RICKETS IN RURAL KENYAN PRESCHOOL CHILDREN: CASE REPORT.

Clinical rickets has not been reported previously in Embu district, Kenya. Baseline clinical assessments performed for a nutrition intervention study in preschool children (n=324) identified 28 cases of rickets (8.6% of study sample). Clinical characteristics included: delays of sitting, walking, and teething; bone and chest deformities; widened wrists and ankles; and bowed lower extremities. Risk factors identified were short duration of breastfeeding with feeding of cereal-based supplements with little or no milk, low calcium intake, limited sunlight exposure. Vitamin D and calcium deficiencies likely contributed to these cases. Treatment with Vitamin D3 and milk resulted in clinical improvement.

Comparison of blood smear microscopy to a rapid diagnostic test for in-vitro testing for P. falciparum malaria in Kenyan school children.

OBJECTIVE: To compare the diagnostic performance of microscopy using Giemsa-stained thick and thin blood smears to a rapid malaria dipstick test (RDT) in detecting P. falciparum malaria in Kenyan school children. DESIGN: Randomised, controlled feeding intervention trial from 1998-2001. SETTING: Rural Embu district, Kenya. The area is considered endemic for malaria, with four rainy seasons per year. Chloroquine resistance was estimated in 80% of patients. Children had a spleen rate of 45%. SUBJECTS: A sample of 515 rural Kenyan primary school children, aged 7-11 years, who were enrolled in a feeding intervention trial from 1998-2001. MAIN OUTCOME MEASURES: Percent positive and negative P. falciparum malaria status, sensitivity, specificity and positive and negative predictive values of RDT. RESULTS: For both years, the RDT yielded positive results of 30% in children compared to microscopy (17%). With microscopy as the "gold standard", RDT yielded a sensitivity of 81.3% in 1998 and 79.3% in 2000. Specificity was 81.6% in 1998 and 78.3% in 2000. Positive predictive value was 47.3% in 1998 and 42.6% in 2000, and negative predictive value was 95.6% in 1998 and 94.9% in 2000. CONCLUSION: Rapid diagnostic testing is a valuable tool for diagnosis and can shorten the interval for starting treatment, particularly where microscopy may not be feasible due to resource and distance limitations.

Nutritional assessment of the child with cancer.

Children with cancer are in need of nutritional support to combat the catabolic effects of malignant tumors and debilitation from surgical or other treatment and complicating infections and to maintain their immune system and other host defenses to combat cancer and infection. Also, growth must be supported in the child. Nutritional assessment should be an integral part of the care of the hospitalized and the ambulatory child. The main components of nutritional assessment are described: medical history; psychocultural history; dietary assessment; clinical examination for signs of deficiency; anthropometry; and biochemical and hematological assessment. Parameters of cell-mediated immunity, often depressed by malnutrition, are also part of the assessment. Appropriate reference data for children are included. Assessment is the first step in nutritional support.

Hair analysis in clinical and experimental medicine.

Each year approximately 9800 papers on trace elements are published. Of these, approximately 75 deal with trace elements and hair. Review articles appear annually. Some of these studies demonstrate that the mean concentration of an essential trace element is lower or that of a potentially toxic element is higher in the hair of a group of people afflicted with a specific disease. Associations between hair analyses and demographic variables have been found. Fewer studies have shown a correlation between essential elements in hair of animals and the same elements in organs. It is possible to measure trace elements in hair to satisfy the skeptical chemist. Although such measurement is a necessary prelude toward medical utility, it is not sufficient. Hair analysis seems potentially useful in experimental medicine but its use in clinical medicine for diagnosis, prognosis, and therapy will remain limited until validation by the standard methods of clinical investigation is achieved.

Biochemical evidence of thiamin deficiency in young Ghanian children.

