Chronic Malnutrition & Child Development

Background: Stunting is a pervasive issue in low‑ and middle‑income countries, reflecting biological processes that adversely affect childhood cognitive development and increase the risk of chronic disease in adulthood. Nutritional intake is an important causative factor in stunting. Understanding the nutritional intake patterns of children with stunting can help inform nutrition program development. Objective: To characterize breastfeeding and dietary patterns from a clinical cohort of children with stunting in Guatemala and identify factors associated with linear growth. Methods: We included children with at least one diet record and one length/height‑for‑age z‑score below -2 from ages 0-5 years. We excluded children enrolled in complex care for severe non‑nutritional illness and records from prior to 6 months of age. We described adherence to World Health Organization infant and young child feeding indicators upon program enrollment. We longitudinally characterized breastfeeding and complementary feeding patterns of the cohort using generalized additive mixed modeling. We identified and quantified associations between various nutritional factors and linear growth using linear mixed effects models. Results: The final analytical dataset included 19,476 patient encounters from 2,352 children. Most children did not meet World Health Organization standards for dietary adequacy upon enrollment in the program. Dietary intakes were predominantly carbohydrate‑based. The factors most strongly associated with linear growth were food insecurity (negatively associated), portion size, and continued breastfeeding from 12 to 23 months. Adherence to the infant and young child feeding indicators was positively associated with linear growth. The intake of most food groups was also positively associated with linear growth. Conclusions: These findings suggest that the nutritional focus of interventions should be on adequate dietary diversity, earlier introduction and higher frequency of the less frequently consumed food groups, age‑appropriate portion sizes, and breastfeeding through 2 years of age. Public policy measures to address food insecurity are also necessary.

To test the feasibility of a smartphone app, BebeApp, that provides evidence-based early childhood development (ECD) guidance in rural Guatemala and pilot procedures for an adequately powered randomised controlled trial. We conducted an individually randomised pilot feasibility trial to compare BebeApp to printed ECD guidance. This trial was conducted in Tecpán, Chimaltenango, a semi-rural community that is 95% Kaqchikel Indigenous Maya. First-time primary caregiver-infant (0-28 days) dyads. BebeApp provides age-dependent, evidence-based caregiver guidance for breastfeeding and complementary feeding, sleep and developmental support. A mixed-methods evaluation of BebeApp's implementation and acceptability using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. App usability, usefulness and satisfaction were assessed via questionnaires, semi-structured interviews and app interaction data. 41 infant-caregiver dyads were enrolled with 40 completing the study. Engagement was high with caregivers opening BebeApp a median (IQR) 11 (6-21) times per month. Usability was found to be acceptable but no difference was found between pre-measurements and post-measurements. In interviews, caregivers expressed some initial difficulty using BebeApp but were able to gain confidence with a training session. App usefulness and satisfaction responses were positive. Caregivers often noted that BebeApp was their only source of ECD information outside of their family. We found that caregivers in rural Guatemala responded positively to a smartphone ECD app and engaged with it throughout the trial. Given the urgent need for ECD programmes in low- and middle-income settings, smartphone apps may be a method to deliver services directly to caregivers.

