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Children, especially disadvantaged children in poor countries, were expected to be among the "biggest victims" of the Covid pandemic. Economic burdens, decreased nutritious foods, reduced medical care, school closures, and ill-health or death of family members were predicted to increase child undernutrition and developmental delays, and diminish home child-rearing quality.A planned nutrition intervention could not be implemented due to Covid restrictions. However, three surveys (pre-Covid [December 2019], July 2021, and September 2021) in 280 Nepali households (309 parent-dyads, 368 children, 6-66 months old) collected demographics, child anthropometry and development (Ages and Stages Questionnaire-3 [ASQ-3]), and home child-rearing quality (caregiver engagement, learning resources, adult supervision [UNICEF's Multiple Indicator Cluster Survey]). Mixed-effect regression models adjusted for household (wealth, maternal education) and child factors (age, gender) and survey round.Height, mid-upper-arm circumference, and head circumference measurements improved over time. The total ASQ-3 score did not change: Communication scores increased while fine motor and personal-social scores declined. Girls' growth and development worsened more than boys. Caregiver engagement (especially mothers') generally declined, but learning resource availability increased. More children were left unsupervised at Round 2 than Round 1 or 3.In this sample, some aspects of child growth, development, and home child-rearing quality improved while others declined. Better understanding of these changes in child well-being and the family environment during the pandemic could provide insight on how to protect children during future crises.

The “second 1000 days” is a period of rapid brain growth which consolidates developmental foundations and establishes school readiness. Understanding the relation between household characteristics, child diet, and child development remains incomplete, especially in resource-poor settings where >250 million children risk not achieving their full developmental potential. Child developmental performance was assessed (Ages & Stages Questionnaire [ASQ]) at ages 2 and 5 years in a cohort of Nepali children (n = 207) whose families participated in a nutrition/livestock management+community development intervention trial. Relationships between child developmental performance and mother’s education, family wealth, child diet (animal source food [ASF] consumption, dietary diversity score [DDS]), school attendance, and intervention group were examined by adjusted linear regressions. These relationships varied at the 2 ages. At age 2 years, ASQ scores related positively to “Full Package Intervention” and negatively to “Partial Package Intervention” membership. At age 5 years, intervention group did not relate to ASQ scores. Mother’s education did not relate to developmental findings for 2-year-olds. Mother’s education, wealth, and school attendance positively predicted ASQ scores for these same children as 5-year-olds. Animal source food consumption was related to child development more strongly at age 5 than at 2 years. DDS had a less pronounced relationship to development than ASF consumption at both ages. Over this time span bracketing the second 1000 days, household characteristics and child diet related differentially to developmental performance depending on child age. Better understanding of the timing and mechanisms of these relationships is needed to effectively design interventions targeting improved child development in resource-poor settings.

The economic and health crises related to the COVID-19 pandemic raised considerable concern about child and family diet, especially among small-holder farming households in low- and middle-income countries (LMIC). In rural Nepal, 309 families (including 368 children aged 6–66 months) were enrolled pre-COVID-19 in a prospective study of a nutrition education intervention and family milk consumption. The intervention could not be implemented due to COVID-19; however, child and family diet was assessed in three household surveys (one before and two during the pandemic). Over time, after adjusting for child and household factors, child and family diet quality declined (reduced diet diversity, consumption of milk and animal-source-foods (ASF)). However, in dairy-animal-owning (vs. non-dairy-animal-owning) households, both children and family were more likely to consume milk (aOR respectively 2.88× (p < 0.05), 5.81× (p < 0.001)). Similarly, in households producing >3.5 L/d milk (vs. ≤3.5 L/d), children and family members were more likely to consume milk (respectively 7.45× and 11.88× (both p < 0.001)). Thus, the overall decline in child and family diet quality, especially related to milk consumption, was buffered independently by household ownership of ≥1 dairy animals (cow or buffalo) and by milk production >3.5 L/day. A better understanding of these protective factors might facilitate the development of interventions to promote resilience in future crises.

Child undernutrition afflicts >150 million children worldwide, contributing to poor child growth, increased risk of infections, and loss of developmental potential. Animal-source foods (ASF) can ameliorate these problems by providing high-quality, high-density, and bioavailable protein and micronutrients. However, many children in developing countries lack ASF in their diet, although generally milk is the ASF most often consumed. Nevertheless, the relation of ASF—and that of specific ASF—to child growth in these contexts has been difficult to define, as has the association between diet and child and household factors in influencing growth outcomes. To better understand these relationships, we evaluated child growth by age groups (6–23 mo, 24–60 mo, and >60 mo) in relation to ASF consumption in rural Nepal. We used an observational study design that leveraged a data set generated through a 3-yr longitudinal controlled impact evaluation of a community-development intervention. Child anthropometry and 24-h diet recall were obtained at 5 household visits. At baseline, children were generally undernourished: 47% were stunted, 46% underweight, 17% wasted, and 24% microcephalic. Patterns of undernutrition varied with age but improved somewhat over time. Over the 3-yr period of study (9,283 observations), ASF were consumed infrequently: milk in 28% of assessments, meat in 27%, and eggs in 15%. Consumption patterns differed by age group, with younger children (6–23 mo) consuming more milk and less meat than children 24 to 60 or >60 mo. Consumption of even a single ASF at any of the 5 surveys was associated with greater growth in bivariate analysis. After adjustment for household (group assignment, survey round and its interaction, wealth, income, livestock and land ownership, maternal education) and child factors (age, sex, baseline anthropometry), mixed-effect linear regression analysis showed that milk consumption related to higher height for age and weight for age z-scores for children >60 mo of age and to higher head circumference z-score for children age 24 to 60 mo. For children >60 mo, egg consumption also related to higher weight z-scores. Household and child factors also influenced these outcomes. Of the ASF, milk had the strongest and most consistent relationship to child growth. Better measures of diet intake could reveal stronger associations between diet consumption patterns and child growth. Regardless, milk may be a key ASF to target for growth promotion among undernourished rural Nepali children.

