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1.  Health and Human Rights in Chin State, Western Burma: A Population-Based Assessment Using Multistaged Household Cluster Sampling 
PLoS Medicine  2011;8(2):e1001007.
Sollom and colleagues report the findings from a household survey study carried out in Western Burma; they report a high prevalence of human rights violations such as forced labor, food theft, forced displacement, beatings, and ethnic persecution.
Background
The Chin State of Burma (also known as Myanmar) is an isolated ethnic minority area with poor health outcomes and reports of food insecurity and human rights violations. We report on a population-based assessment of health and human rights in Chin State. We sought to quantify reported human rights violations in Chin State and associations between these reported violations and health status at the household level.
Methods and Findings
Multistaged household cluster sampling was done. Heads of household were interviewed on demographics, access to health care, health status, food insecurity, forced displacement, forced labor, and other human rights violations during the preceding 12 months. Ratios of the prevalence of household hunger comparing exposed and unexposed to each reported violation were estimated using binomial regression, and 95% confidence intervals (CIs) were constructed. Multivariate models were done to adjust for possible confounders. Overall, 91.9% of households (95% CI 89.7%–94.1%) reported forced labor in the past 12 months. Forty-three percent of households met FANTA-2 (Food and Nutrition Technical Assistance II project) definitions for moderate to severe household hunger. Common violations reported were food theft, livestock theft or killing, forced displacement, beatings and torture, detentions, disappearances, and religious and ethnic persecution. Self reporting of multiple rights abuses was independently associated with household hunger.
Conclusions
Our findings indicate widespread self-reports of human rights violations. The nature and extent of these violations may warrant investigation by the United Nations or International Criminal Court.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
More than 60 years after the adoption of the Universal Declaration of Human Rights, thousands of people around the world are still deprived of their basic human rights—life, liberty, and security of person. In many countries, people live in fear of arbitrary arrest and detention, torture, forced labor, religious and ethnic persecution, forced displacement, and murder. In addition, ongoing conflicts and despotic governments deprive them of the ability to grow sufficient food (resulting in food insecurity) and deny them access to essential health care. In Burma, for example, the military junta, which seized power in 1962, frequently confiscates land unlawfully, demands forced labor, and uses violence against anyone who protests. Burma is also one of the world's poorest countries in terms of health indicators. Its average life expectancy is 54 years, its maternal mortality rate (380 deaths among women from pregnancy-related causes per 100,000 live births) is nearly ten times higher than that of neighboring Thailand, and its under-five death rate (122/1000 live births) is twice that of nearby countries. Moreover, nearly half of Burmese children under 5 are stunted, and a third of young children are underweight, indicators of malnutrition in a country that, on paper, has a food surplus.
Why Was This Study Done?
Investigators are increasingly using population-based methods to quantify the associations between human rights violations and health outcomes. In eastern Burma, for example, population-based research has recently revealed a link between human rights violations and reduced access to maternal health-care services. In this study, the researchers undertake a population-based assessment of health and human rights in Chin State, an ethnic minority area in western Burma where multiple reports of human rights abuses have been documented and from which thousands of people have fled. In particular, the researchers investigate correlations between household hunger and household experiences of human rights violations—food security in Chin State is affected by periodic expansions of rat populations that devastate crop yields, by farmers being forced by the government to grow an inedible oil crop (jatropha), and by the Burmese military regularly stealing food and livestock.
What Did the Researchers Do and Find?
Local surveyors questioned the heads of randomly selected households in Chin State about their household's access to health care and its health status, and about forced labor and other human rights violations experienced by the household during the preceding 12 months. They also asked three standard questions about food availability, the answers to which were combined to provide a measure of household hunger. Of the 621 households interviewed, 91.9% reported at least one episode of a household member being forced to work in the preceding 12 months. The Burmese military imposed two-thirds of these forced labor demands. Other human rights violations reported included beating or torture (14.8% of households), religious or ethnic persecutions (14.1% of households), and detention or imprisonment of a family member (5.9% of households). Forty-three percent of the households met the US Agency for International Development Food and Nutrition Technical Assistance (FANTA) definition for moderate to severe household hunger, and human rights violations related to food insecurity were common. For example, more than half the households were forced to give up food out of fear of violence. A statistical analysis of these data indicated that the prevalence of household hunger was 6.51 times higher in households that had experienced three food-related human rights violations than in households that had not experienced such violations.
What Do These Findings Mean?
These findings quantify the extent to which the Chin ethnic minority in Burma is subjected to multiple human rights violations and indicate the geographical spread of these abuses. Importantly, they show that the health impacts of human rights violations in Chin State are substantial. In addition, they suggest that the indirect health outcomes of human rights violations probably dwarf the mortality from direct killings. Although this study has some limitations (for example, surveyors had to work in secret and it was not safe for them to collect biological samples that could have given a more accurate indication of the health status of households than questions alone), these findings should encourage the international community to intensify its efforts to reduce human rights violations in Burma.
Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001007.
The UN Universal Declaration of Human Rights is available in numerous languages
The Burma Campaign UK and Human Rights Watch provide detailed information about human rights violations in Burma (in several languages)
The World Health Organization provides information on health in Burma and on human rights (in several languages)
The Mae Tao clinic also provides general information about Burma and its health services (including some information in Thai)
A PLoS Medicine Research Article by Luke Mullany and colleagues provides data on human rights violations and maternal health in Burma
The Chin Human Rights Organization is working to protect and promote the rights of the Chin people
The Global Health Access Program (GHAP) provides information on health in Burma
FANTA works to improve nutrition and global food security policies
doi:10.1371/journal.pmed.1001007
PMCID: PMC3035608  PMID: 21346799
2.  Actual implementation of sick children’s rights in Italian pediatric units: a descriptive study based on nurses’ perceptions 
BMC Medical Ethics  2015;16:33.
Background
Several charters of rights have been issued in Europe to solemnly proclaim the rights of children during their hospital stay. However, notwithstanding such general declarations, the actual implementation of hospitalized children’s rights is unclear. The purpose of this study was to understand to which extent such rights, as established by the two main existing charters of rights, are actually implemented and respected in Italian pediatric hospitals and the pediatric units of Italian general hospitals, as perceived by the nurses working in them.
Methods
Cross-sectional study. A 12-item online questionnaire was set up and an invitation was sent by email to Italian pediatric nurses using professional mailing lists and social networks. Responders were asked to score to what extent each right is respected in their hospital using a numeric scale from 1 (never) to 5 (always).
Results
536 questionnaires were returned. The best implemented right is the right of children to have their mothers with them (mean score 4.47). The least respected one is the right of children to express their opinion about care (mean 3.01). Other rights considered were the right to play (4.29), the right to be informed (3.95), the right to the respect of privacy (3.75), the right to be hospitalized with peers (3.39), the right not to experience pain ever (3.41), and the right to school (3.07). According to the majority of nurses, the most important is the right to pain relief.
Significant differences in the implementation of rights were found between areas of Italy and between pediatric hospitals and pediatric units of general hospitals.
Conclusion
According to the perception of pediatric nurses, the implementation of the rights of hospitalized children in Italian pediatrics units is still limited.
doi:10.1186/s12910-015-0021-0
PMCID: PMC4455682  PMID: 25964120
Children; Hospital; Charter of rights
3.  Using international human rights law to improve child health in low-income countries: a framework for healthcare professionals 
Background
The Committee on Economic, Social and Cultural Rights states that the right to health is closely related to, and dependent upon, the realization of other human rights, including the right to food, water, education and shelter which are important determinants of health. Children’s healthcare workers in low income settings may spend the majority of their professional lives trying to mitigate deficiencies of these rights but have little influence over them. In order to advocate successfully at a local level, we should be aware of the proportion of children living in our catchment population who do not have access to their basic rights. In order to carry out a rights audit, a framework within which healthcare workers could play their part is required, as is an agreed minimum core of rights, a timeframe and a set of indicators.
Discussion
A framework to assess how well states and their developmental partners are adhering to human rights principles is discussed, including the role that a healthcare worker might optimally play. A minimum core of economic and social rights seeks to establish a legal minimum set of protections, which should be available with immediate effect and applicable to all nations despite very different resources. Minimum core rights and the impact that progressive realisation may have had on the right to health is discussed, including what they should include from the perspective of children’s health. A set of absolute rights are suggested, based on physiological needs and aligned with the corresponding articles of the United Nations Convention on the Rights of the Child. The development indicators which are likely to be used to monitor progress towards the Sustainable Development Goals is suggested as a way to monitor rights. We consider the ways in which the healthcare worker could use a rights audit to advocate with, and for their community.
