Case-control study of risk of dehydrating diarrhoea in infants in vulnerable period after full weaning.

OBJECTIVES: To investigate risk factors for dehydrating diarrhoea in infants, with special interest in the weaning period. DESIGN: Case-control study. SETTING: Metropolitan area of Porto Alegre, Brazil. SUBJECTS: Cases were 192 children aged 0-23 months hospitalised with acute diarrhoea and moderate to severe dehydration. Controls were 192 children matched for age and neighbourhood who did not have diarrhoea in the previous week. MAIN OUTCOME MEASURES: Associations between dehydrating diarrhoea and child''s age, type of milk consumed, time since breast feeding stopped, and breast feeding status. RESULTS: In infants aged < 12 months the risk of dehydrating diarrhoea was significantly higher in the first 9 months of life (P < 0.001), and in those aged 12-23 months the risk was again greater in younger children (12-17 months) (P = 0.03). The type of milk consumed before start of diarrhoea episode was strongly associated with dehydration independent of socioeconomic, environmental, maternal reproductive, demographic, and health services factors. Compared with infants exclusively breast fed, bottle fed infants were at higher risk (odds ratio (95% confidence interval) for cow''s milk 6.0 (1.8 to 19.8), for formula milk 6.9 (1.4 to 33.3)). Compared with those still breast feeding, children who stopped in the previous two months were more likely to develop dehydrating diarrhoea (odds ratio 8.4 (2.4 to 29.6)). This risk decreased with time since breast feeding stopped. CONCLUSION: These results confirm the protective effect of breast feeding and suggest there is a vulnerable period soon after breast feeding is stopped, which may be of relevance for developing preventive strategies.     

Impact of massive dose of vitamin A given to preschool children with acute diarrhoea on subsequent respiratory and diarrhoeal morbidity.

OBJECTIVE--To assess the impact of vitamin A supplementation on morbidity from acute respiratory tract infections and diarrhoea. DESIGN--Double blind randomised placebo controlled field trial. SETTING--An urban slum area in New Delhi, India. SUBJECTS--900 children aged 12-60 months attending a local health facility for acute diarrhoea of less than seven days'' duration randomly allocated to receive vitamin A 200,000 IU or placebo. MAIN OUTCOME MEASURES--Incidence and prevalence of acute lower respiratory tract infections and diarrhoea during the 90 days after termination of the enrolment diarrhoeal episode measured by twice weekly household surveillance. RESULTS--The incidence (relative risk 1.07; 95% confidence interval 0.92 to 1.26) and average number of days spent with acute lower respiratory tract infections were similar in the vitamin A supplementation and placebo groups. Among children aged 23 months or less there was a significant reduction in the incidence of measles (relative risk 0.06; 95% confidence interval 0.01 to 0.48). The incidence of diarrhoea was also similar (relative risk 0.95; 0.86 to 1.05) in the two groups. There was a 36% reduction in the mean daily prevalence of diarrhoea associated with fever in the vitamin A supplemented children older than 23 months. CONCLUSIONS--Results were consistent with a lack of impact on acute lower respiratory tract related mortality after vitamin A supplementation noted in other trials and a possible reduction in the severity of diarrhoea.     

Prolonged breast feeding,diarrhoeal disease,and survival of children in Guinea-Bissau.

OBJECTIVE--To analyse the impact of breast feeding on diarrhoeal disease and survival in children above 1 year of age in Guinea-Bissau, west Africa. DESIGN--A community study of an open cohort followed up weekly by interviews over 15 months. Data on feeding practices, anthropometry, and survival were recorded for three years. SETTING--301 randomly selected houses in a semiurban area in the capital, Bissau. SUBJECTS--849 children aged less than 3 years. MAIN OUTCOME MEASURES--Incidence and duration of diarrhoea, weight for age, and death of a child. RESULTS--The incidence of diarrhoea was higher in weaned children than in partially breast fed children, both in 1 year olds (relative risk 1.41; 95% confidence interval 1.23 to 1.62) and in 2 year olds (1.67; 1.29 to 2.15). The mean duration of an episode of diarrhoea was 5.3 days in breast fed children compared with 6.3 days in weaned children (P = 0.001). Independent of the age of weaning, a similar increase was found in an analysis comparing, for each child, the rate and duration of diarrhoea one month before and one month after weaning. Children with low weight for age were breast fed longer than the better nourished children (P = 0.02). Children aged 12-35 months who were not breast fed had a 3.5 times higher mortality (1.4 to 8.3) than breast fed children. CONCLUSIONS--The beneficial effects of breast feeding are not restricted to infancy. Though children who are partially breast fed after infancy may have a lower state of nutrition than the weaned ones, the benefit in terms of lower morbidity may be more important for child survival in places with a high morbidity from diarrhoea and with high mortality.     