Detailed biochemical studies for nutritional status were carried out on 146 Ghanaian children ages 6 months to 6 years over a 2-year period. Study children comprised three main groups: severe protein-calorie malnutrition; mild to moderate protein-calorie malnutrition and apparently healthy children. Erythrocyte transketolase activity and the percentage of erythrocyte transketolase pyrophosphate effect were also determined. In the first year of the study elevated percentage of transketolase pyrophosphate effect indicative of thiamin deficiency was found in all three of the above-mentioned groups, with the most widespread deficiency in the normal groups. In year 2, repeat studies of the severely malnourished group after 2 weeks of nutritional therapy with the administration of vitamin capsules, which included thiamin, resulted in the normalization of transketolase pyrophosphate effect. Apoenzyme activity was comparable in all groups studied. There were no obvious clinical signs of thiamin deficiency, although sensory testing was not performed. A relatively large number of children with high percentage of transketolase pyrosphosphate effect also had serum folic acid deficiency. This evidence of widespread biochemical thiamin deficiency is indicative of an at-risk population among young children for clinical thiamin deficiency. Further studies are needed to identify whether the problem is inadequate thiamin intake, destruction of thiamin by thiaminases or food preparation methods, or malabsorption of thiamin.

Birthweight doubling time: a fresh look.

Infant birthweight doubling time is widely quoted as being achieved between 5 and 6 months. The purpose of this study was to determine the time of birthweight doubling and to identify important related variables. A total of 357 normal infants with birthweights between 2,500 and 4,100 gm were studied. Mean age of birthweight doubling for the entire group was 119 days (3.8 months). Bottle-fed infants doubled their birthweights earlier than breast-fed infants: 113 days vs. 124 days (P less than .05). Boys doubled their birthweights earlier than girls: 111 days vs. 129 days (P less than .0001). Solids were introduced earlier in bottle-fed infants (mean , 1.9 months) than in breast-fed infants (mean, 3.9 months). Harvard percentiles for mean group weight and length at the time of birthweight doubling were: for bottle-fed infants, 75th and 55th percentiles respectively: for breast-fed infants, 55th and 60th percentiles respectively; for boys, 75th percentile for both weight and length; for girls, 50th percentile for both weight and length. Thus, bottle-fed infants appear to have weight gains in excess of length gain and may be developing early obesity. In light of the poor prognosis in treating obesity, closer supervision of early infant feeding practices is indicated.

Interrelationship between diarrhea and vitamin A deficiency: is vitamin A deficiency a risk factor for diarrhea?

A cross-sectional study, a follow-up study and an evaluation of impact of community-based distribution of vitamin A capsules (200,000 IU) were conducted in Omdurman (Sudan) between November, 1988, and March, 1989. In the cross-sectional survey 1441 children less than 5 years of age participated, which established the baseline values for plasma retinol-binding protein. During the follow-up period 290 cases of diarrhea occurred. Low concentrations of plasma retinol-binding protein (less than 1.85 mg/dl) proved to be a risk factor for diarrhea, especially in girls. The relative risk increased after the second year of life. Children who received vitamin A supplementation before commencement of the study had a lower incidence of diarrhea. The protective effect of vitamin A supplementation was greater in girls (relative risk, 0.297; 95% confidence interval, 0.240 to 0.368) than in boys (relative risk, 0.404; 95% confidence interval, 0.352 to 0.464).

Choosing an appropriate measure of diarrhoea occurrence: examples from a community-based study in rural Kenya.

Epidemiological studies which aim to identify protective or risk factors for diarrhoea may rely on any of several established measures of disease occurrence, including cumulative incidence, (CI), incidence density (ID), and point prevalence (P); each with its own strengths and limitations. Comparison of these measures was afforded by a community-based study in rural Kenya in which the incidence and prevalence of diarrhoea were measured simultaneously but by independent means in the same group of children. In a cohort study, CI and ID among 138 infants (aged 0-6 months) were 26.1% and 1.41 episodes per 100 infant-weeks, respectively. Among 111 toddlers (aged 18-29 months) CI and ID were 39.6% and 1.96 episodes per 100 toddler-weeks, respectively. In a cross-sectional study of these children, the Ps among infants and toddlers were 9.8 and 6.1%, respectively. Data on incident cases required more time and resources to obtain and evidenced more underreporting of diarrhoea episodes relative to the prevalence data. Other community-based studies have reported the ID of diarrhoea five times more often than any other measure, but appear to have calculated ID incorrectly. The infrequency with which CI and P are reported does not reflect their actual utility.