Summary
These audits could achieve several objectives. They may legitimise healthcare workers’ interests in the determinants of health and, as they are often highly respected by their community, this may facilitate them to be agents for change at a local level. This may raise awareness on basic human rights and their importance to health and contribute to a needed change in mind-set from one of development needs to absolute rights. The results may catalyse colleagues to analyse further the upstream reasons why children, and the families in which they live, are not having their rights met.
doi:10.1186/s12914-016-0083-1
PMCID: PMC4815083  PMID: 27029469
Human rights; Children; Health professionals; Health; Duty bearers; United Nations Convention on the Rights of the Child
4.  Human rights dimensions of food, health and care in children’s homes in Kampala, Uganda – a qualitative study 
Background
More than 14 % of Ugandan children are orphaned and many live in children’s homes. Ugandan authorities have targeted adolescent girls as a priority group for nutrition interventions as safeguarding nutritional health before pregnancy can reduce the chance of passing on malnutrition to the offspring and thus future generations. Ugandan authorities have obligations under international human rights law to progressively realise the rights to adequate food, health and care for all Ugandan children. Two objectives guided this study in children’s homes: (a) To examine female adolescent residents’ experiences, attitudes and views regarding: (i) eating patterns and food, (ii) health conditions, and (iii) care practices; and (b) to consider if the conditions in the homes comply with human rights standards and principles for the promotion of the rights to adequate food, health and care.
Methods
A human rights-based approach guided the planning and conduct of this study. Five children’s homes in Kampala were included where focus group discussions were held with girls aged 12-14 and 15-17 years. These discussions were analysed through a phenomenological approach. The conditions of food, health and care as experienced by the girls, were compared with international standards for the realisation of the human rights to adequate food, health and care.
Results
Food, health and care conditions varied greatly across the five homes. In some of these the girls consumed only one meal per day and had no access to clean drinking water, soap, toilet paper and sanitary napkins. The realisation of the right to adequate food for the girls was not met in three homes, the realisation of the right to health was not met in two homes, and the realisation of the right to care was not met in one home.
Conclusions
In three of the selected children’s homes human rights standards for food, health or care were not met. Care in the children’s homes was an important contributing factor for whether standards for the rights to adequate food and health were met.
doi:10.1186/s12914-016-0086-y
PMCID: PMC4797151  PMID: 26993271
Adolescent girls; Care; Children’s homes; Child care institutions; Human rights; Nutrition; Right to food
5.  Determinants and importance of atrial pressure morphology in atrial septal defect. 
British Heart Journal  1984;51(5):473-479.
A prominent "v" wave relative to the "a" wave in the jugular vein and right atrial pressure tracing is considered to be a common haemodynamic sign of atrial septal defect. Since the prevalence, age relation, and haemodynamic determinants of the "v" greater than or equal to "a" wave configuration have not been studied the pressure recordings from 15 adults and 80 children with an isolated secundum atrial septal defect in sinus rhythm and from 40 adults and 55 children in sinus rhythm without structural cardiac abnormalities or with coronary and valvular heart disease were studied to assess the sensitivity and specificity of the "v" greater than or equal to "a" wave configuration in atrial septal defect. Only 20% of adults with an atrial septal defect had prominent right atrial "v" waves compared with 63% of children, although the specificity was quite high for each group. In adults "left atrialisation " of the right atrium ("v" greater than or equal to "a" wave) occurred in younger patients with higher right atrial and right ventricular end diastolic pressures. In contrast, in children no age related or haemodynamic determinants for the "v" greater than or equal to "a" pattern were found. In addition, most adults but few children with an atrial septal defect had "right atrialisation " of the left atrial wave configuration ("a" greater than "v"). This was found in older adults with lower right atrial and right ventricular end diastolic pressures and in older children with larger left to right shunts. Thus in contrast to children adults with an atrial septal defect rarely show a prominent "v" wave in the right atrium. The presence of a prominent right atrial "v" wave in adults with an atrial septal defect is associated with relatively higher left atrial and right heart pressures than is the absence of this sign and may be related to relatively higher systolic transatrial flow in these patients. The relative paucity of prominent right atrial "v" waves in older adults suggest that the systolic phase flow may diminish with age, possibly from progressive alteration in compliance of the chronically dilated right ventricle.
PMCID: PMC481536  PMID: 6721943
6.  Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Uganda 
PLoS Medicine  2016;13(2):e1001951.
Background
Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food but also by illnesses and by poor infant and child feeding practices. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here, we report on the trial that took place in Kaabong, a poor agropastoral region of Karamoja, in east Uganda. While the region of Karamoja shows an acute malnutrition rate between 8.4% and 11.5% of which 2% to 3% severe malnutrition, more than half (58%) of the population in the district of Kaabong is considered food insecure.
Methods and Findings
We investigated the effect of two types of nutritional supplementation on the incidence of malnutrition in ill children presenting at outpatient clinics during March 2011 to April 2012 in Kaabong, Karamoja region, Uganda, a resource-poor region where malnutrition is a chronic problem for its seminomadic population. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed with malaria, diarrhoea, or lower respiratory tract infection. Non-malnourished children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of ready-to-use therapeutic food (RUTF), two sachets/d of micronutrient powder (MNP), or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate progression to moderate or severe acute malnutrition; it was defined as weight-for-height z-score <−2, mid-upper arm circumference (MUAC) <115 mm, or oedema, whichever came first.
Of the 2,202 randomised participants, 51.2% were girls, and the mean age was 25.2 (±13.8) mo; 148 (6.7%) participants were lost to follow-up, 9 (0.4%) died, and 14 (0.6%) were admitted to hospital. The incidence rates of NNO (first event/year) for the RUTF, MNP, and control groups were 0.143 (95% confidence interval [CI], 0.107–0.191), 0.185 (0.141–0.239), and 0.213 (0.167–0.272), respectively. The incidence rate ratio was 0.67 (95% CI, 0.46–0.98; p = 0.037) for RUTF versus control; a reduction of 33.3%. The incidence rate ratio was 0.86 (0.61–1.23; p = 0.413) for MNP versus control and 0.77 for RUTF versus MNP (95% CI 0.52–1.15; p = 0.200). The average numbers of study illnesses for the RUTF, MNP, and control groups were 2.3 (95% CI, 2.2–2.4), 2.1 (2.0–2.3), and 2.3 (2.2–2.5). The proportions of children who died in the RUTF, MNP, and control groups were 0%, 0.8%, and 0.4%.
The findings apply to ill but not malnourished children and cannot be generalised to a general population including children who are not necessarily ill or who are already malnourished.
Conclusions
A 2-wk nutrition supplementation programme with RUTF as part of routine primary medical care to non-malnourished children with malaria, LRTI, or diarrhoea proved effective in preventing malnutrition in eastern Uganda. The low incidence of malnutrition in this population may warrant a more targeted intervention to improve cost effectiveness.
Trial Registration
clinicaltrials.gov NCT01497236
A clinical trial set in Uganda shows that short-term supplementation with ready-to-use food in children following a bout of acute illness can prevent malnutrition. This short term measure has longer term effects in reducing morbidity in a vulnerable population.
Editors' Summary
Background
Globally, malnutrition—poor nutrition—is thought to contribute to nearly half of all child deaths. Malnutrition can be chronic or acute. Chronic (long-term) malnutrition causes stunting. A child who is stunted has a low height for his or her age when compared to WHO Child Growth Standards, which chart the growth of a reference population. By contrast, acute malnutrition causes wasting. A wasted child has a low weight for his or her height. Malnutrition can be caused by not having enough to eat, by not eating enough of the right foods, or being unable to use the food that one does eat. In many tropical countries, recurrent infections are also an important cause of malnutrition among children. Diarrhea, lower respiratory tract infections, and malaria all have a negative effect on the growth of children. Importantly, inadequate nutrition limits recovery from infection, thereby setting up a vicious cycle of illness and malnutrition.
Why Was This Study Done?
It might be possible to reduce the global burden of malnutrition among children by breaking this vicious cycle. One way to do this might be to provide ill children with a nutritional supplement such as RUTF or a MNP. RUTF—a nutrient supplement based on peanut butter mixed with dried skim milk, vitamins, and minerals—is a paste that can be eaten directly. Micronutrients are vitamins and minerals that everyone needs in small quantities for good health; MNP is added to porridge or other meals. In this randomized controlled trial undertaken by MSF, a not-for-profit organization that delivers emergency medical aid worldwide, the researchers investigate whether short-term provision of RUTF or MNP prevents the development of malnutrition among ill children under 5 y old living in Kaabong, a poor agropastoral region in eastern Uganda, where about 10% of children are acutely malnourished.
What Did the Researchers Do and Find?
The researchers randomly assigned 2,202 non-malnourished children who visited outpatient clinics in Kaabong with malaria, diarrhea or lower respiratory tract infection to one of three trial arms. Children assigned to the two intervention arms were given RUTF or MNP by their caregivers for 14 d following each illness over a 6-mo period. Children assigned to the control arm received no supplement. The primary outcome of the trial was the incidence of the first NNO—a weight-for-height z-score below −2 (a score that compares a child’s weight-for-height with that of a reference population; a z-score of −2 or less indicates acute malnutrition), a MUAC of less than 115 mm, or nutritional edema (swelling caused by malnutrition)—during follow-up (the incidence of a condition is the proportion of a population affected by that condition during a specified time period). The incidence rates of NNO were 0.143, 0.185, and 0.213 first events/year observation in the RUTF, MNP, and control groups, respectively. Notably, the IRR of NNO for RUTF versus control was 0.67, a significant reduction in the incidence of malnutrition in the RUTF group of 33% compared with the control group (a significant reduction is unlikely to have occurred by chance). By contrast, supplementation with NMP did not significantly reduce the incidence of malnutrition.