France receives a relatively large number of international adoptions. However, little is known about the frequency and types of microaggressions experienced by adoptive parents and internationally ...

Early-childhood development (ECD) is an important determinant of a child’s cognitive ability, learning, productivity, and lifetime earnings. Animal-sourced food (ASF), which is a rich source of high-quality protein and micronutrients, has been linked with ECD outcomes. This study investigates the relationship between the number, frequency, and cumulative consumption of ASF at 6, 9, 12, and 18 months of age and ECD outcomes at 24 months of age, controlling for physical growth. The study uses data collected from 701 mother–child pairs from an observational birth cohort study carried out in Banke, Nepal. ECD outcomes were assessed through a standardized ages and stages questionnaire (ASQ-3) tool. Separate multivariable ordinary least squares regression models were used to test for associations. Significant positive association was seen between total ASQ-3 score at 24 months of age and any ASF consumption at 18 months (β = 8.98, p-value < 0.01), controlling for growth outcomes. The study findings highlight the positive contribution and the accumulating benefit of consistent ASF consumption on ECD outcomes. This study recommends support and promotion of ASF intake among young children in Nepal through policy and programming actions relevant to female education; nutrition knowledge; quality ASF production; improved market access; cold storage; and poverty reduction.

BACKGROUND Following initial adversities, most internationally adopted children arrive with significant growth delays. Postplacement recovery has been widely documented, but research about risk or protective factors is still limited. Even less is known about the relationship between growth recovery and the quality of the family environment. METHODS Twenty-eight children in 26 adoptive families were involved in this longitudinal study. A comprehensive evaluation (including anthropometry, cognitive assessment [using the Leiter International Performance Scale-Revised], and completion by both parents of the Parenting Stress Index - Short Form) was done at arrival of the child, and 1 year later. RESULTS Results evidenced that on arrival nearly half of children had growth measurements in the normal range. All the children showed a significant recovery in height and weight at 6 and 12 months postplacement. Initial and follow-up growth measurements correlated strongly. Growth recovery was related to the age of the child at adoption, the proportion of time the child had resided in institutional care, as well as parenting stress. Results suggested that the higher the parenting stress experienced the less improvements occurred in children: for mothers for height and weight, for fathers for all the growth indicators. CONCLUSIONS Results suggested the critical importance of family factor in influencing children's growth recovery.

Objective:To compare the impact on child diet and growth of a multisectoral community intervention v. nutrition education and livestock management training alone.Design:Longitudinal community-based randomized trial involving three groups of villages assigned to receive: (i) Full Package community development activities, delivered via women’s groups; (ii) livestock training and nutrition education alone (Partial Package); or (iii) no intervention (Control). Household surveys, child growth monitoring, child and household diet quality measures (diet diversity (DD), animal-source food (ASF) consumption) were collected at five visits over 36 months. Mixed-effect linear regression and Poisson models used survey round, treatment group and group-by-round interaction to predict outcomes of interest, adjusted for household- and child-specific characteristics.Setting:Banke, Nepal.Participants:Households (n 974) with children aged 1–60 months (n 1333).Results:Children in Full Package households had better endline anthropometry (weight-for-age, weight-for-height, mid-upper-arm-circumference Z-scores), DD, and more consumption of ASF, after adjusting for household- and child-specific characteristics. By endline, compared with Partial Package or Control groups, Full Package households demonstrated preferential child feeding practices and had significantly more improvement in household wealth and hygiene habits.Conclusions:In this longitudinal study, a comprehensive multisectoral intervention was more successful in improving key growth indicators as well as diet quality in young children. Provision of training in livestock management and nutrition education alone had limited effect on these outcomes. Although more time-consuming and costly to administer, incorporating nutrition training with community social capital development was associated with better child growth and nutrition outcomes than isolated training programmes alone.

Maternal depression has been associated with adverse child growth and development; less is known about its relation to children's diet. In a cross‐sectional study embedded at endline of a longitudinal community development intervention, mothers of 629 children (age 23–66 months) in rural Nepal responded to household and children's diet questionnaires and were screened for depression. Child anthropometry and development (Ages and Stages Questionnaire) were assessed. Regression models examined children's diet, growth and development, adjusting for household, child and maternal characteristics. The prevalence of maternal depression was 21%. Maternal depression was associated with 11% lower likelihood that the child consumed one additional food group [Poisson regression, adjusted relative risk (aRR) 0.89, 95% confidence intervals (95% CI 0.81, 0.99), p = 0.024] and 13% lower likelihood that the child consumed one additional animal source food (ASF) [aRR 0.87, (95% CI 0.76, 1.01), p = 0.061] compared with children of nondepressed mothers. However, maternal depression was not associated with either child anthropometry or development: these outcomes were strongly associated with better home child‐rearing quality. Stunting also related to child age and intervention group; child development related to mother's education and household wealth. This study suggests a correlation between maternal depression and child dietary diversity. This association could be due to unmeasured confounders, and therefore, further research is warranted. Understanding the relationship of depression to child outcomes—and the role of other potentially compensatory household factors—could help address some of the earliest, modifiable influences in a child's life and contribute to innovative approaches to improve child well‐being.

