTM D638. Here the simulation was carried out on specimen under different fiber volume fraction and fiber length. The present work includes the Analysis of Palmyra Fiber Reinforced Epoxy Composites using FEA with various fiber volume fractions and these results were validated with the experimental result. The tensile property of Palmyra fiber composite material can be obtained by using tensometer.During the tensile load, the maximum strain, stress and displacement were obtained and, then this experimental result was compared with the analytical results and the error percentage of these results were calculated

Determinants of immunization status of children aged 1-5 years attending a tertiary health care facility: A cross-sectional study

Background: Childhood immunization is one of the key health interventions, which is useful in decreasing the under-five mortality. There has been a recent decline in immunization coverage rates in India as shown by the National Family Health Survey 4. Objective: This study was undertaken with the objective of determining the socio-economic and demographic risk factors associated with partial immunization of children aged 1-5 years attending a tertiary care center in South India. Materials and Methods: This cross-sectional study was done at the outpatient department of Institute of Child Health and Hospital for Children, Chennai, from May 2015 to October 2015. Children aged 1-5 years attending the outpatient department were included by convenient sampling. A sample size of 1100 was calculated based on a pilot study. After obtaining parental informed consent, data were collected on immunization and socio-demographic factors, namely, gender, place of residence, parental education and occupation, family income, number of children, birth order, place of delivery, and awareness of the type of vaccines to be given. The WHO definitions were used to classify immunization status as full, partial, and delayed immunization. Univariate and multivariate logistic regression analyses were performed to determine independent risk factors for partial immunization. Results: Totally, 1104 children were included in the study. 1056 (95.7% [95% confidence interval 94.5-96.9]) were fully immunized, whereas 41 (3.7% [2.59-4.81]) were partially immunized and 7 (0.6% [0.14-1.06]) had delayed immunization. None of the children were totally unimmunized. Univariate analysis identified rural residence, home delivery, having more than 2 children, birth order more than 2, lack of maternal and paternal education beyond primary school level, and lack of awareness on immunization as significant risk factors for partial immunization. After multivariate logistic regression, rural residence, having more than 2 children, and lack of awareness on immunization emerged as independent risk factors for partial immunization. Conclusion: Residing in rural areas, having more than 2 children, and lack of awareness on immunization are significant independent risk factors for a child not being fully immunized

Detection of pulmonary Mycoplasma pneumoniae infections in HIV-infected subjects using culture and serology

SummaryObjectiveThe true prevalence of Mycoplasma pneumoniae infections involving the respiratory tracts of HIV-infected individuals is still unclear. This study examined the prevalence of M. pneumoniae in 100 HIV-infected individuals at an AIDS care center in Chennai, India, using conventional laboratory techniques and interpretation criteria.MethodsDiagnosis was based on culture, cold agglutination test, and commercial enzyme-linked immunosorbent assay (ELISA) for the qualitative determination of IgM antibodies against M. pneumoniae. The efficacies of the different diagnostic procedures used in the study were analyzed.ResultsThe prevalence of M. pneumoniae was 31% by culture and 21% by IgM ELISA. Cough (p=0.03, OR 3.8, 95% CI 1–17.8), myalgia (p=0.04, OR 2.5, 95% CI 1–6.6), rales (p=0.04, OR 2.4, 95% CI 1–6.6), and cervical adenopathy (p=0.03, OR 2.7, 95% CI 1–7.1) were the symptoms that significantly corroborated culture positivity. Patients positive for M. pneumoniae by culture or IgM antibody had significantly greater CD4+ T-cell depletion and anemia than those without any evidence of infection.ConclusionsThis study provides the means to diagnose M. pneumoniae infection and information on the prevalence of the pathogen in HIV-infected individuals in resource constrained settings. Although modern molecular techniques may provide more insight into the prevalence of M. pneumoniae in HIV-infected individuals, conventional methods can still be used in diagnosis

On the arrangement of tidal turbines in rough and oscillatory channel flow

Fast tidal streams are a promising source of clean, predictable power, but the task of arranging tidal turbines for maximum power capture is complicated. Actuator disc models, such as the two-scale actuator disc theory, have proven useful in seeking optimal turbine arrangements, yet these models assume flows that are frictionless and steady, and thus quite unlike the channel flow conditions that actual tidal turbines experience. In this paper, we use numerical methods to relax these assumptions and explore how optimal turbine arrangements change as the flow transitions from frictionless and steady to rough and oscillatory. In so doing, we show that, under certain conditions, the assumption of quasi-steady flow in models of tidal turbines may neglect leading-order physics. When the ratio of drag to inertial forces in the unexploited channel is very low, for instance, the optimal turbine arrangements are found to be quite different, and the potential for enhanced power capture is found to be much greater than predicted by two-scale actuator disc theory

