AbstractIntroductionAntimicrobial resistance (AMR) is a major public health challenge worldwide, threatening the important gains that have been made in reducing mortality due to infectious diseases. Despite current World Health Organization guidelines restricting antibiotics to a small subset of children with dysentery or suspected cholera, many children with diarrhea continue to be treated with antibiotics. We aim to determine the impact of a 3-day course of azithromycin on the risk of AMR at 90 and 180 days after treatment, among a subset of children and their household contacts enrolled into a multi-country, randomized, double-blind, placebo-controlled clinical trial of azithromycin children under 2 years with diarrhea in low income settings,Methods and analysisThe AntiBiotics for Children with Diarrhea (ABCD) trial is testing the efficacy of a 3-day course of azithromycin, compared to placebo, in reducing mortality and linear growth faltering in the subsequent 6 months among 11,500 children aged 2-23 months of age across multiple sites in Bangladesh, India, Kenya Malawi, Mali, Pakistan and Tanzania with diarrhea and one or more of the following; dehydration, severe stunting, or moderate wasting (https://clinicaltrials.gov/ct2/show/NCT03130114). A sub-set of enrolled children are randomly selected to participate in a sub-study of AMR. A fecal sample (stool or rectal swab) will be collected at baseline from all enrolled children. A fecal sample and a nasopharyngeal (NP) swab will be collected at day 90 and 180 after enrolment from participating children and a close household child contact. Escherichia coli and Streptococcus pneumoniae will be isolated and Minimum Inhibitory Concentration for azithromycin and other commonly used antibiotics will be determined and compared between trial arms.Ethics and disseminationThis study was reviewed by an independent ethical review committee. Dissemination of results is planned to local and international policy makers and the public.Registration details (Parent ABCD trial)https://clinicaltrials.gov/ct2/show/NCT03130114Strengths and limitations of this study (3-5 points)✤This study will provide evidence from a randomized controlled trial regarding the risk of short term azithromycin use on resistance to azithromycin and selected commonly used antibiotics, 90 and 180 days after administration in treated children and their household contacts. Few RCTs of antibiotics for diarrhoea have provided such long-term follow-up and close contact data, both of which are key to understanding the potential risk of short-term antibiotic use in the context of diarrhoea.✤This study will also provide data on antibiotic resistance from multiple countries in sub-Saharan Africa and Asia where availability of such data is limited.✤Escherichia coli and Streptococcus pneumoniae will be used as indicator organisms to monitor the impact of empiric antibiotic azithromycin administration on the development of resistance in bacteria colonising the gut and nasopharynx respectively – both are suitable for this purpose as they have pathogenic potential and are also commensal organisms which may act as reservoirs of transmissible genetic resistance elements.✤With only two follow-up visits at 90 and 180 days, lack of culturing of other bacterial pathogens, and minimal collection of information on other antibiotic use during follow-up, this study will not evaluate impact of azithromycin beyond 180 days, the impact on other pathogenic bacteria, nor the added impact of the use of other antibiotics on resistance profiles

Twenty five infants who were small for gestational age received glucagon (0.5 mg/day by continuous infusion) in the treatment of hypoglycaemia. Twenty responded within three hours with a rise in blood glucose concentration to above 4 mmol/l. Five subjects subsequently required hydrocortisone to maintain glucose concentrations. Rebound hypoglycaemia occurred in nine infants after rapid discontinuation of glucagon or interruption of the intravenous infusions. Response was poor after maternal beta blockade.

