Personalized Medicine in Pediatrics: The Clinical Potential of Orodispersible Films

Children frequently receive medicines that are designed for adults. The dose of commercially available products is adapted, mostly based on the child’s bodyweight, thereby neglecting differences in pharmacokinetic and pharmacodynamics parameters. If commercial products are unsuitable for administration to children or are unavailable, extemporaneous pharmacy preparations are a good alternative. For this particular population, orodispersible films (ODFs) can be a highly attractive dosage form for the oral administration of drugs. ODFs are relatively easy to prepare in a hospital setting, create dose flexibility, and may suit an individual approach, especially for patients having difficulties in swallowing tablets or being fluid restricted. In this article, various aspects related to pharmacy preparations, clinical application, and preparation of ODFs for pediatric patients are highlighted and discussed.     

Birth spacing,breastfeeding, and early child mortality in a traditional Indian society: A hazards model analysis

Abstract

There are few studies of the interrelationships among breastfeeding, child spacing, and child mortality in traditional societies that incorporate extensive controls for social and demographic characteristics of the mother and child. In this paper, we investigate the impact of breastfeeding and the length of the preceding birth interval on early child mortality (defined as a death in the first two years of life) using data from a traditional society of India. Multivariate hazards models are used to analyze the data. Most prior analyses related the impact of breastfeeding duration to the duration of child survivability by taking breastfeeding as a fixed covariate. The present study has a methodological focus in the sense that breastfeeding information from retrospective survey data is treated as a time‐dependent covariate both as a status variate as well as a duration—with empirical findings compared across the two specifications. The effects of postpartum amenorrhoea and various other demographic and socioeconomic characteristics of mother and child are also studied. The results suggest that breastfeeding duration has a strong impact in reducing the relative risk of early child mortality; but it does not explain the effect of the length of the preceding birth interval on early child mortality.     

Household food group expenditure patterns are associated with child anthropometry at ages 5, 8 and 12 years in Ethiopia,India, Peru and Vietnam

Population-level analysis of dietary influences on nutritional status is challenging in part due to limitations in dietary intake data. Household expenditure surveys, covering recent household expenditures and including key food groups, are routinely conducted in low- and middle-income countries. These data may help identify patterns of food expenditure that relate to child growth.ObjectivesWe investigated the relationship between household food expenditures and child growth using factor analysis.MethodsWe used data on 6993 children from Ethiopia, India, Peru and Vietnam at ages 5, 8 and 12y from the Young Lives cohort. We compared associations between household food expenditures and child growth (height-for-age z scores, HAZ; body mass index-for-age z scores, BMI-Z) using total household food expenditures and the “household food group expenditure index” (HFGEI) extracted from household expenditures with factor analysis on the seven food groups in the child dietary diversity scale, controlling for total food expenditures, child dietary diversity, data collection round, rural/urban residence and child sex. We used the HFGEI to capture households’ allocations of their finances across food groups in the context of local food pricing, availability and pReferencesResultsThe HFGEI was associated with significant increases in child HAZ in Ethiopia (0.07), India (0.14), and Vietnam (0.07) after adjusting for all control variables. Total food expenditures remained significantly associated with increases in BMI-Z for India (0.15), Peru (0.11) and Vietnam (0.06) after adjusting for study round, HFGEI, dietary diversity, rural residence, and whether the child was female. Dietary diversity was inversely associated with BMI-Z in India and Peru. Mean dietary diversity increased from age 5y to 8y and decreased from age 8y to 12y in all countries.ConclusionHousehold food expenditure data provide insights into household food purchasing patterns that significantly predict HAZ and BMI-Z. Including food expenditure patterns data in analyses may yield important information about child nutritional status and linear growth.     

Use of Antibiotics in Pediatrics: 8-Years Survey in Italian Hospitals

Objectives

To evaluate antibiotic consumption in the pediatric wards of Emilia-Romagna Region, from 2004 to 2011, with a focus on the antibiotics reserved to the most serious infections, and to analyse the ADRs reported for antibiotics by the pediatric wards of Emilia-Romagna hospitals.