To assess the cost of co-creating an adaptation of the International Guide for Monitoring Child Development (intervention for use by community health workers (CHWs)) in rural Guatemala and India. We developed survey instruments to capture the costs, from health-system and societal perspectives, of adapting the guide with local partners and international experts in the two sites. We included the costs of human resources, information technology, and infrastructure and logistic support. To improve the transparency and comparability of cost estimates, we reported the required resources for adaptation, such as time and expertise of human resources, and the quantity, function and usage time of the resources used. Adaptation of the guide took 14 months in India and 18 months in Guatemala during 2021-2022. Total costs by site were 38 174.57 United States dollars (US$) in Guatemala, US$ 39 287.15 in India and US$ 81 846.59 for international consultants. International consultants accounted for about half of the costs, and the Guatemala and India sites each accounted for about a quarter of the costs. Human resources were the largest contributor to the adaptation costs in both sites (90.1%; 34 398.20/38 174.57 in Guatemala and 94.8%; 37 262.74/39 287.15 in India) followed by infrastructure support and information technology. Since most of the required steps to adapt the guide for use by CHWs have now been done by our study, we expect future adaptation costs to be lower. The methods used in this study provide an example of how to cost intervention adaptations in the future. Évaluer le coût de la création conjointe d'une adaptation du Guide international d’observation du développement de l’enfant (intervention destinée aux agents de santé communautaire) dans les zones rurales du Guatemala et de l’Inde. Nous avons mis au point des outils d’enquête afin de recenser les coûts, d’un point de vue sociétal et du système de santé, liés à l’adaptation du guide en collaboration avec des partenaires locaux et des experts internationaux dans les deux pays. Nous avons pris en compte le coût des ressources humaines, de l’équipement informatique, de l’infrastructure et du soutien logistique. Afin d’améliorer la transparence et la comparabilité des estimations de coûts, nous avons énuméré les ressources nécessaires à l’adaptation, telles que le temps mis et l’expertise des ressources humaines, ainsi que la quantité, la fonction et la durée d’utilisation des ressources mobilisées. L’adaptation du guide a nécessité 14 mois en Inde et 18 mois au Guatemala sur la période 2021–2022. Les coûts totaux par pays étaient de 38 174,57 dollars américains (USD) au Guatemala, de 39 287,15 USD en Inde et de 81 846,59 USD pour les consultants internationaux. Ceux-ci représentaient environ la moitié des coûts, tandis que l’Inde et le Guatemala représentaient chacun environ un quart des coûts. Les ressources humaines représentaient le poste de dépenses principal dans les coûts d’adaptation dans les deux pays (90,1%; 34 398,20 / 38 174,57 au Guatemala et 94,8%; 37 262,74 / 39 287,15 en Inde), suivies de l’infrastructure et de l’équipement informatique. Dans la mesure où la plupart des étapes nécessaires à l’adaptation du guide à l’usage des agents de santé communautaire ont déjà été réalisées dans le cadre de notre étude, les futurs coûts d’adaptation devraient être inférieurs. Les méthodes appliquées dans la présente étude offrent un exemple de la façon de chiffrer le coût des adaptations d’interventions dans le futur. Evaluar el coste de la cocreación de una adaptación de la Guía Internacional para el Seguimiento del Desarrollo Infantil (intervención para su uso por trabajadores comunitarios de salud [TCS ]) en zonas rurales de Guatemala e India. Se desarrollaron instrumentos de encuesta para estimar los costes, desde las perspectivas del sistema sanitario y de la sociedad, de la adaptación de la guía con socios locales y expertos internacionales en ambos emplazamientos. Se incluyeron los costes de recursos humanos, tecnologías de la información y apoyo de infraestructura y logístico. Para mejorar la transparencia y la comparabilidad de las estimaciones de costes, se describieron los recursos necesarios para la adaptación, como el tiempo y la experiencia del personal, así como la cantidad, la función y el tiempo de uso de los recursos utilizados. La adaptación de la guía requirió 14 meses en India y 18 meses en Guatemala durante el periodo 2021-2022. Los costes totales por emplazamiento fueron de 38 174,57 dólares de los Estados Unidos (US$) en Guatemala, US$ 39 287,15 en India y US$ 81 846,59 correspondientes a consultores internacionales. Los consultores internacionales representaron aproximadamente la mitad de los costes, mientras que los emplazamientos de Guatemala e India representaron cada uno alrededor de una cuarta parte. Los recursos humanos constituyeron el principal componente de los costes de adaptación en ambos emplazamientos (90,1%; 34 398,20/38 174,57 en Guatemala y 94,8%; 37 262,74/39 287,15 en India), seguidos del apoyo a la infraestructura y de las tecnologías de la información. Dado que la mayoría de las etapas necesarias para adaptar la guía para su uso por trabajadores comunitarios de salud ya se han llevado a cabo en este estudio, se espera que los costes de adaptación futuros sean menores. Los métodos utilizados en este estudio proporcionan un ejemplo de cómo estimar los costes de adaptaciones de intervenciones en el futuro. تقييم تكلفة المشاركة في إنشاء نسخة مُعدّلة من الدليل الدولي لرصد نمو الطفل (تدخل لاستخدامها بواسطة العاملين في مجال الصحة المجتمعية (CHW) في المناطق الريفية في غواتيمالا والهند. قمنا بتطوير أدوات للمسح لرصد تكاليف تكييف الدليل، من منظور النظام الصحي والمنظور المجتمعي، بالتعاون مع شركاء محليين وخبراء دوليين في الموقعين. وقمنا بتضمين تكاليف الموارد البشرية، وتكنولوجيا المعلومات، والبنية التحتية، والدعم اللوجستي. ولتحسين شفافية تقديرات التكلفة وقابلية مقارنتها، قمنا بإعداد تقارير عن الموارد المطلوبة للتكييف، مثل وقت وخبرة الموارد البشرية، وكمية الموارد المستخدمة ووظيفتها ومدة استخدامها. استغرق تكييف الدليل 14 شهرًا في الهند و18 شهرًا في غواتيمالا خلال الفترة من 2021 إلى 2022. وبلغت التكاليف الإجمالية حسب الموقع 38174.57 دولارًا أمريكيًا في غواتيمالا، و39287.15 دولارًا أمريكيًا في الهند، و81846.59 دولارًا أمريكيًا للاستشاريين الدوليين. شكل الاستشاريون الدوليون حوالي نصف التكاليف، بينما شكلت تكاليف كل من غواتيمالا والهند حوالي ربع التكاليف. كانت الموارد البشرية المساهم الأكبر في تكاليف التكييف في كلا الموقعين (%90.1؛ 34398.20/38174.57 في غواتيمالا، و%94.8؛ 37262.74/39287.15 في الهند)، يليها دعم البنية التحتية وتكنولوجيا المعلومات. نظرًا لأن معظم الخطوات المطلوبة لتكييف الدليل لاستخدامه بواسطة العاملين في مجال الصحة المجتمعية، قد تم إنجازها في دراستنا، فإننا نتوقع انخفاض تكاليف التكييف المستقبلية. تقدم الأساليب المستخدمة في هذه الدراسة مثالًا على كيفية حساب تكاليف تكييف التدخلات في المستقبل. 旨在评估共同制定《儿童发展监测国际指南》改编版本【供危地马拉和印度农村地区的社区卫生工作者 (CHW) 采取干预措施时使用】所需成本。. 我们开发了调查工具，以从卫生系统和社会的角度计算在这两个国家聘请当地合作伙伴和国际专家改编指南所需成本。我们将人力资源成本、信息技术成本以及基础设施和后勤支助成本全部计算在内。为了提升成本估计的透明度和可比性，我们报告了改编指南所需资源（例如人力资源方面的时间投入和专门知识投入）以及所用资源的数量、功能和使用时间。. 在 2021-2022 年期间，印度和危地马拉分别历时 14 个月和 18 个月完成了指南改编工作。按现场划分算得的总成本分别为 38,174.57 美元（危地马拉）、39287.15 美元（印度）和 81846.59 美元（聘请国际顾问的花费）。聘请国际顾问的花费约占成本的一半，而危地马拉和印度两个现场的支出分别约占成本的四分之一。在两国改编成本中，占比最大的都是人力资源支出（在危地马拉占 90.1%，即 34398.20/38174.57；在印度占 94.8%，即 37262.74/39287.15），其次是在基础设施支助和信息技术方面的支出。. 由于我们现已在开展研究的过程中完成了大部分指南改编（以供 CHW 使用）相关必要步骤，我们预计未来的改编成本将会降低。我们在本次研究中所用方法为未来如何计算干预措施改编成本提供了范例。. Оценить затраты на совместное создание адаптированной версии Международного руководства по мониторингу развития детей (предназначенного для использования общинными медико-санитарными работниками (ОМСР) в сельских районах Гватемалы и Индии). Авторы разработали опросники, чтобы определить затраты (с точки зрения системы здравоохранения и общества) на адаптацию руководства с привлечением местных партнеров и международных экспертов в двух странах. В расчет включались затраты на кадровые ресурсы, информационные технологии, инфраструктуру и материально-техническую поддержку. Чтобы повысить прозрачность и обеспечить сравнимость оценок затрат, авторы представили данные о требуемых для адаптации ресурсах, таких как время, квалификация кадровых ресурсов, количество, функциональное назначение и время использования каждого из ресурсов. Адаптация руководства заняла 14 месяцев в Индии и 18 месяцев в Гватемале на протяжении 2021–2022 годов. Общие затраты составили 38 174,57 доллара США для Гватемалы, 39 287,15 доллара США для Индии и 81 846,59 доллара США на международных консультантов. Почти половина расходов пришлась на международных консультантов, а расходы на местах в Гватемале и Индии составили примерно по четверти от общей суммы. Наибольшая доля затрат в обеих странах пришлась на оплату кадровых ресурсов (90,1%, 34 398,20/38 174,57 доллара США в Гватемале и 94,8%, 37 262,74/39 287,15 доллара США в Индии), за которыми следовали инфраструктурная поддержка и информационные технологии. Поскольку большая часть шагов для адаптации руководства к использованию ОМСР была выполнена в ходе описываемого исследования, авторы полагают, что впредь затраты на адаптацию будут ниже. Методы, использованные в данном исследовании, служат примером того, каким образом оценивать затраты на адаптацию мер в будущем.

BackgroundStunting is a pervasive issue in low- and middle-income countries, particularly affecting rural and Indigenous populations. Little reported data is available on the growth of clinical populations of children with stunting, including those with more severe stunting.ObjectiveThis study examines growth trajectories of children under 5 years of age from a long-standing clinical care program to address childhood stunting that provides monthly at-home growth monitoring, family food rations, nutrition counseling, micronutrient supplementation, and childhood illness management.HypothesisWe hypothesized that children with stunting are a clinically heterogeneous group, where some experience ongoing growth failure and others catch-up growth.MethodsWe utilized data from 2827 children and 38 864 height measurements. We applied superimposition by translation and rotation modeling to characterize growth patterns.ResultsMedian age at first measurement was 9 months (IQR: 3, 16) and median length of growth monitoring was 17 months (IQR: 8, 30). Median height-for-age Z-score at first measurement was -2.51 (IQR: -3.23, -1.68). There was variability in growth dynamics, with some children showing potential catch-up growth, particularly those with the lowest initial height-for-age metrics. In regression analysis, factors significantly associated with growth improvement over time included greater initial severity of stunting, male sex, and geographical region.ConclusionsThese findings underscore the heterogeneity of growth responses among stunted children and the need for individualized intervention strategies. They emphasize the necessity for ongoing investigations of both tailored clinical interventions and novel factors associated with growth variability and catch-up growth. Understanding growth patterns of stunted children under 5 years of age in Guatemala: a chart review.