What Do These Findings Mean?
These findings show that, among non-malnourished children with malaria, lower respiratory tract infection, or diarrhea living in Kaabong, Uganda, provision of an RUTF-based nutritional supplement for 14 d following an illness as part of routine primary medical care prevented malnutrition. Because this trial only enrolled children who were non-malnourished, these findings cannot be generalized to all ill children with an infectious illness in Kaabong or similar settings—many ill children presenting at outpatient clinics are acutely malnourished. Interestingly, a companion trial undertaken by MSF in Goronyo, Nigeria found no reduction in the incidence of malnutrition among non-malnourished and moderately acutely malnourished children following short-term supplementation with either RUTF or MNP. The researchers suggest that the different results in the two trials may reflect the higher incidence of malnutrition and illness in Goronyo compared to Kaabong. Indeed, given the low incidence of malnutrition in Kaabong, the researchers suggest that a more targeted intervention such as only providing RUTF to ill children younger than 3 y old might be more cost-effective than providing nutritional supplementation to all ill children in Kaabong and similar settings.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001951.
A PLOS Medicine Research Article by van der Kam et al. describing the companion trial investigating the effect of short-term food supplementation for children in Nigeria after illness on the incidence of malnutrition is available
More information about this trial is available
The MSF website contains information about malnutrition around the world; "Starved for Attention" is an international multimedia campaign launched in 2010 by MSF and the VII Photo agency to rewrite the story of childhood malnutrition
The not-for-profit organization UNICEF, which protects the rights of children and young people around the world, provides detailed information on nutrition among children and statistics on malnutrition among children; a short 2013 article describes UNICEF efforts to reduce malnutrition in Uganda
The WHO Child Growth Standards are available (in several languages)
The World Food Programme is the world’s largest humanitarian agency fighting hunger worldwide; its website provides information about hunger and malnutrition in Uganda
The Emergency Nutrition Network (ENN) is an interactive website for knowledge sharing and peer support to strengthen the evidence and know-how for effective nutrition interventions in countries prone to crisis and high levels of malnutrition
The International Lipid-based Nutrient Supplements (iLiNS) project aims to help prevent malnutrition by developing Lipid-based Nutrient Supplements and test their efficiency and by collecting and sharing publications on LNS.
doi:10.1371/journal.pmed.1001951
PMCID: PMC4747529  PMID: 26859481
7.  Effect of Short-Term Supplementation with Ready-to-Use Therapeutic Food or Micronutrients for Children after Illness for Prevention of Malnutrition: A Randomised Controlled Trial in Nigeria 
PLoS Medicine  2016;13(2):e1001952.
Background
Globally, Médecins Sans Frontières (MSF) treats more than 300,000 severely malnourished children annually. Malnutrition is not only caused by lack of food and poor infant and child feeding practices but also by illnesses. Breaking the vicious cycle of illness and malnutrition by providing ill children with nutritional supplementation is a potentially powerful strategy for preventing malnutrition that has not been adequately investigated. Therefore, MSF investigated whether incidence of malnutrition among ill children <5 y old could be reduced by providing a fortified food product or micronutrients during their 2-wk convalescence period. Two trials, one in Nigeria and one in Uganda, were conducted; here we report on the trial that took place in Goronyo, a rural region of northwest Nigeria with high morbidity and malnutrition rates.
Methods and Findings
We investigated the effect of supplementation with ready-to-use therapeutic food (RUTF) and a micronutrient powder (MNP) on the incidence of malnutrition in ill children presenting at an outpatient clinic in Goronyo during February to September 2012. A three-armed, partially-blinded, randomised controlled trial was conducted in children diagnosed as having malaria, diarrhoea, or lower respiratory tract infection. Children aged 6 to 59 mo were randomised to one of three arms: one sachet/d of RUTF; two sachets/d of micronutrients or no supplement (control) for 14 d for each illness over 6 mo. The primary outcome was the incidence of first negative nutritional outcome (NNO) during the 6 mo follow-up. NNO was a study-specific measure used to indicate occurrence of malnutrition; it was defined as low weight-for-height z-score (<−2 for non-malnourished and <−3 for moderately malnourished children), mid-upper arm circumference <115 mm, or oedema, whichever came first.
Of the 2,213 randomised participants, 50.0% were female and the mean age was 20.2 (standard deviation 11.2) months; 160 (7.2%) were lost to follow-up, 54 (2.4%) were admitted to hospital, and 29 (1.3%) died. The incidence rates of NNO for the RUTF, MNP, and control groups were 0.522 (95% confidence interval (95% CI), 0.442–0.617), 0.495 (0.415–0.589), and 0.566 (0.479–0.668) first events/y, respectively. The incidence rate ratio was 0.92 (95% CI, 0.74–1.15; p = 0.471) for RUTF versus control; 0.87 (0.70–1.10; p = 0.242) for MNP versus control and 1.06 (0.84–1.33, p = 0.642) for RUTF versus MNP. A subgroup analysis showed no interaction nor confounding, nor a different effectiveness of supplementation, among children who were moderately malnourished compared with non-malnourished at enrollment. The average number of study illnesses for the RUTF, MNP, and control groups were 4.2 (95% CI, 4.0–4.3), 3.4 (3.2–3.6), and 3.6 (3.4–3.7). The proportion of children who died in the RUTF, MNP, and control groups were 0.8% (95% CI, 0.3–1.8), 1.8% (1.0–3.3), and 1.4% (0.7–2.8).
Conclusions
A 2-wk supplementation with RUTF or MNP to ill children as part of routine primary medical care did not reduce the incidence of malnutrition. The lack of effect in Goronyo may be due to a high frequency of morbidity, which probably further affects a child’s nutritional status and children’s ability to escape from the illness–malnutrition cycle. The duration of the supplementation may have been too short or the doses of the supplements may have been too low to mitigate the effects of high morbidity and pre-existing malnutrition. An integrated approach combining prevention and treatment of diseases and treatment of moderate malnutrition, rather than prevention of malnutrition by nutritional supplementation alone, might be more effective in reducing the incidence of acute malnutrition in ill children.
Trial Registration
clinicaltrials.gov NCT01154803
A trial in Nigeria reveals no reduction of malnutrition in children who are treated with ready-to-use food following a bout of acute illness. Compared to reductions seen in a similar trial in Uganda, the children in this setting were more malnourished initially.
Editors' Summary
Background
Malnutrition among children is a global public health problem. Malnourished children have about a 10-fold greater risk of death than well-nourished children and, worldwide, more than 70 million children have moderate or severe acute malnutrition. Acute malnutrition causes wasting—a wasted child has a low weight for his or her height compared to the World Health Organization Child Growth Standards, which chart the growth of a reference population. Multiple factors can cause malnutrition among children, including not having enough to eat and being given the wrong types of food. In addition, recurrent infections are a major cause of malnutrition among children in many tropical countries. Common infections such as malaria, diarrhea, and lower respiratory tract infections all negatively affect the growth of children. Moreover, inadequate nutrition limits recovery from infection and the ability of the immune system to fight off infection, thereby setting up a vicious cycle of malnutrition and illness.
Why Was This Study Done?
One way to interrupt this cycle and reduce the global burden of malnutrition among children might be to ensure that ill children receive a nutritional supplement such as a ready-to-use therapeutic food (RUTF) or a micronutrient powder (MNP) at the same time as their prescribed medical treatment. RUTF, which is based on peanut butter, contains dried skim milk, vitamins, and micronutrients and is supplied as a paste that is eaten directly. Micronutrients are vitamins and minerals that are needed in small quantities for immune system function and for good health. MNP is consumed by mixing it with porridge or other meals. In this randomized controlled trial undertaken by Médicins San Frontières (MSF, a not-for-profit organization that delivers emergency medical aid worldwide), the researchers investigate whether short-term provision of RUTF or MNP prevents the development of malnutrition among ill children under 5 y old living in Goronyo, a rural region of northwest Nigeria where up to 15% of children are acutely malnourished and where levels of illness among children are high.
What Did the Researchers Do and Find?
The researchers randomly assigned 2,213 non-malnourished and moderately malnourished children who visited outpatient clinics in Goronyo with malaria, diarrhea or lower respiratory tract infection to be given RUTF or MNP by their caregivers for 14 d following each illness over a 6-mo period or to receive no supplement. The primary trial outcome was the incidence of the first negative nutritional outcome (NNO) during follow-up (the proportion of the population experiencing NNO during follow-up). NNO was defined as a weight-for-height z-score below −2 or −3 for non-malnourished and moderately malnourished children, respectively (this score compares a child’s weight-for-height with that of a reference population; a z-score of −2 or less indicates acute malnutrition), a mid-upper arm circumference of less than 115 mm, or nutritional oedema (swelling caused by malnutrition). The incidence rates of NNO were 0.522, 0.495, and 0.566 first events/y in the RUTF, MNP, and control groups, respectively. The incidence rate ratio for RUTF versus control was 0.92, a nonsignificant reduction in the incidence of malnutrition (a nonsignificant change in an outcome could have occurred by chance). Provision of MNP also did not significantly reduce the incidence of malnutrition.