Excess mortality among children discharged from hospital after treatment for diarrhoea in rural Bangladesh.

Five hundred and fifty one children aged between 3 months and 3 years were followed up at home for 12 months after treatment of diarrhoea in a rural treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh. During follow up the children were found to have a significantly higher mortality than generally observed in the community. The first three months after discharge appeared to be crucial, some 70% of the deaths occurring in that period. Severely malnourished children (nutritional state below 56% of the American National Center for Health Statistics (NCHS) standard of weight for age ratio) had a risk of death 14 times that of their well nourished counterparts (nutritional state 66% or more of the NCHS standard). The highest mortality occurred in 2 year olds, one in three of the severely malnourished children dying compared with one in 10 of the moderately malnourished. This pattern was not seen in children aged under 2 years. Immediate priority should be given to providing nutritional rehabilitation for malnourished children who contract diarrhoea.     

Childhood mortality after a high dose of vitamin A in a high risk population.

OBJECTIVES--To determine whether a single high dose of vitamin A given to all children in communities with high mortality and malnutrition could affect mortality and to assess whether periodic community wide supplementation could be readily incorporated into an ongoing primary health programme. DESIGN--Opportunistic controlled trial. SETTING--Jumla district, Nepal. SUBJECTS--All children aged under 5 years; 3786 in eight subdistricts given single dose of vitamin A and 3411 in remaining eight subdistricts given no supplementation. MAIN OUTCOME MEASURES--Mortality and cause of death in the five months after supplementation. RESULTS--Risk of death for children aged 1-59 months in supplemented communities was 26% lower (relative risk 0.74, 95% confidence interval 0.55 to 0.99) than in unsupplemented communities. The reduction in mortality was greatest among children aged 6-11 months: death rate (deaths/1000 child years at risk) was 133.8 in supplemented children and 260.8 in unsupplemented children (relative risk 0.51, 0.30 to 0.89). The death rate from diarrhoea was also reduced (63.5 supplemented v 97.5 unsupplemented; relative risk 0.65, 0.44 to 0.95). The extra cost per death averted was about $11. CONCLUSION--The results support a role for Vitamin A in increasing child survival. The supplementation programme was readily integrated with the ongoing community health programme at little extra cost.     

Risk factors for persistent diarrhoea.

With a systematically sampled population of children aged under 5 attending this centre for diarrhoeal disease research during 1983-5 a retrospective analysis of persistent diarrhoea (defined as greater than 14 days'' duration) was performed to identify the possible risk factors for this syndrome. Of the 4155 children included in the analysis, 410 (10%) gave a history of persistent diarrhoea. A comparison with children with acute diarrhoea matched for age showed that 11 factors were correlated with persistent diarrhoea, and strongly associated factors were stools with blood or mucus, or both, lower respiratory tract infection, malnutrition, vitamin A deficiency, and antibiotic use before presentation. The peak age was 2 years, and there was no sex difference. Deaths occurred more often in the group with persistent diarrhoea. Although Shigella spp, Campylobacter jejuni, and Giardia lamblia were frequently identified, their rates of isolation were not significantly higher among patients with persistent diarrhoea. No seasonal variation was observed in the rates of persistent diarrhoea. Although the introduction of family food to the diet was associated with higher rates, this factor was difficult to separate from the age dependent risks.     

Single dose vitamin A treatment in acute shigellosis in Bangladesh children: randomised double blind controlled trial.

