Water, sanitation and hygiene (WASH) interventions: effects on child development in low-and middle-income countries.

The majority of serum phenytoin concentrations were in the therapeutic range. Estimating weight in children for the 20 mg/kg intravenous loading dose of phenytoin is often clinically necessary but inaccurate, resulting in up to 138% of the expected and recommended dose in this cohort.

The indirect effects of COVID-19 on children's education, health, and well-being due to school closures have raised concerns, particularly in low-and middle-income countries (LMICs) (Armitage &

Introduction: School-age health, growth and development are poorly characterised in low- and middle-income countries. We developed the School-Age Health, Activity, Resilience, Anthropometry and Neurocognitive (SAHARAN) toolbox to measure growth, cognitive and physical function in rural Zimbabwe. Methods: The SAHARAN toolbox was developed using a stepwise approach, with tool selection based on COSMIN principles. Growth was measured with anthropometry, skinfold thicknesses and bioimpedance analysis to obtain lean mass index (LMI) and phase angle. Cognition was assessed using a fine motor finger tapping task, school achievement test (SAT), and the Kaufmann Assessment Battery for Children (KABC-2) to determine the mental processing index (MPI). Physical function combined grip strength, broad jump and the 20m shuttle run test to produce a total physical score (TPS). A detailed caregiver questionnaire was performed in parallel. Results: 80 Zimbabwean children with mean (SD) age 7.6 (0.2) years had mean height-for-age (HAZ) and weight-for-age Z-scores (WAZ) of -0.63 (0.81) and -0.55 (0.85), respectively. For growth measures, LMI and total skinfold thicknesses were highly related to both WAZ and BMI Z-score, but not to HAZ. For physical function, TPS was associated with unit rises in HAZ (1.29, 95%CI 0.75,1.82, p<0.001), and LMI (0.50, 95%CI 0.16,0.83, p=0.004), but not skinfold thicknesses. For cognition, the SAT was highly associated with unit increases in the MPI (0.9 marks, 95%CI 0.4,1.3, p<0.001) and a child socioemotional questionnaire (8.2 marks, 95%CI 2.9,13.5, p=0.003). Phase angle was associated with 3.5 seconds quicker time to complete the finger tapping task (95%CI 0.6,6.4, p=0.02). No child outcomes were associated with socioeconomic status, nurturing, discipline, food and water insecurity, or household adversity. Conclusions: We found clear associations between growth, height-adjusted lean mass and physical function, but not cognitive function, in a cohort of Zimbabwean children. The SAHARAN toolbox could be deployed to characterise school-age growth, development and function in sub-Saharan Africa.

HIV and severe wasting are associated with post-discharge mortality and hospital readmission among children with complicated severe acute malnutrition (SAM); however, the reasons remain unclear. We assessed body composition at hospital discharge, stratified by HIV and oedema status, in a cohort of children with complicated SAM in three hospitals in Zambia and Zimbabwe. We measured skinfold thicknesses and bioelectrical impedance analysis (BIA) to investigate whether fat and lean mass were independent predictors of time to death or readmission. Cox proportional hazards models were used to estimate the association between death/readmission and discharge body composition. Mixed effects models were fitted to compare longitudinal changes in body composition over one year. At discharge, 284 and 546 children had complete BIA and skinfold measurements, respectively. Low discharge lean and peripheral fat mass were independently associated with death/hospital readmission. Each unit z-score increase in impedance index and triceps skinfolds was associated with 48% (aHR 0.52, 95%CI 0.30,0.90) and 17% (aHR 0.83, 95%CI 0.71, 0.96) lower hazard of death/readmission respectively. HIV-positive versus HIV-negative children had lower gains in sum of skinfolds (mean difference -1.49, 95%CI -2.01, -0.97) and impedance index z-scores (-0.13, 95%CI -0.24, -0.01) over 52 weeks. Children with non-oedematous versus oedematous SAM had lower mean changes in sum of skinfolds (-1.47, 95%CI -1.97, -0.97) and impedance index z-scores (-0.23, 95%CI -0.36, -0.09). Risk stratification to identify children at risk for mortality or readmission, and interventions to increase lean and peripheral fat mass, should be considered in the post-discharge care of these children.

