Inequalities in Child Mortality in India: A District-Level Analysis

This paper measures the degree of inequality in child mortality rates across districts in India, using data from the 1981, 1991 and 2001 Indian population censuses. The results show that child mortality is more concentrated in less developed districts in all three census years. Further, between 1981 and 2001, the inequality in child mortality seems to have increased to the advantage of the more developed districts (i.e., there was an increasing concentration of child mortality in less developed districts). However, the inequality in female child mortality rates seems to have declined between 1991 and 2001, even as it increased – albeit at a slower rate than before – for male child mortality rates. In the decomposition analysis, it is found that while a more equitable distribution of medical facilities and safe drinking water across districts did contribute towards reducing inequality in child mortality between 1981 and 1991, different levels of structural change among districts were responsible for a very large part of the inequality in child mortality to the advantage of the more developed districts in all three census years. Other variables which played important roles in increasing inequality included a measure of infrastructure development, female literacy, and a social group status variable. The paper concludes with some brief comments on the policy implications of the findings.

Reversible behavioural autistic-like regression: A manifestation of a special (new?) epileptic syndrome in a 28-month-old child. A 2-year longitudinal study .

A 28-month-old boy was referred for acute onset of abnormal head movements. History revealed an insidious progressive regression in behaviour and communication over several months. Head and shoulder 'spasms' with alteration of consciousness and on one occasion ictal laughter were seen. The electroencephalograph (EEG) showed repeated bursts of brief generalized polyspikes and spike-wave during the 'spasms', followed by flattening, a special pattern which never recurred after treatment. Review of family videos showed a single 'minor' identical seizure 6 months previously. Magnetic resonance imaging was normal. Clonazepam brought immediate cessation of seizures, normalization of the EEG and a parallel spectacular improvement in communication, mood and language. Follow-up over the next 10 months showed a new regression unaccompained by recognized seizures, although numerous seizures were discovered during the videotaped neuropsychological examination, when stereotyped subtle brief paroxysmal changes in posture and behaviour could be studied in slow motion and compared with the 'prototypical' initial ones. The EEG showed predominant rare left-sided fronto-temporal discharges. Clonazepam was changed to carbamazepin with marked improvement in behaviour, language and cognition which has been sustained up to the last control at 51 months. Videotaped home observations allowed the documentation of striking qualitative and quantitative variations in social interaction and play of autistic type in relation to the epileptic activity. We conclude that this child has a special characteristic epileptic syndrome with subtle motor and vegetative symptomatology associated with an insidious catastrophic 'autistic-like' regression which could be overlooked. The methods used to document such fluctuating epileptic behavioural manifestations are discussed.

Allergic asthma to thaumatin : case report

Background: Thaumatin is a protein originally isolated from an African fruit (the "katemfe"), but various thaumatin-like proteins have been found in apples, grapes, kiwis and olives, etc. Thaumatin has natural sweetening properties and is about 2000 to 3000 times more potent than sucrose. It is therefore used in the food industry, particularly in the processing of low-calories sweeteners. Recently, thaumatin-like proteins have been described as a new family of allergens. Methods: We report the case of a 44-year-old woman occupationally exposed to thaumatin, who developed an allergy to it. The first symptom was an urticaria, which she presented two years after the factory she was working in (a sweeteners manufacturer), started to use thaumatin. Later on, she perceived an acute episode of a sensation of lump in the throat, persisting mild dyspnea, dysphonia and cough. Despite normal peak flow values and a normal chest examination, her general practitioner treated her with local corticoids and systemic antihistaminic drugs, which improved the symptoms. As occupational physicians, we were asked about the likelihood of an occupational disease. We visited her working place, and assessed the exposure to thaumatin. We concluded that the probability for a delayed asthma related to a thaumatin exposure was high, despite the lack of an exposure test. Results: The case was submitted to the insurance company as an occupational disease, and was accepted as such. It was therefore decided not to perform the exposure test, given the absence of true benefit for the patient, who was advised to switch job, and to avoid any exposure to thaumatin in the future. A few months later, the symptoms had completely disappeared. Conclusion: Some molecules only used in specific industry sectors, can cause health problems, such as allergy, but also toxic impairments, etc. The occupational physician, trained to find out which products and identify which molecules are involved, can contribute to the diagnosis, and help make possible a safe return to work for the patient.