OBJECTIVE: To evaluate the efficacy of a single large oral dose of vitamin A in treating acute shigellosis in children in Bangladesh. DESIGN: Randomised double blind controlled clinical trial. SETTING: Dhaka Hospital, International Centre for Diarrhoeal Disease Research, Bangladesh. SUBJECTS: 83 children aged 1-7 years with bacteriologically proved shigellosis but no clinical signs of vitamin A deficiency; 42 were randomised to treatment with vitamin A and 41 formed a control group. INTERVENTION: Children were given a single oral dose of 200,000 IU of vitamin A plus 25 IU vitamin E or a control preparation of 25 IU vitamin E. MAIN OUTCOME MEASURES: Clinical cure on study day 5 and bacteriological cure. RESULTS: Baseline characteristics of the subjects in the two treatment groups were similar. Significantly more children in the vitamin A group than in the control group achieved clinical cure (19/42 (45%) v 8/14 (20%); chi 2 = 5.14, 1 df, P = 0.02; risk ratio = 0.68 (95% confidence interval; 0.50 to 0.93)). When cure was determined bacteriologically, the groups had similar rates (16/42 (38%) v 16/41 (39%); chi 2 = 0.02, 1 df, P = 0.89; risk ratio = 0.98 (0.70 to 1.39)). CONCLUSIONS: Vitamin A reduces the severity of acute shigellosis in children living in areas where vitamin A deficiency is a major public health problem.     

Evaluation of Essential Trace and Toxic Elements in Biological Samples of Normal and Night Blindness Children of Age Groups 3–7 and 8–12 Years

The most common cause of blindness in developing countries is vitamin A deficiency. The World Health Organization estimates 13.8 million children to have some degree of visual loss related to vitamin A deficiency. The causes of night blindness in children are multifactorial, and particular consideration has been given to childhood nutritional deficiency, which is the most common problem found in underdeveloped countries. Such deficiency can result in physiological and pathological processes that in turn influence biological samples composition. Vitamin and mineral deficiency prevents more than two billion people from achieving their full intellectual and physical potential. This study was designed to compare the levels of Zn, Mg, Ca, K, Na, As, Cd, and Pb in scalp hair, blood, and urine of night blindness children age ranged 3–7 and 8–12 years of both genders, comparing them to sex- and age-matched controls. A microwave-assisted wet acid digestion procedure was developed as a sample pretreatment, for the determination of As, Ca, Cd, K, Pb, Mg, Na, and Zn in biological samples of night blindness children. The proposed method was validated by using conventional wet digestion and certified reference samples of hair, blood, and urine. The concentrations of trace and toxic elements were measured by atomic absorption spectrophotometer prior to microwave-assisted acid digestion. The results of this study showed that the mean values of As, Cd, Na, and Pb were significantly higher in scalp hair, blood, and urine samples of male and female night blindness children than in referents (p?<?0.001), whereas the concentrations of Zn, Ca, K, and Mg were lower in the scalp hair and blood but higher in the urine samples of night blindness children. These data present guidance to clinicians and other professional investigating deficiency of essential mineral elements in biological samples (scalp hair and blood) of night blindness children.     

Breast feeding,nutritional state,and child survival in rural Bangladesh

The effect of breast feeding on nutritional state, morbidity, and child survival was examined prospectively in a community in rural Bangladesh. Every month for six months health workers inquired about breast feeding and illness and measured arm circumference in an average of 4612 children aged 12-36 months. Data from children who died within one month of a visit were compared with those from children who survived. Roughly one third of the deaths in the age range 18-36 months were attributable to absence of breast feeding. Within this age range protection conferred by breast feeding was independent of age but was evident only in severely malnourished children.In communities with a high prevalence of malnutrition breast feeding may substantially enhance child survival up to 3 years of age.     

Effect on clinical outcome of breast feeding during acute diarrhoea.

The effects of oral rehydration fluid alone and of oral rehydration fluid plus breast feeding on the course and outcome of acute diarrhoea were assessed in two groups of 26 children aged under 2 years. Children who continued to be breast fed during treatment with oral rehydration solutions passed significantly fewer diarrhoeal stools. They also passed, on average, a smaller volume of diarrhoeal stools and recovered from diarrhoea sooner after the start of treatment. Their requirement for oral rehydration fluid was significantly reduced. Breast feeding exerts a beneficial effect on the course and outcome of acute diarrhoea by reducing the number and volume of diarrhoeal stools.     

