Objectives

To assess whether serial measurements of childhood body mass index (BMI) give clinically useful predictions of the risk of developing adult metabolic syndrome and impaired glucose tolerance or type 2 diabetes.

Design/setting

Follow-up of a community-based birth cohort in Delhi, India.

Participants

1,492 men and women aged 26-32 years whose BMI was recorded 6-monthly throughout childhood.

Main outcome measures

The predictive value of childhood BMI for adult metabolic syndrome (MS) defined using waist circumference, blood pressure and fasting glucose, triglyceride and HDL-cholesterol concentrations, and impaired glucose tolerance (IGT) and diabetes (DM) diagnosed by oral glucose tolerance tests.

Results

Twenty-five percent of subjects had MS and 15% had IGT/DM. Both outcomes were associated with greater childhood BMI gain (MS: OR 1.63 [95% CI 1.44 to 1.85]; IGT/DM: 1.39 [1.20 to 1.60] per unit increase in within-cohort BMI SD-score between 5-14 years). Best predictions of adult disease were obtained using a combined test comprising i) any increase in BMI SD-score between 5-14 years and ii) a BMI SD-score >0 at 14 years (MS: sensitivity 45%, specificity 78%; IGT/DM: 37%, 73%). Likelihood ratios were low (MS: 1.4-2.0; IGT/DM: 1.2-1.4). A single high BMI measurement at 14 years (overweight or obese, International Obesity Task Force criteria) was highly specific but insensitive (MS: sensitivity 7%, specificity 97%; IGT/DM: 8%, 97%). Charts for plotting BMI SD-scores through childhood were produced.

Conclusions

Serial measurements of childhood BMI give useful predictions of adult risk and could guide advice to children and parents on preventing later disease.

Objectives

To document distinct patterns of language use by bilingual children (use of an alternative language exclusively, LE, or along with English, BIL). To establish how these patterns affect onset of stuttering, school performance and recovery rate relative to monolingual speakers who stutter (MONO).

Design

Clinical referral sample with cases classified by speech-language therapists. Supplementary data obtained from speech recordings, interviews with child and family.

Setting

South-East England, 1999-2007.

Participants

Children aged 8-12 plus who stuttered (monolingual and bilingual) and fluent bilingual controls (FB).

Main outcome measures

Participants’ stuttering history, SATS scores, measures of recovery or persistence of stuttering.

Results

The sample of 317 children had 69 bilinguals (prevalence rate of bilingualism in the stuttering sample was 21.8%). 38 children used a language other than English primarily or exclusively in the home and 36 of these (94.7%) bilinguals who stuttered did so in both their languages. There were fewer LE than BIL stuttering children at time of first referral to clinic (of the bilinguals who stuttered, 15/38, 39.5%, were LE and 23/38, 60.5%, were BIL). The reverse was the case in the fluent control sample (of the bilinguals who did not stutter, 28/38, 73.7%, were LE and 10/38, 26.3%, were BIL). The association between stuttering and bilingual group (LE/BIL) was significant by χ2 and this is consistent with a higher chance of stuttering for BIL than LE speakers. For speakers who stuttered, age of stuttering onset for LE and BIL was similar to that reported for MONO groups (4 years 9 months, 4 years 10 months and 4 years 3 months for LE, BIL, MONO respectively) and males were affected in each of these groups to about the same extent (the male/female ratio was 4.1:1, 4.75:1 and 4.43:1 for LE, BIL and MONO respectively). For the 29 children who were old enough to complete the assessments, educational achievement at key stages one and two was not affected by either form of bilingualism relative to the MONO and fluent bilingual groups. For these same children, recovery rate for LE and MONO controls was significantly higher by χ2 than for those who were BIL since birth (recovery rate for LE and MONO together was 55%, and for BIL was 25%).

Conclusions

There was an increased chance of stuttering onset for BIL children. The chances of recovery from stuttering were lower for BIL speakers than for LE and MONO speakers.

Objective

To establish incidence rates, clinic referrals, hospitalisations, mortality rates and baseline determinants of morbidity among infants in an Indian slum.

Design

A community-based birth cohort with twice-weekly surveillance.

Setting

Vellore, South India.

Subjects

452 newborns recruited over 18 months, followed through infancy.

Main outcome measures

Incidence rates of gastrointestinal illness, respiratory illness, undifferentiated fever, other infections and non-infectious morbidity; rates of community-based diagnoses, clinic visits and hospitalisation; and rate ratios of baseline factors for morbidity.

Results

Infants experienced 12 episodes (95% confidence interval (CI) 11 to 13) of illness, spending about one fifth of their infancy with an illness. Respiratory and gastrointestinal symptoms were most common with incidence rates (95% CI) of 7.4 (6.9 to 7.9) and 3.6 (3.3 to 3.9) episodes per child-year. Factors independently associated with a higher incidence of respiratory and gastrointestinal illness were age (3-5 months), male sex, cold/wet season and household involved in beedi work. The rate (95% CI) of hospitalisation, mainly for respiratory and gastrointestinal illness, was 0.28 (0.22 to 0.35) per child-year.

Conclusions

The morbidity burden due to respiratory and gastrointestinal illness is high in a South Indian urban slum, with children ill for approximately one fifth of infancy, mainly with respiratory and gastrointestinal illnesses. The risk factors identified were younger age, male sex, cold/wet season and household involvement in beedi work.

Objective:

To examine UK country and regional differences, within England only, in childhood overweight (including obesity) at three years and determine whether any differences persist after adjustment for individual risk factors.

Design:

Nationally representative prospective study

Setting:

England, Wales, Scotland, and Northern Ireland

Participants:

13 194 singleton children from the UK Millennium Cohort Study with height and weight data at age three years.

Main outcome measure:

Overweight (including obesity) was defined by the International Obesity TaskForce cut-offs for body mass index, which are age and sex specific.

Results:

At three years, 23.0% (3102) of children were overweight or obese. In univariable analyses, children from Northern Ireland (odds ratio 1.30, 95% Confidence Interval 1.14 to 1.48) and Wales (1.26, 1.11 to 1.44) were more likely to be overweight than children from England. There were no differences in overweight between children from Scotland and England. Within England, children from the East (0.71, 0.57 to 0.88) and South East regions (0.82, 0.68 to 0.99) were less likely to be overweight than children from London. There were no differences in overweight between children from other English regions and children from London. These differences were maintained after adjustment for individual socio-demographic characteristics and other risk factors for overweight.

Conclusions:

UK country and English regional differences in early childhood overweight are independent of individual risk factors. This suggests a role for policies to support environmental changes that remove barriers to physical activity or healthy eating for young children.

The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.

Summary

Small hospitals sit at the apex of the pyramid of primary care in many low-income country health systems. If the Millennium Development Goal for child survival is to be achieved hospital care for severely ill, referred children will need to be improved considerably in parallel with primary care in many countries. Yet we know little about how to achieve this. We describe the evolution and final design of an intervention study attempting to improve hospital care for children in Kenyan district hospitals. We believe our experience illustrates many of the difficulties involved in reconciling epidemiological rigour and feasibility in studies at a health system rather than an individual level and the importance of the depth and breadth of analysis when trying to provide a plausible answer to the question - does it work? While there are increasing calls for more health systems research in low-income countries the importance of strong, broadly-based local partnerships and long term commitment even to initiate projects are not always appreciated.