PIP: Researchers conducted a cross sectional analysis (126 infants born in May-June 1986) within a cohort study (138 infants followed between 1984-1986) in the rural Embu District of Kenya to compare the utility, validity, and affordability of various measures of diarrhea occurrence. They were able to follow up on all infants. Cumulative incidence of diarrhea for the 1st 6 months of life stood at 26.1% and for 12 months, 54.9%. The cumulative incidence for the 1st 6 months of followup for toddlers was 39.6%. These toddlers and the infants suffered from an average of 1.96 and 1.41 diarrheal episodes each (incidence density) respectively. Incidence density could then be used to determine the resources needed for treating diarrhea in the community. For example, 1.41 diarrheal episodes among infants/100 infant weeks x 200 infants in a community equals about 2.8 episodes/week. Since the mean duration of each diarrhea episodes in this study was 5.7 days, the needed number of oral rehydration solution packets each week would be 16. The point prevalences of infants and toddlers in the cross sectional analysis were 9.8% and 6.1% respectively. The cross sectional study uncovered 11 more cases than were identified in the cohort study. This suggested more accurate reporting. The point prevalence for infants translated into 13.4 episodes/100 infant weeks which was about 10 times that estimated by the cohort study. This disparity could be due to underreporting of diarrhea in the cohort study and instability in incidence density. Point prevalence could not easily identify risk factors, however. Nevertheless cross sectional studies do produce accurate and useful data more rapidly and inexpensively than do cohort studies. Further few cross sectional and cohort studies have reported cumulative incidence and point prevalence, so it is difficult to estimate their actual utility.

Analysis of false positive HIV-1 serologic testing in Kenya.

Sera of 95 mothers and 129 children from Nairobi, Kenya, collected in 1976, and of 466 adults and 193 children of Embu District, Kenya, collected in 1984 and 1985, were analyzed for the presence of human immunodeficiency virus type 1 (HIV-1) antibodies. Although no HIV-1 seropositivity was demonstrated by western blot analysis in both study groups, 7% of Nairobi mothers and 10% of adult females from Embu District had false positive results by enzyme immunoassay (EIA) compared with less than 1% seroreactivity rates observed in adult males and children. False positive results were not due to simian T lymphotropic virus type III (STLV-IIIAGM)/human T lymphotropic virus type IV (HTLV-IV) seropositivity. Sixty-one percent of the HIV-1 EIA reactive sera could not be explained by cytotoxic activity to lymphocytes bearing the HLA-DR4 or HLA-DQw3 phenotype. We conclude that false positive HIV EIA tests are frequently encountered in East Africa. Seroprevalence rates in rural Africa must be interpreted with caution due to the decreased specificity of HIV EIAs.

The influence of reproductive status on rural Kenyan women's time use.

To determine the effects that pregnancy and infant care have on Embu women's commercial, agricultural and household activities, time use patterns were studied for women at different stages of pregnancy and lactation. Time allocation data were collected from 169 households, visited at random intervals over a year, by use of the spot observations technique. Detailed reproductive data were collected monthly, and household socioeconomic data quarterly. Analyses of Embu women's time use by reproductive status reveal that the demands of pregnancy and lactation require women to decrease the amount of time spent on subsistence agriculture, commercial activities, housework, and tending animals; and to devote more time to resting, breastfeeding, and child care. Agricultural and economic activities are curtailed especially in the 3rd trimester of pregnancy and the 1st period of lactation. This data provide insight into how pregnancy and lactation require women to adjust their time allocation between reproductive and farm labor activities. This decrease in time spent on subsistence agriculture, commercial activities, and household work increases the risk of household economic insecurity during the woman's reproductive years.