Pseudo-Foster Kennedy Syndrome due to unilateral optic nerve hypoplasia: a case report

Introduction

The presentation of cystic fibrosis is dependant upon which organs are affected. Common presentations include chronic respiratory infections and malabsorption. Patients with atypical disease tend to present late in childhood or as adults. Eye manifestations of cystic fibrosis are less well known.

Case presentation

A 14-year-old Caucasian boy presented with tiredness and difficulty seeing at night, over a period of 6 months. Good vision was only described in bright conditions. There was no history of jaundice, steatorrhea or diarrhoea.

Conclusion

This is the first reported case of newly diagnosed cystic fibrosis-related liver disease in a teenage boy, whose presenting symptom was night blindness secondary to vitamin A deficiency.     

The Effect of Breast‐Feeding with and without Formula Use on the Risk of Obesity at 4 Years of Age

Objective: To determine the minimal duration of breast‐feeding required to protect against later obesity, whether the concurrent use of formula lessened any protective effect of breast‐feeding, and what maternal or child characteristics might modify the association between breast‐feeding and child obesity. Research Methods and Procedures: This was a retrospective cohort study. Participants were 73, 458 white and black low‐income children followed from birth through 4 years of age. Obesity at age 4 years was defined as measured BMI ≥ 95th percentile. Feeding exposure was based on breast‐feeding duration and the age of formula initiation. Covariates were obtained from the children's birth certificates. Results: At age 4 years, the prevalence of obesity was 11.5%. Only 16% of children were breast‐fed 8 weeks or longer. Breast‐feeding was associated with a reduced risk of obesity only in white children whose mothers had not smoked in pregnancy. In this subgroup, the reduction in obesity risk (adjusted odds ratio, 95% confidence interval), compared with those never breast‐fed, occurred only for children who were breast‐fed at least 16 weeks without formula (0.71, 0.56 to 0.92) or at least 26 weeks with concurrent formula (0.70, 0.61 to 0.81). Among whites whose mothers smoked in pregnancy and among blacks, breast‐feeding was not associated with a reduced risk of obesity at age 4 years. Discussion: In a population of low‐income children, breast‐feeding was associated with a reduced risk of obesity at age 4 years only among whites whose mothers did not smoke in pregnancy and only when breast‐feeding continued for at least 16 weeks without formula or at least 26 weeks with formula.     

Immunisation in a curative setting.

OBJECTIVE--To study the uptake of vaccination offered to women and children attending a curative health facility. DESIGN--Prospective survey over eight months of the uptake of vaccination offered to unimmunised women and children attending a diarrhoeal treatment centre as patients or attendants. SETTING--The International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh. SUBJECTS--An estimated 19,349 unimmunised women aged 15 to 45 and 17,372 children attending the centre for treatment or accompanying patients between 1 January and 31 August 1989. MAIN OUTCOME MEASURES--The number of women and children who were unimmunised or incompletely immunised was calculated and the percentage of this target population accepting vaccination was recorded. RESULTS--7530 (84.2%) Of 8944 eligible children and 7730 (40.4%) of 19,138 eligible women were vaccinated. Of the children, 63.8% were boys, 75.9% were aged under 1 year, and 23.0% were aged 1 to 2 years. The estimated number of missed opportunities for vaccination was 716 among the children (8.0% of the target population) and 11,408 among the women (59.6% of those eligible). CONCLUSION--It is possible to establish immunisation services at a health facility treating acutely ill patients.     

Breast-feeding, diarrhoea and sanitation as components of infant and child health: a study of large scale survey data from Ghana and Nigeria

Using Demographic and Health Survey datasets from Ghana and Nigeria, this study examined whether the protective effects of breast-feeding are greatest where the poorest sanitation conditions prevail. It was found that mixed-fed infants aged between 0 and 11 months tend to have a higher risk of diarrhoea than fully breast-fed children, while the risk of diarrhoea among weaned infants is twice that of mixed-fed infants. The probit regression models employed in the analysis were used to predict the probability of diarrhoea associated with each breast-feeding pattern for both 'poor' and 'good' sanitation areas. It was found that the risk of diarrhoea among mixed-fed infants in the poor sanitation areas tends to be high while the same risk among fully breast-fed infants tends to be minimal. In essence, the health risks of mixed feeding are real, particularly for infants aged less than 7 months, and are even worse for those weaned before 6 months of age.     