AIM In the context of global changes in the epidemiology of internationally adopted children (IACs), the prevalence of infectious diseases and nutritional impairment has not been recently reviewed. Moreover, in France, these characteristics of the children according to their continents of origin and preadoption special needs (SN) status have been incompletely explored. METHODS Demographic, infectious data and anthropometric of all the newly arrived IACs seen in a specialised clinic for international adoptees in Paris, France, between 2013 and 2016 were retrospectively reviewed. RESULTS Three hundred and fifty IACs [mean age: 3.4 years (±2.7), 204 male] from 39 countries were included; 55% had SN. Ninety-nine patients had at least one infection, 42% being classified as 'serious' (chronic viral infection, tuberculosis or malaria). Chronic viral infection was diagnosed in 26 (7%) patients (HIV: 16 cases, HBV: 5, HCV: 4) and affected especially Asian children (P

Developmental delays affect between 150 and 200 million children

Individual-level dietary data within households are rarely observed over extended periods of time, which limits our understanding of intrahousehold food allocation dynamics. This study explores whether and how dietary patterns of children within households changed over a four-year period in rural Nepal. Fixed-effects analysis of the panel data indicates that there were not disparities in dietary variability between girls and boys, but that there were disparities in dietary variability across age groups. Older children had slightly higher dietary diversity, and their diets were more likely to change as household diets changed, especially for animal sourced foods. For younger children, diets were less diverse but slightly more stable over time. This stability may protect younger children when household diets decline in quality, but younger children may be left out when household dietary quality improves. In contrast, older children reap more gains relative to younger children when household dietary quality improves, but would also bear the brunt of food shortages when they arise. These results emphasize the importance of examining differences in dietary quality within households across age groups, especially for children over five years of age who are less likely to be targeted by international nutrition interventions and programs.

Background Many organizations seek to alleviate poverty in the developing world, often focusing their interventions on women. The role, status, and education of women are fundamentally important facets of development. Thus, understanding the interaction of women’s educational level and the response to interventions is important. Therefore, we examined the impact of educational level of household adults on responses to a livestock-based community intervention. Methods Six pair-matched communities in 3 districts of Nepal (Chitwan/Nawalparasi/Nuwakot), were randomly assigned to receive community development activities via women’s self-help groups at baseline or 1 year later. At 6 intervals over 48 months, a 125- item questionnaire addressing family demographics and child health/nutrition was completed in each household, plus child growth monitoring. Results were analyzed in relation to the highest education attained by any woman in the household, the child’s mother, men, or any other adult in the household. Results Outcomes (wealth, water/toilet availability, child diet diversity and growth) all significantly related to adult education. However, notable differences were found comparing the impact of men’s and women’s education. Percent change in wealth score was significant only in households where women had primary or secondary education (respectively, p = .0009 and p

Objective: To compare the impact on child diet and growth of a multisectoral community intervention v . nutrition education and livestock management training alone. Design: Longitudinal community-based randomized trial involving three groups of villages assigned to receive: (i) Full Package community development activities, delivered via women’s groups; (ii) livestock training and nutrition education alone (Partial Package); or (iii) no intervention (Control). Household surveys, child growth monitoring, child and household diet quality measures (diet diversity (DD), animal-source food (ASF) consumption) were collected at five visits over 36 months. Mixed-effect linear regression and Poisson models used survey round, treatment group and group-by-round interaction to predict outcomes of interest, adjusted for household- and child-specific characteristics. Setting: Banke, Nepal. Participants: Households ( n 974) with children aged 1–60 months ( n 1333). Results: Children in Full Package households had better endline anthropometry (weight-for-age, weight-for-height, mid-upper-arm-circumference Z -scores), DD, and more consumption of ASF, after adjusting for household- and child-specific characteristics. By endline, compared with Partial Package or Control groups, Full Package households demonstrated preferential child feeding practices and had significantly more improvement in household wealth and hygiene habits. Conclusions: In this longitudinal study, a comprehensive multisectoral intervention was more successful in improving key growth indicators as well as diet quality in young children. Provision of training in livestock management and nutrition education alone had limited effect on these outcomes. Although more time-consuming and costly to administer, incorporating nutrition training with community social capital development was associated with better child growth and nutrition outcomes than isolated training programmes alone.

Poverty adversely affects child development through multiple pathways in low- and middle-income countries. Relationships between diet and child development are poorly understood. In this study, we aimed to explore these associations in a longitudinal cohort of 305 children in rural Nepal (baseline mean age 14 months), evaluating dietary diversity and the consumption of specific food groups at three timepoints over 1.5 years. Child development was assessed using the Ages and Stages questionnaire-version 3 (ASQ-3). Associations between the number of days that children consumed minimum dietary diversity (MDD) (&ge, 4/8 items) and specific food groups over time (range 0&ndash, 3) and total and subscale ASQ scores at age 23&ndash, 38 months were estimated using multiple linear and logistic regression, dichotomizing scores at the lowest quartile. After adjusting for confounders, each additional day of consuming MDD was associated with a 35% reduction in the odds of low total ASQ score [OR 0.65, 95% CI (0.46, 0.92)]. The consumption of animal source foods [OR 0.64, (0.46, 0.89)], and vegetables/fruits [OR 0.60, (0.41, 0.90), but not processed foods [OR 0.99, (0.62, 1.59)] was associated with lower odds of low total development. Vegetables, fruits and animal source foods may be important for child development in this setting.