The Child is father of the man: implications for the demographic transition

We propose a new theory of the demographic transition based on the evidence that body development during childhood is an important predictor of adult life expectancy. This theory is embodied in an OLG framework where fertility, longevity and education all result from individual decisions. The model displays different regimes, allowing the economy to move slowly from an initial Malthusian regime towards the Modern era. The dynamics reproduces the key features of the demographic transition, including the permanent increase in life expectancy, resulting from improvements in body development, the hump in both population growth and fertility, and a late increase in secondary educational attainments.

Child sun protection in New Zealand: parental view and societal responsibilities

Issue addressed: Cutaneous melanoma is a significant health problem in New Zealand. Excessive sun exposure in early life increases subsequent risk. This study investigated parental opinions, understanding and practices concerning the sun protection of young children. The study aimed to identify areas where improvements in sun protection may be most needed. Methods: Parents were recruited through licensed childcare centres and kindergartens in Dunedin to take part in semi-structured focus groups. Feedback was obtained from participants in response to summary reports based on audiotapes. Results: Parents noted increased social acceptability of sun protective behaviours and child sunburn was now unacceptable. Past media campaigns were well recalled. The 'time to burn' used in media weather reports was easier to understand than the Ultra Violet Index (UVI), about which more information was wanted. Protective messages were expected to be straightforward, consistent and readily and regularly available. Local radio may provide the most timely, relevant information. There was a perceived lack of authoritative information about sunscreens and sunglasses and a shortage of acceptable protective clothing. Fuller information on sunscreen containers and greater use of UV Protection Factor (UPF) ratings for clothing and Eye Protection Factor (EPF) for sunglasses would assist. The use of shade and rescheduling of activities were scarcely mentioned. Conclusions: Parents were aware of the need for child sun protection but lacked confidence about how best to achieve this. Future health promotion programs should emphasise how optimal protection can be achieved more than why sun protection is needed. Programs should include a repertoire of strategies targeted towards individuals through the education of children and caregivers. They should also aim at achieving modifications in physical and social environments, including appropriate product design and promotion. So what?: The development of a balanced, comprehensive program with environmental components that reinforce protective behaviours has the potential to sustain sun protection among the largest number of children in the longer term.

Early mother-child interaction and later quality of attachment in infants with an orofacial cleft compared to infants without cleft.

Objective : The main objective of this study was to assess mother-child patterns of interaction in relation to later quality of attachment in a group of children with an orofacial cleft compared with children without cleft. Design : Families were contacted when the child was 2 months old for a direct assessment of mother-child interaction and then at 12 months for a direct assessment of the child's attachment. Data concerning socioeconomical information and posttraumatic stress symptoms in mothers were collected at the first appointment. Participants : Forty families of children with a cleft and 45 families of children without cleft were included in the study. Families were recruited at birth in the University Hospital of Lausanne. Results : Results showed that children with a cleft were more difficult and less cooperative during interaction at 2 months of age with their mother compared with children without a cleft. No significant differences were found in mothers or in dyadic interactive styles. Concerning the child's attachment at 12 months old, no differences were found in attachment security. However, secure children with a cleft were significantly more avoidant with their mother during the reunion episodes than secure children without cleft. Conclusion : Despite the facial disfigurement and the stress engendered by treatment during the first months of the infant's life, children with cleft and their mothers are doing as well as families without cleft with regard to the mothers' mental health, mother-child relationships, and later quality of attachment. A potential contribution for this absence of difference may be the pluridisciplinary support that families of children with cleft benefit from in Lausanne.

