Boniface Kalanda

Breast and Complementary Feeding Practices in Relation to Morbidity and Growth in Malawian Infants

Objectives:The objective of this study was to compare growth, morbidity incidence and risk factors for undernutrition between infants receiving complementary feeding early, before 3 months of age, with those receiving complementary foods after 3 months in a poor rural Malawian community.Methods:A cohort of babies was enrolled at birth for follow-up to 12 months of age. Weight, length, morbidity and feeding patterns were recorded at 4 weekly intervals from birth to 52 weeks.Results:Mean age at introduction of water was 2.5 months (range 0–11.8), complementary foods 3.4 months (range, 1.0–10.7) and solids 4.5 months (range 1.2–13.8). Over 40% of infants had received complementary foods by 2 months and 65% by 3 months. The proportion of exclusively breast-fed infants, which included those receiving supplemental water, was 13% at 4 months, 6.3% at 5 months and 1.5% at 6 months. Infants with early complementary feeding had lower weight for age at 3 and 6 months (P<0.05), and at 9 months (P=0.07) and at 2 months they were approximately 200 g lighter. Early complementary feeding was significantly associated with increased risk for respiratory infection (P<0.05), and marginally increased risk for eye infection and episodes of malaria. Maternal illiteracy was associated with early complementary feeding (OR=2.1, 95% CI 1.3, 3.2), while later complementary feeding was associated with reduced infant morbidity and improved growth.Conclusion:Breast-feeding promotion programmes should target illiterate women. Greater emphasis is required to improve complementary feeding practices.

Risk factors for fetal anaemia in a malarious area of Malawi

Abstract The prevalence of infants born with low cord haemoglobin (fetal anaemia) is high in areas where malaria and iron deficiency anaemia in pregnancy are common. The objective of the present study was to determine risk factors for fetal anaemia in an area of high malaria transmission in southern Malawi. A case control study was undertaken with fetal anaemia defined as cord haemoglobin (Hb) < 12.5 g/dl. Between March 1993 and July 1994, pregnant women attending the study hospitals for the first time in that pregnancy were enrolled. Data on socio-economic status, anthropometry, previous obstetric history and current pregnancy were collected. Malaria parasitaemia, Hb levels and iron status were measured in maternal blood at recruitment and delivery and in umbilical venous blood. Fetal anaemia occurred in 23.4% of babies. Mean (SD) cord Hb was 13.6 g/dl (1.83). Factors associated with fetal anaemia were: birth in the rainy season [adjusted odds ratio (AOR) 2.33, 95% CI 1.73–3.14], pre-term delivery (AOR 1.60, 1.03–2.49), infant Hb <14 g/dl at 24 hours (AOR 2.35, 1.20–4.59), maternal Hb at delivery <8 g/dl (AOR 1.61, 1.10–2.42) or <11 g/dl (AOR 1.60, 1.10–2.31). A higher prevalence of fetal anaemia occurred with increasing peripheral Plasmodium falciparum parasite density (p=0.03) and geometric mean placental parasite densities were higher in babies with fetal anaemia than in those without (3331 vs 2152 parasites/μl, p=0.07). Interventions should aim to reduce fetal anaemia by improving malaria and anaemia control in pregnancy and by addressing the determinants of pre-term delivery.

Post-neonatal infant mortality in Malawi: the importance of maternal health

Abstract In a cohort study of mothers and their infants, information was collected from women attending the antenatal services of two hospitals in a rural area of Malawi and 561 of their babies were enrolled in a follow-up study. There were 128 with a low birthweight (LBW, <2500 g), 138 with fetal anaemia (FA, cord haemoglobin <12.5 g/dl), 42 with both and 228 with a normal birthweight and no FA. Infants were seen monthly for 1 year. Risk factors for post-neonatal infant mortality (PNIM) were calculated using Cox regression analysis adjusting for LBW and FA. PNIM was 9.3%. Respiratory infections and diarrhoeal disease were the principal attributable causes of death. PNIM increased with LBW (RR 3.08, 95% CI 1.51-6.23) but not significantly so with FA (RR 1.60, 95% CI 0.78-3.27). An additional effect on PNIM was observed with maternal HIV (RR 3.44, 95% CI 1.63-7.26) and malaria at the first antenatal visit (RR 2.26, 95% CI 1.09-4.73). Illiteracy was not associated with mortality. Placental malaria in HIV-seronegative mothers was significantly associated with increased PNIM. Improving birthweight through effective antimalarial control in pregnancy will lead to a reduction in PNIM. Reduction of HIV prevalence and prevention of mother-to-child transmission of HIV must be a main target for government health policy.