Onset and evolution of stunting in infants and children. Examples from the Human Nutrition Collaborative Research Support Program. Kenya and Egypt studies.

The etiology of the early onset of stunting is diverse among populations of varying biological, environmental and cultural circumstances. This is exemplified within the Nutrition CRSP project, which took place in three different populations and ecological conditions. Within each study area a different mix and varying proportions of causative factors were identified. At least in Kenya, and probably in Mexico, the problem has its antecedents in prepregnancy and pregnancy. Powerful determinants of the infants' size at birth and during the first 6 months of life are maternal size upon entry into pregnancy, and weight and fat gain during pregnancy and lactation. In all three countries a low pregnancy weight gain was observed. Notably in Kenya, where the energy intake of the mother decreases progressively throughout pregnancy, not only do mothers gain only half as much as European or North American women, but they even lose weight and fat in the last month of pregnancy, and some mothers gain no weight or lose weight during the whole of pregnancy. Mothers in Kenya start lactation with relatively poor fat stores. Although their energy intake increases somewhat during lactation, preliminary estimates suggest that these increases may be insufficient to maintain their bodily integrity, to carry out their normal tasks of daily living, and to produce a sufficient amount of milk for optimal infant growth. In addition to an energy deficit, diet quality is a problem, particularly in Kenya and Mexico and less so in Egypt. Intakes of animal products and animal protein are very low. Zinc and iron intakes are not only low, but the bioavailability of these nutrients is poor because of the high phytate, fiber and tea content of the diet. Also vitamin B12 intake is extremely low, and at least mild-to-moderate iodine deficiency (IDD) is present in Kenya. The above micronutrients have been demonstrated to affect the linear growth of the Kenyan children, even after confounding factors have been controlled. The early use of supplemental feeding in Kenya is a double-edged sword. On the one hand, there is a slight increase in febrile illness and possible displacement of breast milk intake in the supplemented infants, although mothers do not decrease breast feeding frequency and duration. On the other hand, even the modest amounts of available zinc and B12 in supplemental foods appear to have a positive effect on linear growth.(ABSTRACT TRUNCATED AT 400 WORDS)

PIP: Findings from the Nutritional Collaborative Research Support Program (CRSP) in Kenya, Mexico, and Egypt demonstrate how the etiology of the early onset of stunting varies among populations of varying biological, environmental, and cultural circumstances. In Kenya, and probably Mexico, the problem has its antecedents in prepregnancy and pregnancy. Maternal size upon entry into pregnancy and weight and fat gain during pregnancy and lactation are powerful determinants of an infant's size at birth and during the first six months of life. Low pregnancy weight gain was observed in all three countries. Mothers in Kenya even lose weight and fat in the last month of pregnancy, with some gaining no weight or losing weight during the whole of pregnancy. Mothers in Kenya begin lactation with relatively poor fat stores, thus possibly unable to produce a sufficient amount of milk for optimal infant growth even though their energy intake increases somewhat during lactation. Intakes of animal products and animal protein are also low especially in Kenya and Mexico. Intakes of zinc, iron, vitamin B12, and iodine are low, and have been shown to affect the linear growth of the Kenyan children even after controlling for confounding factors. The early use of supplemental feeding in Kenya positively affects linear growth, yet increases febrile illness and possibly displaces breast milk intake in supplemented infants. Morbidity negatively affects attained length in six-month old infants and the rate of linear growth, while cultural patterns of child rearing also appear important for growth. A major deceleration of growth occurs in the first six months of life; from 18 months onward the quantity and quality of diet and environmental factors do not permit catch-up to the normal or near normal centiles observed in newborns.

Management of the obese adolescent.