Methods

Reference population was represented by all the patients (0–14 years old) admitted to the pediatric wards of all the hospitals of Emilia-Romagna Region. Drug consumption was expressed as number of DDDs per 100 Bed-Days (BD) and data were analysed by active substance, by therapeutic subgroups or by ward type. The time trends of antibiotic consumption were statistically analysed by linear regression. All the suspected ADR reports associated with antibiotics, reported between January 2004 and December 2011 were drawn by the Italian Spontaneous Reporting Database.

Results

Overall antibiotic consumption showed only a slight increase (p = 0.224). Among the pediatric wards, pediatric surgery showed the highest increase from 2004 to 2011 (p = 0.011). Penicillins and β-lactamase inhibitors was the first therapeutic group with a statistically significant increase over years (p = 0.038), whereas penicillins with extended spectrum presented a statistically significant reduction (p = 0.008). Moreover, only 5 drugs out of the 8 antibiotics reserved to the most serious infections were used. Pharmacovigilance data showed 27 spontaneous ADR reports associated to ATC J01 drugs. Amoxicillin/clavulanic acid had the highest number of ADR reports (n = 7).

Conclusions

The steadily increasing consumption in penicillins and β-lactamase inhibitors, in association with a considerable decrease of plain penicillins, raises a serious concern. Pharmacovigilance reports seem to suggest a safe use of antibiotics in the hospital setting of Emilia-Romagna. Further studies to investigate the reason for prescribing antibiotics in children inpatients are needed.     

Grandpaternal care and child survival in a pastoralist society in western China

Human parents require significant support to raise multiple, highly dependent offspring. Grandmothers are often highlighted as key allomothers (non-maternal caregivers) and their presence is frequently associated with increased child survivorship, leading some to describe humans as cooperative breeders. Equally well documented is the diversity of human childcare systems, where a wide range of individuals support parents including male kin. However, the role of grandfathers has been less well documented, and they seem to have an inconsistent relationship with child survivorship, dependent on socio-ecological factors. Here, we explore the relationship between grandparental allomothering and child survivorship using demographic and time budget data from a pastoralists community in western China. We find that under-five mortality is negatively associated with grandpaternal, but not grandmaternal, living status. Pastoralists in Maqu have recently transitioned from mobile to half-settled livelihoods in which women are more economically active than males. As a result, women's childcare workloads have decreased, while older men (who are excluded from the household economy) supervise children. Our results suggest that patterns of childcare are flexible and highlight the need to consider social and ecological factors to understand allomothering and child survival.     

Helpful grandmothers in rural Ethiopia: A study of the effect of kin on child survival and growth

Kin selection and parental investment theories state that, in highly social species, such as humans, individuals can increase their inclusive fitness by extending support to their relatives. Here, we document patterns of kin support in a rural Ethiopian community, where postmarital residence practices provide differential access to relatives. Using demographic, anthropometric, and behavioral data collected from four villages we are able to (a) identify the effects of the presence of kin on child mortality and growth patterns and (b) provide detailed information on the role of relatives within the household.

Mortality analyses indicate that grandmothers had a positive effect on child survival. Anthropometric data reveal that maternal grandmothers had a particularly beneficial effect on child height, but paternal grandmothers less so. Time allocation data suggest that grandmothers continued to visit their daughters' households, irrespective of postmarital residence, where they relieved their daughters of heavy domestic tasks rather than helping with direct grandchild care. Matrilocal postmarital residence was associated with improved child survival, although children in matrilocal households were actually smaller. This may be due to wealth effects, increased competition between siblings, or higher survival of smaller infants in matrilocal households.     

The impact of unwaged domestic work on the duration and timing of sleep of female nurses working full-time on rotating 3-shift rosters

The study examined the impact of family type on the timing and duration of sleep of 16 experienced female shiftworkers working a rotating 3-shift roster. The nurses lived in one of three domestic lifestyle arrangements: single with no child care responsibilities (N = 4), partnered with no child care responsibilities (N = 5) and partnered with child care responsibilities (N = 7). Self report sleep diaries were used to collect data over a period of 28 days, following which each nurse took part in a conversational interview. Comparisons of the roster mean sleep durations between groups show that nurses who do not have the added unwaged workload of child care, record significantly more sleep than nurses with such responsibilities. Analysis of the data by shift type shows a significant difference for afternoon shift: nurses with child care responsibilities record a significantly earlier rise time and a significantly shorter total sleep duration. The interview data further highlights how sleep patterns are related to the time constraints of both domestic and waged work.     