Adverse birth outcomes in a malarious area

To determine factors associated with fetal growth, preterm delivery and stillbirth in an area of high malaria transmission in Southern Malawi, a cross-sectional study of pregnant women attending and delivering at two study hospitals was undertaken. A total of 243 (17.3%) babies were preterm and 54 (3.7%) stillborn. Intra-uterine growth retardation (IUGR) occurred in 285 (20.3%), of whom 109 (38.2%) were low birthweight and 26 (9.1%) preterm. Factors associated with IUGR were maternal short stature [adjusted odds ratio (AOR) 1.6, 95% confidence interval (CI) 1.0-2.5]; primigravidae (AOR 1.9, 95% CI 1.4-2.7); placental or peripheral malaria at delivery (AOR 1.4, 95% CI 1.0-1.9) and maternal anaemia at recruitment (Hb<8 g/dl) (AOR 1.9, 95% CI 1.3-2.7). Increasing parasite density in the placenta was associated with both IUGR (P=0.008) and prematurity (P=0.02). Factors associated with disproportionate fetal growth were maternal malnutrition [mid-upper arm circumference (MUAC)<23 cm, AOR 1.9, 95% CI 1.0-3.7] and primigravidae (AOR 1.8, 95% CI 1.0-3.1). Preterm delivery and stillbirth were associated with <5 antenatal care visits (AOR 2.2, 95% CI 1.3-3.7 and AOR 3.1, 95% CI 1.4-7.0 respectively) and stillbirth with a positive Venereal Disease Research Laboratory (VDRL) test (AOR 4.7, 95% CI 1.5-14.8). Interventions to reduce poor pregnancy outcomes must reduce the burden of malaria in pregnancy, improve antenatal care and maternal malnutrition.

Anthropometry of fetal growth in rural Malawi in relation to maternal malaria and HIV status

Objective: To describe fetal growth centiles in relation to maternal malaria and HIV status, using cross sectional measurements at birth. Design: A cross sectional study of pregnant women and their babies. Data on maternal socioeconomic status and current pregnancy, including HIV status and newborn anthropometry, were collected. Malaria parasitaemia was assessed in maternal peripheral and placental blood, fetal haemoglobin was measured in cord blood, and maternal HIV status was determined. Setting: Two district hospitals in rural southern Malawi, between March 1993 and July 1994. Outcome variables: Newborn weight, length, Rohrer’s ponderal index. Results: Maternal HIV (adjusted odds ratio (AOR) 1.76 (95% confidence interval 1.04 to 2.98)) and first pregnancy (AOR 1.83 (1.10 to 3.05)) were independently associated with low weight for age. Placental or peripheral parasitaemia at delivery (AOR 1.73 (1.02 to 2.88)) and primigravidae (AOR 2.13 (1.27 to 3.59)) were independently associated with low length for age. Maternal malaria at delivery and primiparity were associated with reduced newborn weight and length but not with disproportionate growth. Maternal HIV infection was associated only with reduced birth weight. The malaria and parity effect occurred throughout gestational weeks 30–40, but the HIV effect primarily after 38 weeks gestation. Conclusion: Fetal growth retardation in weight and length commonly occurs in this highly malarious area and is present from 30 weeks gestation. A maternal HIV effect on fetal weight occurred after 38 weeks gestation.