What Do These Findings Mean?
These findings show that, among non-malnourished and moderately malnourished children living in Goronyo, Nigeria, provision of RUTF or MNP as part of routine primary medical care during convalescence following malaria, diarrhea, or a lower respiratory tract infection did not reduce the incidence of malnutrition. Because RUTF is popular with caregivers and children, the lack of blinding in this trial (participants knew whether they were being given RUTF, MNP or no supplement) may limit the accuracy of these findings. Moreover, these findings only apply to ill children and cannot be extrapolated to healthy children. Notably, a companion trial undertaken by MSF in Kaabong, Uganda found that short-term supplementation with RUTF reduced the incidence of malnutrition following illness. The researchers suggest that the lack of effect of nutritional supplementation in Goronyo may be because the duration and/or dose of supplementation was insufficient to mitigate the effects of high levels of illness and pre-existing malnutrition present in this setting. Thus, they suggest, an integrated approach that combines the prevention and treatment of diseases with the treatment of moderate malnutrition might be necessary to break the illness–malnutrition cycle among children living in Goronyo and similar settings.
Additional Information
This list of resources contains links that can be accessed when viewing the PDF on a device or via the online version of the article at http://dx.doi.org/10.1371/journal.pmed.1001952.
A PLOS Medicine Research Article by van der Kam et al. describes the companion trial investigating the effect of short-term food supplementation for children in Uganda after illness on the incidence of malnutrition
More information about this trial is available
The MSF website contains information about malnutrition around the world; "Starved for Attention" is an international multimedia campaign launched in 2010 by MSF and the VII Photo agency to rewrite the story of childhood malnutrition
The not-for-profit organization UNICEF, which protects the rights of children and young people around the world, provides detailed information on nutrition among children and statistics on malnutrition among children; a short 2013 article describes UNICEF efforts to reduce malnutrition in Nigeria
The WHO Child Growth Standards are available (in several languages)
The World Food Programme is the world’s largest humanitarian agency fighting hunger worldwide
The Emergency Nutrition Network (ENN) is an interactive website for knowledge sharing and peer support to strengthen the evidence and know-how for effective nutrition interventions in countries prone to crisis and high levels of malnutrition
The International Lipid-based Nutrient Supplements (iLiNS) project aims to help prevent malnutrition by developing Lipid-based Nutrient Supplements and test their efficiency and by collecting and sharing publications on LNS.
doi:10.1371/journal.pmed.1001952
PMCID: PMC4747530  PMID: 26859559
8.  A systematic review of factors affecting children’s right to health in cluster randomized trials in Kenya 
Trials  2014;15:287.
Following the South African case, Treatment Action Campaign and Others v Minister of Health and Others, the use of 'pilot’ studies to investigate interventions already proven efficacious, offered free of charge to government, but confined by the government to a small part of the population, may violate children’s right to health, and the negative duty on governments not to prevent access to treatment. The applicants challenged a government decision to offer Nevirapine in a few pilot sites when evidence showed Nevirapine significantly reduced HIV transmission rates and despite donor offers of a free supply. The government refused to expand access, arguing they needed to collect more information, and citing concerns about long-term hazards, side effects, resistance and inadequate infrastructure. The court ruled this violated children’s right to health and asked the government to immediately expand access. Cluster randomized trials involving children are increasingly popular, and are often used to reduce 'contamination’: the possibility that members of a cluster adopt behavior of other clusters. However, they raise unique issues insufficiently addressed in literature and ethical guidelines. This case provides additional crucial guidance, based on a common human rights framework, for the Kenyan government and other involved stakeholders. Children possess special rights, often represent a 'captive’ group, and so motivate extra consideration. In a systematic review, we therefore investigated whether cluster trial designs are used to prevent or delay children’s access to treatment in Kenya or otherwise inconsistently with children’s right to health as outlined in the above case. Although we did not find state sponsored cluster trials, most had significant public sector involvement. Core obligations under children’s right to health were inadequately addressed across trials. Few cluster trials reported rationale for cluster randomization, offered post- trial access or planned to implement successful interventions. A small number of trials may have unnecessarily evaluated proven interventions, offered their control arm trial conditions worse than local standards of care or evaluated interventions ostensibly worse than local standards of care. Further research is required to establish if children’s right to health in cluster trials is well understood and to explain why some obligations are unmet.
doi:10.1186/1745-6215-15-287
PMCID: PMC4223386  PMID: 25027410
Cluster randomized trial; Children; Right to health; Access to treatment; Standard of care; Kenya
9.  Objective Measures of the Built Environment and Physical Activity in Children: From Walkability to Moveability 
Features of the built environment that may influence physical activity (PA) levels are commonly captured using a so-called walkability index. Since such indices typically describe opportunities for walking in everyday life of adults, they might not be applicable to assess urban opportunities for PA in children. Particularly, the spatial availability of recreational facilities may have an impact on PA in children and should be additionally considered. We linked individual data of 400 2- to 9-year-old children recruited in the European IDEFICS study to geographic data of one German study region, based on individual network-dependent neighborhoods. Environmental features of the walkability concept and the availability of recreational facilities, i.e. playgrounds, green spaces, and parks, were measured. Relevant features were combined to a moveability index that should capture urban opportunities for PA in children. A gamma log-regression model was used to model linear and non-linear effects of individual variables on accelerometer-based moderate-to-vigorous physical activity (MVPA) stratified by pre-school children (<6 years) and school children (≥6 years). Single environmental features and the resulting indices were separately included into the model to investigate the effect of each variable on MVPA. In school children, commonly used features such as residential density \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=0.5\cdot {10}^{-4},p=0.02\right) $$\end{document}β^=0.5⋅10−4,p=0.02, intersection density \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=0.003,p=0.04\right) $$\end{document}β^=0.003,p=0.04, and public transit density \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=0.037,p=0.01\right) $$\end{document}β^=0.037,p=0.01 showed a positive effect on MVPA, while land use mix revealed a negative effect on MVPA \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=-0.173,p=0.13\right) $$\end{document}β^=−0.173,p=0.13. In particular, playground density \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=0.048,p=0.01\right) $$\end{document}β^=0.048,p=0.01 and density of public open spaces, i.e., playgrounds and parks combined \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=0.040,p=0.01\right) $$\end{document}β^=0.040,p=0.01, showed positive effects on MVPA. However, availability of green spaces showed no effect on MVPA. Different moveability indices were constructed based on the walkability index accounting for the negative impact of land use mix. Moveability indices showed also strong effects on MVPA in school children for both components, expanded by playground density \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=0.014,p=0.008\right) $$\end{document}β^=0.014,p=0.008 or by public open space density \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \left(\widehat{\beta}=0.014,p=0.007\right) $$\end{document}β^=0.014,p=0.007, but no effects of urban measures and moveability indices were found in pre-school children. The final moveability indices capture relevant opportunities for PA in school children. Particularly, availability of public open spaces seems to be a strong predictor of MVPA. Future studies involving children should consider quantitative assessment of public recreational facilities in larger cities or urban sprawls in order to investigate the influence of the moveability on childhood PA in a broader sample.
doi:10.1007/s11524-014-9915-2
PMCID: PMC4338118  PMID: 25380722
Accelerometry; Built environment; Children; IDEFICS study; Moderate-to-vigorous physical activity; Walkability
10.  Right prefrontal activation as a neuro-functional biomarker for monitoring acute effects of methylphenidate in ADHD children: An fNIRS study☆ 
NeuroImage : Clinical  2012;1(1):131-140.
An objective biomarker is a compelling need for the early diagnosis of attention deficit hyperactivity disorder (ADHD), as well as for the monitoring of pharmacological treatment effectiveness. The advent of fNIRS, which is relatively robust to the body movements of ADHD children, raised the possibility of introducing functional neuroimaging diagnosis in younger ADHD children. Using fNIRS, we monitored the oxy-hemoglobin signal changes of 16 ADHD children (6 to 13 years old) performing a go/no-go task before and 1.5 h after MPH or placebo administration, in a randomized, double-blind, placebo-controlled, crossover design. 16 age- and gender-matched normal controls without MPH administration were also monitored. Relative to control subjects, unmedicated ADHD children exhibited reduced activation in the right inferior frontal gyrus (IFG) and middle frontal gyrus (MFG) during go/no-go tasks. The reduced right IFG/MFG activation was acutely normalized after MPH administration, but not after placebo administration. The MPH-induced right IFG/MFG activation was significantly larger than the placebo-induced activation. Post-scan exclusion rate was 0% among 16 right-handed ADHD children with IQ > 70. We revealed that the right IFG/MFG activation could serve as a neuro-functional biomarker for monitoring the acute effects of methylphenidate in ADHD children. fNIRS-based examinations were applicable to ADHD children as young as 6 years old, and thus would contribute to early clinical diagnosis and treatment of ADHD children.