Internationally adopted children arrive in their new countries with many infectious disease and other health risks. Physicians provide advice prior to the arrival of the child, including pretravel health and vaccine recommendations for adoptive parents. After arrival, the adoptee should be screened for infectious diseases, including parasites, tuberculosis, hepatitis A/B/C, HIV, and syphilis, and also undergo general health evaluation. Careful assessment of immunity to vaccine-preventable diseases is also required. Follow-up screening for tuberculosis, HIV, hepatitis B/C is recommended 6 or more months after arrival. Growth and developmental delays, emotional/behavioral problems, and medical special needs are often found in this population. Parent preparation is essential to facilitate the adjustment of the child to a new family.

Introduction Both adoption status and ethnic differences may contribute to stigmatization and microaggressions experienced by adopted individuals and their families. Internationally adopted children have been increasingly recognized to have elevated rates of special needs (SN), especially learning disabilities, attention deficit hyperactivity disorder (ADHD), emotional-behavioral problems, and medical-physical issues. However, relatively little is known about the feelings, perceptions, and stigma experienced by families of internationally adopted children with SN. Methods 461 French parents responded to a questionnaire (308 on-line, 153 paper) regarding their feelings and perceptions after international adoption (feelings of difference, ease of attachment, similarities to and dissimilarities from their child), as well as their views of their child’s feelings and experiences (difference, exclusion, and prejudice). Parents were asked if their children were diagnosed by professionals as having special needs, specifically: (1) medical/physical conditions, (2) ADHD, (3) learning disabilities, or (4) emotional-behavioral difficulties. Results were compared for parents of children with or without SN. Results The children (57%M; 43%F) of the parent respondents were adopted from 47 countries. The children were age (mean ± SD) 3.19 ± 2.59 years old at arrival and 11.33 ± 5.03 years old at the time of the survey. 301 (65%) parents reported that their child had at least one SN: physical-medical SN (13% of children) were reported significantly less often than the other 3 categories (ADHD 39%, learning disabilities 36%, emotional-behavioral problems 40%). Overall, parents reported 652 distinct SN among these 301 children: 102/301 (34%) had a diagnosis in a single category, whereas 199/301 (66%) had diagnoses in at least two categories. SN diagnoses varied by continent of origin: Eastern European children had proportionally more ADHD, learning disabilities, and emotional-behavior problems, as well as more diagnoses per child. Compared with parents of non-SN children, parents of SN children (especially those with learning disabilities or emotional-behavioral problems) significantly more often endorsed feelings of difference, more difficulties attaching to their child, and fewer similarities to and more dissimilarities from their child. The SN parents also more often reported that their child experienced exclusion and/or prejudice. The more SN diagnosed in their children, the more likely their parents’ feelings and perceptions differed from parents of children without SN. These relationships remained significant after controlling for arrival age, current age, gender, and adoption visibility, and after adjusting for exclusion due to adopted status or country of origin. Conclusions Compared to adoptive parents of children without SN, parents of children with SN report differing patterns of perceptions and feelings. Child SN represent an additional burden for parents of internationally adopted children, and for their children’s feelings and experiences (difference, exclusion, and prejudice, as reported by the parents). These perceptions and feelings are present, even when the SN are not physically obvious. SN must be recognized as an increasingly common, complex, and added dimension to the issues of adoptive status and (often) ethnic differences faced by internationally adopted children and their parents.

Economic growth and poverty reduction are not always sufficient to improve child health and nutritional status. Heifer International promotes livestock introduction and related training for community development and poverty alleviation. These programmes do not directly address child health or nutrition. To determine effects of its activities on these important outcomes, Heifer conducted a 4-year longitudinal investigation in rural Nepal. The intervention was associated with significantly improved child anthropometry (related to the duration of intervention exposure) and child health. Heifer activities represent a viable ‘nutrition sensitive’ intervention, but these impacts take time to manifest and be sustained.

More than 700,000 children were adopted internationally between 1990 and 2014. The USA and France have been among the top receiving countries in these years. Recently, many factors, including the ratification of the Hague Convention on Inter-country Adoption, have favored domestic adoption for children in need of families. As a result, the number of inter-country adoptions has declined considerably. Concurrently, the proportion of internationally adopted children with defined special needs has risen dramatically. These special needs may be generally categorized as medical issues (such as physical disabilities), age (> 5 years), or being part of a sibling group. Additional special needs, frequently behavioral or emotional problems, are often diagnosed after evaluation in the receiving country. These changing trends have greatly modified the need for and type of pre-adoption preparation of prospective adoptive parents, as well as for post-adoption support for these families and their children. In this review, the authors comprehensively analyze pediatric and child psychiatric considerations for preparing and supporting families and children. Based on clinical and epidemiological studies, as well as parent questionnaires, the need for pediatric and child psychiatric support before and after the arrival child is confirmed. Consultations with professionals specializing in international adoption can provide needed advice, diagnosis, and treatment tailored to the origin of the child and his prior experiences. The high prevalence of behavioral and emotional problems often justifies the need for psychological and child psychiatric guidance. Thus, the changing trends in inter-country adoption emphasize the needs for comprehensive support linked to the specific needs of these children.

Nutrition-sensitive agricultural interventions have the potential to improve child dietary quality in rural households, as evidenced by a growing body of work which concurrently measures agricultural and nutrition indicators. Our objective was to investigate whether children in rural farming communities of Nepal participating in a community-level, nutrition-sensitive development intervention had improved dietary quality compared with children living in non-participating matched rural communities. Six rural communities of Nepal where livelihoods were predominantly agricultural were selected to participate in the phased implementation of a community-level development intervention by Heifer International . Households and children in each community were surveyed at baseline, and follow-up surveys were implemented every six months for twenty-four months. Detailed data on food consumption for children older than 6 months of age were collected using a 24 h recall for 17 foods and food groups; parents responded for children. A difference-in-differences model with household fixed-effects and an analysis of covariance model were used to analyze the resulting panel data. Results indicated that the impacts of the intervention varied by agro-ecological region and by season. In the Hills region, which is poorer on average and more conducive to livestock production, children who had received the intervention for two years were 2.2 times as likely to have consumed food from an additional food group, 1.27 times as likely to have achieved minimum dietary diversity and 1.38 times as likely to have consumed animal source foods as children who received the intervention for only one year. In the Terai region, which is more conducive to crop production, there was no significant change in dietary quality attributable to the intervention. These results provide evidence that particularly vulnerable families can take advantage of community-level development activities. Given that the effects of community-level development activities were disparate across communities within the same country, we conclude that tailoring development activities for particular locations is necessary for success.