Effects of drought on child health in Marsabit District,Northern Kenya

This study uses five years of panel data (2009–2013) for Northern Kenya’s Marsabit district to analyze the levels and extent of malnutrition among children aged five and under in that area. We measure drought based on the standardized normalized difference vegetation index (NDVI) and assess its effect on child health using mid-upper arm circumference (MUAC). The results show that approximately 20 percent of the children in the study area are malnourished and a one standard deviation increase in NDVI z-score decreases the probability of child malnourishment by 12–16 percent. These findings suggest that remote sensing data can be usefully applied to develop and evaluate new interventions to reduce drought effects on child malnutrition, including better coping strategies and improved targeting of food aid.     

Infant and child mortality in India in the last two decades: a geospatial analysis

BACKGROUND: Studies examining the intricate interplay between poverty, female literacy, child malnutrition, and child mortality are rare in demographic literature. Given the recent focus on Millennium Development Goals 4 (child survival) and 5 (maternal health), we explored whether the geographic regions that were underprivileged in terms of wealth, female literacy, child nutrition, or safe delivery were also grappling with the elevated risk of child mortality; whether there were any spatial outliers; whether these relationships have undergone any significant change over historical time periods. METHODOLOGY: The present paper attempted to investigate these critical questions using data from household surveys like NFHS 1992-1993, NFHS 1998-1999 and DLHS 2002-2004. For the first time, we employed geo-spatial techniques like Moran's-I, univariate LISA, bivariate LISA, spatial error regression, and spatiotemporal regression to address the research problem. For carrying out the geospatial analysis, we classified India into 76 natural regions based on the agro-climatic scheme proposed by Bhat and Zavier (1999) following the Census of India Study and all estimates were generated for each of the geographic regions. RESULT/CONCLUSIONS: This study brings out the stark intra-state and inter-regional disparities in infant and under-five mortality in India over the past two decades. It further reveals, for the first time, that geographic regions that were underprivileged in child nutrition or wealth or female literacy were also likely to be disadvantaged in terms of infant and child survival irrespective of the state to which they belong. While the role of economic status in explaining child malnutrition and child survival has weakened, the effect of mother's education has actually become stronger over time.     

Demography and childcare in preindustrial societies

The preliminary comparison of hunter gatherers, horticulturalists, and pastoralists is based on 57 preindustrial populations with demographic and child care data out of a potential of 1264 documented cultures from the Ethnographic Atlas. The purpose of this effort is to demonstrate that the demographic characteristics of a population influence its child care practices and provides clues to understanding child care patterns. Traditional practices and provides clues to understanding child care patterns. Traditional practices including multiple caregiving, multistage play groups, and parents or siblings as cultural transmitters are reviewed in a demographic context. Other emerging practices are also discussed: the role of stepparents and differential parental investment in sons and daughters. Anthropological data published and unpublished included only those using standardized methods on total fertility, infant or child mortality, and/or sex/age distribution. Problems with the data set include limited cultural representation, small study sizes, limited time trends, and reliability. There is a concentration on the ]Kung San, Efe, Aka, Gidjingali, Yanomamo, Dusan, Semai, and Kipsigis. Only 7 of the 57 are outside the tropics. Foragers are farmers are primarily represented, because the pastoralists are primarily East African and smaller samples. Tables provide cultural specific data on total fertility rates (TRF), infant and child mortality, and sex ratios at birth and among the juvenile and adult population. Sections are devoted to methods, general patterns, traditional characteristics of childcare based on 5 hypotheses, and emergent trends with 2 more hypotheses on stepparenting and male preference. 2 patterns prevail: 1) hunter gatherers and horticulturalists/pastoralists show great intercultural variability in fertility and mortality rates, and 2) the ranges and means of both groups are very similiar. In the discussion of specific cultures, the hypothesis is proposed and then examples are drawn from the 57 studies to provide support or rejection of the hypothesis. The 1st postulated that the level of multiple care increases with the number of adult women without children increasing. The 2nd hypothesis is that the greater the density or compactness of the settlement, the greater the level of multiple care. It is reasoned in the 3rd that fertility and mortality patterns influence the nature of indulgent care of infants. The 4th hypothesis is that sex and age distributions and compactness of the camp influence the nature of the play ground and type of supervision. The 5th is that father involvement will be greater in societies with low population densities or isolated. The 6th is that a child rarely stays with natural parents throughout the dependency period. The 7th is that male biased juvenile sex ratios will exist in societies where the cost of raising males is or = that of raising families, or where males contribute more calories to the diet, or where male mortality is high.     