Anthropometry of Malawian live births between 35 and 41 weeks of gestation

The aim of this analysis was to construct cross-sectional gestational age specific percentile curves for birthweight, length, head and mid-arm circumference for Malawian babies, and to compare these percentiles with reference values for babies born to women with normal pregnancies, from a developed country. A cross-sectional study which enrolled pregnant women attending two study hospitals between March 1993 and July 1994 was undertaken. Data on maternal socio-economic status, newborn anthropometry, previous obstetric history and current pregnancy were collected. Smoothed percentile values were derived using the LMS method. Malawian reference percentiles were constructed for fetal growth from 35 weeks’ gestation for singleton births. Mean birthweight, length and head circumference were lower at all gestational ages for Malawian compared with Swedish newborns. Fetal growth per completed gestational week was higher by 60 g in weight, 0.5 cm in length and 0.2 cm in head circumference in Swedish compared with Malawian babies. Growth restriction was present from 35 to 41 weeks’ gestation. The pattern for the 10th percentile suggested that this was occurring from well before 35 weeks’ gestation in a proportion of babies. Résumé. Le but de cette analyse est de construire des courbes transversales de percentiles spécifiques de l’âge gestatif pour le poids à la naissance, la longueur du corps, la circonférence de la tête et du bras chez des nourrissons du Malawi et de comparer ces percentiles avec ceux de bébés nés de femmes ayant eu une grossesse normale dans un pays développé. Un étude transversale a incorporé des femmes enceintes qui fréquentaient deux centres hospitalo-universitaires entre mars 1993 et juillet 1994. Des valeurs lissées de percentiles ont été établies par la méthode des plus petits carrés moyens. Les percentiles de référence du Malawi ont été construits pour des croissances fœtales de 35 semaines d’enfants non gémellaires. Le poids de naissance moyen les circonférences de la tête et du bras sont plus bas à tous les âges gestatifs chez les les nouveaux-nés Malawiens que chez leurs pairs suédois. La croissance fœtale par semaine de gestation achevée est plus élevée chez les suédois de 60 g en poids, 0,5 cm en longueur et 0,2 cm en circonférence de la tête que chez les malawiens. Des restrictions à la croissance ont été présentes entre la 35ème et la 41ème semaine de gestation. L’allure du 10ème percentile suggère que ceci se produit longtemps avant la 35ème semaine de gestation pour une partie des bébés. Zusammenfassung. Das Ziel dieser Analyse war, Schwangerschaftsdauer-spezifische Querschnittsperzentilkurven für Geburtsgewicht, Länge, Kopfumfang und Umfang des mittleren Armes für Säuglinge aus Malawi zu konstruieren, und diese Perzentilen mit Referenzwerten für Säuglinge aus normalen Schwangerschaften aus einem entwickelten Land zu vergleichen. Mit schwangeren Frauen, die sich zwischen März 1993 und Juli 1994 in zwei Studienkrankenhäusern vorgestellt hatten, wurde eine Querschnittstudie gemacht. Daten betreffend den mütterlichen sozio-ökonomischen Status, Neugeborenenmaße, frühere geburtshilfliche Anamnese und die jetzige Schwangerschaft wurden gesammelt. Mit LMS-Methode wurden geglättete Perzentilwerte gerechnet. Referenzperzentilen wurden für fetales Wachstum von Einlingen aus Malawi ab der 35. Gestationswoche konstruiert. In allen Altersgruppen waren das mittlere Geburtsgewicht, die Länge und der Kopfumfang von Neugeborenen aus Malawi niedriger als von Schwedischen Neugeborene. Mit jeder vollendeten Schwangerschaftswoche waren Schwedische Neugeborene um 60 g schwerer, um 0,5 cm länger und hatten einen um 0,2 cm größeren Kopfumfang als Neugeborene aus Malawi. Gehemmtes Wachstum fand sich von der 35 bis zur 41 Schwangerschaftswoche. Der Verlauf der 10 Perzentile legte nahe, dass dies bei einem Teil der Kinder bereits deutlich vor der 35 Schwangerschaftswoche bestanden hatte. Resumen. El objetivo de este análisis fue construir curvas percentilares transversales, específicas para la edad gestacional, para el peso al nacimiento, longitud, circunferencias de la cabeza y del brazo medio, en niños de Malawi, y comparar estos percentiles con los valores de referencia para niños nacidos de mujeres con embarazos normales de un país desarrollado. Se emprendió un estudio transversal que incluía mujeres embarazadas que acudían a dos hospitales estudiados entre Marzo de 1993 y Julio de 1994. Se recogieron datos sobre el nivel socioeconómico materno, la antropometría del recién nacido, la historia obstétrica previa y el embarazo actual. Los valores percentilares suavizados se derivaron mediante el método LMS. Los percentiles de referencia de Malawi se construyeron para el crecimiento fetal a partir de la semana 35 de gestación para los nacimientos simples. En Malawi, los valores medios del peso al nacimiento, longitud y circunferencia de la cabeza fueron menores a todas las edades gestacionales, comparados con los recién nacidos suecos. El crecimiento fetal por semana de gestación completada fue 60 g mayor para el peso, 0,5 cm para la longitud y 0,2 cm para la circunferencia de la cabeza en los niños suecos comparados con los de Malawi. La restricción del crecimiento estaba presente desde la semana 35 a la 41 de gestación. El patrón del percentil 10 sugería que esto ocurría ya antes de la semana 35 de gestación en una cierta proporción de bebés.

Size and morbidity in Malawian twins

Objective:Twins in developing countries may be disadvantaged due to their small size at birth, compromised nutrition and high infection risk. Although twinning is common in Africa, there are few longitudinal studies of growth and morbidity in this high-risk group. The aim of the present paper was to describe growth and morbidity of Malawian twins compared to singletons.Methods:Morbidity episodes were recorded at 4 weekly intervals and at extra visits made to health centres for illness. Weight, length, head and arm circumference were recorded at birth and weight, length and MUAC at 4 weekly intervals to 52 weeks of age.Results:Twins showed reduced fetal growth compared to singletons, with increasing fall-off in percentiles from 33 weeks gestation. Infant growth percentiles for twins were below those for singletons at all ages, but showed no fall-off from singleton percentile values. There were no differences in morbidity incidence during infancy between twins and singletons.Conclusion:Malawian twins showed no catch-up growth during infancy, their smaller size was not associated with higher morbidity incidence compared to singletons.