Highlights
► We assessed the effects of MPH administration to ADHD children using fNIRS. ► Normal healthy control subjects recruited the right IFG/MFG during go/no-go task. ► Unmedicated ADHD children exhibited reduced right IFG/MFG activation. ► The activation was acutely normalized by MPH administration, but not by placebo. ► The right IFG/MFG activation may serve as an objective neuro-functional biomarker.
doi:10.1016/j.nicl.2012.10.001
PMCID: PMC3757725  PMID: 24179746
Cortical hemodynamics; Developmental disorder; Dorsolateral prefrontal cortex; Optical topography; Ventrolateral prefrontal cortex
11.  Sequence Learning Under Uncertainty in Children: Self-Reflection vs. Self-Assertion 
We know that stochastic feedback impairs children’s associative stimulus–response (S–R) learning (Crone et al., 2004a; Eppinger et al., 2009), but the impact of stochastic feedback on sequence learning that involves deductive reasoning has not been not tested so far. In the current study, 8- to 11-year-old children (N = 171) learned a sequence of four left and right button presses, LLRR, RRLL, LRLR, RLRL, LRRL, and RLLR, which needed to be deduced from feedback because no directional cues were given. One group of children experienced consistent feedback only (deterministic feedback, 100% correct). In this condition, green feedback on the screen indicated that the children had been right when they were right, and red feedback indicated that the children had been wrong when they were wrong. Another group of children experienced inconsistent feedback (stochastic feedback, 85% correct, 15% false), where in some trials, green feedback on the screen could signal that children were right when in fact they were wrong, and red feedback could indicate that they were wrong when in fact they had been right. Independently of age, children’s sequence learning in the stochastic condition was initially much lower than in the deterministic condition, but increased gradually and improved with practice. Responses toward positive vs. negative feedback varied with age. Children were increasingly able to understand that they could have been wrong when feedback indicated they were right (self-reflection), but they remained unable to understand that they could have been right when feedback indicated they were wrong (self-assertion).
doi:10.3389/fpsyg.2012.00127
PMCID: PMC3342618  PMID: 22563324
sequence learning; learning under uncertainty; stochastic feedback; positive and negative feedback
12.  Altered Gray Matter Volume and School Age Anxiety in Children Born Late Preterm 
The Journal of pediatrics  2014;165(5):928-935.
Objectives
To determine if late preterm (LP) children differ from full term (FT) children in volumes of the cortex, hippocampus, corpus callosum, or amygdala and whether these differences are associated with anxiety symptoms at school-age.
Study design
LP children born between 34 and 36 weeks gestation and FT children born between 39 and 41 weeks gestation from a larger longitudinal cohort had MRI scans at school-age. Brain volumes, cortical surface area and thickness measures were obtained. Anxiety symptoms were assessed using a structured diagnostic interview annually beginning at preschool-age and following the MRI.
Results
LP children (n=21) had a smaller percentage of total, right parietal, and right temporal lobe gray matter volume than FT children (n=87). There were no differences in hippocampal, callosal, or amygdala volumes or cortical thickness. LP children also had a relative decrease in right parietal lobe cortical surface area. LP children had greater anxiety symptoms over all assessments. The relationship between late prematurity and school-age anxiety symptoms was mediated by the relative decrease in right temporal lobe volume.
Conclusion
LP children, comprising 70% of preterm children, are also at increased risk for altered brain development particularly in the right temporal and parietal cortices. Alterations in the right temporal lobe cortical volume may underlie the increased rate of anxiety symptoms among these LP children. These findings suggest that LP delivery may disrupt temporal and parietal cortical development that persists until school-age with the right temporal lobe conferring risk for elevated anxiety symptoms.
doi:10.1016/j.jpeds.2014.06.063
PMCID: PMC4252475  PMID: 25108541
prematurity; temporal lobe; parietal lobe; cortical surface area
13.  Left-Handedness and Language Lateralization in Children 
Brain research  2011;1433C:85-97.
This fMRI study investigated the development of language lateralization in left- and right-handed children between 5 and 18 years of age. Twenty-seven left-handed children (17 boys, 10 girls) and 54 age- and gender-matched right-handed children were included. We used functional MRI at 3T and a verb generation task to measure hemispheric language dominance based on either frontal or temporo-parietal regions of interest (ROIs) defined for the entire group and applied on an individual basis. Based on the frontal ROI, in the left-handed group, 23 participants (85%) demonstrated left-hemispheric language lateralization, 3 (11%) demonstrated symmetric activation, and 1 (4%) demonstrated right-hemispheric lateralization. In contrast, 50 (93%) of the right-handed children showed left-hemisphere lateralization and 3 (6%) demonstrated a symmetric activation pattern, while one (2%) demonstrated a right- hemisphere lateralization. The corresponding values for the temporo-parietal ROI for the left-handed children were 18 (67%) left-dominant, 6 (22%) symmetric, 3 (11%) right-dominant and for the right-handed children 49 (91%), 4 (7%), 1 (2%). Left-hemispheric language lateralization increased with age in both groups but somewhat different lateralization trajectories were observed in girls when compared to boys. The incidence of atypical language lateralization in left-handed children in this study was similar to that reported in adults. We also found similar rates of increase in left-hemispheric language lateralization with age between groups (i.e., independent of handedness) indicating the presence of similar mechanisms for language lateralization in left- and right-handed children.
doi:10.1016/j.brainres.2011.11.026
PMCID: PMC3249496  PMID: 22177775
Language lateralization; language development; handedness; fMRI
14.  Spatial acuity in two-to-three-year-old children with normal acoustic hearing, unilateral cochlear implants and bilateral cochlear implants 
Ear and hearing  2012;33(5):561-572.
Objectives
To measure spatial acuity on a right-left discrimination task in 2-to-3-year-old children who use a unilateral cochlear implant (UCI) or bilateral cochlear implants (BICIs); to test the hypothesis that BICI users perform significantly better when they use two CIs than when using a single CI, and that they perform better than the children in the UCI group; to determine how well children with CIs perform compared with children who have normal acoustic hearing; to determine the effect of intensity roving on spatial acuity.
Design
Three groups of children between 26-to-36 months of age participated in this study: 8 children with normal acoustic hearing (mean age: 30.9 months), 12 children who use a UCI (mean age: 31.9 months), and 27 children who use BICIs (mean age: 30.7 months). Testing was conducted in a large sound-treated booth with loudspeakers positioned on a horizontal arc with a radius of 1.2 m. The observer-based psychophysical procedure was used to measure the children’s ability to identify the hemifield containing the sound source (right vs. left). Two methods were used for quantifying spatial acuity, an adaptive-tracking method and a fixed-angle method. In Experiment 1 an adaptive tracking algorithm was used to vary source angle, and the minimum audible angle (MAA; smallest angle at which right-left discrimination performance is better than chance) was estimated. All three groups participated in Experiment 1. In Experiment 2 source angles were fixed at ±50°, and performance was evaluated by computing the number of standard deviations above chance. Children in the UCI and BICI groups participated in Experiment 2.
Results
In Experiment 1, when stimulus intensity was roved by 8 dB, MAA thresholds were 3.3º to 30.2º (mean = 14.5º) and 5.7º to 69.6º (mean = 30.9º) in children who have normal acoustic hearing and the BICI group, respectively. When the intensity level was fixed for the BICI group, performance did not improve. Within the BICI group, 5/27 children obtained MAA thresholds within one standard deviation of their peers who have normal acoustic hearing; all 5 had greater than 12 months of bilateral listening experience. In Experiment 2, BICIs provided some advantages when the intensity level was fixed. First, the BICI group outperformed the UCI group. Second, children in the BICI group who repeated the task with their first CI alone had statistically significantly better performance when using both devices. In addition, when intensity roving was introduced, a larger percentage of children who had 12 or more months of BICI experience continued to perform above chance than children who had less than 12 months of BICI experience. Taken together, the results suggest that children with BICIs have spatial acuity that is better than when using their first CI alone as well as better than their peers who use UCI. In addition, longer durations of BICI use tend to result in better performance, although this cannot be generalized to all participants.