Background Chlorhexidine, a broad-spectrum topical antiseptic with strong residual activity, has a potential to reduce infections during the neonatal period. However, the challenge remains what would be the best mode to deliver the intervention. As a part of formative research, we evaluated three possible modes of chlorhexidine delivery i.e. 100ml bottle with cotton swab, 10ml single use dropper bottle and 3g single application squeeze tube containing gel, as an umbilical cord care intervention using Trials for Improved Practices (TIPS) methodology in preparation for a large double-blind randomized controlled trial evaluating the impact of chlorhexidine. in Pemba, Tanzania. Methods 204 mother-newborn pairs were enrolled from hospital and community setting. Three different modes of application of intervention were tested (3 days for each preparation) in a cross over design. Mothers (on day 10), MCH, TBA and hospital staff was interviewed about their experience and feedback of their preference among the three delivery modes. Convenient and preference scores were calculated based on their feedback. Results 97% mothers applied intervention for all 9 days. 10ml dropper bottle (49.7%) was rated as most convenient by the mothers, gel tube (32.2%) and 100ml bottle (19.8%). Mothers opted 10ml dropper bottle (44.6%) as their first choice over the 100ml bottle (21.5%) or gel tube (33.9%). MCH/hospital staff’s choice was to use gel tube (84%) or 10ml dropper bottle (82%). Conclusions Overall acceptability was high, in terms of convenience and preference 10ml dropper bottle was a winner. Based on their choice the 10ml dropper bottle was selected for RCT.

Introduction Studies in Nepal, Pakistan, and Bangladesh have shown using 4% CHX solution for umbilical cord cleansing reduces neonatal mortality and omphalitis. Data evaluating the effect of 4% Chlorhexidine umbilical cord cleansing from the Sub-Saharan region is lacking. Considering this need we are undertaking a double blind, controlled study in Eastern Africa. Before starting the trial, in this pilot we tested the impact of 4% Chlorhexidine and control solution specially prepared for the trial on colonization and colony count. Methods Total 512 newborns in both the hospital and community were enrolled in the study. Newborns were randomly assigned the Chlorhexidine, placebo or dry cord care group. Umbilical swabs were collected at baseline (before the application of intervention), 2 hour and 48 hour after application of the assigned intervention. Presence of growth, identification to gram positive/negative groups and semi-quantitative colony count was estimated for all samples. Results The positivity was high baseline swabs 30% (154 of 512 samples). In 2 hour post intervention group Chlorhexidine significantly reduced the growth of pathogens compared to placebo (OR 0.15, p< 0.01) and dry cord [OR 0.07, p=0.00]. In 48-hour swabs reduction in growth and density of organisms was observed in Chlorhexidine group (OR 0.11, p<0.01). There was no difference between the control solution and dry cord group (OR 0.97, p=0.92). Conclusions Chlorhexidine preparation was effective in reducing the growth and density of pathogens over the umbilical cord. The control preparation did not increase colonization but was similar to dry cord care group.

Background Iron deficiency remains a major nutritional problem among infants and young children in India. The tablet/syrup-based programs do have logistic, supply and compliance challenges. Tablet/Syrup may have increased risk of free iron in blood, oxidative stress and risk of infections. Objective In a community based RCT we evaluated 3 approaches of iron delivery for impact on iron status, pro and anti-inflammatory interleukins and non-transferrin bound iron (NTBI) with 30 day intervention. Methods 300 children 22–34 months were enrolled and randomized to receive either iron fortified biscuit (n=74), iron tablet (n=77), iron+ zinc tablet (n=74) or placebo (n=75) for 30 days. Results Delivery of iron through biscuit showed better impact on hemoglobin (Mean Diff: 0.60; 95 % CI: 0.16–1.04) and other hematological markers like RDW, MCV and MCH at 30 day post supplementation. The NTBI estimation at day 1 and 30 post supplementation, 3 hours after ingestion of supplement dose; an indicator of oxidative stress caused by dose after iron status repletion, suggested the lowest burden with biscuit (2 %) and a higher burden with supplements (6–7 %). At day 30 there was no effect on interleukins in the biscuit group; increase in IL-6/IL10 in iron tablet, increase in IL-8/IL10 in iron+zinc tablet group. Conclusion Providing iron through fortified biscuits was as efficient and effective in improvement of iron status and hematological markers as iron tablets. Biscuit was marginally better for NTBI or immune response. The benefit of using biscuits needs to be evaluated in a larger community based effectiveness program.