Child growth failure (CGF), which includes underweight, wasting, and stunting, is among the factors most strongly associated with mortality and morbidity in children younger than 5 years worldwide. Poor height and bodyweight gain arise from a variety of biological and sociodemographic factors and are associated with increased vulnerability to infectious diseases. We used data from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 to estimate CGF prevalence, the risk of infectious diseases associated with CGF, and the disease mortality, morbidity, and overall burden associated with CGF. In this analysis we estimated the all-cause and cause-specific (diarrhoea, lower respiratory tract infections, malaria, and measles) disability-adjusted life-years (DALYs) lost and mortality associated with stunting, wasting, underweight, and CGF in aggregate. We combined the burden associated with mild, moderate, and severe forms of CGF: stunting was defined as height-for-age Z scores (HAZ) less than -1, underweight was defined as weight-for-age Z scores (WAZ) less than -1, and wasting was defined as weight-for-height Z scores (WHZ) less than -1, according to WHO Child Growth Standards. Population-level continuous distributions of HAZ, WAZ, and WHZ were estimated for 2000 to 2023 using data from surveys, literature, and individual-level study data. The risk of incidence of, and mortality due to, diarrhoea, lower respiratory infections, malaria, and measles was separately estimated in a meta-regression framework from longitudinal cohort data for Z scores less than -1. Finally, fatal outcomes associated with these diseases were estimated with vital registration, verbal autopsy, and case-fatality data, while non-fatal outcomes were estimated with surveys as well as health-care utilisation and case reporting data. The exposure prevalence and relative risk estimates were from continuous distributions, allowing for direct assessment of the attributable fractions for mild, moderate, and severe stunting, underweight, wasting, and the combined impact of child growth failure within populations. All estimates were age-specific, sex-specific, geography-specific, and year-specific. We estimated that, in children younger than 5 years in 2023, CGF was associated with 79·4 million (95% uncertainty interval [UI] 47·0-106) DALYs lost and 880 000 (517 000-1 170 000) deaths. This represented 17·9% (10·6-23·8) of 444 million (434-457) total under-5 DALYs and 18·8% (11·1-25·0) of all 4·67 million (4·59-4·75) under-5 deaths. Compared to stunting (33·0 million [24·1-42·2] DALYs, 373 000 [272 000-477 000] deaths) and wasting (39·2 million [23·8-53·0] DALYs, 428 000 [256 000-583 000] deaths), childhood underweight was associated with the largest share of CGF-related disease burden: 52·2 million (21·9-75·1) DALYs and 573 000 (236 000-824 000) deaths in children younger than 5 years in 2023. CGF remains a leading factor associated with death and disability in children younger than 5 years, despite global attention and focused interventions to reduce the prevalence of associated CGF indicators. Our findings underscore the need for policies, strategies, and interventions that focus on all indicators of CGF to reduce its associated health burden. Gates Foundation.

There is worldwide interest in determining whether frequent egg provision during complementary feeding enhances child development and growth in low-resource settings. We evaluated effects of adding one whole egg per day to local standard nutrition care on infant outcomes. The Saqmolo' Project individually randomized, partially blinded, comparative effectiveness clinical trial was conducted in rural Guatemala from 2021 to 2023. Maya infants aged 6-9 months were randomized to standard nutrition care alone (growth monitoring, complementary and responsive feeding education, deworming medication, multiple micronutrient powders, and referrals for medical care) versus standard care plus one whole egg per day for 6 months. Mixed linear or logistic regression models were used to estimate between-group differences in primary (global development score) and secondary (growth, anemia status, and diet quality) outcomes. This trial included 1200 Maya infants (51.3% male). After adjustment for baseline values and participant characteristics, there was no significant between-group difference in global development score (β -0.08 points [95% CI -0.22 to 0.06]). There were also no significant between-group differences for most secondary outcomes. Intervention participants did have significantly higher odds of stunting (odds ratio [OR] 1.42 [95% CI 1.10-1.82]; p = 0.007) and of meeting minimum dietary diversity (OR 1.41 [95% CI 1.20-1.65]; p < 0.001) and minimum adequate diet (OR 1.44 [95% CI 1.26-1.64]; p < 0.001) benchmarks than standard care participants. Provision of one whole egg per day in addition to standard care improved diet quality but did not benefit development, growth, or anemia status among Maya infants. Academy of Nutrition and Dietetics Foundation via an Egg Nutrition Center investigator-initiated research grant.

To assess human papillomavirus (HPV) vaccine awareness and uptake among caregivers in rural Indigenous communities in Guatemala and to identify sociodemographic predictors of vaccine unawareness and non-uptake. This cross-sectional survey was conducted across 12 rural Indigenous communities in Guatemala's Central Highlands. Using a community-engaged research approach, trained multilingual health workers administered surveys in Spanish, Kaqchikel or K'iche'. Eligible participants were adults who served as primary caregivers to children. The survey assessed HPV vaccine awareness, vaccine attitudes and uptake among those with daughters aged 8 or older. Logistic regression was used to examine predictors of vaccine unawareness and bivariate analysis explored differences in vaccine uptake. Among 602 participants (92.5% identified as Indigenous), 95% expressed willingness to vaccinate a child against cervical cancer, yet only 56% had heard of the HPV vaccine. Of the 175 participants with eligible daughters, only 33.7% reported vaccination. Indigenous identity, older age and illiteracy were significantly associated with HPV vaccine unawareness. Speaking an Indigenous language at home was associated with greater awareness. Departmental differences were significant: participants from Sololá were more likely to be unaware of the vaccine, while those from Sacatepéquez had higher awareness and uptake. Community partners noted that access to information, geographic connectivity and social desirability may influence both awareness and response accuracy. Despite strong willingness to vaccinate, significant knowledge gaps persist among Indigenous caregivers. Tailored, community-informed education strategies-delivered through trusted channels and adapted linguistically and culturally-are urgently needed to increase awareness and uptake of the HPV vaccine in underserved Guatemalan communities.