Prenatal manifestation and management of a mother and child affected by spondyloperipheral dysplasia with a C-propeptide mutation in COL2A1: case report.

It is not unusual for patients with "rare" conditions, such as skeletal dysplasias, to remain undiagnosed until adulthood. In such cases, a pregnancy may unexpectedly reveal hidden problems and special needs. A 28 year old primigravida was referred to us at 17 weeks for counselling with an undiagnosed skeletal dysplasia with specific skeletal anomalies suggesting the collagen 2 disorder, spondyloperipheral dysplasia (SPD; MIM 156550).She was counselled about the probability of dominant inheritance and was offered a prenatal diagnosis by sonography. US examination at 17, 18 and 20 weeks revealed fetal macrocephaly, a narrow thorax, and shortening and bowing of long bones. The parents elected to continue the pregnancy. At birth the baby showed severe respiratory distress for four weeks which then resolved. Mutation analysis of both mother and child revealed a hitherto undescribed heterozygous nonsense mutation in the C-propeptide coding region of COL2A1 confirming the diagnosis of SPD while reinforcing the genotype-phenotype correlations between C-propeptide COL2A1 mutations and the SPD-Torrance spectrum. This case demonstrates the importance of a correct diagnosis even in adulthood, enabling individuals affected by rare conditions to be made aware about recurrence and pregnancy-associated risks, and potential complications in the newborn.

Three-dimensional cholangio-spiral CT demonstration of a post-traumatic bile leak in a child.

Bilioma is a rare complication of traumatic liver injury, and the precise site of bile leak is often difficult to demonstrate with a non-invasive technique. We report a case of post-traumatic bile leak in a 15-year-old girl in whom spiral CT after intravenous cholangiography allowed excellent preoperative demonstration of the extent of the liver rupture and an exact location of the bile leak. We think that spiral-CT cholangiography could be an accurate, non-invasive technique to investigate the biliary system in cases of paediatric liver trauma.

CD4+CD25-mTGFbeta+ T cells induced by nasal application of ovalbumin transfer tolerance in a therapeutic model of asthma.

Background: Intranasal administration of high amount of allergen was shown to induce tolerance and to reverse the allergic phenotype. However, mechanisms of tolerance induction via the mucosal route are still unclear. Objectives: To characterize the therapeutic effects of intranasal application of ovalbumin (OVA) in a mouse model of bronchial inflammation as well as the cellular and molecular mechanisms leading to protection upon re-exposure to allergen. Methods: After induction of bronchial inflammation, mice were treated intranasally with OVA and re-exposed to OVA aerosols 10 days later. Bronchoalveolar lavage fluid (BALF), T cell proliferation and cytokine secretion were examined. The respective role of CD4(+)CD25(+) and CD4(+)CD25(-) T cells in the induction of tolerance was analysed. Results: Intranasal treatment with OVA drastically reduced inflammatory cell recruitment into BALF and bronchial hyperresponsiveness upon re-exposure to allergen. Both OVA- specific-proliferation of T cells, T(h)1 and T(h)2 cytokine production from lung and bronchial lymph nodes were inhibited. Transfer of CD4(+)CD25(-) T cells, which strongly expressed membrane-bound transforming growth factor beta (mTGF beta), from tolerized mice protected asthmatic recipient mice from subsequent aerosol challenges. The presence of CD4(+)CD25(+)(Foxp3(+)) T cells during the process of tolerization was indispensable to CD4(+)CD25(-) T cells to acquire regulatory properties. Whereas the presence of IL-10 appeared dispensable in this model, the suppression of CD4(+)CD25(-)mTGF beta(+) T cells in transfer experiments significantly impaired the down-regulation of airways inflammation. Conclusion: Nasal application of OVA in established asthma led to the induction of CD4(+)CD25(-)mTGF beta(+) T cells with regulatory properties, able to confer protection upon allergen re-exposure.