Anthropometry and body composition of 18 year old men according to duration of breast feeding: birth cohort study from Brazil

Objective To assess the association between duration of breast feeding and measures of adiposity in adolescence.Design Population based birth cohort study.Setting Pelotas, a city of 320 000 inhabitants in a relatively developed area in southern Brazil.Participants All newborn infants in the city''s hospitals were enrolled in 1982; 78.8% (2250) of all male participants were located at age 18 years when enrolling in the national army.Main outcome measures Weight, height, sitting height, subscapular and triceps skinfolds, and body composition (body fat, lean mass).Results Neither the duration of total breast feeding nor that of predominant breast feeding (breast milk plus non-nutritive fluids) showed consistent associations with anthropometric or body composition indices. After adjustment for confounding factors, the only significant associations were a greater than 50% reduction in obesity among participants breast fed for three to five months compared with all other breastfeeding categories (P = 0.007) and a linear decreasing trend in obesity with increasing duration of predominant breast feeding (P = 0.03). Similar significant effects were not observed for other measures of adiposity. Borderline direct associations also occurred between total duration of breast feeding and adult height (P = 0.06).Conclusions The significant reduction in obesity among children breast fed for three to five months is difficult to interpret, as no a priori hypothesis existed regarding a protective effect of intermediate duration of breast feeding. The findings indicate that, in this population, breast feeding has no marked protective effect against adolescent adiposity.     

Iron status in rats fed a purified diet without vitamin A

The effect of vitamin A deficiency on iron status was investigated in rats. After 28 d of feeding either low or high vitamin A diets (0 vs 4000 IU of vitamin A per kg feed), the final body weight was slightly but significantly lowered by the low vitamin A diet. Plasma retinol concentrations were decreased in rats fed diets low in vitamin A. Marginal vitamin A deficiency produced slightly, but significantly lower blood hemoglobin concentrations; it did not clearly affect hematocrit. The concentration of iron in liver was significantly higher when diets low in vitamin A were fed while significantly lower levels were observed in femur.     

Impact of breast feeding on admission for pneumonia during postneonatal period in Brazil: nested case-control study

ObjectiveTo determine whether breast feeding protects infants against pneumonia and whether the protection varies with age.DesignNested case-control study.SettingPelotas, southern Brazil.SubjectsCases were 152 infants aged 28-364 days who had been admitted to hospital for pneumonia. Controls were 2391 cases in a population based case-control study.ResultsInfants who were not being breast fed were 17 times more likely than those being breast fed without formula milk to be admitted to hospital for pneumonia (95% confidence interval 7.7 to 36.0). This relative risk was 61 (19.0 to 195.5) for children under 3 months old, decreasing to 10 (2.8 to 36.2) thereafter. Supplementation with solids was associated with a relative risk of 13.4 (7.6 to 23.5) for all infants and 175 (21.8 to 1405.1) for those under 3 months old.ConclusionBreast feeding protects young children against pneumonia, especially in the first months of life. These results may be used for targeting intervention campaigns at the most vulnerable age groups.

Key messages

• Pneumonia is the leading cause of death in children under 5 years old across the world
• In Brazil infants who were not breast fed were 17 times more likely than those receiving breast milk alone to be admitted for pneumonia
• The relative risk of admission was 61 for children under 3 months of age, decreasing to 10 thereafter
• Supplementation with solids was associated with a relative risk of 13.4 for all infants
• Mothers must be encouraged to breast feed very young infants and be advised of the right time to introduce supplementary foods

     