Conclusion
This report is consistent with a growing body of evidence that spatial hearing skills can emerge in young children who use BICIs. The observation that these skills are not concomitantly emerging in age- and experience-matched children who use UCIs suggests that BICIs provide cues that are necessary for these spatial hearing skills which UCIs do not provide.
doi:10.1097/AUD.0b013e31824c7801
PMCID: PMC3402640  PMID: 22517185
15.  Up or down? Reading direction influences vertical counting direction in the horizontal plane – a cross-cultural comparison 
Most adults and children in cultures where reading text progresses from left to right also count objects from the left to the right side of space. The reverse is found in cultures with a right-to-left reading direction. The current set of experiments investigated whether vertical counting in the horizontal plane is also influenced by reading direction. Participants were either from a left-to-right reading culture (UK) or from a mixed (left-to-right and top-to-bottom) reading culture (Hong Kong). In Experiment 1, native English-speaking children and adults and native Cantonese-speaking children and adults performed three object counting tasks. Objects were presented flat on a table in a horizontal, vertical, and square display. Independent of culture, the horizontal array was mostly counted from left to right. While the majority of English-speaking children counted the vertical display from bottom to top, the majority of the Cantonese-speaking children as well as both Cantonese- and English-speaking adults counted the vertical display from top to bottom. This pattern was replicated in the counting pattern for squares: all groups except the English-speaking children started counting with the top left coin. In Experiment 2, Cantonese-speaking adults counted a square array of objects after they read a text presented to them either in left-to-right or in top-to-bottom reading direction. Most Cantonese-speaking adults started counting the array by moving horizontally from left to right. However, significantly more Cantonese-speaking adults started counting with a top-to-bottom movement after reading the text presented in a top-to-bottom reading direction than in a left-to-right reading direction. Our results show clearly that vertical counting in the horizontal plane is influenced by longstanding as well as more recent experience of reading direction.
doi:10.3389/fpsyg.2015.00228
PMCID: PMC4366652  PMID: 25852583
mental number line; grounded cognition; SNARC; spatial–numerical association; children; physical world account
16.  Risk Factors for Death among Children Less than 5 Years Old Hospitalized with Diarrhea in Rural Western Kenya, 2005–2007: A Cohort Study 
PLoS Medicine  2012;9(7):e1001256.
A hospital-based surveillance study conducted by Ciara O'Reilly and colleagues describes the risk factors for death amongst children who have been hospitalized with diarrhea in rural Kenya.
Background
Diarrhea is a leading cause of childhood morbidity and mortality in sub-Saharan Africa. Data on risk factors for mortality are limited. We conducted hospital-based surveillance to characterize the etiology of diarrhea and identify risk factors for death among children hospitalized with diarrhea in rural western Kenya.
Methods and Findings
We enrolled all children <5 years old, hospitalized with diarrhea (≥3 loose stools in 24 hours) at two district hospitals in Nyanza Province, western Kenya. Clinical and demographic information was collected. Stool specimens were tested for bacterial and viral pathogens. Bivariate and multivariable logistic regression analyses were carried out to identify risk factors for death. From May 23, 2005 to May 22, 2007, 1,146 children <5 years old were enrolled; 107 (9%) children died during hospitalization. Nontyphoidal Salmonella were identified in 10% (118), Campylobacter in 5% (57), and Shigella in 4% (42) of 1,137 stool samples; rotavirus was detected in 19% (196) of 1,021 stool samples. Among stools from children who died, nontyphoidal Salmonella were detected in 22%, Shigella in 11%, rotavirus in 9%, Campylobacter in 5%, and S. Typhi in <1%. In multivariable analysis, infants who died were more likely to have nontyphoidal Salmonella (adjusted odds ratio [aOR] = 6·8; 95% CI 3·1–14·9), and children <5 years to have Shigella (aOR = 5·5; 95% CI 2·2–14·0) identified than children who survived. Children who died were less likely to be infected with rotavirus (OR = 0·4; 95% CI 0·2–0·8). Further risk factors for death included being malnourished (aOR = 4·2; 95% CI 2·1–8·7); having oral thrush on physical exam (aOR = 2·3; 95% CI 1·4–3·8); having previously sought care at a hospital for the illness (aOR = 2·2; 95% CI 1·2–3·8); and being dehydrated as diagnosed at discharge/death (aOR = 2·5; 95% CI 1·5–4·1). A clinical diagnosis of malaria, and malaria parasites seen on blood smear, were not associated with increased risk of death. This study only captured in-hospital childhood deaths, and likely missed a substantial number of additional deaths that occurred at home.
Conclusion
Nontyphoidal Salmonella and Shigella are associated with mortality among rural Kenyan children with diarrhea who access a hospital. Improved prevention and treatment of diarrheal disease is necessary. Enhanced surveillance and simplified laboratory diagnostics in Africa may assist clinicians in appropriately treating potentially fatal diarrheal illness.
Please see later in the article for the Editors' Summary
Editors' Summary
Background
Diarrhea—passing three or more loose or liquid stools per day—kills about 1.5 million young children every year, mainly in low- and middle-income countries. Globally, it is the second leading cause of death in under-5-year olds, causing nearly one in five child deaths. Diarrhea, which can lead to life-threatening dehydration, is a common symptom of gastrointestinal infections. The pathogens (viruses, bacteria, and parasites) that cause diarrhea spread through contaminated food or drinking water, and from person to person through poor hygiene and inadequate sanitation (unsafe disposal of human excreta). Interventions that prevent diarrhea include improvements in water supplies, sanitation and hygiene, the promotion of breast feeding, and vaccination against rotavirus (a major viral cause of diarrhea). Treatments for diarrhea include oral rehydration salts, which prevent and treat dehydration, zinc supplementation, which decreases the severity and duration of diarrhea, and the use of appropriate antibiotics when indicated for severe bacterial diarrhea.
Why Was This Study Done?
Nearly half of deaths from diarrhea among young children occur in Africa where diarrhea is the single largest cause of death among under 5-year-olds and a major cause of childhood illness. Unfortunately, although some of the risk factors for death from diarrhea in children in sub-Saharan Africa have been identified (for example, having other illnesses, poor nutrition, and not being breastfed), little is known about the relative contributions of different diarrhea-causing pathogens to diarrheal deaths. Clinicians need to know which of these pathogens are most likely to cause death in children so that they can manage their patients appropriately. In this cohort study, the researchers characterize the causes and risk factors associated with death among young children hospitalized for diarrhea in Nyanza Province, western Kenya, an area where most households have no access to safe drinking water and a quarter lack latrines. In a cohort study, a group of people with a specific condition is observed to identify which factors lead to different outcomes.
What Did the Researchers Do and Find?
The researchers enrolled all the children under 5 years old who were hospitalized over a two-year period for diarrhea at two district hospitals in Nyanza Province, tested their stool samples for diarrhea-causing viral and bacterial pathogens, and recorded which patients died in-hospital. They then used multivariable regression analysis (a statistical method) to determine which risk factors and diarrheal pathogens were associated with death among the children. During the study, 1,146 children were hospitalized, 107 of whom died in the hospital. 10% of all the stool samples contained nontyphoidal Salmonella, 4% contained Shigella (two types of diarrhea-causing bacteria), and 19% contained rotavirus. By contrast, 22% of the samples taken from children who died contained nontyphoidal Salmonella, 11% contained Shigella, 9% contained rotavirus, and 5% contained Campylobacter (another bacterial pathogen that causes diarrhea). Compared to survivors, infants (children under 1 year of age) who died were nearly seven times more likely to have nontyphoidal Salmonella in their stools and children under 5 years old who died were five and half times more likely to have Shigella in their stools but less likely to have rotavirus in their stools. Other factors associated with death included being malnourished, having oral thrush (a fungal infection of the mouth), having previously sought hospital care for diarrhea, and being dehydrated.
What Do These Findings Mean?
These findings indicate that, among young children admitted to the hospital in western Kenya with diarrhea, infections with nontyphoidal Salmonella and with Shigella (but not with rotavirus) were associated with an increased risk of death. Because this study only captured deaths in hospital and most diarrheal deaths in developing countries occur at home, these results may not accurately reflect the pathogens associated with overall childhood diarrheal deaths. In addition, they may not be generalizable to other geographical regions. Nevertheless, given that that there are currently no vaccines available for most bacterial diarrheal diseases, these findings highlight the importance of Kenya and other developing countries implementing effective strategies for the prevention and management of diarrheal diseases in children such as increasing access to improved water, sanitation, and hygiene, and community-level promotion of the use of oral rehydration solution and zinc supplements. They also suggest that enhanced surveillance and simplified laboratory diagnostics for diarrheal pathogens could help clinicians identify those children presenting to hospital with diarrhea who are at high risk of death and prioritize their treatment.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1001256.
The World Health Organization provides information on diarrhea (in several languages); its 2009 report with UNICEF Diarrhea: why children are still dying and what can be done, which includes the WHO/UNICEF recommendations for the treatment and prevention of diarrhea in children, can be downloaded from the Internet
The children's charity UNICEF, which protects the rights of children and young people around the world, provides information on diarrhea (in several languages)
doi:10.1371/journal.pmed.1001256
PMCID: PMC3389023  PMID: 22802736
17.  Situation of children's rights in Isfahan city 
BACKGROUND:
Taking care of children makes them happy, lively and healthy, and it makes the society healthy. Children's rights have been discussed for years and the United Nation General Assembly has two conventions to prevent children abuse, the Minimum Age Convention of 1973 and the Convention on the Rights of the Child on 1989 However, in spite of these international agreements, the statistics show that the cases of children abuse increased from 749 cases in 1960 to one million cases in 1995 in the Western countries Islamic republic of IRAN agreed this international agreement in 1993. This study investigated the nature, structure and process of children's right in the city of Isfahan.
METHODS:
The study is qualitative, using Content Analysis. The purpose of the study is to discover children's right nature, and to describe the existing condition. Sampling method was purposive (or judgmental) and continued until data collection was completed. Sample consisted of 43 children, parents and teachers or trainers. Data were collected by observing schools and other public communities and also by interviews which were recorded, transcribed, reviewed and coded in three steps using qualitative research methods, Thematic Analysis, to extract the main conception.