Helicobacter pylori Infection in Pediatrics

This review summarizes the articles published on Helicobacter pylori infection in children between April 2008 and March 2009. Recent evidence highlights the decreasing prevalence trend of H. pylori infection and supports both intrafamilial and extrafamilial transmission. The association with various symptoms is still being debated. Interestingly, H. pylori infection seems inversely associated with allergic diseases. Monoclonal stool antigen tests are widely used and accurate for the diagnosis of H. pylori infection, but less accurate in young children. The new biprobe real-time PCR assay applied to stools showed a poor sensitivity in children. Using the urea hydrolysis rate next to the delta over baseline values, the ¹³C-urea breath test provides excellent results for all age children, even for young children. Treatment of H. pylori infection remains a challenge, considering suboptimal efficacy of current therapy. Among emerging alternatives, sequential treatment appears promising. The adjunction of probiotics to conventional regimens, although eliciting great interest, has shown limited therapeutic benefit.     

Cost Effectiveness of Seasonal Intermittent Preventive Treatment Using Amodiaquine & Artesunate or Sulphadoxine-Pyrimethamine in Ghanaian Children

Background

Intermittent preventive treatment for malaria in children (IPTc) involves the administration of a full course of an anti-malarial treatment to children under 5 years old at specified time points regardless of whether or not they are known to be infected, in areas where malaria transmission is seasonal. It is important to determine the costs associated with IPTc delivery via community based volunteers and also the potential savings to health care providers and caretakers due to malaria episodes averted as a consequence of IPTc.

Methods

Two thousand four hundred and fifty-one children aged 3–59 months were randomly allocated to four groups to receive: three days of artesunate plus amodiaquine (AS+AQ) monthly, three days of AS+AQ bimonthly, one dose of sulphadoxine-pyrimethamine (SP) bi-monthly or placebo. This paper focuses on incremental cost effectiveness ratios (ICERs) of the three IPTc drug regimens as delivered by community based volunteers (CBV) in Hohoe, Ghana compared to current practice, i.e. case management in the absence of IPTc. Financial and economic costs from the publicly funded health system perspective are presented. Treatment costs borne by patients and their caretakers are also estimated to present societal costs. The costs and effects of IPTc during the intervention period were considered with and without a one year follow up. Probabilistic sensitivity analysis was undertaken to account for uncertainty.

Results

Economic costs per child receiving at least the first dose of each course of IPTc show SP bimonthly, at US$8.19, is the cheapest to deliver, followed by AS+AQ bimonthly at US$10.67 and then by AS+AQ monthly at US$14.79. Training, drug delivery and supervision accounted for approximately 20–30% each of total unit costs. During the intervention period AS & AQ monthly was the most cost effective IPTc drug regimen at US$67.77 (61.71–74.75, CI 95%) per malaria case averted based on intervention costs only, US$64.93 (58.92–71.92, CI 95%) per malaria case averted once the provider cost savings are included and US$61.00 (54.98, 67.99, CI 95%) when direct household cost savings are also taken into account. SP bimonthly was US$105.35 (75.01–157.31, CI 95%) and AS & AQ bimonthly US$211.80 (127.05–399.14, CI 95%) per malaria case averted based on intervention costs only. The incidence of malaria in the post intervention period was higher in children who were <1 year old when they received AS+AQ monthly compared to the placebo group leading to higher cost effectiveness ratios when one year follow up is included. The cost per child enrolled fell considerably when modelled to district level as compared to those encountered under trial conditions.

