Initiation of breast-feeding within 1 h after birth has been associated with reduced neonatal mortality in a rural Ghanaian population. In South Asia, however, breast-feeding patterns and low birth weight rates differ and this relationship has not been quantified. Data were collected during a community-based randomized trial of the impact of topical chlorhexidine antisepsis interventions on neonatal mortality and morbidity in southern Nepal. In-home visits were conducted on d 1-4, 6, 8, 10, 12, 14, 21, and 28 to collect longitudinal information on timing of initiation and pattern of breast-feeding. Multivariable regression modeling was used to estimate the association between death and breast-feeding initiation time. Analysis was based on 22,838 breast-fed newborns surviving to 48 h. Within 1 h of birth, 3.4% of infants were breast-fed and 56.6% were breast-fed within 24 h of birth. Partially breast-fed infants (72.6%) were at higher mortality risk [relative risk (RR) = 1.77; 95% CI = 1.32-2.39] than those exclusively breast-fed. There was a trend (P = 0.03) toward higher mortality with increasing delay in breast-feeding initiation. Mortality was higher among late (> or = 24 h) compared with early (< 24 h) initiators (RR = 1.41; 95% CI = 1.08-1.86) after adjustment for low birth weight, preterm birth, and other covariates. Improvements in breast-feeding practices in this setting may reduce neonatal mortality substantially. Approximately 7.7 and 19.1% of all neonatal deaths may be avoided with universal initiation of breast-feeding within the first day or hour of life, respectively. Community-based breast-feeding promotion programs should remain a priority, with renewed emphasis on early initiation in addition to exclusiveness and duration of breast-feeding.

Objective To assess the impact on mortality related to pregnancy of supplementing women of reproductive age each week with a recommended dietary allowance of vitamin A, either preformed or as carotene. Design Double blind, cluster randomised, placebo controlled field trial. Setting Rural southeast central plains of Nepal (Sarlahi district). Subjects 44 646 married women, of whom 20 119 became pregnant 22 189 times. Intervention 270 wards randomised to 3 groups of 90 each for women to receive weekly a single oral supplement of placebo, vitamin A (7000 g retinol equivalents) or carotene (42 mg, or 7000 g retinol equivalents) for over 3 1 ⁄2 years. Main outcome measures All cause mortality in women during pregnancy up to 12 weeks post partum (pregnancy related mortality) and mortality during pregnancy to 6 weeks postpartum, excluding deaths apparently related to injury (maternal mortality). Results Mortality related to pregnancy in the placebo, vitamin A, and carotene groups was 704, 426, and 361 deaths per 100 000 pregnancies, yielding relative risks (95% confidence intervals) of 0.60 (0.37 to 0.97) and 0.51 (0.30 to 0.86). This represented reductions of 40% (P < 0.04) and 49% (P < 0.01) among those who received vitamin A and carotene. Combined, vitamin A or carotene lowered mortality by 44% (0.56 (0.37 to 0.84), P < 0.005) and reduced the maternal mortality ratio from 645 to 385 deaths per 100 000 live births, or by 40% (P < 0.02). Differences in cause of death could not be reliably distinguished between supplemented and placebo groups. Conclusion Supplementation of women with either vitamin A or carotene at recommended dietary amounts during childbearing years can lower mortality related to pregnancy in rural, undernourished populations of south Asia.

Summary Background Influenza immunisation during pregnancy is recommended but not widely implemented in some low-income regions. We assessed the safety and efficacy in mothers and infants of year-round maternal influenza immunisation in Nepal, where influenza viruses circulate throughout the year. Methods In this phase 4, randomised, placebo-controlled trial, we enrolled two consecutive sequential annual cohorts of pregnant women from the Sarlahi district in southern Nepal. We randomised mothers 1:1 to receive seasonally recommended trivalent inactivated influenza vaccine or saline placebo in blocks of eight, stratified by gestational age at enrolment (17–25 weeks vs 26–34 weeks). Women were eligible if they were married, 15–40 years of age, 17–34 weeks’ gestation at enrolment, and had not previously received any influenza vaccine that season. We collected serum samples before and after immunisation, and cord blood from a subset of women and infants. Staff masked to allocation made home visits every week from enrolment to 6 months after delivery. Midnasal swabs for respiratory virus PCR testing were collected during maternal acute febrile respiratory infections, and from infants with any respiratory symptom. We assessed vaccine immunogenicity, safety, and three primary outcomes: the incidence of maternal influenza-like illness in pregnancy and 0–180 days postpartum, the incidence of low birthweight (<2500 g), and the incidence of laboratory-confirmed infant influenza disease from 0 to 180 days. This trial is registered with ClinicalTrials.gov, number NCT01034254. Findings From April 25, 2011, to Sept 9, 2013, we enrolled 3693 women in two cohorts of 2090 (1041 assigned to placebo and 1049 to vaccine) and 1603 (805 assigned to placebo and 798 to vaccine), with 3646 liveborn infants (cohort 1, 999 in placebo group and 1010 in vaccine group; cohort 2, 805 in placebo group and 798 in vaccine group). Immunisation reduced maternal febrile influenza-like illness with an overall efficacy of 19% (95% CI 1 to 34) in the combined cohorts; 9% efficacy (−16 to 29) in the first cohort, and 36% efficacy (9 to 55) in the second cohort. For laboratory-confirmed influenza infections in infants aged 0–6 months, immunisation had an overall efficacy for the combined cohorts of 30% (95% CI 5 to 48); in the first cohort, the efficacy was 16% (−19 to 41), and in the second cohort it was 60% (26 to 88). Maternal immunisation reduced the rates of low birthweight by 15% (95% CI 3–25) in both cohorts combined. The rate of small for gestational age infants was not modified by immunisation. The number of adverse events was similar regardless of immunisation status. Miscarriage occurred in three (0·2%) participants in the placebo group versus five (0·3%) in the vaccine group, stillbirth occurred in 31 (1·7%) versus 33 (1·8%), and congenital defects occurred in 18 (1·0%) versus 20 (1·1%). Five women died in the placebo group and three died in the vaccine group. The number of infant deaths at age 0–6 months was similar in each group (50 in...

ICRONUTRIENT INADequacy is a critical concern among pregnant women and young children throughout the world. Gestation and the early postnatal period are considered sensitive periods for brain development, and nutritional deprivation during this period may lead to functional impairments. Early iron deficiency can alter neuroanatomy, biochemistry, and metabolism, leading to changes in neurophysiologic processes that support cognitive and sensorimotor development. 1,2 It also has an adverse effect on neurogenesis, altering brain morphology in specific regions such as the hippocampus and striatum. 3,4 In addition, the timing of iron availability for myelin production, especially to oligodendrocytes, is critical 5 ; hypomyelination due to iron deficiency persists later in life. 6,7 Iron deficiency also alters neurochemistry, specifically monoamine transmission, reception, and metabolism. 6 Finally, iron is important for energy metabolism in the brain. 2,8 Abnormal cerebral energy metabolism, as measured via loss of cytochrome c oxidase in the hippocampus and frontal cortex 9 and via mag-Author Affiliations are listed at the end of this article.

Recommendations for dry cord care should be reconsidered on the basis of these findings that early antisepsis with chlorhexidine of the umbilical cord reduces local cord infections and overall neonatal mortality.