No comprehensive studies have examined the utility of family drawings within the context of international adoption. We examined the relationship of Kinetic Family Drawings by 54 internationally adopted children in the USA (65% female; M age = 8.57 years, SD = 2.1) to demographics, child competencies (Child Behavior Checklist: CBCL/6–18) and parental adoption satisfaction (Adoption Satisfaction Questionnaire: ASQ). Two raters independently scored drawings for: emotion (positive, neutral and negative), boundaries (unifying and dividing), family composition (inclusion of family members), interactivity (active or passive) and self-emphasis. Drawing features moderately correlated with CBCL subscales (emotion, boundaries, drawing composite: r range = −.43 to 0.31, all p

Leptospirosis is an important zoonotic disease in Nepal; however, there is a lack of information on sources of leptospirosis infection for people and associated risk factors. We implemented a case-control study nested within a cross-sectional survey to investigate zoonotic risks of human leptospirosis among adult, febrile patients seeking treatment in healthcare centres in Kaski District, Nepal, from April to October 2013. The study population was 239 febrile patients; the data consisted of paired blood samples; questionnaires on clinical symptoms; occupational, environmental and animal exposures; and a blood sample from animals in the household. In total, 63 cattle, 92 buffalo, 181 goats, 20 dogs and 14 rodents from 119 households were blood sampled. Serology was performed on the samples using the microscopic agglutination test (MAT) for a panel of 20 serovars with a starting dilution of 1:50. Clinical leptospirosis was defined as a titre of 1:400 or stronger, or a 4-fold or greater rise between acute and convalescent titres, or evidence of seroconversion for one or more serovars represented by a titre of

Emotional well-being of child care providers is important to the welfare of their young charges. Elevated depression and job-related stress may affect caregivers’ ability to establish empathic connections with children. This study examined work conditions, job-related stress, and depression in 51 orphanage workers and 69 preschool teachers in Ukraine. Clinically significant levels of depressive symptoms were found in both groups. Hierarchical regression analyses showed that higher levels of perceived job resources and vacation use predicted lower depression. Predictors of perceived job resources included depression, perceived job control, and proportion of children between ages 2 and 3 in the group. A moderating effect of cognitive coping on the relationship between job control and job resources was found. This article informs interventions to promote positive development of children by identifying several factors that appear to reduce caregiver stress and depression.

To examine the association between ethnicity and disease activity in patients with juvenile idiopathic arthritis (JIA), and to determine the association of ethnicity with disease severity and disability in this population. CARRAnet, a US database containing information (collected between May 2010 and June 2011) on almost 3,000 subjects with JIA, was used. Demographic variables were compared between Hispanic patients and non-Hispanic patients. Mann-Whitney and chi-square tests were used to compare indicators of disease activity, as well as imaging evidence of joint damage, and Childhood Health Assessment Questionnaire (CHAQ) scores between ethnicities. Two linear regression models were used to determine the association of ethnicity with number of active joints in JIA, and the association between ethnicity and disability (CHAQ scores). A total of 2,704 patients with JIA (277 Hispanic; 2,427 non-Hispanic) were included. Income and health insurance coverage were higher in non-Hispanics. RF-positive polyarticular JIA, positive RF and anti-CCP, as well as use of systemic steroids were more frequent in Hispanics. Imaging evidence of joint damage was present in 32 % of the Hispanic patients compared to 24 % of the non-Hispanic patients (p = 0.008). In multivariate linear regression analyses, the number of active joints was significantly higher in Hispanics than in non-Hispanics (p = 0.03), as well as CHAQ scores (p = 0.003), after adjusting for confounders. Hispanic patients with JIA had higher disease activity than non-Hispanic patients, as well as higher disease severity and disability. Since ethnicity influences disease activity, severity, and disability, different management and treatment plans should be planned accordingly.

More than 40,000 children per year cross borders to enter new families, usually traveling from lower to higher income countries (U.S. Department of State, 2011c). These children arrive in their new adoptive countries with a variety of medical, growth, and developmental issues. Many of these issues relate to the conditions in which the children reside prior to adoptive placement. Although some children receive the emotional and physical benefits of loving foster care prior to adoption, most reside in orphanages where nurturing care and material resources are usually limited. In this chapter, the general health status-including growth, infectious diseases, and other medical issues-of internationally adopted children at arrival will be reviewed. Developmental and emotional issues are described in Chapters 13, 15, and 16.