Background Efficacy studies of application of chlorhexidine on umbilical cord have suggested significant improvement in neonatal outcomes. An important question for new trials and programs however is what should be the quantity used. There are concerns about the increased risk of hypothermia resulting from spillage or over use of any cleansing liquid solution in newborn. In context of a randomized controlled trial evaluating impact of cord cleansing in Africa, on recommendation of DSMB we undertook a pilot study, which aimed to determine the optimal quantity of the intervention solution required for application on umbilical cord of newborn. Methods Children were enrolled from both community and hospital in Pemba (n=62) and only from Hospitals in Delhi (n=50). Trained Hospital staff/MCH applied the intervention solution from a dropper bottle filled with 10 ml, on the umbilical cord of the baby generously such that it covered umbilical cord and periumbilical area. A study supervisor to maintain consistency supervised the process. After application the unused volume from each of the containers was measured to determine the actual usage. Results The mean volume of usage did not differ between Pemba and Delhi (4.58±0.8 ml and 4.79±1.88 ml respectively). The quantity of solution used ranged from 3ml to 7.5ml with a median of 4.5ml. Conclusions The optimal requirement for application was found to be 5 ml. However to be little conservative we recommend use 6 ml to adjust for any spillage and/or any abnormally long cord.

Background Infections in new-borns are the single most important cause for neonatal mortality in developing countries. Of topical antiseptics chlorhexidine has shown potential as an effective cord care agent. Results from randomized double-blind trials examining the effect of chlorhexidine in Asia have been encouraging. A 4% chlorhexidine solution is not comercially available we contracted Galantic Pharma to prepare supplies for two large clinical trials in Africa. This study aimed to evaluate the effect this 4% chlorhexidine solution on the colonization and colony counts in hospital born infants. Methods Newborns (n=247) from normal deliveries at a hospital in New Delhi were randomly assigned to one of three groups chlorhexidine, placebo or dry cord care. Swab samples were used to collect smear samples before, after 2hrs and 48hrs of application of chlorhexidine and at same times from the dry cord group. All swabs were analysed for growth and colony counts. Results The overall baseline positivity was 20% (50 of 247 swabs). Chlorhexidine reduced colonisation and bacterial counts in both (2hr and 48 hr) samples. As compared to placebo and dry cord, the reduction in positivity in chlorhexidine group in 2-hour samples was 80% [odds ratio of 0.20, p=0.001 and odds of 0.19, p=0.00 respectively]. In 48-hour post intervention, chlorhexidine significantly reduced colonisation in comparison to placebo [difference in mean of –1.01, p=0.006] and dry cord [difference in mean –1.16, p=0.004]. Conclusion Cord cleaning with 4% Chlorhexidine soon after birth reduces colonisation as well as density of pathogens significantly.

BACKGROUND:Anaemia caused by iron deficiency is common in children younger than age 5 years in eastern Africa. However, there is concern that universal supplementation of children with iron and folic acid in areas of high malaria transmission might be harmful. METHODS:We did a randomised, placebo-controlled trial, of children aged 1-35 months and living in Pemba, Zanzibar. We assigned children to daily oral supplementation with: iron (12.5 mg) and folic acid (50 mug; n=7950), iron, folic acid, and zinc (n=8120), or placebo (n=8006); children aged 1-11 months received half the dose. Our primary endpoints were all-cause mortality and admission to hospital. Analyses were by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59549825. FINDINGS:The iron and folic acid-containing groups of the trial were stopped early on Aug 19, 2003, on the recommendation of the data and safety monitoring board. To this date, 24 076 children contributed a follow-up of 25,524 child-years. Those who received iron and folic acid with or without zinc were 12% (95% CI 2-23, p=0.02) more likely to die or need treatment in hospital for an adverse event and 11% (1-23%, p=0.03) more likely to be admitted to hospital; there were also 15% (-7 to 41, p=0.19) more deaths in these groups. INTERPRETATION:Routine supplementation with iron and folic acid in preschool children in a population with high rates of malaria can result in an increased risk of severe illness and death. In the presence of an active programme to detect and treat malaria and other infections, iron-deficient and anaemic children can benefit from supplementation. However, supplementation of those who are not iron deficient might be harmful. As such, current guidelines for universal supplementation with iron and folic acid should be revised.