Acceptability and Reliability of the Bayley Scales of Infant Development III Cognitive and Motor Scales among Children in Makwanpur

BACKGROUND: The Bayley Scales of Infant Development III (BSID III) is an instrument to measure the development of children aged 1-42 months. Our study sought to assess the feasibility and reliability of the BSID III's cognitive and motor sub-scales among children in rural Nepal. METHODS: For this study, translation and back translation in Nepali and English for cognitive and motor sub-scale of BSID III were done. Two testers assessed a total of 102 children aged 1-42 months and were video-recorded and rescored by the third tester. Raw scores were calculated for each assessment. Inter and intra-observer reliability of scores across the three testers was examined. Raw score was converted into scaled score to examine the mean score. The study received ethical clearance from NHRC. RESULTS: A total of 102 children were assessed. The inter-rater reliability of the BSID III among three testers using the Intraclass Correlation Coefficient by age group was 0.997 (95% CI: 0.996-0.998) for the cognitive scale, 0.997 (95% CI: 0.996- 0.998) for the gross motor scale, and 0.998 (95% CI: 0.997- 0.999) for the fine motor scale. All were statistically significant (p< 0.0001). The mean scaled cognitive, fine motor and gross motor development scores in this group of children were 8.3 (SD: 2.5), 8.5 (SD: 2.6) and 9.5 (3.2), respectively. CONCLUSIONS: Assessing the cognitive and motor development of children under five using the BSID III was feasible in Makwanpur district, Nepal. The inter-rater reliability was highly comparable among the three testers

Body composition in Nepalese children using isotope dilution: the production of ethnic-specific calibration equations and an exploration of methodological issues.

Background. Body composition is important as a marker of both current and future health. Bioelectrical impedance (BIA) is a simple and accurate method for estimating body composition, but requires population-specific calibration equations. Objectives. (1) To generate population specific calibration equations to predict lean mass (LM) from BIA in Nepalese children aged 7-9 years. (2) To explore methodological changes that may extend the range and improve accuracy. Methods. BIA measurements were obtained from 102 Nepalese children (52 girls) using the Tanita BC-418. Isotope dilution with deuterium oxide was used to measure total body water and to estimate LM. Prediction equations for estimating LM from BIA data were developed using linear regression, and estimates were compared with those obtained from the Tanita system. We assessed the effects of flexing the arms of children to extend the range of coverage towards lower weights. We also estimated potential error if the number of children included in the study was reduced. Findings. Prediction equations were generated, incorporating height, impedance index, weight and sex as predictors (R (2) 93%). The Tanita system tended to under-estimate LM, with a mean error of 2.2%, but extending up to 25.8%. Flexing the arms to 90° increased the lower weight range, but produced a small error that was not significant when applied to children <16 kg (p 0.42). Reducing the number of children increased the error at the tails of the weight distribution. Conclusions. Population-specific isotope calibration of BIA for Nepalese children has high accuracy. Arm position is important and can be used to extend the range of low weight covered. Smaller samples reduce resource requirements, but leads to large errors at the tails of the weight distribution

Community interventions to reduce child mortality in Dhanusha, Nepal: study protocol for a cluster randomized controlled trial

Background: Neonatal mortality remains high in rural Nepal. Previous work suggests that local women's groups can effect significant improvement through community mobilisation. The possibility of identification and management of newborn infections by community-based workers has also arisen.Methods/Design: The objective of this trial is to evaluate the effects on newborn health of two community-based interventions involving Female Community Health Volunteers.MIRA Dhanusha community groups: a participatory intervention with women's groups. MIRA Dhanusha sepsis management: training of community volunteers in the recognition and management of neonatal sepsis. The study design is a cluster randomized controlled trial involving 60 village development committee clusters allocated 1:1 to two interventions in a factorial design.MIRA Dhanusha community groups: Female Community Health Volunteers (FCHVs) are supported in convening monthly women's groups. Nine groups per cluster (270 in total) work through two action research cycles in which they (i) identify local issues around maternity, newborn health and nutrition, (ii) prioritise key problems, (iii) develop strategies to address them, (iv) implement the strategies, and (v) evaluate their success. Cycle 1 focuses on maternal and newborn health and cycle 2 on nutrition in pregnancy and infancy and associated postpartum care practices. MIRA Dhanusha sepsis management: FCHVs are trained to care for vulnerable newborn infants. They (i) identify local births, (ii) identify low birth weight infants, (iii) identify possible newborn infection, (iv) manage the process of treatment with oral antibiotics and referral to a health facility to receive parenteral gentamicin, and (v) follow up infants and support families.Primary outcome: neonatal mortality rates. Secondary outcomes: MIRA Dhanusha community group: stillbirth, infant and under-two mortality rates, care practices and health care seeking behaviour, maternal diet, breastfeeding and complementary feeding practices, maternal and under-2 anthropometric status. MIRA Dhanusha sepsis management: identification and treatment of neonatal sepsis by community health volunteers, infection-specific neonatal mortality