For more than three decades, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) has provided a framework to quantify health loss due to diseases, injuries, and associated risk factors. This paper presents GBD 2023 findings on disease and injury burden and risk-attributable health loss, offering a global audit of the state of world health to inform public health priorities. This work captures the evolving landscape of health metrics across age groups, sexes, and locations, while reflecting on the remaining post-COVID-19 challenges to achieving our collective global health ambitions. The GBD 2023 combined analysis estimated years lived with disability (YLDs), years of life lost (YLLs), and disability-adjusted life-years (DALYs) for 375 diseases and injuries, and risk-attributable burden associated with 88 modifiable risk factors. Of the more than 310 000 total data sources used for all GBD 2023 (about 30% of which were new to this estimation round), more than 120 000 sources were used for estimation of disease and injury burden and 59 000 for risk factor estimation, and included vital registration systems, surveys, disease registries, and published scientific literature. Data were analysed using previously established modelling approaches, such as disease modelling meta-regression version 2.1 (DisMod-MR 2.1) and comparative risk assessment methods. Diseases and injuries were categorised into four levels on the basis of the established GBD cause hierarchy, as were risk factors using the GBD risk hierarchy. Estimates stratified by age, sex, location, and year from 1990 to 2023 were focused on disease-specific time trends over the 2010-23 period and presented as counts (to three significant figures) and age-standardised rates per 100 000 person-years (to one decimal place). For each measure, 95% uncertainty intervals [UIs] were calculated with the 2·5th and 97·5th percentile ordered values from a 250-draw distribution. Total numbers of global DALYs grew 6·1% (95% UI 4·0-8·1), from 2·64 billion (2·46-2·86) in 2010 to 2·80 billion (2·57-3·08) in 2023, but age-standardised DALY rates, which account for population growth and ageing, decreased by 12·6% (11·0-14·1), revealing large long-term health improvements. Non-communicable diseases (NCDs) contributed 1·45 billion (1·31-1·61) global DALYs in 2010, increasing to 1·80 billion (1·63-2·03) in 2023, alongside a concurrent 4·1% (1·9-6·3) reduction in age-standardised rates. Based on DALY counts, the leading level 3 NCDs in 2023 were ischaemic heart disease (193 million [176-209] DALYs), stroke (157 million [141-172]), and diabetes (90·2 million [75·2-107]), with the largest increases in age-standardised rates since 2010 occurring for anxiety disorders (62·8% [34·0-107·5]), depressive disorders (26·3% [11·6-42·9]), and diabetes (14·9% [7·5-25·6]). Remarkable health gains were made for communicable, maternal, neonatal, and nutritional (CMNN) diseases, with DALYs falling from 874 million (837-917) in 2010 to 681 million (642-736) in 2023, and a 25·8% (22·6-28·7) reduction in age-standardised DALY rates. During the COVID-19 pandemic, DALYs due to CMNN diseases rose but returned to pre-pandemic levels by 2023. From 2010 to 2023, decreases in age-standardised rates for CMNN diseases were led by rate decreases of 49·1% (32·7-61·0) for diarrhoeal diseases, 42·9% (38·0-48·0) for HIV/AIDS, and 42·2% (23·6-56·6) for tuberculosis. Neonatal disorders and lower respiratory infections remained the leading level 3 CMNN causes globally in 2023, although both showed notable rate decreases from 2010, declining by 16·5% (10·6-22·0) and 24·8% (7·4-36·7), respectively. Injury-related age-standardised DALY rates decreased by 15·6% (10·7-19·8) over the same period. Differences in burden due to NCDs, CMNN diseases, and injuries persisted across age, sex, time, and location. Based on our risk analysis, nearly 50% (1·27 billion [1·18-1·38]) of the roughly 2·80 billion total global DALYs in 2023 were attributable to the 88 risk factors analysed in GBD. Globally, the five level 3 risk factors contributing the highest proportion of risk-attributable DALYs were high systolic blood pressure (SBP), particulate matter pollution, high fasting plasma glucose (FPG), smoking, and low birthweight and short gestation-with high SBP accounting for 8·4% (6·9-10·0) of total DALYs. Of the three overarching level 1 GBD risk factor categories-behavioural, metabolic, and environmental and occupational-risk-attributable DALYs rose between 2010 and 2023 only for metabolic risks, increasing by 30·7% (24·8-37·3); however, age-standardised DALY rates attributable to metabolic risks decreased by 6·7% (2·0-11·0) over the same period. For all but three of the 25 leading level 3 risk factors, age-standardised rates dropped between 2010 and 2023-eg, declining by 54·4% (38·7-65·3) for unsafe sanitation, 50·5% (33·3-63·1) for unsafe water source, and 45·2% (25·6-72·0) for no access to handwashing facility, and by 44·9% (37·3-53·5) for child growth failure. The three leading level 3 risk factors for which age-standardised attributable DALY rates rose were high BMI (10·5% [0·1 to 20·9]), drug use (8·4% [2·6 to 15·3]), and high FPG (6·2% [-2·7 to 15·6]; non-significant). Our findings underscore the complex and dynamic nature of global health challenges. Since 2010, there have been large decreases in burden due to CMNN diseases and many environmental and behavioural risk factors, juxtaposed with sizeable increases in DALYs attributable to metabolic risk factors and NCDs in growing and ageing populations. This long-observed consequence of the global epidemiological transition was only temporarily interrupted by the COVID-19 pandemic. The substantially decreasing CMNN disease burden, despite the 2008 global financial crisis and pandemic-related disruptions, is one of the greatest collective public health successes known. However, these achievements are at risk of being reversed due to major cuts to development assistance for health globally, the effects of which will hit low-income countries with high burden the hardest. Without sustained investment in evidence-based interventions and policies, progress could stall or reverse, leading to widespread human costs and geopolitical instability. Moreover, the rising NCD burden necessitates intensified efforts to mitigate exposure to leading risk factors-eg, air pollution, smoking, and metabolic risks, such as high SBP, BMI, and FPG-including policies that promote food security, healthier diets, physical activity, and equitable and expanded access to potential treatments, such as GLP-1 receptor agonists. Decisive, coordinated action is needed to address long-standing yet growing health challenges, including depressive and anxiety disorders. Yet this can be only part of the solution. Our response to the NCD syndemic-the complex interaction of multiple health risks, social determinants, and systemic challenges-will define the future landscape of global health. To ensure human wellbeing, economic stability, and social equity, global action to sustain and advance health gains must prioritise reducing disparities by addressing socioeconomic and demographic determinants, ensuring equitable health-care access, tackling malnutrition, strengthening health systems, and improving vaccination coverage. We live in times of great opportunity. Gates Foundation and Bloomberg Philanthropies.

Timely and comprehensive analyses of causes of death stratified by age, sex, and location are essential for shaping effective health policies aimed at reducing global mortality. The Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 provides cause-specific mortality estimates measured in counts, rates, and years of life lost (YLLs). GBD 2023 aimed to enhance our understanding of the relationship between age and cause of death by quantifying the probability of dying before age 70 years (70q0) and the mean age at death by cause and sex. This study enables comparisons of the impact of causes of death over time, offering a deeper understanding of how these causes affect global populations. GBD 2023 produced estimates for 292 causes of death disaggregated by age-sex-location-year in 204 countries and territories and 660 subnational locations for each year from 1990 until 2023. We used a modelling tool developed for GBD, the Cause of Death Ensemble model (CODEm), to estimate cause-specific death rates for most causes. We computed YLLs as the product of the number of deaths for each cause-age-sex-location-year and the standard life expectancy at each age. Probability of death was calculated as the chance of dying from a given cause in a specific age period, for a specific population. Mean age at death was calculated by first assigning the midpoint age of each age group for every death, followed by computing the mean of all midpoint ages across all deaths attributed to a given cause. We used GBD death estimates to calculate the observed mean age at death and to model the expected mean age across causes, sexes, years, and locations. The expected mean age reflects the expected mean age at death for individuals within a population, based on global mortality rates and the population's age structure. Comparatively, the observed mean age represents the actual mean age at death, influenced by all factors unique to a location-specific population, including its age structure. As part of the modelling process, uncertainty intervals (UIs) were generated using the 2·5th and 97·5th percentiles from a 250-draw distribution for each metric. Findings are reported as counts and age-standardised rates. Methodological improvements for cause-of-death estimates in GBD 2023 include a correction for the misclassification of deaths due to COVID-19, updates to the method used to estimate COVID-19, and updates to the CODEm modelling framework. This analysis used 55 761 data sources, including vital registration and verbal autopsy data as well as data from surveys, censuses, surveillance systems, and cancer registries, among others. For GBD 2023, there were 312 new country-years of vital registration cause-of-death data, 3 country-years of surveillance data, 51 country-years of verbal autopsy data, and 144 country-years of other data types that were added to those used in previous GBD rounds. The initial years of the COVID-19 pandemic caused shifts in long-standing rankings of the leading causes of global deaths: it ranked as the number one age-standardised cause of death at Level 3 of the GBD cause classification hierarchy in 2021. By 2023, COVID-19 dropped to the 20th place among the leading global causes, returning the rankings of the leading two causes to those typical across the time series (ie, ischaemic heart disease and stroke). While ischaemic heart disease and stroke persist as leading causes of death, there has been progress in reducing their age-standardised mortality rates globally. Four other leading causes have also shown large declines in global age-standardised mortality rates across the study period: diarrhoeal diseases, tuberculosis, stomach cancer, and measles. Other causes of death showed disparate patterns between sexes, notably for deaths from conflict and terrorism in some locations. A large reduction in age-standardised rates of YLLs occurred for neonatal disorders. Despite this, neonatal disorders remained the leading cause of global YLLs over the period studied, except in 2021, when COVID-19 was temporarily the leading cause. Compared to 1990, there has been a considerable reduction in total YLLs in many vaccine-preventable diseases, most notably diphtheria, pertussis, tetanus, and measles. In addition, this study quantified the mean age at death for all-cause mortality and cause-specific mortality and found noticeable variation by sex and location. The global all-cause mean age at death increased from 46·8 years (95% UI 46·6-47·0) in 1990 to 63·4 years (63·1-63·7) in 2023. For males, mean age increased from 45·4 years (45·1-45·7) to 61·2 years (60·7-61·6), and for females it increased from 48·5 years (48·1-48·8) to 65·9 years (65·5-66·3), from 1990 to 2023. The highest all-cause mean age at death in 2023 was found in the high-income super-region, where the mean age for females reached 80·9 years (80·9-81·0) and for males 74·8 years (74·8-74·9). By comparison, the lowest all-cause mean age at death occurred in sub-Saharan Africa, where it was 38·0 years (37·5-38·4) for females and 35·6 years (35·2-35·9) for males in 2023. Lastly, our study found that all-cause 70q0 decreased across each GBD super-region and region from 2000 to 2023, although with large variability between them. For females, we found that 70q0 notably increased from drug use disorders and conflict and terrorism. Leading causes that increased 70q0 for males also included drug use disorders, as well as diabetes. In sub-Saharan Africa, there was an increase in 70q0 for many non-communicable diseases (NCDs). Additionally, the mean age at death from NCDs was lower than the expected mean age at death for this super-region. By comparison, there was an increase in 70q0 for drug use disorders in the high-income super-region, which also had an observed mean age at death lower than the expected value. We examined global mortality patterns over the past three decades, highlighting-with enhanced estimation methods-the impacts of major events such as the COVID-19 pandemic, in addition to broader trends such as increasing NCDs in low-income regions that reflect ongoing shifts in the global epidemiological transition. This study also delves into premature mortality patterns, exploring the interplay between age and causes of death and deepening our understanding of where targeted resources could be applied to further reduce preventable sources of mortality. We provide essential insights into global and regional health disparities, identifying locations in need of targeted interventions to address both communicable and non-communicable diseases. There is an ever-present need for strengthened health-care systems that are resilient to future pandemics and the shifting burden of disease, particularly among ageing populations in regions with high mortality rates. Robust estimates of causes of death are increasingly essential to inform health priorities and guide efforts toward achieving global health equity. The need for global collaboration to reduce preventable mortality is more important than ever, as shifting burdens of disease are affecting all nations, albeit at different paces and scales. Gates Foundation.