Brain development in early childhood is a key determinant of later cognition, social achievement and educational success. Head circumference (HC) measurements are a simple method to assess brain growth, yet reports of these measurements are uncommon in nutritional surveys of undernourished children.To evaluate HC measurements in a population of rural Nepali children and relate these measurements to demographics, health and diet.An observational study of head growth was nested within a longitudinal evaluation of a livestock-based agricultural intervention in rural Nepal. Between 538 and 689 children (aged 6 months to 8 years) were measured (height, weight, HC) at each of six survey visits. A total of 3652 HC measurements were obtained. Results were converted to Z-scores (WHO Anthro).Mean head circumference Z-scores (HCZ) diminished progressively over the first 4 years of life; a decline of 30% occurred between 3 and 4 years of age (-1.73 to -2.45, P 0.0001). Overall, 56% of HCZ were -2. Gender-adjusted HCZ (but not other measurements) were significantly lower for girls than boys [mean (SD) -2.31 (1.0) vs -1.99 (0.094), P 0.0001]; girls more often had microcephaly (61% vs 50%, P 0.0001). For children 3 years of age, HCZ were better in those who had eaten two or more animal-source foods (ASFs) within the previous 24 h [-1.69 (.05) vs -2.08 (0.10), P = 0.001] than in those who had eaten none or only one; HCZ correlated with the number of ASFs consumed (P 0.001). Regression analyses demonstrated that the main determinants of HCZ were age, weight-for-age Z-scores (WAZ) and gender; 43% of the variance in HCZ in younger children was explained by WAZ and ASF consumption.HCs reflect brain size in young children; brain size is linked to cognitive function. Poor head growth represents another facet of the 'silent emergency' of child undernutrition. Routine HCZ assessments may contribute to better understanding of the links between poverty and cognitive development.

Objective.To evaluate the prevalence of vitamin D deficiency, as well as factors associated with serum 25-hydroxyvitamin D [25(OH)D] levels, in children attending a pediatric rheumatology clinic, and to determine whether there was a difference in serum 25(OH)D levels and in vitamin D deficiency between children with autoimmune disorders and nonautoimmune conditions.Methods.Cross-sectional analysis of serum 25(OH)D levels of patients between the ages of 2 and 19 years, seen between November 2008 and October 2009.Results.A total of 254 patients were studied (169 autoimmune disorders, 85 nonautoimmune conditions). The mean age of study patients was 12.3 years; 67% were female and 80% were white. In the autoimmune disorders group, 23% had vitamin D deficiency [serum 25(OH)D < 20 ng/ml], and in the nonautoimmune conditions group 14% were vitamin D deficient. The average level of serum 25(OH)D was 28.6 (± 11) ng/ml (range 2 to 59). Age, ethnicity, body mass index, use of supplements, and season were significantly associated with serum levels of 25(OH)D (all p ≤ 0.02). The OR of patients with autoimmune disorders being vitamin D deficient was 2.3, in relation to patients with nonautoimmune conditions (p = 0.04).Conclusion.Twenty percent of patients attending a pediatric rheumatology clinic were vitamin D deficient. Patients with autoimmune disorders were more likely to be vitamin D deficient than patients with nonautoimmune conditions. Screening of serum 25(OH)D levels should be performed for patients with autoimmune disorders.

Institutional caregiving can have adverse effects on children, yet little is known about the caregivers of institutionalized young children. We surveyed staff in three Ukrainian Baby Homes about their attitudes toward the nature of their work and the needs of the young children in their care. Seventy-one caregivers completed anonymous, semistructured surveys. Popular reasons for working in Baby Homes included benefits and convenient work shifts, morality, and affection for children. Caregivers reported both favorable aspects of the work (enjoyment of children, professional satisfaction) and work difficulties (conflicts, lack of cooperation, little administrative support). In addition, they noted deficiencies in care: high caregiver-child ratio, frequent care disruptions, and lack of stimulation. Direct caregivers (in-room "nannies," educators, and nurses) and other providers (e.g., clinic nurses, physicians, therapists) differed in university-degree attainment, professional motivation, enjoyment of children, professional satisfaction, and perceptions of self as substitute mother. A number of potential "windows for change" were identified, including recognition of deficiencies in institutional care and possibilities for improvement. Implications for interventions are discussed, including the need to consider lack of staff support, high emotional stress, internal conflicts, beliefs and attitudes about institutionalized children and their biological parents, and differences in staff educational achievement.

Behavioral problems are frequent among post-institutionalized Eastern European adoptees. However, risk factors related to outcomes have not been fully delineated. We evaluated 50 Eastern European adoptees, age 8—10 years, with their adoptive families for more than five years. Cognitive and behavioral outcomes and parenting stress were evaluated in relation to pre-adoptive risk factors, including arrival age, growth, and facial phenotype related to prenatal alcohol exposure. At follow-up, IQ and achievement scores were ≥ average in most children (≥74%). Behavioral and school problems were common (externalizing 44%, internalizing 18%, behavioral symptoms 50%, attention deficit hyperactivity disorder (ADHD) 46%, learning disabilities 40%, mental health disorders 28%); 38% had multiple problems. Behavioral problems correlated inversely with IQ. Parent stress was high and correlated with child externalizing behaviors and inversely to child full scale IQ. Children with “severe behavioral disturbances” (24%) were more likely to have had smaller head circumferences at arrival. Child's age at adoption related inversely to parent stress, possibly due to the longer duration of time that children resided with their families. “High/intermediate risk” phenotypic facial scores for prenatal alcohol exposure (58%) correlated with head circumference z scores at arrival and follow-up. Otherwise, arrival age, growth, and facial phenotype did not correlate with these specific outcome measures.