Sustainability of community-based women’s groups: reflections from a participatory intervention for newborn and maternal health in Nepal

Participatory community-based women’s group interventions have been successful in improving maternal and newborn survival. In rural Makwanpur, Nepal, exposure to these Participatory Learning and Action groups resulted in a thirty-percent reduction in neonatal mortality rate and significantly fewer maternal deaths. It is often theorised that participatory approaches are more likely to be sustained than top-down approaches, but this is rarely evaluated after the withdrawal of external support. We sought to understand how participatory learning and action (PLA) groups in Makwanpur fared after the supporting non-governmental organisation withdrew their support as well as factors affecting their sustainability. We used mixed methods, conducting a cross-sectional survey of 239 groups, thirty focus group discussions with group members and thirty key informant interviews within twelve–seventeen months after support was withdrawn. Eighty percent of groups were still active which suggests that PLA groups have a high chance of being sustained over time. Groups were more likely to be sustained if the group had local importance and members continued to acquire new knowledge. However, the participatory nature of the group and local embeddedness were not enough to sustain all groups. They also needed leadership capacity, a unifying activity such as a fund, and a strong belief in the value of their meeting to sustain. These key factors should be considered when seeking to enable sustainability of participatory interventions

Blood pressure and the capacity-load model in 8-year-old children from Nepal: Testing the contributions of kidney size and intergenerational effects.

OBJECTIVES: Growth patterns in early life are increasingly linked with subsequent cardio-metabolic risk, but the underlying mechanisms require elucidation. We have developed a theoretical model of blood pressure, treating it as a function of homeostatic metabolic capacity, and antagonistic metabolic load. We sought to differentiate prenatal and postnatal components of metabolic capacity, and to identify intergenerational contributions to offspring capacity and load. METHODS: We followed up at 8 years a cohort of children originally recruited into a randomized trial of maternal micronutrient supplementation in pregnancy. Maternal anthropometry was measured at recruitment. Offspring anthropometry was measured at birth, 2 years and 8 years. Offspring blood pressure, kidney size, and body composition were measured at 8 years. Regression analysis was used to investigate potential associations of maternal phenotype, birth phenotype, and current body composition with kidney size and blood pressure. RESULTS: Blood pressure was positively associated with body fat, but negatively associated with birth weight and relative leg length. Kidney size was positively associated with birth weight but not with relative leg length. Adjusting for adiposity, blood pressure was independently negatively associated with birth weight, relative leg length, and kidney length. Maternal height and BMI predicted offspring size at birth and at 8 years, but not blood pressure. CONCLUSIONS: Our data provide support for the capacity-load model of blood pressure in Nepalese children. Fetal and postnatal growth and kidney dimensions all contribute to metabolic capacity. Maternal phenotype contributed to offspring capacity and load, but these associations did not propagate to blood pressure. Am. J. Hum. Biol., 2016. © 2016 The Authors American Journal of Human Biology Published by Wiley Periodicals, Inc

Independent associations of women's age at marriage and first pregnancy with their height in rural lowland Nepal