Early broncoconstriction in anesthetized sheep: a simplified experimental model of asthma

Résumé Cette étude décrit un modèle expérimental de bronchoconstriction précoce induite par aérosolisation d'un extrait d'Ascaris suum chez des moutons anesthésiés par de l'isoflurane et ventilés mécaniquement. Dix moutons adultes ont été anesthésiés et ventilés mécaniquement puis ont été exposés à un stimulus bronchoconstrictif sous forme d'un aérosol d'extrait d'Ascaris suum durant 25 minutes. Tous les moutons ont été exposés deux fois à huit semaines d'intervalle à ce même stimulus. Les échanges gazeux ainsi que les paramètres respiratoires ont été mesurés régulièrement durant la période d'aérosolisation ainsi que durant les 60 minutes suivantes. A la fin de la période d'aérosolisation, une augmentation significative (p<0.05) des pressions de crête (+114%) et de plateau (+148%), de la résistance expiratoire (+93%) et de la pression partielle artérielle de gaz carbonique PaCO2 (+25%) a été constatée, de même qu'une diminution significative (p<0.05) de la compliance respiratoire (-41 %) et de la pression partielle artérielle d'oxygène PaO2 (-49%). Ces modifications sont restées stables durant toute la période d'observation. Ce modèle expérimental animal de bronchoconstriction offre de nombreux avantages : la stabilité hémodynamique et le confort de l'animal sont améliorés et la réaction de stress est inhibée. Il permet de plus une distribution optimale de l'antigène respiratoire et finalement évite l'utilisation d'un pléthysmographe corporel. Abstract This study describes a simplified experimental model of early bronchoconstriction induced by aerosolization of Ascaris suum extract in isoflurane-anesthetized and mechanically ventilated sheep. Ten adult sheep were anesthetized, mechanically ventilated and then challenged with an aerosol of Ascaris suum extract during 25 minutes. All of them were challenged twice at eight weeks intervals. During the bronchoconstrictive challenges and the following sixty minutes, gas exchange was measured and respiratory mechanics parameters computed from a lung mechanics calculator. At the end of the challenge, a significant increase (p<0.05) was observed in peak (+114%) and plateau (+148%) pressures, expiratory resistance (+93%) and PaCO2 (+25%) along with a significant decrease (p<0.05) in respiratory compliance (-41 %) and PaO2 (-49%). These changes remained stable throughout the 60 minutes study period. This model offers several advantages: hemodynamic stability and animal welfare are improved and the stress response is blunted. It allows an optimal distribution of the antigen and finally avoids the need of a body plethysmograph.