Cancer is a leading cause of death globally. Accurate cancer burden information is crucial for policy planning, but many countries do not have up-to-date cancer surveillance data. To inform global cancer-control efforts, we used the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2023 framework to generate and analyse estimates of cancer burden for 47 cancer types or groupings by age, sex, and 204 countries and territories from 1990 to 2023, cancer burden attributable to selected risk factors from 1990 to 2023, and forecasted cancer burden up to 2050. Cancer estimation in GBD 2023 used data from population-based cancer registration systems, vital registration systems, and verbal autopsies. Cancer mortality was estimated using ensemble models, with incidence informed by mortality estimates and mortality-to-incidence ratios (MIRs). Prevalence estimates were generated from modelled survival estimates, then multiplied by disability weights to estimate years lived with disability (YLDs). Years of life lost (YLLs) were estimated by multiplying age-specific cancer deaths by the GBD standard life expectancy at the age of death. Disability-adjusted life-years (DALYs) were calculated as the sum of YLLs and YLDs. We used the GBD 2023 comparative risk assessment framework to estimate cancer burden attributable to 44 behavioural, environmental and occupational, and metabolic risk factors. To forecast cancer burden from 2024 to 2050, we used the GBD 2023 forecasting framework, which included forecasts of relevant risk factor exposures and used Socio-demographic Index as a covariate for forecasting the proportion of each cancer not affected by these risk factors. Progress towards the UN Sustainable Development Goal (SDG) target 3.4 aim to reduce non-communicable disease mortality by a third between 2015 and 2030 was estimated for cancer. In 2023, excluding non-melanoma skin cancers, there were 18·5 million (95% uncertainty interval 16·4 to 20·7) incident cases of cancer and 10·4 million (9·65 to 10·9) deaths, contributing to 271 million (255 to 285) DALYs globally. Of these, 57·9% (56·1 to 59·8) of incident cases and 65·8% (64·3 to 67·6) of cancer deaths occurred in low-income to upper-middle-income countries based on World Bank income group classifications. Cancer was the second leading cause of deaths globally in 2023 after cardiovascular diseases. There were 4·33 million (3·85 to 4·78) risk-attributable cancer deaths globally in 2023, comprising 41·7% (37·8 to 45·4) of all cancer deaths. Risk-attributable cancer deaths increased by 72·3% (57·1 to 86·8) from 1990 to 2023, whereas overall global cancer deaths increased by 74·3% (62·2 to 86·2) over the same period. The reference forecasts (the most likely future) estimate that in 2050 there will be 30·5 million (22·9 to 38·9) cases and 18·6 million (15·6 to 21·5) deaths from cancer globally, 60·7% (41·9 to 80·6) and 74·5% (50·1 to 104·2) increases from 2024, respectively. These forecasted increases in deaths are greater in low-income and middle-income countries (90·6% [61·0 to 127·0]) compared with high-income countries (42·8% [28·3 to 58·6]). Most of these increases are likely due to demographic changes, as age-standardised death rates are forecast to change by -5·6% (-12·8 to 4·6) between 2024 and 2050 globally. Between 2015 and 2030, the probability of dying due to cancer between the ages of 30 years and 70 years was forecasted to have a relative decrease of 6·5% (3·2 to 10·3). Cancer is a major contributor to global disease burden, with increasing numbers of cases and deaths forecasted up to 2050 and a disproportionate growth in burden in countries with scarce resources. The decline in age-standardised mortality rates from cancer is encouraging but insufficient to meet the SDG target set for 2030. Effectively and sustainably addressing cancer burden globally will require comprehensive national and international efforts that consider health systems and context in the development and implementation of cancer-control strategies across the continuum of prevention, diagnosis, and treatment. Gates Foundation, St Jude Children's Research Hospital, and St Baldrick's Foundation.

Sensitive measures to predict neuromotor outcomes from data collected early in infancy are lacking. Measures derived from the recordings of infant movement using wearable sensors may be a useful new technique. We collected full-day leg movement of 41 infants in rural Guatemala across 3 visits between birth and 6 months of age using wearable sensors. Average leg movement rate and fuzzy entropy, a measure to describe the complexity of signals, of the leg movements' peak acceleration time series and the time series itself were derived. We tested the three measures for the predictability of infants' developmental outcome, Bayley Scales of Infant and Toddler Development III motor, language, or cognitive composite score assessed at 12 months of age. We performed quantile regressions with clustered standard errors, accounting for the multiple visits for each infant. Fuzzy entropy was associated with the motor composite score at the 0.5 quantiles; this association was not found for the other two measures. Also, no leg movement characteristic was associated with language or cognitive composite scores. We propose that the entropy of leg movement associated peak accelerations calculated from the wearable sensor data collected for a full-day can be considered as one predictor for infants' motor developmental outcome assessed with Bayley Scales of Infant and Toddler Development III at 12 months of age.

There is little evidence on optimizing the effectiveness and implementation of evidence-based early childhood development (ECD) interventions when task-shifted to frontline workers. In this Methods Forum paper, we describe our adaptation of the International Guide for Monitoring Child Development (GMCD) for task-shifting to frontline workers in Guatemala and India. In 2021-2022, implementers, trainers, frontline workers, caregivers, and international GMCD experts collaborated to adapt the GMCD for a task shifted implementation by frontline workers. We used an eight-step co-creating process: assembling a multidisciplinary team, training on the existing package, working groups to begin modifications, revision of draft modifications, tailoring of visual materials and language, train-the-trainers activities, pilot frontline worker trainings, final review and feedback. Preliminary effectiveness of adaptations was evaluated through narrative notes and group-based qualitative feedback following pilot trainings with 16 frontline workers in India and 6 in Guatemala. Final adaptations included: refining training techniques to match skill levels and learning styles of frontline workers; tailoring all visual materials to local languages and contexts; design of job aids for providing developmental support messages; modification of referral and triage processes for children in need of enhanced support and speciality referral; and creation of post-training support procedures. Feedback from pilot trainings included: (1) group consensus that training improved ECD skills and knowledge across multiple domains; and (2) feedback on ongoing needed adjustments to pacing, use of video-based vs. role-playing materials, and time allocated to small group work. We use the Framework for Reporting Adaptations and Modifications to Evidence-based Implementation Strategies (FRAME-IS) framework to document our adaptations. The co-creating approach we use, as well as systematic documentation of adaptation decisions will be of use to other community-based early childhood interventions and implementation strategies. Main findings: The International Guide for Monitoring Child Development, an early childhood development support and monitoring tool, was successfully adapted for use by frontline workers in rural India and Guatemala.Added knowledge: Our Methods Forum paper uses a detailed framework to document the collaborative, co-creating process used and the adaptive decisions taken.Global health impact for policy and action: Evidence on how best to adapt and optimize early childhood interventions for frontline workers will be useful or scaling up support for children globally.

