Risk Factors Associated with Malnutrition in One-Year-Old Children Living in the Peruvian Amazon

Background: Children under two years of age are in the most critical window for growth and development. As mobility increases, this time period also coincides with first exposure to soil-transmitted helminth (STH) infections in tropical and sub-tropical environments. The association between malnutrition and STH infection, however, has been understudied in this vulnerable age group. Methodology/Principal Findings A nested cross-sectional survey was conducted in 12 and 13-month old children participating in a deworming trial in Iquitos, an STH-endemic area of the Peruvian Amazon. An extensive socio-demo-epi questionnaire was administered to the child's parent. Length and weight were measured, and the Bayley Scales of Infant and Toddler Development were administered to measure cognition, language, and fine motor development. Stool specimens were collected to determine the presence of STH. The association between malnutrition (i.e. stunting and underweight) and STH infection, and other child, maternal, and household characteristics, was analyzed using multivariable Poisson regression. A total of 1760 children were recruited between September 2011 and June 2012. Baseline data showed a prevalence of stunting and underweight of 24.2% and 8.6%, respectively. In a subgroup of 880 randomly-allocated children whose specimens were analyzed by the Kato-Katz method, the prevalence of any STH infection was 14.5%. Risk factors for stunting in these 880 children included infection with at least one STH species (aRR = 1.37; 95% CI 1.01, 1.86) and a lower development score (aRR = 0.97; 95% CI: 0.95, 0.99). A lower development score was also a significant risk factor for underweight (aRR = 0.92; 95% CI: 0.89, 0.95). Conclusions: The high prevalence of malnutrition, particularly stunting, and its association with STH infection and lower developmental attainment in early preschool-age children is of concern. Emphasis should be placed on determining the most cost-effective, integrated interventions to reduce disease and malnutrition burdens in this vulnerable age group

A double-blind randomized controlled trial of maternal postpartum deworming to improve infant weight gain in the Peruvian Amazon

Background : Nutritional interventions targeting the critical growth and development period before two years of age can have the greatest impact on health trajectories over the life course. Compelling evidence has demonstrated that interventions investing in maternal health in the first 1000 days of life are beneficial for both mothers and their children. One such potential intervention is deworming integrated into maternal postpartum care in areas where soil-transmitted helminth (STH) infections are endemic. Methodology/Principal Findings : From February to August 2014, 1010 mother-infant pairs were recruited into a trial aimed at assessing the effectiveness of maternal postpartum deworming on infant and maternal health outcomes. Following delivery, mothers were randomly assigned to receive either single-dose 400 mg albendazole or placebo. Participants were followed-up at 1 and 6 months postpartum. There was no statistically significant difference in mean weight gain between infants in the experimental and control groups (mean difference: -0.02; 95% CI: -0.1, 0.08) at 6 months of age. Further, deworming had no effect on measured infant morbidity indicators. However, ad hoc analyses restricted to mothers who tested positive for STHs at baseline suggest that infants of mothers in the experimental group had greater mean length gain in cm (mean difference: 0.8; 95% CI: 0.1, 1.4) and length-for-age z-score (mean difference: 0.5; 95% CI: 0.2, 0.8) at 6 months of age. Conclusions/Significance : In a study population composed of both STH-infected and uninfected mothers, maternal postpartum deworming was insufficient to impact infant growth and morbidity indicators up to 6 months postpartum. Among STH-infected mothers, however, important improvements in infant length gain and length-for-age were observed. The benefits of maternal postpartum deworming should be further investigated in study populations having higher overall prevalences and intensities of STH infections and, in particular, where whipworm and hookworm infections are of public health concern

Maternal Deworming Research Study (MADRES) protocol: a double-blind, placebo-controlled randomised trial to determine the effectiveness of deworming in the immediate postpartum period

Introduction: Soil-transmitted helminth infections are endemic in 114 countries worldwide, and cause the highest burden of disease among all neglected tropical diseases. The WHO includes women of reproductive age as a high-risk group for infection. The primary consequence of infection in this population is anaemia. During lactation, anaemia may contribute to reduced quality and quantity of milk, decreasing the duration of exclusive breastfeeding and lowering the age at weaning. To date, no study has investigated the effects of maternal postpartum deworming on infant or maternal health outcomes. Methods and analysis: A single-centre, parallel, double-blind, randomised, placebo-controlled trial will be carried out in Iquitos, Peru, to assess the effectiveness of integrating single-dose 400 mg albendazole into routine maternal postpartum care. A total of 1010 mother-infant pairs will be randomised to either the intervention or control arm, following inhospital delivery and prior to discharge. Participants will be visited in their homes at 1, 6, 12 and 24 months following delivery for outcome ascertainment. The primary outcome is infant mean weight gain between birth and 6 months of age. Secondary outcomes include other infant growth indicators and morbidity, maternal soil-transmitted helminth infection and intensity, anaemia, fatigue, and breastfeeding practices. All statistical analyses will be performed on an intention-to-treat basis. Ethics and dissemination: Research ethics board approval has been obtained from the McGill University Health Centre (Canada), the Asociacion Civil Impacta Salud y Educacion (Peru) and the Instituto Nacional de Salud (Peru). A data safety and monitoring committee is in place to oversee study progression and evaluate adverse events. The results of the analyses will be published in peer-reviewed journals, and presented at national and international conferences

Mejora en el diagnóstico y tratamiento oportuno de la malaria con el uso de pruebas rápidas por promotores de salud en la Amazonía peruana.