0～3岁婴幼儿超声骨密度现状调查及影响因素分析

目的:了解0~3岁婴幼儿的骨密度现状,并分析其相关影响因素,为婴幼儿骨密度不足的预防工作提供依据。方法:选取2016年1月-2018年10月期间于我院进行健康体检的0~3岁婴幼儿860例为研究对象。采用超声骨密度测量仪对入选婴幼儿左腿胫骨中段骨密度进行检测,并对婴幼儿的骨密度现状进行分析。采用问卷调查方式收集所有婴幼儿的性别、年龄、喂养方式、是否补充维生素D、户外活动时间等资料,并采用单因素和多因素Logistic回归分析0~3岁婴幼儿骨密度的影响因素。结果:860例婴幼儿中,骨密度正常婴幼儿336例,轻度骨密度不足婴幼儿196例,中度骨密度不足婴幼儿179例,重度骨密度不足婴幼儿149例,骨密度不足发生率为60.93%。单因素分析结果显示,不同年龄、性别、是否补充维生素D及不同户外活动时间婴幼儿之间的骨密度不足发生率比较差异有统计学意义(P0.05),而不同喂养方式婴幼儿之间的骨密度不足发生率比较差异无统计学意义(P0.05)。多因素Logistic回归分析结果显示,年龄(0~6个月,7~12个月)、性别(女)、补充维生素D(否)、户外活动时间(1 h)为0~3岁婴幼儿骨密度的危险因素(P0.05)。结论:0~3岁婴幼儿的骨密度不足发生率较高,年龄、女性、未补充维生素D、户外活动时间过少均是0~3岁婴幼儿骨密度的危险因素,可通过适量补充维生素D、增加户外活动时间以提高婴幼儿骨密度值。     

Evaluation of Status of Zinc, Copper, and Iron Levels in Biological Samples of Normal Children and Children with Night Blindness with Age Groups of 3–7 and 8–12 Years

The causes of night blindness in children are multifactorial, and particular consideration has been given to childhood nutritional deficiency, which is the most common problem found in underdeveloped countries. Such deficiency can result in physiological and pathological processes that in turn influence hair composition. This study was designed to compare the levels of zinc (Zn), copper (Cu), and iron (Fe) in scalp hair, blood, and urine of both genders of children with night blindness with age range of 3–7 and 8–12 years, comparing them to sex- and age-matched controls. A microwave-assisted wet acid digestion procedure was developed as a sample pretreatment, for the determination of zinc, copper, and iron in biological samples of children with night blindness. The proposed method was validated by using conventional wet digestion and certified reference samples of hair, blood, and urine. The digests of all biological samples were analyzed for Cu, Fe, and Zn by flame atomic absorption spectrometry using an air/acetylene flame. The results indicated significantly lower levels of Fe, Cu, and Zn in the biological samples (blood and scalp hair) of male and female children with night blindness, compared with control subjects of both genders. These data present guidance to clinicians and other professionals investigating the deficiency of essential trace metals in biological samples (scalp hair and blood) of children with night blindness.     

The effect of maternal and child health and family planning services on mortality: is prevention enough?

OBJECTIVE--To examine the impact on mortality of a child survival strategy, mostly based on preventive interventions. DESIGN--Cross sectional comparison of cause specific mortality in two communities differing in the type, coverage, and quality of maternal and child health and family planning services. In the intervention area the services were mainly preventive, community based, and home delivered. SUBJECTS--Neonates, infants, children, and mothers in two contiguous areas of rural Bangladesh. INTERVENTIONS--In the intervention area community health workers provided advice on contraception and on feeding and weaning babies; distributed oral rehydration solution, vitamin A tablets for children under 5, and ferrous fumarate and folic acid during pregnancy; immunised children; trained birth attendants in safe delivery and when to refer; treated minor ailments; and referred seriously ill people and malnourished children to a central clinic. MAIN OUTCOME MEASURES--Overall and age and cause specific death rates, obtained by a multiple step "verbal autopsy" process. RESULTS--During the two years covered by the study overall mortality was 17% lower among neonates, 9% lower among infants aged 1-5 months, 30% lower among children aged 6-35 months, and 19% lower among women living in the study area than in those living in the control area. These differences were mainly due to fewer deaths from neonatal tetanus, measles, persistent diarrhoea with severe malnutrition among children, and fewer abortions among women. CONCLUSIONS--The programme was effective in preventing some deaths. In addition to preventive components such as tetanus and measles immunisation, health and nutrition education, and family planning, curative services are needed to reduce mortality further.