RESULTS:
The findings of observations and interviews classified in 260 codes and then joined together again to extract the main concepts and categories related to children's rights. This step lead to 12 categories and in the third step, four major categories including psychological and personality, physical, economic and cultural factors were extracted.
CONCLUSIONS:
Based on the findings of this study, it is recommended that parents, teachers and other significant figures in the children's life should receive education on the children's rights and needs in various fields to become capable of developing policies and plans in this regard.
PMCID: PMC3249763  PMID: 22224097
Children; human rights; personality; culture
18.  Neural correlates of cerebellar-mediated timing during finger tapping in children with fetal alcohol spectrum disorders 
NeuroImage : Clinical  2014;7:562-570.
Objectives
Classical eyeblink conditioning (EBC), an elemental form of learning, is among the most sensitive indicators of fetal alcohol spectrum disorders. The cerebellum plays a key role in maintaining timed movements with millisecond accuracy required for EBC. Functional MRI (fMRI) was used to identify cerebellar regions that mediate timing in healthy controls and the degree to which these areas are also recruited in children with prenatal alcohol exposure.
Experimental design
fMRI data were acquired during an auditory rhythmic/non-rhythmic finger tapping task. We present results for 17 children with fetal alcohol syndrome (FAS) or partial FAS, 17 heavily exposed (HE) nonsyndromal children and 16 non- or minimally exposed controls.
Principal observations
Controls showed greater cerebellar blood oxygen level dependent (BOLD) activation in right crus I, vermis IV–VI, and right lobule VI during rhythmic than non-rhythmic finger tapping. The alcohol-exposed children showed smaller activation increases during rhythmic tapping in right crus I than the control children and the most severely affected children with either FAS or PFAS showed smaller increases in vermis IV–V. Higher levels of maternal alcohol intake per occasion during pregnancy were associated with reduced activation increases during rhythmic tapping in all four regions associated with rhythmic tapping in controls.
Conclusions
The four cerebellar areas activated by the controls more during rhythmic than non-rhythmic tapping have been implicated in the production of timed responses in several previous studies. These data provide evidence linking binge-like drinking during pregnancy to poorer function in cerebellar regions involved in timing and somatosensory processing needed for complex tasks requiring precise timing.
Highlights
•Identified 4 cerebellar regions activated more during rhythmic tapping in controls•These regions are right crus I, vermis IV–V, vermis VI and right lobule VI•Fetal alcohol exposed children activated right crus I less than control children•Children with FAS and PFAS activated vermis IV–V less than the other children•Activity in all 4 regions is reduced with higher levels of alcohol exposure
doi:10.1016/j.nicl.2014.12.016
PMCID: PMC4377649  PMID: 25844307
Functional magnetic resonance imaging (fMRI); Cerebellum; Finger tapping; Prenatal alcohol exposure; Fetal alcohol syndrome; Eyeblink conditioning
19.  Models of care for orphaned and separated children and upholding children’s rights: cross-sectional evidence from western Kenya 
Background
Sub-Saharan Africa is home to approximately 55 million orphaned children. The growing orphan crisis has overwhelmed many communities and has weakened the ability of extended families to meet traditional care-taking expectations. Other models of care and support have emerged in sub-Saharan Africa to address the growing orphan crisis, yet there is a lack of information on these models available in the literature. We applied a human rights framework using the United Nations Convention on the Rights of the Child to understand what extent children’s basic human rights were being upheld in institutional vs. community- or family-based care settings in Uasin Gishu County, Kenya.
Methods
The Orphaned and Separated Children’s Assessments Related to their Health and Well-Being Project is a 5-year cohort of orphaned children and adolescents aged ≤18 year. This descriptive analysis was restricted to baseline data. Chi-Square test was used to test for associations between categorical /dichotomous variables. Fisher’s exact test was also used if some cells had expected value of less than 5.
Results
Included in this analysis are data from 300 households, 19 Charitable Children’s Institutions (CCIs) and 7 community-based organizations. In total, 2871 children were enrolled and had baseline assessments done: 1390 in CCI’s and 1481 living in households in the community. We identified and described four broad models of care for orphaned and separated children, including: institutional care (sub-classified as ‘Pure CCI’ for those only providing residential care, ‘CCI-Plus’ for those providing both residential care and community-based supports to orphaned children , and ‘CCI-Shelter’ which are rescue, detention, or other short-term residential support), family-based care, community-based care and self-care. Children in institutional care (95%) were significantly (p < 0.0001) more likely to have their basic material needs met in comparison to those in family-based care (17%) and institutions were better able to provide an adequate standard of living.
Conclusions
Each model of care we identified has strengths and weaknesses. The orphan crisis in sub-Saharan Africa requires a diversity of care environments in order to meet the needs of children and uphold their rights. Family-based care plays an essential role; however, households require increased support to adequately care for children.
doi:10.1186/1472-698X-14-9
PMCID: PMC4021203  PMID: 24685118
Orphans; Vulnerable children; Sub-saharan africa; Kenya; Street children; Children’s rights
20.  Perceived and desired weight, weight related eating and exercising behaviours, and advice received from parents among thin, overweight, obese or normal weight Australian children and adolescents 
Background
Thin children are less muscular, weaker, less active, and have lower performance in measures of physical fitness than their normal weight peers. Thin children are also more frequently subjected to teasing and stigmatization. Little is known about thin children's weight perceptions, desired weight and attitudes and behaviours towards food and exercise. The study aimed to compare perceived weight status, desired weight, eating and exercise behaviours and advice received from parents among thin, overweight, obese or normal weight Australian children and adolescents.
Methods
The sample included 8550 school children aged 6 to 18 years selected from every state and territory of Australia. The children were weighed, measured and classified as thin, normal, overweight or obese using international standards. The main outcome measures were perceived and desired weight, weight related eating and exercising behaviours, and advice received from parents.
Results
The distribution of weight status was - thin 4.4%; normal weight 70.7%; overweight 18.3%; and obese 6.6%. Thin children were significantly shorter than normal weight, overweight or obese children and they were also more likely to report regularly consuming meals and snacks. 57.4% of thin children, 83.1% of normal weight children, 63.7% of overweight and 38.3% of obese children perceived their weight as "about right". Of the thin children, 53.9% wanted to be heavier, 36.2% wanted to stay the same weight, and 9.8% wanted to weigh less. Thin children were significantly less likely than obese children to respond positively to statements such as "I am trying to get fitter" or "I need to get more exercise." Parents were significantly less likely to recommend exercise for thin children compared with other weight groups.
Conclusions
Thin children, as well as those who are overweight or obese, are less likely than normal weight children to consider their weight "about right'. Thin children differ from children of other weights in that thin children are less likely to desire to get fitter or be encouraged to exercise. Both extremes of the spectrum of weight, from underweight to obese, may have serious health consequences for the individuals, as well as for public health policy. Health and wellness programs that promote positive social experiences and encourage exercise should include children of all sizes.
doi:10.1186/1479-5868-8-68
PMCID: PMC3132157  PMID: 21703026
21.  Auditory encoding abnormalities in children with autism spectrum disorder suggest delayed development of auditory cortex 
Molecular Autism  2015;6:69.
Background
Findings of auditory abnormalities in children with autism spectrum disorder (ASD) include delayed superior temporal gyrus auditory responses, pre- and post-stimulus superior temporal gyrus (STG) auditory oscillatory abnormalities, and atypical hemispheric lateralization. These abnormalities are likely associated with abnormal brain maturation. To better understand changes in brain activity as a function of age, the present study investigated associations between age and STG auditory time-domain and time-frequency neural activity.
Methods
While 306-channel magnetoencephalography (MEG) data were recorded, 500- and 1000-Hz tones of 300-ms duration were binaurally presented. Evaluable data were obtained from 63 typically developing children (TDC) (6 to 14 years old) and 52 children with ASD (6 to 14 years old). T1-weighted structural MRI was obtained, and a source model created using single dipoles anatomically constrained to each participant’s left and right STG. Using this source model, left and right 50-ms (M50), 100-ms (M100), and 200-ms (M200) time-domain and time-frequency measures (total power (TP) and inter-trial coherence (ITC)) were obtained.
Results
Paired t tests showed a right STG M100 latency delay in ASD versus TDC (significant for right 500 Hz and marginally significant for right 1000 Hz). In the left and right STG, time-frequency analyses showed a greater pre- to post-stimulus increase in 4- to 16-Hz TP for both tones in ASD versus TDC after 150 ms. In the right STG, greater post-stimulus 4- to 16-Hz ITC for both tones was observed in TDC versus ASD after 200 ms. Analyses of age effects suggested M200 group differences that were due to a maturational delay in ASD, with left and right M200 decreasing with age in TDC but significantly less so in ASD. Additional evidence indicating delayed maturation of auditory cortex in ASD included atypical hemispheric functional asymmetries, including a right versus left M100 latency advantage in TDC but not ASD, and a stronger left than right M50 response in TDC but not ASD.