[Abstract not available]

Tools to accurately assess infants' neurodevelopmental status very early in their lives are limited. Wearable sensors may provide a novel approach for very early assessment of infant neurodevelopmental status. This may be especially relevant in rural and low-resource global settings. We conducted a longitudinal observational study and used wearable sensors to repeatedly measure the kinematic leg movement characteristics of 41 infants in rural Guatemala three times across full days between birth and 6 months of age. In addition, we collected sociodemographic data, growth data, and caregiver estimates of swaddling behaviors. We used visual analysis and multivariable linear mixed models to evaluate the associations between two leg movement kinematic variables (awake movement rate, peak acceleration per movement) and infant age, swaddling behaviors, growth, and other covariates. Multivariable mixed models of sensor data showed age-dependent increases in leg movement rates (2.16 [95% CI 0.80,3.52] movements/awake hour/day of life) and movement acceleration (5.04e-3 m/s2 [95% CI 3.79e-3, 6.27e-3]/day of life). Swaddling time as well as growth status, poverty status and multiple other clinical and sociodemographic variables had no impact on either movement variable. Collecting wearable sensor data on young infants in a rural low-resource setting is feasible and can be used to monitor age-dependent changes in movement kinematics. Future work will evaluate associations between these kinematic variables from sensors and formal developmental measures, such as the Bayley Scales of Infant and Toddler Development.

Multiple studies have highlighted the inequities minority and Indigenous children face when accessing health care. Health and wellbeing are positively impacted when Indigenous children are educated and receive care in their maternal language. However, less is known about the association between minority or Indigenous language use and child development risks and outcomes. In this study, we provide global estimates of development risks and assess the associations between minority or Indigenous language status and early child development using the ten-item Early Child Development Index (ECDI), a tool widely used for global population assessments in children aged 3-4 years. We did a secondary analysis of cross-sectional data from 65 UNICEF Multiple Indicator Cluster Surveys (MICS) containing the ECDI from 2009-19 (waves 4-6). We included individual-level data for children aged 2-4 years (23-60 months) from datasets with ECDI modules, for surveys that captured the language of the respondent, interview, or head of household. The Expanded Graded Intergenerational Disruption Scale was used to classify household languages as dominant versus minority or Indigenous at the country level. Our primary outcome was on-track overall development, defined per UNICEF's guidelines as development being on track for at least three of the four ECDI domains (literacy-numeracy, learning, physical, and socioemotional). We performed logistic regression of pooled, weighted ECDI scores, aggregated by language status and adjusting for the covariables of child sex, child nutritional status (stunting), household wealth, maternal education, developmental support by an adult caregiver, and country-level early child education proportion. Regression analyses were done for all children aged 3-4 years with ECDI results, and separately for children with functional disabilities and ECDI results. 65 MICS datasets were included. 186 393 children aged 3-4 years had ECDI and language data, corresponding to an estimated represented population of 34 714 992 individuals. Estimated prevalence of on-track overall development as measured by ECDI scores was 65·7% (95% CI 64·2-67·2) for children from a minority or Indigenous language-speaking household, and 76·6% (75·7-77·4) for those from a dominant language-speaking household. After adjustment, dominant language status was associated with increased odds of on-track overall development (adjusted OR 1·54, 95% CI 1·40-1·71), which appeared to be largely driven by significantly increased odds of on-track development in the literacy-numeracy and socioemotional domains. For the represented population aged 2-4 years (n=11 465 601), the estimated prevalence of family-reported functional disability was 3·6% (95% CI 3·0-4·4). For the represented population aged 3-4 years with a functional disability (n=292 691), language status was not associated with on-track overall development (adjusted OR 1·02, 95% CI 0·43-2·45). In a global dataset, children speaking a minority or Indigenous language were less likely to have on-track ECDI scores than those speaking a dominant language. Given the strong positive benefits of speaking an Indigenous language on the health and development of Indigenous children, this disparity is likely to reflect the sociolinguistic marginalisation faced by speakers of minority or Indigenous languages as well as differences in the performance of ECDI in these languages. Global efforts should consider performance of measures and monitor developmental data disaggregated by language status to stimulate efforts to address this disparity. None. For the Spanish, Kaqchikel and K'iche' translations of the abstract see Supplementary Materials section.

The potential of chicken eggs as a nutritionally complete protein and source of key micronutrients during the first 1000 days post-conception has been progressively recognized across the globe, particularly in resource-poor settings. Fluctuation of egg nutrient content by season is relatively unknown, which may influence international food composition databases and outcomes in intervention studies using egg supplementation. To better interpret the findings of The Saqmolo' Project, we conducted comprehensive nutrient analyses on eggs produced during the wet and dry seasons in the highlands of central Guatemala. We randomly collected 36 shell eggs from a local farm during both seasons, hard-boiled, and prepared them for transport to the United States, where they were pooled and assessed for their nutrient composition. Methods of the Association of Official Analytical Chemists, the American Oil Chemists Society, and the American Association of Cereal Chemists were utilized to determine total energy, moisture, ash, total protein, total fat, fatty acids, total carbohydrates, 12 vitamins, 11 minerals, and carotenoids, by season, in some instances with modifications. Differences in nutrient composition between de-shelled hard-boiled eggs collected between seasons were assessed using an analysis of variance (ANOVA) and Tukey's family error rate comparison test. Most nutrients in eggs produced in the highlands of central Guatemala differed negligibly (but statistically significantly) based on seasonality. Only vitamins A and E, folate, choline, and calcium fluctuated at clinically significant levels relative to the AI/RDA for infants 7-12 months. Total energy, protein, trans fatty acids, moisture, and vitamin D3 levels did not differ between seasons (p > .05). Further multi-year sampling is needed to examine how seasonal variation affects the nutrient composition of eggs. These data may be used to supplement existing national and regional food composition databases.

[Abstract not available]

Aflatoxin B1 (AFB1) is a carcinogen produced by Aspergillus flavus and Aspergillus parasiticus which grow on maize. Given the high prevalence of child stunting (ie, impaired growth) and other nutritional disorders in low-income and middle-income countries, where maize is consumed, the role of aflatoxin exposure may be significant. Observational reports have demonstrated associations between aflatoxin exposure and impaired child growth; however, most have been cross-sectional and have not assessed seasonal variations in aflatoxin, food preparation and dynamic changes in growth. Biological mechanistic data on how aflatoxin may exert an impact on child growth is missing. This study incorporates a prospective cohort of children from rural Guatemala to assess (1) temporal associations between aflatoxin exposure and child growth and (2) possible mediation of the gut microbiome among aflatoxin exposure, inflammation and child growth. We will prospectively evaluate aflatoxin exposure and height-for-age difference trajectories for 18 months in a cohort of 185 children aged 6-9 months at enrolment. We will assess aflatoxin exposure levels and biomarkers of gut and systemic inflammation. We will examine the faecal microbiome of each child and identify key species and metabolic pathways for differing AFB1 exposure levels and child growth trajectories. In parallel, we will use bioreactors, inoculated with faeces, to investigate the response of the gut microbiome to varying levels of AFB1 exposure. We will monitor key microbial metabolites and AFB1 biotransformation products to study nutrient metabolism and the impact of the gut microbiome on aflatoxin detoxification/metabolism. Finally, we will use path analysis to summarise the effect of aflatoxin exposure and the gut microbiome on child growth. Ethics approval was obtained from Arizona State University Institutional Review Board (IRB; STUDY00016799) and Wuqu' Kawoq/Maya Health Alliance IRB (WK-2022-003). Findings will be disseminated in scientific presentations and peer-reviewed publications.

