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Ramadan is observed by 1.6 billion Muslims. In an accompanying article that uses data from the Nouna Health and Demographic Surveillance System in Burkina Faso, Schoeps et al. (Am J Epidemiol. 2018;187(10):2085–2092) find that exposure to Ramadan in early pregnancy is associated with an increased risk of mortality among children under age 5 years. Ramadan exposes observant individuals to a specific pattern of nutrition and other behaviors, including changes in sleep patterns. How these behaviors might result in child mortality is not yet understood, and the findings reported in this paper should be replicated in other settings. [ABSTRACT FROM AUTHOR]

In this issue of the Journal, Isanaka et al. (Am J Epidemiol. 2016;184(12):861-869) set out to update an incidence correction factor used for estimating numbers of cases of severe acute malnutrition (SAM) in children aged 6-59 months. The total number of current SAM cases (prevalent cases) increases by the number of new (incident) cases and decreases as a result of recovery or death. Prevalence estimates are obtained from cross-sectional surveys. Calculation of incidence typically requires longitudinal data, which evidently are rarely collected for SAM, and so a correction factor is applied instead. Isanaka et al. pool and meta-analyze data from longitudinal and community programs in 3 West African countries (Mali, Niger, and Burkina Faso), covering the period 2009-2012. Heterogeneity and the ongoing lack of data undermine the use of a single incidence correction factor for SAM estimates. Routine data collection is recommended as a way forward and aligns with recommendations of the World Health Organization. This commentary helps to outline a context for the use of such data and provide some perspective on the inadequacy of data, relative to the importance of the issue. [ABSTRACT FROM AUTHOR]

Populations that are reliant on subsistence farming are particularly vulnerable to climatic effects on crop yields. However, empirical evidence on the role of the timing of exposure to crop yield deficits in early-life development is limited. We examined the relationship between child survival and annual crop yield reductions at different stages of early-life development in a subsistence farming population in Burkina Faso. Using shared frailty Cox proportional hazards models adjusting for confounders, we analyzed 57,288 children under 5 years of age followed by the Nouna Health and Demographic Surveillance System (1994–2016) in relation to provincial food-crop yield levels experienced in 5 nonoverlapping time windows (12 months before conception, gestation, birth–age 5.9 months, ages 6.0 months–1.9 years, and ages 2.0–4.9 years) and their aggregates (birth–1.9 years, first 1,000 days from conception, and birth–4.9 years). Of the nonoverlapping windows, point estimates were largest for child survival related to food-crop yields for the time window of 6.0 months–1.9 years: The adjusted mortality hazard ratio was 1.10 (95% confidence interval: 1.03, 1.19) for a 90th-to-10th percentile yield reduction. These findings suggest that child survival in this setting is particularly vulnerable to cereal-crop yield reductions during the period of nonexclusive breastfeeding. [ABSTRACT FROM AUTHOR]

Ramadan exposure in utero can be regarded as a natural experiment with which to study how nutritional conditions in utero influence susceptibility to disease later in life. We analyzed data from rural Burkina Faso on 41,025 children born between 1993 and 2012, of whom 25,093 were born to Muslim mothers. Ramadan exposure was assigned on the basis of overlap between Ramadan dates and gestation, creating 7 exclusive categories. We used proportional hazards regression with difference-in-differences analysis to estimate the association between Ramadan exposure at different gestational ages and mortality among children under 5 years of age. Under-5 mortality was 32 deaths per 1,000 child-years. Under-5 mortality among Muslims was 15% higher than that among non-Muslims (P < 0.001). In the difference-in-differences analysis, the occurrence of Ramadan during conception or the first or second trimester was associated with higher under-5 mortality rates among Muslims only. The mortality rates of children born to Muslim mothers were 33%, 29%, and 22% higher when Ramadan occurred during conception, the first trimester, and the second trimester, respectively, compared with children of non-Muslim mothers born at the same time (P = 0.01, P < 0.001, and P = 0.007). Having a Muslim mother was not associated with mortality when the child was not exposed to Ramadan, born during Ramadan, or exposed during the third trimester. Observance of Ramadan during early pregnancy can have detrimental consequences for the future health of the unborn child. [ABSTRACT FROM AUTHOR]