Conclusions
Present findings indicated maturational abnormalities in the development of primary/secondary auditory areas in children with ASD. It is hypothesized that a longitudinal investigation of the maturation of auditory network activity will indicate delayed development of each component of the auditory processing system in ASD.
Electronic supplementary material
The online version of this article (doi:10.1186/s13229-015-0065-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13229-015-0065-5
PMCID: PMC4696177  PMID: 26719787
Autism spectrum disorder; Development; Magnetoencephalography; Auditory
22.  Children’s belief- and desire-reasoning in the temporoparietal junction: evidence for specialization from functional near-infrared spectroscopy 
Behaviorally, children’s explicit theory of mind (ToM) proceeds in a progression of mental-state understandings: developmentally, children demonstrate accurate explicit desire-reasoning before accurate explicit belief-reasoning. Given its robust and cross-cultural nature, we hypothesize this progression may be paced in part by maturation/specialization of the brain. Neuroimaging research demonstrates that the right temporoparietal junction (TPJ) becomes increasingly selective for ToM reasoning as children age, and as their ToM improves. But this research has narrowly focused on beliefs or on undifferentiated mental-states. A recent ERP study in children included a critical contrast to desire-reasoning, and demonstrated that right posterior potentials differentiated belief-reasoning from desire-reasoning. Taken together, the literature suggests that children’s desire-belief progression may be paced by specialization of the right TPJ for belief-reasoning specifically, beyond desire-reasoning. In the present study, we tested this hypothesis directly by examining children’s belief- and desire-reasoning using functional near-infrared spectroscopy in conjunction with structural magnetic resonance imaging to pinpoint brain activation in the right TPJ. Results showed greatest activation in the right TPJ for belief-reasoning, beyond desire-reasoning, and beyond non-mental reasoning (control). Findings replicate and critically extend prior ERP results, and provide clear evidence for a specific neural mechanism underlying children’s progression from understanding desires to understanding beliefs.
doi:10.3389/fnhum.2015.00560
PMCID: PMC4595792  PMID: 26500527
theory of mind (ToM); fNIRS; temporoparietal junction (TPJ); beliefs; desires; child development; developmental cognitive neuroscience
23.  Acute neuropharmacological effects of atomoxetine on inhibitory control in ADHD children: A fNIRS study 
NeuroImage : Clinical  2014;6:192-201.
The object of the current study is to explore the neural substrate for effects of atomoxetine (ATX) on inhibitory control in school-aged children with attention deficit hyperactivity disorder (ADHD) using functional near-infrared spectroscopy (fNIRS). We monitored the oxy-hemoglobin signal changes of sixteen ADHD children (6–14 years old) performing a go/no-go task before and 1.5 h after ATX or placebo administration, in a randomized, double-blind, placebo-controlled, crossover design. Sixteen age- and gender-matched normal controls without ATX administration were also monitored. In the control subjects, the go/no-go task recruited the right inferior and middle prefrontal gyri (IFG/MFG), and this activation was absent in pre-medicated ADHD children. The reduction of right IFG/MFG activation was acutely normalized after ATX administration but not placebo administration in ADHD children. These results are reminiscent of the neuropharmacological effects of methylphenidate to up-regulate reduced right IFG/MFG function in ADHD children during inhibitory tasks. As with methylphenidate, activation in the IFG/MFG could serve as an objective neuro-functional biomarker to indicate the effects of ATX on inhibitory control in ADHD children. This promising technique will enhance early clinical diagnosis and treatment of ADHD in children, especially in those with a hyperactivity/impulsivity phenotype.
Highlights
•We assessed the effects of atomoxetine administration to ADHD children using fNIRS.•Normal healthy control subjects recruited the right IFG/MFG during go/no-go tasks.•Pre-medicated ADHD children exhibited reduced right IFG/MFG activation.•The activation was acutely normalized by atomoxetine, but not by placebo.•The right IFG/MFG activation may serve as an objective neuro-functional biomarker.
doi:10.1016/j.nicl.2014.09.001
PMCID: PMC4215398  PMID: 25379431
Cortical hemodynamics; Developmental disorder; Dorsolateral prefrontal cortex; Optical topography; Stop signal task
24.  Effect of handedness on the occurrence of semantic N400 priming effect in 18- and 24-month-old children 
It is frequently stated that right-handedness reflects hemispheric dominance for language. Indeed, most right-handers process phonological aspects of language with the left hemisphere (and other aspects with the right hemisphere). However, given the overwhelming majority of right-handers and of individuals showing left-hemisphere language dominance, there is a high probability to be right-handed and at the same time process phonology within the left hemisphere even if there was no causal link between both. One way to understand the link between handedness and language lateralization is to observe how they co-develop. In this study, we investigated to what extent handedness is related to the occurrence of a right-hemisphere lateralized N400 event related potential in a semantic priming task in children. The N400 component in a semantic priming task is more negative for unrelated than for related word pairs. We have shown earlier that N400 effect occurred in 24-month-olds over the right parietal-occipital recording sites, whereas no significant effect was obtained over the left hemisphere sites. In 18-month-olds, this effect was observed only in those children with higher word production ability. Since handedness has also been associated with the vocabulary size at these ages, we investigated the relationship between the N400 and handedness in 18- and 24-months as a function of their vocabulary. The results showed that right-handers had significantly higher vocabulary size and more pronounced N400 effect over the right hemisphere than non-lateralized children, but only in the 18-month-old group. We propose that the emergences of right-handedness and right-distributed N400 effect are not causally related, but that both developmental processes reflect a general tendency to recruit the hemispheres in a lateralized manner. The lack of this relationship at 24 months further suggests that there is no direct causal relation between handedness and language lateralization.
doi:10.3389/fpsyg.2014.00355
PMCID: PMC4009411  PMID: 24808875
semantic priming; ERPs; N400; handedness; vocabulary; children
25.  Longitudinal Changes in Cortical Thickness in Children after Traumatic Brain Injury and their Relation to Behavioral Regulation and Emotional Control 
The purpose of this study was to assess patterns of cortical development over time in children who had sustained traumatic brain injury (TBI) as compared to children with orthopedic injury (OI), and to examine how these patterns related to emotional control and behavioral dysregulation, two common post-TBI symptoms. Cortical thickness was measured at approximately 3 and 18 months post-injury in 20 children aged 8.2 to 17.5 years who had sustained moderate-to-severe closed head injury and 21 children aged 7.4 to 16.7 years who had sustained OI. At approximately 3 months post-injury, the TBI group evidenced decreased cortical thickness bilaterally in aspects of the superior frontal, dorsolateral frontal, orbital frontal, and anterior cingulate regions compared to the control cohort, areas of anticipated vulnerability to TBI-induced change. At 18 months post-injury, some of the regions previously evident at 3 months post-injury remained significantly decreased in the TBI group, including bilateral frontal, fusiform, and lingual regions. Additional regions of significant cortical thinning emerged at this time interval (bilateral frontal regions and fusiform gyrus and left parietal regions). However, differences in other regions appeared attenuated (no longer areas of significant cortical thinning) by 18 months post-injury including large bilateral regions of the medial aspects of the frontal lobes and anterior cingulate. Cortical thinning within the OI group was evident over time in dorsolateral frontal and temporal regions bilaterally and aspects of the left medial frontal and precuneus, and right inferior parietal regions. Longitudinal analyses within the TBI group revealed decreases in cortical thickness over time in numerous aspects throughout the right and left cortical surface, but with notable “sparing” of the right and left frontal and temporal poles, the medial aspects of both the frontal lobes, the left fusiform gyrus, and the cingulate bilaterally. An analysis of longitudinal changes in cortical thickness over time (18 months – 3 months) in the TBI versus OI group demonstrated regions of relative cortical thinning in the TBI group in bilateral superior parietal and right paracentral regions, but relative cortical thickness increases in aspects of the medial orbital frontal lobes and bilateral cingulate and in the right lateral orbital frontal lobe. Finally, findings from analyses correlating the longitudinal cortical thickness changes in TBI with symptom report on the Emotional Control subscale of the Behavior Rating Inventory of Executive Function (BRIEF) demonstrated a region of significant correlation in the right medial frontal and right anterior cingulate gyrus. A region of significant correlation between the longitudinal cortical thickness changes in the TBI group and symptom report on the Behavioral Regulation Index was also seen in the medial aspect of the left frontal lobe.
Longitudinal analyses of cortical thickness highlight an important deviation from the expected pattern of developmental change in children and adolescents with TBI, particularly in the medial frontal lobes, where typical patterns of thinning fail to occur over time. Regions which fail to undergo expected cortical thinning in the medial aspects of the frontal lobes correlate with difficulties in emotional control and behavioral regulation, common problems for youth with TBI. Examination of post-TBI brain development in children may be critical to identification of children that may be at risk for persistent problems with executive functioning deficits and the development of interventions to address these issues.
doi:10.1016/j.ijdevneu.2012.01.003
PMCID: PMC3322311  PMID: 22266409
traumatic brain injury; child; imaging; volumetrics; longitudinal; behavior; emotion; frontal lobes; cortical thickness

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