A Study on Development of Pediatric Reference Charts

RATIONALE: Pediatric growth pattern differences continue even after controlling for various factors such as nutrition, income distribution, environment, maternal/child health care and availability of health care infrastructures. Therefore it is recommended that every country should use reference height and weight curves based on measurements on their own children. AIM OF THE STUDY: To construct pediatric reference centile charts for weight, height and body mass index using maximum penalized likelihood LMS method for boys and girls separately from ages 6 -12 years. STUDY OBJECTIVES: The Primary outcome measures were; 1. Construction of percentile charts using LMS method, 2. Calculation of Z- score using LMS method. Secondary outcome measures were; 1. Making Weight-for- age centile chart for boys and girls separately. 2. Making Height-for-age centile chart for boys and girls separately. 3. Making weight-for-height centile chart for boys and girls separately. 4. Making Body Mass Index centile chart for boys and girls separately. 5. Calculation of WAZ, WHZ ,HAZ and BMI Z score for boys and girls separately. 6. Comparison of American National Center for Health Statistics/ Center for Disease Control (NCHS/CDC2000/WHO2007) references with locally weighted. 7. Estimation of prevalence of malnutrition, overweight and obesity among Tamil Nadu children. STUDY DESIGN: Population based cross-sectional multi-site (various schools) study design. SETTING: The study was conducted at the Institute of Child Health and Hospital for children, Egmore, Chennai-8. STUDY POPULATION: The study population consisted of 6-12 years children from all social groups and from families of high, moderate and low income. TARGET POPULATION: The target population consisted of 6-12 years children in the selected urban–rural middle schools based on a representative sample of 2520 boys and 2520 girls. SAMPLE SIZE: Sample size was estimated using previous studies prevalence of normal children in the population 48%, with 5% relative precision and 95% of confidence. The calculated sample size was 1665.This was multiplied by 3 (bringing the sample size up to 4995) to allow for design effect due to application of cluster sampling method. For equal distribution of sample in clusters the ultimate sample size required for the study was determined to 5040 children. Tools used: Part I: Socio-demographic data tool, Part II: Anthropometric measurement tool. Outcome variables: 1. Percentile charts. 2. Z- score. 3. Comparison with NCHS/WHO2007/CDC2000 charts. 4. Prevalence of wasted ,stunted, underweight, overweight, obesity. METHODOLOGY: A total of 5040 apparently healthy boys and girls aged 6 to 12 years were recruited using population based cross-sectional multi-site (various schools) study design. Anthropometric measurements were collected as per WHO standards. To construct smoothened percentile reference charts, the lamda-mu-sigma-additional parameter (LMSP) method using Box-Cox power exponential (BCPE) distribution model was adopted. LMSP summarizes the changing distribution with age according to 4 curves representing the median (M), the coefficient of variation (S), skewness (L), and kurtosis (P). BCPE distribution takes the idea of having a range of power transformations (rather than the traditional square root, log, and inverse) available to improve the efficacy of normalizing and variance equalizing for both positively and negatively skewed, and for both leptokurtic-platykurtic variables. Maximum penalized likelihood, the Generalized Additive Models were used. The centile curves of height, weight and BMI were fitted by BCPE (μ, _, _, _ ) models, and the parameters, μ, _, _ and _, were smoothened by cubic smoothing splines. The goodness-of-fit of BCPE models were assessed by worm plot and Q-test. The degrees of freedom, with respect to the parameter curves of μ, _, _ and _ from BCPE distribution, were selected according as the smallest AIC and GAIC(3), and the centile curves were fitted by BCPE distribution. RESULTS: Comparing present study charts with those of NCHS/WHO2007/CDC2000 chart showed significant differences between growth patterns of our children and other populations. Estimated median 50th percentile shows Tamil Nadu children anthropometric measurements are lower than NCHS/WHO2007/CDC2000 standard children. The study revealed that total prevalence of overweight was 10.6% (9.8%- 11.5%) and obesity was 3.0% (2.6%- 3.5%) when considering Body Mass Index of children between 6-12 years. Boys are having more overweight and obese than girls based on CDC2000 reference distributions of Z-scores for BMI. Present study shows prevalence of underweight is 31.7%, stunting is 19.7% and wasting is 24% among 6-12 years children. The boys had a risk of 1.23 (95%CI: 1.09-1.39) times greater to be underweight, 1.05 (95%CI: 0.92- 1.20) times greater to be stunting, and 1.03 (95%CI: 0.88- 1.20) times greater to be wasting than the girls. CONCLUSION: Since there is a secular trend in upward increase both in height and weight, a comparison of growth curves requires both methodological and secular similarity to determine similarity or difference. Local references would then provide a useful tool for health planning and screening inter-population differences. The results of the current study demonstrate the possibility of preparation of local growth charts and their importance in evaluating children's growth. Also their differences, relative to those prepared by global references, reflect the necessity of preparing local charts in future studies using longitudinal data