OBJECTIVES: In many South Asian communities, the majority of women are married during adolescence and reproduce before 20 years. Early reproduction may adversely affect maternal nutrition and linear growth, however whether early marriage has similar effects is unknown. Shorter women might also be preferentially chosen for earlier marriage. We hypothesized that early marriage and early pregnancy may each be associated with women's shorter height, independent of any selection effects. MATERIALS AND METHODS: We analyzed cross-sectional data on 7,146 women aged 20-30 years from rural lowland Nepal. Linear regression models tested associations of early marriage and early reproduction with height, adjusting for women's education and husbands' characteristics (education and wealth) that might index preferential selection of short young women for marriage. RESULTS: Median ages at marriage and first pregnancy were 15 and 18 years, respectively, with 20% pregnant <16 years. Both early marriage and early pregnancy were independently associated with shorter stature, accounting for a decrement of 1.4 cm, which decreased to 1 cm after adjusting for women's education. Effects of early marriage and reproduction persisted after adjusting for the tendency of poorer and less educated men to marry young and short women, indicating a role for social selection. DISCUSSION: The decrements in height associated with early marriage and reproduction are indicative of broader adverse effects on maternal metabolism during a "critical period" of growth and maturation in the life-course of women. Although the magnitudes of effect are relatively small, they affect large numbers of women in this population

Change in cost and affordability of a typical and nutritionally adequate diet among socio-economic groups in rural Nepal after the 2008 food price crisis

Diet quality is an important determinant of nutrition and food security and access can be constrained by changes in food prices and affordability. Poverty, malnutrition, and food insecurity are high in Nepal and may have been aggravated by the 2008 food price crisis. To assess the potential impact of the food price crisis on the affordability of a nutritionally adequate diet in the rural plains of Nepal, data on consumption patterns and local food prices were used to construct typical food baskets, consumed by four different wealth groups in Dhanusha district in 2005 and 2008. A modelled diet designed to meet household requirements for energy and essential nutrients at minimum cost, was also constructed using the ‘Cost of Diet’ linear programming tool, developed by Save the Children. Between 2005 and 2008, the cost of the four typical food baskets increased by 19% – 26% and the cost of the nutritionally adequate modelled diet increased by 28%. Typical food baskets of all wealth groups were low in macro and micronutrients. Income data for the four wealth groups in 2005 and 2008 were used to assess diet affordability. The nutritionally adequate diet was not affordable for poorer households in both 2005 and 2008. Due to an increase in household income levels, the affordability scenario did not deteriorate further in 2008. Poverty constrained access to nutritionally adequate diets for rural households in Dhanusha, even before the 2008 food price crisis. Despite increased income in 2008, households remain financially unable to meet their nutritional requirements

Causes of stillbirths and neonatal deaths in Dhanusha district, Nepal: A verbal autopsy study

Background: Perinatal (stillbirths and first week neonatal deaths) and neonatal (deaths in the first 4 weeks) mortality rates remain high in developing countries like Nepal. As most births and deaths occur in the community, an option to ascertain causes of death is to conduct verbal autopsy. Objective: The objective of this study was to classify and review the causes of stillbirths and neonatal deaths in Dhanusha district, Nepal. Materials and Methods: Births and neonatal deaths were identified prospectively in 60 village development committees of Dhanusha district. Families were interviewed at six weeks after delivery, using a structured questionnaire. Cause of death was assigned independently by two pediatricians according to a predefined algorithm; disagreement was resolved in discussion with a consultant neonatologist. Results: There were 25,982 deliveries in the 2 years from September 2006 to August 2008. Verbal autopsies were available for 601/813 stillbirths and 671/954 neonatal deaths. The perinatal mortality rate was 60 per 1000 births and the neonatal mortality rate 38 per 1000 live births. 84% of stillbirths were fresh and obstetric complications were the leading cause (67%). The three leading causes of neonatal death were birth asphyxia (37%), severe infection (30%) and prematurity or low birth weight (15%). Most infants were delivered at home (65%), 28% by relatives. Half of women received an injection (presumably an oxytocic) during home delivery to augment labour. Description of symptoms commensurate with birth asphyxia was commoner in the group of infants who died (41%) than in the surviving group (14%). Conclusion: The current high rates of stillbirth and neonatal death in Dhanusha suggest that the quality of care provided during pregnancy and delivery remains sub-optimal. The high rates of stillbirth and asphyxial mortality imply that, while efforts to improve hygiene need to continue, intrapartum care is a priority. A second area for consideration is the need to reduce the uncontrolled use of oxytocic for augmentation of labour

Closing the Gaps: From Science to Action in Maternal, Newborn, and Child Health in Africa

As part of a series on maternal, neonatal, and child health in sub-Saharan Africa, Sara Bennett and Freddie Ssengooba discuss the challenges of getting science into policy in Africa