Obesity as a health problem appears to be increasing in incidence. Adolescent obesity is generally exogenous in type. The teenagers are basically healthy with advanced sexual and bone maturation. They suffer from peer ridicule and exclusion from activities. The weight problem bars them from successful adult adjustment in their social lives and career choice. To the physician who treats the obese adolescent, it would be wise to review the pitfalls of previous programs. The multidisciplinary approach is an attempt to combine dietary restriction and increased physical activity to gradually mobilize fat stores and provide psychologic support. Motivation is reinforced by a committed staff and by the patients' own obese peers with whom they meet weekly. Despite the repeated record of failure in adolescent weight reduction programs, it is hoped that the challenge of obesity management spurs the interest of physicians to increase their knowledge of nutrition and to intervene with early effective preventive measures.

Office assessment of nutritional status.

The standard components of nutritional assessment-anthropometry, clinical examination, dietary intake, and biochemical analysis--have been discussed in the context of "office or clinic practice." With appropriate modifications of these tehcniques, nutritional assessment can become a basic and integral part of pediatric care.

Determinants of undernutrition among homeless adults.

Factors associated with undernutrition were investigated in a broad community-based sample of 457 homeless adults (344 men and 113 women) who were interviewed and examined in a variety of settings during the summer of 1985. Latent variables representing drug use, alcohol use, a stereotyped homeless appearance, mental illness, poor physical health status, and measured variables of age, sex, income, and number of free food sources were used as predictors of undernutrition. Undernutrition was indicated with three anthropometric measures (weight, triceps skinfold, and upper arm muscle area in the lowest 15th percentile) and one observational measure. Thirty-three percent of the sample was undernourished as defined by at least one of the anthropometric measures. Undernutrition was significantly associated with more drug use, fewer free food sources, less income, and male sex. The findings identify persons at risk for undernutrition and suggest programs to alleviate their hunger, including increased funding for food stamps and other income supports, more free food sources such as shelters and souplines, and drug treatment programs.

Infant predictors of cognitive development in an undernourished Kenyan population.

Assessments of infant sociability, motoric capacities, and nutritional factors were performed to elucidate early influences on infant development in an undernourished Kenya population. In this longitudinal study, infant social skills were assessed using both the Bayley Behavior Record and home observations during the first 6 months of the infants' lives. Abilities were measured using an adapted version of the Bayley scales of infant development at 6 and 30 months, and a short battery of cognitive measures at 5 years. Infant size measurements were used as indicators of infant nutritional status. Shorter and lighter infants, and those infants showing growth faltering in weight attainment, were significantly less sociable at 6 months than infants who were taller and maintained heavier weights. Infants with smaller arm circumferences displayed lower motor scores at 6 months and lower Bayley mental scores at 30 months than infants with greater arm circumference. Furthermore, infants who were more motorically able and socially adept at 6 months had higher Bayley scores at 30 months and higher verbal comprehension scores at 5 years.

Plasma retinol-binding protein levels of children under five years of age in a displaced Sudanese community.

Blood samples (100-160 microliters) were obtained from 1360 children by a finger prick in heparinized collection tubes, and an LC-Partigen retinol-binding protein (RBP) kit was used for quantification of RBP in the plasma. Only three boys and two girls had plasma RBP that was equal to or more than 3.0 mg/dL, a recommended cut-off point for normal values. The mean +/- SD) plasma RBP levels were at 1.150 +/- 0.613 mg/dL for boys (N = 689) and 1.233 +/- 0.572 mg/dL for girls (N = 671). The difference between boys and girls was statistically significant (p < 0.001). None of the children included in this study had eye signs of vitamin A deficiency. Two hundred eighty-two children (19.6%) received vitamin A supplements (200,000 IU) before the beginning of the study. The mean +/- SD for plasma RBP for children who received vitamin A supplement were 1.159 +/- .762 mg/dL for boys and 1.151 +/- 0.470 mg/dL for girls. The observed discrepancy between the biochemical and clinical manifestations of vitamin A deficiency was discussed.