Original Article - Physical growth and psychomotor development of infants exposed to antiepileptic drugs in utero

Objective: To evaluates the physical growth and psychomotor development of infants born to women with epilepsy on regular Anti Epileptic Drugs (AEDs). Setting: Govt. Stanley Medical College and Hospital, Tertiary care referral centre, Chennai. Design: Open prospective cohort study with a control group. Materials and Methods: Consecutive women with epilepsy who were on regular anticonvulsants were followed up from their first trimester. Their babies were examined at birth and anthropometric measurements including anterior fontanelle size were noted. They were followed up till one year and periodically evaluated at 1st, 6th and 12th month of age. Development testing using Griffith scale was done at 2nd, 6th and 12th month. An equal number of control babies were also studied using the same scale for one year at the specified intervals. The results in both the groups were compared. Results : 30 babies were enrolled in the case and control group. The AEDs received by the mothers with epilepsy were Phenytoin, Carbamazepine, and Sodium valproate. At birth and 1st month the weight, head circumference and length of case and control babies were equal. At 6th and 12th month reduction in the above 3 parameters were noted in the case babies ( P < 0.01). Area of anterior fontanelle (AF) was larger in the study group particularly in those exposed to phenytoin in utero( P < 0.001). In the case babies reduction in the sitting, prone and erect progression of the locomotor scores was observed at 2nd month ( P < 0.001). Prone progression alone improved by 12th month and other two remained less than the control ( P < 0.001). No difference was observed in reaching behaviour and personal/social scores in both groups. Infants exposed to Phenytoin monotherapy had a negative impact on sitting progression. Conclusion : Among infants exposed to AEDs in utero physical growth was equal to that of control at birth but reduced at 6th and 12th month probably due to extraneous factors. The Locomotor scores showed reduction in all areas in 2nd, 6th and 12th month except prone progression which alone improved by 12th month. Phenytoin exposure in utero resulted in large AF and it had a negative impact on sitting progression in comparison with Carbamazepine and Sodium valproate

Original Article - Nonepileptic attack disorder among married women

Aim : To study the clinical features, precipitating stressful life events and prognosis of nonepileptic attack disorder (NEAD) among married women. Design: Prospective cohort study with 1-year follow-up. Setting: A tertiary care teaching hospital. Subjects: Of the 1020 patients with epilepsy referred to the epilepsy clinic during 2002-2003, 30 were married women with NEAD. Materials and Methods: The diagnostic criteria for NEAD included normal EEG during ictal and post-ictal phase of the generalized ′attack.′ The data collected included clinical characteristics, semiology of the attacks, precipitating stressful events, and co-morbid psychiatric disorders. The control group included 30 age-matched married women with generalized tonic-clonic seizures. The long-term outcome and factors influencing the outcomes were analyzed. Results: The mean duration of illness was 18 months, and the pattern of the attack was ′fall and lying still′ in 53% and ′fall with generalized motor movements′ in 47%. The frequency was one or more per week in 57% and occasionally in 43%. The important stressful events were matrimonial discord following illegal relationship of the husband with another woman (χ2 = 9.02, P = 0.003) and constant quarrel with other family members (χ2 = 5.19, P = 0.02). The prevalence of sexual abuse was low (7%). Co-morbid psychiatric disorder was observed in 70%. At the end of 1 year, 39% were free from the attack. Resolution of the stressful life events (χ2 = 4.52, P = 0.03) and lower frequency of attack at the time of reporting (χ2 = 3.88, P = 0.05) correlated with good outcomes. Conclusion : Among patients with NEAD in India, the major precipitating factors were matrimonial discord following illegal relationship of the husband with another woman and constant quarrel with other family members and not sexual abuse. Women with low frequency of attack at the time of reporting and the remission of the stressful events had better outcomes