PurposeThis paper aims to address a central concern in modeling and simulating electric grids and the information infrastructure that monitors and controls them. The paper discusses the need for and methods to construct simulation models that include important interactions between the physical and computational elements of a large power system.Design/methodology/approachThe paper offers a particular approach to modeling and simulation of hybrid systems as an enabling technology for analysis (via simulation) of modern electric power grids. The approach, based on the discrete event system specification, integrates existing simulation tools into a unified simulation scheme. The paper demonstrates this approach with an integrated information and electric grid model of a distributed, automatic frequency maintenance activity.FindingsPower grid modernization efforts need powerful modeling and simulation tools for hybrid systems.Research limitations/implicationsThe main limitation of this approach is a lack of advanced simulation tools that support it. Existing commercial offerings are not designed to support integration with other simulation software products. The approach to integrating continuous and discrete event simulation models can overcome this problem by allowing specific tools to focus on continuous or discrete event dynamics. This will require, however, adjustments to the underlying simulation technology.Originality/valueThis paper demonstrates an approach to simulating complex hybrid systems that can, in principle, be supported by existing simulation tools. It also indicates how existing tools must be modified to support our approach.

Aims: Survey the health of young children residing in Russian orphanages. Methods: Retrospective chart review of all 193 ‘healthy’ young children (105M:88F, age range 2–72 months) residing in orphanages in Murmansk, Russia. Results: Mothers of these institutionalized children had complex histories including chronic health problems (38%), use of tobacco (41%), alcohol (39%) and illicit drugs (7%). Frequent diagnoses of the children included rickets (21%), foetal alcohol syndrome (10%), anemia (6%), developmental delay (11% mild, 25% moderate, 28% severe), behavioural problems (60%) and ‘perinatal encephalopathy’ (46%

Background More than 50% of children in Nepal are malnourished. Economic growth and poverty reduction are not always sufficient to improve the health and nutritional status of children. Heifer Nepal uses livestock training as a tool for community development and poverty alleviation but does not directly address child health and nutrition. Objective To systematically assess the effects of Heifer activities on child health and nutrition. Methods The study was a 2-year, longitudinal, randomized, controlled trial in six communities in Nepal (both Terai and hills), pair-matched for specific characteristics, randomly assigned to receive Heifer community development activities at baseline (intervention) or 1 year (control). At 6-month intervals over a period of 2 years, child anthropometric and comprehensive household surveys were performed. Results Four hundred fifteen households were enrolled containing 607 children 6 months to 5 years of age. The intervention and control communities were equivalent for baseline socioeconomic status, household size, ownership of land and animals, and child nutrition and health. At 12 months (prior to animal donations), the Terai intervention group had improved child weight ( p = .04), improved child height ( p = .05), and reduced sick days ( p = .03), as well as increased household income ( p = .004), increased ownership of animals ( p = .04) and land ( p = .04), and improved sanitation practices ( p < .01). In all districts, longer participation in Heifer activities corresponded to more improvement in child height-for-age z-scores. Conclusions Heifer interventions resulted in improved socioeconomic status and household income per family member. Children under 60 months of age in the intervention group had greater incremental improvement in height-for-age and weight-for-age z-scores than children in the control group, and longer participation in Heifer activities was associated with better growth. Poverty alleviation programs, such as Heifer, may indirectly benefit child growth.

More than 230,000 children have been adopted from other countries by American parents since 1989, including more than 72,000 from Eastern Europe. Many arrive with growth and developmental delays, and medical problems. Yet, little is known about the long-term outcomes for these children. Therefore, we assessed long-term developmental, neurobehavioral, and educational performance outcomes in a group of adopted 8- to 12-year-old children from Eastern Europe. A parent questionnaire was mailed to families of school-age Eastern European adopted children who had been in the United States for two years or more. Of the 81 children (33M: 48F) described in the returned surveys, 84 percent were 3 years old or older at adoption. Sixty-one percent of the children received special education services, and 32 percent received occupational therapy. Fifty-two percent had language disorders, 38 percent had attentional problems, and 36 percent had learning disabilities. Thirty-five percent had multiple neurodevelopme...

Background: Alcohol use in Russia is among the highest in the world. Over 600,000 children reside in institutional care in Russia, most of them in baby homes and orphanages. The actual prevalence of fetal alcohol spectrum disorders (FASD) among these children is unknown. Therefore, we performed a systematic survey of phenotypic features associated with prenatal alcohol exposure among institutionalized Russian children and related these findings to their growth, development, medical, and social histories. Methods: Phenotypic screening was conducted of all 234 baby home residents in the Murmansk region of Russia (mean age 21+12.6 months). Phenotypic expression scores were devised based on facial dysmorphology and other readily observable physical findings. Growth measurements from birth, time of placement in the baby home, and at present were analyzed. In addition, the charts of 64% of the children were randomly selected for retrospective review. Information collected included maternal, medical, developmental, and social histories. Results: Thirteen percent of children had facial phenotype scores highly compatible with prenatal alcohol exposure and 45% had intermediate facial phenotype scores. These scores correlated with maternal gravidity and age. At least 40% of mothers in whom history was available ingested alcohol during pregnancy; some also used illicit drugs and tobacco. Z scores for growth measurements corresponded to phenotypic score, as did the degree of developmental delay. Children with no or mild delay had significantly lower phenotypic scores than those with moderate or severe delay (p=0.04); more than 70% of children with high phenotypic scores were moderately or severely delayed. Conclusions: More than half of residents of the baby homes in Murmansk, Russia, have intermediate (45%) or high (13%) phenotypic expression scores suggesting prenatal exposure to alcohol. Despite good physical care, stable daily routine, availability of well-trained specialists, and access to medical care, these vulnerable children show significant growth and developmental delays compared with their institutionalized peers.