Objectives. To compare the achievement of a timely diagnosis and appropriate therapy for malaria before and after the incorporation of rapid tests for diagnosing this disease used by health promoters in peripheral communities in Iquitos. Material and methods. A longitudinal study with pre- and post- intervention assessments was performed. Two hundred febrile patients (suspected malaria cases) seen by health promoters during the last 6 weeks were selected, and data related to a timely malaria diagnosis and therapy, as well as confirmatory diagnoses using thick smears was collected. Results. There was a significant decrease in the time elapsed from symptom onset to therapy initiation with the intervention, from 110 hours (4.6 days) to 46,3 hours (1.9 days) (p0.001). This variation was mainly due to a reduction of the time since the patient was first seen by a health promoter until the time when a diagnosis was achieved, from 69 hours (2.9 days) to only 20 minutes (p0.001). There was also a significant increase in the frequency of malaria patients who received timely antimalarial therapy, from 1,5% to 54,9% (p0.001); the proportion of malaria patients receiving appropriate therapy according to the parasite species increased from 26.7% to 83.5% (p0.001), and the proportion of P. falciparum malaria patients who received appropriate therapy rose from 5.3% to 73.1% (p0.001). Conclusions. Now it is possible to achieve a timely diagnosis and appropriate therapy for malaria with the use of rapid tests by health promoters in these selected communities.Objetivos. Comparar la oportunidad en el diagnóstico y tratamiento apropiado de la malaria antes y después de la incorporación del uso de pruebas rápidas por promotores de salud en comunidades periféricas de Iquitos. Material y métodos. Estudio longitudinal con evaluación pre y postintervención. En ambas evaluaciones se recolectó un número mínimo de 200 pacientes febriles (casos sospechosos de malaria) que habían sido atendidos por el promotor en las seis semanas previas, datos relacionados a la oportunidad en el diagnóstico y tratamiento, y los diagnósticos confirmatorios por gota gruesa. Resultados. Con la intervención hubo una disminución significativa del tiempo transcurrido entre el inicio de síntomas y el inicio del tratamiento de 110 horas (4,6 días) a 46,3 horas (1,9 días) (p0,001). Dicha variación fue debida mayormente a la reducción del tiempo transcurrido desde la consulta al promotor hasta la obtención del diagnóstico del paciente, de 69 horas (2,9 días) a sólo 20 minutos (p0,001). Además, hubo un incremento significativo de la proporción de pacientes con malaria que recibieron tratamiento antimalárico oportuno de 15,5 a 54,9% (p0,001), la proporción de pacientes con malaria que recibieron tratamiento apropiado a la especie del parásito de 26,7% a 83,5% (p0,001) y la proporción de pacientes con malaria falciparum que recibieron tratamiento apropiado de 5,3 a 73,1%(p0,001). Conclusiones. A través de la incorporación del uso de pruebas rápidas por promotores de salud en las comunidades seleccionadas, se ha mejorado la oportunidad en el diagnóstico y tratamiento apropiado de la malaria

The effect of deworming on early childhood development in Peru: A randomized controlled trial

Background: There is a knowledge gap on the effect of early childhood deworming on development in low- and middle-income countries. This evidence is important in the critical window of growth and development before two years of age. Methods: A randomized controlled trial of the benefit, and optimal timing and frequency, of deworming on development was conducted in Iquitos, Peru. Children were enrolled during routine 12-month growth and development visits and randomly allocated to: (1) deworming at the 12-month visit and placebo at the 18-month visit; (2) placebo at the 12-month visit and deworming at the 18-month visit; (3) deworming at the 12 and 18-month visits; or (4) placebo at the 12 and 18-month visits. The Bayley Scales of Infant Development III was used to assess cognitive, language and motor skills at the 12 and 24-month visits. One-way ANOVA analyses used an intention-to-treat approach. Results: Between September 2011 and June 2012, 1760 children were enrolled. Attendance at the 24-month visit was 88.8% (n=1563). Raw scores on all subtests increased over 12 months; however, cognitive and expressive language scaled scores decreased. There was no statistically significant benefit of deworming, or effect of timing or frequency, on any of the development scores. Baseline height and weight and maternal education were associated with development scores at 24 months. Conclusions: After 12 months of follow-up, an overall benefit of deworming on cognition, language or fine motor development was not detected. Additional integrated child and maternal interventions should be considered to prevent developmental deficits in this critical period

Risk factors for stunting and underweight in 12 and 13-month old children in Iquitos, Peru, September 2011 to June 2012 (n = 796^*).

<p>*The analysis was restricted to the 880 children whose stool specimens were analyzed by the Kato-Katz method. The adjusted models include a sample size of 796 due to 84 missing responses on birth weight.</p><p>**Reference group includes mild or no stunting (i.e. LAZ≥−2 SD) and mild or no underweight (i.e. WAZ≥−2 SD).</p><p>***RR = risk ratio: Crude results include variables with a p level<0.20 for model-building purposes.</p>‡1<p>RR for stunting adjusted for any STH infection, sex, age, birth weight, any hospitalizations since birth, development score and socioeconomic status;</p>2<p>RR for underweight adjusted for any STH infection, birth weight, continued breastfeeding, development score and socioeconomic status.</p>‡<p>NS = not statistically significant.</p>†<p>Up-to-date vaccinations include those scheduled between birth and 11 months of age (i.e. one dose of Bacille Calmette-Guérin (BCG), one dose of hepatitis B, three doses of polio, three doses of pentavalent, two doses of rotavirus, and two doses of pneumococcal vaccines).</p>§<p>Mean development score is the combined sum of the raw scores of each individual subtest of the Bayley-III.</p>∥<p>SES = socioeconomic status (lowest quartile = lowest SES; highest quartile = highest SES).</p><p>Risk factors for stunting and underweight in 12 and 13-month old children in Iquitos, Peru, September 2011 to June 2012 (n = 796^{<a href="http://www.plosntds.org/article/info:doi/10.1371/journal.pntd.0003369#nt113" target="_blank">*</a>}).</p