IL-5 and IL-5 receptor in asthma

Eosinophils, along with mast cells are key cells involved in the innate immune response against parasitic infection whereas the adaptive immune response is largely dependent on lymphocytes. In chronic parasitic disease and in chronic allergic disease, IL-5 is predominantly a T cell derived cytokine which is particularly important for the terminal differentiation, activation and survival of committed eosinophil precursors. The human IL-5 gene is located on chromosome 5 in a gene cluster that contains the evolutionary related IL-4 family of cytokine genes. The human IL-5 receptor complex is a heterodimer consisting of a unique a subunit (predominantly expressed on eosinophils) and a beta subunit which is shared between the receptors for IL-3 & GM-CSF (more widely expressed). The a subunit is required for ligand-specific binding whereas association with the beta subunit results in increased binding affinity. The alternative splicing of the alphaIL-5R gene which contains 14 exons can yield several alphaIL-5R isoforms including a membrane-anchored isoform (alphaIL-5Rm) and a soluble isoform (alphaIL-5Rs). Cytokines such as IL-5 produce specific and non-specific cellular responses through specific cell membrane receptor mediated activation of intracellular signal transduction pathways which, to a large part, regulate gene expression. The major intracellular signal transduction mechanism is activation of non-receptor associated tyrosine kinases including JAK and MAP kinases which can then transduce signals via a novel family of transcriptional factors named signal transducers and activators of transcription (STATS). JAK2, STAT1 and STAT 5 appear to be particularly important in IL-5 mediated eosinophil responses. Asthma is characterized by episodic airways obstruction, increased bronchial responsiveness, and airway inflammation. Several studies have shown an association between the number of activated T cells and eosinophils in the airways and abnormalities in FEV1, airway reactivity and clinical severity in asthma. It has now been well documented that IL-5 is highly expressed in the bronchial mucosa of atopic and intrinsic asthmatics and that the increased IL-5 mRNA present in airway tissues is predominantly T cell derived. Immunocytochemical staining of bronchial biopsy sections has confirmed that IL-5 mRNA transcripts are translated into protein in asthmatic subjects. Furthermore, the number of activated CD 4 + T cells and IL-5 mRNA positive cells are increased in asthmatic airways following antigen challenge and studies that have examined IL-5 expression in asthmatic subjects before and after steroids have shown significantly decreased expression following oral corticosteroid treatment in steroid-sensitive asthma but not in steroid resistant and chronic severe steroid dependent asthma. The link between T cell derived IL-5 and eosinophil activation in asthmatic airways is further strengthened by the demonstration that there is an increased number of alphaIL-5R mRNA positive cells in the bronchial biopsies of atopic and non-atopic asthmatic subjects and that the eosinophil is the predominant site of this increased alphaIL-5R mRNA expression. We have also shown that the subset of activated eosinophils that expressed mRNA for membrane bound alpha IL5r inversely correlated with FEV1, whereas the subset of activated eosinophils that expressed mRNA for soluble alphaIL5r directly correlated with FEV1. Hence, not only does this data suggest that the presence of eosinophils expressing alphaIL-5R mRNA contribute towards the pathogenesis of bronchial asthma, but also that the eosinophil phenotype with respect to alphaIL-5R isoform expression is of central importance. Finally, there are several animal, and more recently in vitro lung explant, models of allergen induced eosinophilia, late airway responses(LARS), and bronchial hyperresponsiveness(BHR) - all of which support a link between IL-5 and airway eosinophila and bronchial hyperresponsiveness. The most direct demonstration of T cell involvement in LARS is the finding that these physiological responses can be transferred by CD4+ but not CD8+ T cells in rats. The importance of IL-5 in animal models of allergen induced bronchial hyperresponsiveness has been further demonstrated by a number of studies which have indicated that IL-5 administration is able to induce late phase responses and BHR and that anti-IL-5 antibody can block allergen induced late phase responses and BHR. In summary, activated T lymphocytes, IL5 production and eosinophil activation are particularly important in the asthmatic response. Human studies in asthma and studies in allergic animal models have clearly emphasised the unique role of IL-5 in linking T lymphocytes and adaptive immunity, the eosinophil effector cell, and the asthma phenotype. The central role of activated lymphocytes and eosinophils in asthma would argue for the likely therapeutic success of strategies to block T cell and eosinophil activation (eg steroids). Importantly, more targeted therapies may avoid the complications associated with steroids. Such therapies could target key T cell activation proteins and cytokines by various means including blocking antibodies (eg anti-CD4, anti-CD40, anti-IL-5 etc), antisense oligonucleotides to their specific mRNAs, and/or selective inhibition of the promoter sites for these genes. Another option would be to target key eosinophil activation mechanisms including the aIL5r. As always, the risk to benefit ratio of such strategies await the results of well conducted clinical trials.

The role of the object and the mourning process in the child

The young child's ability to go through a genuine mourning process has been a source of controversy in the psychoanalytical literature. This may seem surprising, considering that mourning is essential for and inherent to psychic development. This paper attempts to show that the young child's ability to go through a mourning process does not depend mainly on ego maturity, nor just on an acknowledgment of a loss in the external world, nor on the child's understanding the idea of death at an intellectual and cognitive level. But it may depend mainly on the establishment of the primordial mourning process inherent to the separation of the transnarcissistic mother-child relation and on the existence of the objectalizing function (A. Green, 1986) in the remaining or substitute parent's psyche. A clinical example serves to illustrate these hypotheses.