[Abstract not available]

Child stunting is a critical global health issue. Guatemala has one of the world's highest levels of stunting despite the sustained commitment to international nutrition policy best practices endorsed by the Scaling Up Nutrition (SUN) movement. Our objective was to use Guatemala as a case study to project the impact of a recently published national nutrition policy, the Great Crusade, that is consistent with SUN principles. We used the Lives Saved Tool (LiST) to project the impact of scaling-up of nutrition interventions proposed in the Great Crusade and recommended by SUN. Our outcomes were changes in stunting prevalence, number of stunting cases averted, and number of cases averted by intervention in children under 5 years of age from 2020 to 2030. We considered 4 scenarios: (1) intervention coverage continues based on historical trends, (2) coverage targets in the Great Crusade are achieved, (3) coverage targets in the Great Crusade are achieved with reduced fertility risk, and (4) coverage reaches an aspirational level. All scenarios led to modest reductions in stunting prevalence. In 2024, stunting prevalence was estimated to change by -0.1% (95% confidence interval [CI]= 0.0%,-0.2%) if historical trends continue, -1.1% (95% CI=-0.8%,-1.5%) in the Great Crusade scenario, and -2.2% (95% CI=-1.6%,-3.0%) in the aspirational scenario. In 2030, we projected a stunting prevalence of -0.4% (95% CI=-0.2%,-0.8%) and -3.7% (95% CI=-2.8%,-5.1%) in the historical trends and aspirational scenario, respectively. Complementary feeding, sanitation, and breastfeeding were the highest-impact interventions across models. Targeted reductions in child stunting prevalence in Guatemala are unlikely to be achieved solely based on increases in intervention coverage. Our results show the limitations of current paradigms recommended by the international nutrition community. Policies and strategies are needed to address the broader structural drivers of stunting.

More than 40% of children under 5 years of age in low-income and middle-income countries are at risk of not reaching their developmental potential. The international Guide for Monitoring Child Development (GMCD) early intervention package is a comprehensive programme to address developmental difficulties using an individualised intervention plan for young children and their families. We will conduct a hybrid type 1 effectiveness-implementation evaluation of the GMCD intervention in rural India and Guatemala. Using a cluster-randomised design, 624 children aged 0-24 months in 52 clusters (26 in India, 26 in Guatemala) will be assigned to usual care or the GMCD intervention plus usual care delivered by frontline workers for 12 months. After 12 months, the usual care arm will cross over to the intervention, which will continue for 12 additional months (24 total). The intervention will be delivered using a digital mobile device interface. Effectiveness will be assessed for developmental functioning (Bayley Scales of Infant Development, 3rd edition) and nurturing care (Home Observation for Measurement of the Environment Scale) outcomes. Implementation will be assessed using the Reach, Effectiveness, Adoption, Implementation, Maintenance framework. Explanatory qualitative analysis guided by the Consolidated Framework for Implementation Research will explore determinants between clusters with high versus low implementation effectiveness. The study has been approved by the Institutional Review Boards of Brigham and Women's Hospital, Mahatma Gandhi Institute of Medical Sciences and Maya Health Alliance; and by the Indian Council of Medical Research/Health Ministry Screening Committee. Key study findings will be published in international open-access journals. NCT04665297, CTRI/2020/12/029748. 1.0 (12 November 2020).

Jordan hosts the largest Palestine refugee population in the world. The United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA) is the primary healthcare provider for Palestine refugees. To better inform UNRWA's health programme, we conducted this study to assess the prevalence and determinants of malnutrition among Palestine refugee children in Jordan and to analyse caregiver perceptions of food insecurity and structural barriers to accessing food. A cross-sectional study was conducted with a randomly selected sample of 405 households, for children under 5 years old in two refugee camps in Jordan, Jerash and Souf. Sociodemographic, food insecurity, diet quality and child anthropometric data were collected. Also, twenty in-depth interviews were conducted with children's caregivers, along with two focus group discussions with UNRWA staff. Out of the 367 participants, the prevalence of stunting was 23.8% in Jerash and 20.4% in Souf (p=0.46), and overweight was 18.2% versus 7.1%, respectively (p=0.008). However, high food insecurity in Jerash was 45.7% and 26.5% in Souf (p=0.001), with no significant difference after multivariable adjustment. Qualitative perspectives saw food insecurity and low-quality children's diets as largely mediated by job and income insecurity, especially marked in Jerash due to the lack of Jordanian citizenship. We found a moderate-to-high prevalence of stunting and overweight levels among Palestine refugee children, which are three times higher than the 2012 Demographic and Health Survey data for Jordanian non-refugee children. High rates of household food insecurity were closely tied to households' lack of essential civil and economic rights. We call for international collective efforts to expand economic livelihoods for Palestine refugees and to support UNRWA's ongoing operations.

Adequate nutrition during the complementary feeding period is critical for optimal child growth and development and for promoting long-term educational attainment and economic potential. To prioritize limited public health resources, there is a need for studies that rigorously assess the influence of multicomponent integrated nutrition interventions in children younger than age 2 years in different contexts. This study aimed to describe the rationale and protocol for the Saqmolo' Project using the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. The Saqmolo' (ie, "egg" in the Mayan language, Kaqchiquel) Project is an individually randomized, partially blinded, controlled comparative effectiveness trial to evaluate the influence of adding delivery of a single whole egg per day to local standard nutrition care (ie, growth monitoring, medical care, deworming medication, multiple micronutrient powders for point-of-use food fortification [chispitas], and individualized complementary and responsive feeding education for caregivers) for 6 months, compared with the local standard nutrition care package alone, on child development, growth, and diet quality measures in rural indigenous Mayan infants aged 6 to 9 months at baseline (N = 1,200). The study is being executed in partnership with the Wuqu' Kawoq/Maya Health Alliance, a primary health care organization located in central Guatemala. Primary outcomes for this study are changes in global development scores, assessed using the Guide for Monitoring Global Development and the Caregiver Reported Child Development Instruments. Secondary outcomes include changes in infant hemoglobin, anthropometric measures (including z scores for weight for age, length for age, weight for length, and head circumference for age), and diet quality as measured using the World Health Organization's infant and young child feeding indicators. The results of the Saqmolo' Project may help to inform public health decision making regarding resource allocation for effective nutrition interventions during the complementary feeding period.

We propose that the collection of infant experiential and environmental data using smartphone surveys has the potential to fill a gap in foundational and clinical knowledge. To achieve this, these data need to be collected in a systematic way that is translatable globally. We can then begin to understand differences in child development and physical therapy from a variety of cultures and traditions. An infant's development is shaped by experiences in everyday life, and everyday experiences vary around the world. Hence, it is important to quantify these experiences to better understand variability in developmental trajectories. Recent increase in smartphone access has made the capability of collecting infant experiential data more feasible around the world. We provide examples and suggestions for ways in which experiential and environmental data can be collected for future practice.

Rural Guatemala has one of the highest rates of chronic child malnutrition (stunting) in the world, with little progress despite considerable efforts to scale up evidence-based nutrition interventions. Recent literature suggests that one factor limiting impact is inadequate supervisory support for frontline workers. Here we describe a community-based quality improvement intervention in a region with a high rate of stunting. The intervention provided audit and feedback support to frontline nutrition workers through electronic worklists, performance dashboards, and one-on-one feedback sessions. We visualized performance indicators and child nutrition outcomes during the improvement intervention using run charts and control charts. In this small community-based sample (125 households at program initiation), over the two-year improvement period, there were marked improvements in the delivery of program components, such as growth monitoring services and micronutrient supplements. The prevalence of child stunting fell from 42.4 to 30.6%, meeting criteria for special cause variation. The mean length/height-for-age Z-score rose from -1.77 to -1.47, also meeting criteria for special cause variation. In conclusion, the addition of structured performance visualization and audit and feedback components to an existing community-based nutrition program improved child health indicators significantly through improving the fidelity of an existing evidence-based nutrition package.