The purpose of this study was to present the clinical courses and histologic findings of 4 children with cutaneous vasculitis characterized by tender cutaneous nodules and fever in the absence of major organ involvement. We conducted a retrospective chart review of 4 patients with cutaneous vasculitis followed up for a mean of 68 months (range, 12-114 months). The patients included 3 boys and 1 girl (ages at onset, 2-10 years). Clinical and laboratory manifestations included tender erythematous cutaneous nodules (n = 4/4), fever 39 degrees C or higher (4/4), nondeforming arthritis (3/4), leukocytosis and elevated erythrocyte sedimentation rate (4/4), positive antinuclear antibodies (1/4), and elevated streptococcal enzymes (3/4). Skin biopsy results showed inflammation of medium-sized cutaneous arteries with a mixed inflammatory cell infiltrate consistent with cutaneous polyarteritis nodosa (4/4). Patients were treated with prednisone with good initial response, but exacerbation occurred once prednisone was tapered. Additional medications given were methotrexate (2/4), dapsone (2/4), colchicine (1/4), and cyclophosphamide (1/4). One patient is in clinical remission after 48 months of disease; the others have continuing disease that requires treatment. Patients with evidence of streptococcal infection received oral penicillin prophylaxis; two of the three patients had recurrent attacks of vasculitis despite penicillin. No patients have developed major organ system involvement after 12 to 114 months of follow-up. Cutaneous polyarteritis nodosa in children is a recognizable entity characterized by painful nodules, fever, absence of major organ involvement, and chronic or recurrent course. Patients should be screened for streptococcal infection and treated with antibiotics when needed.

The arrival of a newly adopted child into the family is usually a joyous time. Behavioral concerns arise in many internationally adopted children, most of whom are infants or toddlers at the time of placement with their adoptive families. Problems with feeding, sleeping, and other daily activities are often prominent in the first few weeks after the adoption. Some children display emotional distress and developmental delays; however, most recover rapidly. Anticipatory guidance from the pediatrician can assist families and children with this major life transition.

Nearly 220,000 children have been adopted from other countries by American parents since 1986. Approximately 65,000 children have arrived from China and Russia, mostly in the past 6 years. Most of these children reside in orphanages before adoption, where they may experience malnutrition, environmental deprivation, neglect, and exposure to infectious diseases. After arrival to the United States, international adoptees should undergo specialized screening evaluation for infectious diseases and other conditions. Infectious conditions of special concern include hepatitis B and C, syphilis, human immunodeficiency virus infection, tuberculosis, and presence of intestinal parasites. Before the adoption occurs, the infectious disease consultant may be asked to assist the primary care provider and the adoptive family with advice about travel and review of preadoptive medical records. After the adoption, the infectious diseases consultant may be asked to assess the adequacy of the child's vaccination record from the birth country and to assist in screening, evaluation, and management of infectious diseases.

Background.Helicobacter pylori (H. pylori) infection has been linked to gastritis, diarrhea, peptic ulcers, failure-to-thrive, anemia, as well as predisposition to gastric malignancies. Because many internationally adopted children have diarrhea, failure-to-thrive, and anemia on arrival to the US, we determined the prevalence of HP antibodies among these children. Methods. Serum samples from 226 unselected children from 18 countries who were evaluated in the International Adoption Clinic at New England Medical Center were tested for antibodies to H. pylori. The results of serologic screening were analyzed in relation to age at adoption, site of residence prior to adoption, weight and height, and the presence or absence of anemia, diarrhea, or intestinal parasites. Results. 31% of internationally adopted children had antibodies to H. pylori. The presence of H. pylori-antibodies was associated with residence in an orphanage (vs. foster care) prior to adoption, older age at adoption, and coinfection with intestinal parasites. No direct effects on height or weight were identified; no associations with diarrhea or anemia were found. Conclusions. Internationally adopted children have a high incidence of exposure to H. pylori, as diagnosed serologically. Residence in an orphanage (compared with foster care), older age at adoption, and coinfection with intestinal parasites were more common among children seropositive for anti-H. pylori antibodies.

To describe the clinical profiles of five patients with Down syndrome and elevated levels of antiphospholipid antibodies. Medical records of all 149 patients screened for anticardiolipin antibodies (aCL) in the pediatric hematology or pediatric rheumatology clinics at New England Medical Center between 1996 and 1998 were retrospectively reviewed, and patients with Down syndrome identified. Thirty-four patients (23%) had elevated IgG titers of aCL antibodies. Of these, five had Down syndrome (15%). Two presented with discoloration of the distal digits, and one each with thrombocytopenia, autoimmune hepatitis, and undifferentiated autoimmune disease. The mothers of two of the four individuals with available family history had experienced frequent miscarriages. An association may exist between Down syndrome and antiphospholipid antibodies, in particular an increased frequency of aCL antibodies. Screening patients with Down syndrome and certain clinical findings may prove useful.

Since 1987, >316,000 children have been adopted from other countries by American parents [1]. Worldwide, -40,000 children annually cross borders to join new families via international adoption. Along with many joys and challenges, these children also bring the risk of communicable diseases to their new families and communities. Some of these risks are well documented; others are less well known. For example, a child adopted from the Marshall Islands was the source case for an outbreak of tuberculosis in North Dakota that affected 56 people, including 3 of the child's 4 household members, 16 of his 24 classroom contacts, 10 of 32 school-bus riders, and 9 of 61 day-care contacts [2]. The index patient, the child's adoptive mother, presented with multifocal tuberculous osteomyelitis. Although a tine test had been placed on the child at the time of arrival, apparently it was not read, and he was not obviously ill. A total of 118 people in the town received preventive therapy, including 56 young children who wer tr ated for at least 12 weeks, until skin test results became negative. Hepatitis B virus (HBV) infection may also be spread by international adoptees. Several serosurveys performed before the availability of hepatitis B vaccine clearly demonstrate intraand extra-familial