Conclusions

We demonstrate how cost-effective IPTc is using three different drug regimens and the possibilities for reducing costs further if the intervention was to be scaled up to the district level. The need for effective training, drug delivery channels and supervision to support a strong network of community based volunteers is emphasised.     

Confidence of paternity,divorce, and investment in children by Albuquerque men

Using a sample of men living in Albuquerque, NM, we examined the relationship between paternity confidence and men's investment in children. In humans, men may reduce their investment in a child in two ways: indirectly, by ending their relationship with the child's mother and ceasing to cohabit with the child (e.g., divorce), and directly, by allocating less time and fewer resources to the child. In this article, we tested two hypotheses regarding the effect of paternity confidence on investment in children: (1) men will be more likely to divorce women if they suspect or are sure that they are not the father of their wife's child, and (2) controlling for divorce, men will reduce direct investments in low paternity confidence children relative to high paternity confidence children. The first hypothesis was supported by the data. The second hypothesis was supported for two out of three measures of paternal investment we examined; low paternity confidence reduces the time men spend with a child in a group with other children or adults, and it reduces extensive involvement with the child's educational progress; there was no effect of paternity confidence on the amount of time men spend with children in one-on-one interactions. We also examined the effects of unstated paternity confidence (e.g., when men decline to answer the question) on divorce and paternal investment. Overall, the results suggested that paternity confidence plays an important role in shaping men's relationships with women and with their putative genetic children.     

Sibling mortality correlation in Kenya

This paper examines whether infant and child mortality risks among successive siblings are closely correlated, and if so, whether the survival status of the preceding child is an important factor affecting infant and child mortality in Kenya. The data were drawn from the 1988/89 Kenya Demographic and Health Survey. Logistic regression was used as the major method of data analysis. The results show that both infant and child mortality rates are significantly higher among subsequent children whose preceding siblings had died in infancy than for those whose preceding sibling had survived through infancy. The effect of the survival status of the preceding child on infant mortality was statistically strong, even after a large number of control variables were taken into account. However, its effect on child mortality appears to be spurious since it was rendered statistically insignificant when just a few control variables were introduced into the analysis. The results provide empirical evidence that infant and child mortality risks among successive siblings are closely correlated in Kenyan families, and that the effect of the survival status of the preceding child is important in determining infant mortality but not child mortality.     

Mortality differentials within large American cities in 1890

This article presents a multiple regression analysis of demographic and social data for 335 wards in 17 American cities in 1890. The most important findings are: (1) Density effects on mortality were uniformly positive and statistically significant; the magnitude of these effects was much greater for child mortality than for adult mortality; and child mortality was more sensitive to persons per dwelling than to persons per acre. (2) Unsanitary conditions, as measured by the city-specific typhoid fever death rate, significantly increased mortality and child mortality was much more sensitive in this respect than adult mortality. (3) Given the same age composition and population density, foreign-born whites, native-born whites, and the colored population had about the same adult death rate.     

Retrospective report revisited: Long-term recall in European American mothers moderated by developmental domain,child age,person, and metric of agreement

Abstract

Retrospective parental reports are common in the developmental science literature, but their validity has been questioned. We investigated the consistency of retrospective maternal recall by comparing original with retrospective maternal reports in three domains (maternal cognitions, mother-reported child and mother behaviors, and observed child and mother behaviors) at three retention intervals (12, 14, and 15 years) in two metrics (individual standing and group level). In a longitudinal study, European American mothers (N?=?46) provided data when their children were 5, 20, and 48 months of age and retrospective recall data for each age when their children were 16 years. Overall, mothers recalled similar average mean levels (49% of variables explored) or better mean levels (41% of variables) retrospectively; better levels indicating a positive recollection bias. At least moderate consistency in relative standing was evident for 52% of variables. However, the findings varied somewhat by domain, child age, and person. Retrospective parental reports can provide accurate accounts of the past, but should be used with caution, as their consistency varies and is specific to moderating factors.     