Ever since the 1960s, Guatemala has been a principle site for global academic research on child growth and nutrition. Nevertheless, Guatemala still has one of the highest rates of child stunting in the world. Since 2012, Guatemala has had a comprehensive national policy on stunting, calling for a renewed investment in innovative, multilevel nutrition interventions and implementation science. Our objective was to perform a systematic search and scoping review of the literature on stunting in Guatemala to identify gaps in research and opportunities for responding to this unique policy opportunity. We conducted a systematic search and scoping review on stunting in Guatemala, searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were of any design or format, published in English and Spanish from 2000 to 2018. Articles were thematically grouped by those published before (2000-2011) and after (2012-2018) the new national policy initiatives. We identified a total of 1934 articles through database searches. After full-text review, 104 were included in the synthesis. The volume of published articles on stunting increased from a mean of 3.2 to 9.4 articles/year before and after 2012. There was a shift toward articles generating new data on priority populations, including rural indigenous Maya populations (34% vs 61%, χ2 test, p=0.01). However, the proportion of studies conducting implementation evaluations or testing new interventions was low and did not change significantly (34% vs 18%, χ2 test, p=0.07). Among 17 identified intervention studies, only 4 tested multilevel interventions, and there were no published interventions incorporating nutrition-sensitive interventions. A systematic search and scoping review of the literature on child stunting in Guatemala identified critical opportunities for new research in multilevel interventions, nutrition-sensitive interventions and implementation science.

There has been limited research on the relationship between contraception and child growth in low-income and middle-income countries (LMICs). This study examines the association between contraception and child linear growth in Guatemala, an LMIC with a very high prevalence of child stunting. We hypothesise that contraceptive use is associated with better child linear growth and less stunting in Guatemala. Using representative national data on 12 440 children 0-59 months of age from the 2014-2015 Demographic and Health Survey in Guatemala, we constructed multivariable linear and Poisson regression models to assess whether child linear growth and stunting were associated with contraception variables. All models were adjusted for a comprehensive set of prespecified confounding variables. Contraceptive use was generally associated with modest, statistically significant greater height-for-age z-score. Current use of a modern method for at least 15 months was associated with a prevalence ratio of stunting of 0.87 (95% CI 0.81 to 0.94; p<0.001), and prior use of a modern method was associated with a prevalence ratio of stunting of 0.93 (95% CI 0.87 to 0.98; p<0.05). The severe stunting models found generally similar associations with modern contraceptive use as the stunting models. There was no significant association between use of a modern method for less than 15 months and the prevalence ratio of stunting or severe stunting. Contraceptive use was associated with better child linear growth and less child stunting in Guatemala. In addition to the human rights imperative to expand contraceptive access and choice, family planning merits further study as a strategy to improve child growth in Guatemala and other countries with high prevalence of stunting.

Conducting research with children in low/middle-income countries (LMIC) requires consideration of socioeconomic inequalities and cultural and linguistic differences. Our objective was to survey the literature on informed consent in paediatric LMIC research, assessing for practical guidance for culturally and linguistically appropriate procedures. We conducted a scoping review on informed consent in paediatric LMIC research searching the PubMed, Web of Science and PsycINFO databases. Eligible articles were published in English, from any date range, of any study design or format. The search identified 2027 references, of which 50 were included in the analysis following full-text review. Reviewed guidelines emphasised individual, informed and voluntary consent from parents and caregivers. Reviewed articles provided detailed practical guidance on adapting these guiding principles to LMIC settings, including considerations for community engagement, verbal or other alternative consent procedures for low-literacy settings or less commonly spoken languages and guarding against therapeutic misconception by caregivers. There was uncertainty, however, on how to best protect individual autonomy, especially when influenced by gender dynamics, leadership hierarchies or the social status of researchers themselves. There was, furthermore, limited research discussing the special case of research involving adolescents or of procedures for documenting assent by participating children. A scoping review of paediatric research in LMICs revealed substantial guidance on several features of culturally appropriate informed consent. However, additional research and guidance is needed, especially in the areas of gender imbalances, research with adolescents and children's own assent to participate in research.

Stunting is a common cause of early child developmental delay; Guatemala has the fourth highest rate of stunting globally. The goal of this study was to examine the impact of an intensive community health worker-led complementary feeding intervention on early child development in Guatemala. We hypothesised that the intervention would improve child development over usual care. A substudy from a larger individually randomised (1:1 allocation ratio), parallel-group superiority trial, with blinding of study staff collecting outcomes data. Rural, indigenous Maya communities in Guatemala. 210 stunted children (height-for-age z-score ≤-2.5) aged 6-24 months, previously randomised to usual care (106) or an intensive complementary feeding intervention (104). 84 in the intervention and 91 in the usual care arm agreed to participate. Community health workers conducted monthly home visits for 6 months, providing usual care or individualised complementary feeding education. The primary outcomes were change in z-scores for the subscales of the Bayley Scales of Infant Development (BSID), Third Edition. 100 individuals were included in the final analysis, 47 in the intervention and 53 in the usual care arm. No statistically significant differences in age-adjusted scores between the arms were observed for any subscale. However, improvements within-subjects in both arms were observed (median duration between measurements 189 days (IQR 182-189)). Mean change for subscales was 0.45 (95% CI 0.23 to 0.67) z-scores in the intervention, and 0.43 (95% CI 0.25 to 0.61) in the usual care arm. An intensive complementary feeding intervention did not significantly improve developmental outcomes more than usual care in stunted, indigenous Guatemalan children. However, both interventions had significant positive impacts on developmental outcomes. NCT02509936. Results.

Guatemala's indigenous Maya population has one of the highest rates of childhood stunting in the world. The goal of this study was to examine the impact of an intensive, individualised approach to complementary feeding education for caregivers on feeding practices and growth over usual care. An individually randomised (1:1 allocation ratio), parallel-group superiority trial, with blinding of study staff collecting outcome data. Rural Maya communities in Guatemala. 324 children aged 6-24 months with a height-for-age Z score of less than or equal to -2.5 SD were randomised, 161 to the intervention and 163 to usual care. Community health workers conducted home visits for 6 months, providing usual care or usual care plus individualised caregiver education. The main outcome was change in length/height-for-age Z score. Secondary outcomes were changes in complementary feeding indicators. Data were analysed for 296 subjects (intervention 145, usual care 151). There was a non-significant trend to improved growth in the intervention arm (length/height-for-age Z score change difference 0.07(95% CI -0.04 to 0.18)). The intervention led to a 22% improvement in minimum dietary diversity (RR 1.22, 95% CI 1.11 to 1.35) and a 23% improvement in minimal acceptable diet (RR 1.23, 95% CI 1.08 to 1.40) over usual care. Complementary feeding outcomes improved in the intervention arm, and a non-significant trend towards improved linear growth was observed. Community health workers in a low-resource rural environment can implement individualised caregiver complementary feeding education with significant improvements in child dietary quality over standard approaches. NCT02509936. Stage: Results.

Guatemala's rural indigenous population suffers from one of the highest rates of chronic child malnutrition (stunting) in the world. Successfully addressing stunting requires defining the barriers to and opportunities for new behaviour-change initiatives. We undertook a mixed-methods assessment of feeding practices and food purchasing behaviours around infants and young children aged 6-36 months in two rural indigenous Guatemalan communities. We found that most caregivers were aware only of acute forms of child malnutrition and that they greatly underestimated the local prevalence of malnutrition. Despite moderate adherence to exclusive breastfeeding and timing of complementary food introduction, diets had poor diversity and inadequate meal frequency. Furthermore, perceptions of food insecurity were high even in the presence of land ownership and agricultural production. Although fortified foods were highly valued, they were considered expensive. At the same time, proportionally equivalent amounts of money were spent on junk foods or other processed foods by most participants. Biological mothers often lacked autonomy for food purchasing and nutritional decisions because of the power exerted by husbands and paternal grandmothers. Our findings suggest several creative and community-based programming initiatives including education about the acute vs. chronic malnutrition distinction, engaging landowners in discussions about domestic food consumption, engaging with caregivers to redirect funds towards fortified foods rather than junk food purchases and directing behaviour-change initiatives towards all household stakeholders.