Interest in measuring cognition in children in low-resourced settings has increased in recent years, but options for cognitive assessments are limited. Researchers are faced with challenges when using existing assessments in these settings, such as trained workforce shortages, less relevant testing stimuli, limitations of proprietary assessments, and inadequate parental knowledge of cognitive milestones. Tablet-based direct child assessments are emerging as a practical solution to these challenges, but evidence of their validity and utility in cross-cultural settings is limited. In this overview, we introduce key concepts of this field while exploring the current landscape of tablet-based assessments for low-resourced settings. We also make recommendations for future directions of this relatively novel field. We conclude that tablet-based assessments are an emerging and promising method of assessing cognition in young children. Further awareness and dissemination of validated tablet-based assessments may increase capacity for child development research and clinical practice in low-resourced settings.

For children with acute malnutrition, ready-to-use therapeutic foods (RUTF) are lifesaving treatments. In 2012, detailed testing detected Enterobacteriaceae including Cronobacter species at low levels in RUTF from all UNICEF-approved producers. Cronobacter in milk feeds has previously been associated with severe neonatal infections. Thus, given the susceptibility of severely malnourished children to invasive bacterial infections, concerns arose about the potential for Cronobacter infections from RUTF. This led to widespread production and supply problems in emergency feeding programmes. The KEMRI/Wellcome Trust Research Programme has conducted systematic surveillance for invasive bacterial infections among children admitted to Kilifi County Hospital, Kenya since 1998. 65,426 paediatric blood and cerebrospinal fluid cultures from 52,733 admissions resulted in 3953 with growth of a pathogenic organism. From the 60 Enterobacter and Cronobacter isolates, possible Cronobacter species were initially selected from their original API-20E biochemical profile, which was repeated and then confirmed using ID-32E. Only two isolates were consistent with Cronobacter species, neither case had received RUTF. Serious infection due to Cronobacter species does not have a significant burden in this population. This has important implications for the continued supply, manufacture and monitoring of emergency feeds for malnourished children.

Background: Neurodevelopment assessment tools for low-resource settings are urgently needed. However, most available tools were developed in high-income settings and may lack cross-cultural validity. Methods: We piloted and adapted two subtests (pattern reasoning and story completion) within the Kaufman Assessment Battery for Children-2nd edition (KABC-II) for use in rural Zimbabwean children aged 7 years old, both within the planning domain. After initial assessments of face validity, we substituted and added items in the test battery through a co-design process with fieldworkers and child development experts. To assess how successful the changes were, T-tests adjusting for unequal variances were used to compare scores between the original and adapted versions of the same subtest. ANOVA and pairwise analysis was performed to compare the performance of KABC-II subtests across domains. Intraclass correlation coefficient was calculated to explore the variability between domains. Results: Initial test scores on the planning domain were significantly lower than the other three domains of learning, sequential memory and simultaneous reasoning (P<0.001) in 50 children. Modified subtests were administered to another 20 children, who showed story completion scores that were 0.7 marks higher (95% CI 0.0, 1.4; P=0.05) and pattern reasoning scores 1.8 marks higher (95% CI 0.5, 3.2; P=0.01). Overall, the planning domain mean score increased from 8.1 (SD 2.9) to 10.6 (SD 3.4). The intra class correlation coefficient between all four KABC-II domains was initially 0.43 (95% CI 0.13, 0.64) and after modification was 0.69 (95% CI 0.37, 0.87), suggesting an increase in the construct validity. Conclusions: The KABC-II planning domain was successfully adapted to improve cross-cultural validity. Construct validity was enhanced, based on increased inter-correlations among scales. This pilot has since been applied to the SHINE follow-up study. The process of co-design to modify tests for new settings may be beneficial for other commonly used neurodevelopmental tools.