Kin influences on fertility in Thailand: Effects and mechanisms

It has been suggested that human mothers are cooperative breeders, as they need help from others to successfully raise offspring. Studies working under this framework have found correlations between the presence of kin and both child survival and female fertility rates. This study seeks to understand the proximate mechanisms by which kin influence fertility using data from the 1987 Thailand Demographic and Health Survey (DHS), a nationally representative sample of 6775 women. Kin influence is measured by the length of time couples live with the husband's or wife's parents after marriage. Event history analysis, multilevel modeling and structural equation modeling are used to investigate both fertility outcomes and potential pathways through which postnuptial residence may influence fertility outcomes, including employment status, maternal and child outcomes, contraceptive use, breastfeeding duration, and age at marriage. We show that living virilocally (with husband's kin after marriage) increases total fertility by shortening time from marriage to first birth, and increasing the likelihood of progression to each subsequent birth. These effects are mediated through correlations between virilocal residence and earlier age at marriage as well as delayed initiation of contraceptive use. We find no influence of husband's kin on maternal or child outcomes. Living uxorilocally (with wife's kin after marriage) also reduces age at marriage, shortens time from marriage to first birth and (marginally) improves child survivorship, but has no effect on other child and maternal outcomes or progression to subsequent births and results in a similar number of living children as women living neolocally.     

Effectiveness of Antenatal Clinics to Deliver Intermittent Preventive Treatment and Insecticide Treated Nets for the Control of Malaria in Pregnancy in Kenya

Background

Malaria in pregnancy can have devastating consequences for mother and baby. Coverage with the WHO prevention strategy for sub-Saharan Africa of intermittent-preventive-treatment (IPTp) with two doses of sulphadoxine-pyrimethamine (SP) and insecticide-treated-nets (ITNs) in pregnancy is low. We analysed household survey data to evaluate the effectiveness of antenatal clinics (ANC) to deliver IPTp and ITNs to pregnant women in Nyando district, Kenya.

Methods

We assessed the systems effectiveness of ANC to deliver IPTp and ITNs to pregnant women and the impact on low birthweight (LBW). Logistic regression was used to identify predictors of receipt of IPTp and ITN use during pregnancy.

Results

Among 89% of recently pregnant women who attended ANC at least once between 4–9 months gestation, 59% reported receiving one dose of SP and 90% attended ANC again, of whom 57% received a second dose, resulting in a cumulative effectiveness for IPTp of 27%, most of whom used an ITN (96%). Overall ITN use was 89%, and ANC the main source (76%). Women were less likely to receive IPTp if they had low malaria knowledge (0.26, 95% CI 0.08–0.83), had a child who had died (OR 0.36, 95% CI 0.14–0.95), or if they first attended ANC late (OR 0.20, 95% CI 0.06–0.67). Women who experienced side effects to SP (OR 0.18, CI 0.03–0.90) or had low malaria knowledge (OR 0.78, 95% CI 0.11–5.43) were less likely to receive IPTp by directly observed therapy. Ineffective delivery of IPTp reduced its potential impact by 231 LBW cases averted (95% CI 64–359) per 10,000 pregnant women.

Conclusion

IPTp presents greater challenges to deliver through ANC than ITNs in this setting. The reduction in public health impact on LBW resulting from ineffective delivery of IPTp is estimated to be substantial. Urgent efforts are required to improve service delivery of this important intervention.     

The Imagined Child: Ambiguity and Agency in Australian Intercountry Adoption

The adoption by Australian couples of children from ‘overseas’ involves claborate processes of bureaucratic assessment, approval and ‘parent education’. This paper explores adults' notions of ‘child’(ren) from ‘overseas’, which help shape and constitute such social processes, not only with couples seeking to adopt, but also with those cultural brokers who assess, regulate and ‘educate’ couples pursuing adoption, such as social workers and psychologists. The ways in which the adoptive ‘child’ is imagined and anticipated by counsellors and would‐be parents alike are explored through ethnographic data from South Australia. However, the proclivities of prospective adoptive parents to imagine their child‐to‐be are attenuated by certain social knowledge in relation to countries of origin. This leads to an exploration of ambiguities and tensions between the intercountry adoptive child as a tabula rasa and as a culturally and historically constituted person. The significance of ambiguities and contradictions for the child's agency and identities is highlighted, within the context of certain social policies around adoption. The chronological age of the child at the time of ‘allocation’ to its adoptive parents is considered as constituting a cultural fulcrum, upon which the identity and situational significance of the ‘origins’ of the child are deemed to subsequently turn.