Evaluation of serum retinol, the modified-relative-dose-response ratio, and breast-milk vitamin A as indicators of response to postpartum maternal vitamin A supplementation.

BACKGROUND: Conflicting results have been reported regarding the relative performance of serum retinol, the modified-relative-dose-response (MRDR) ratio, and breast-milk vitamin A concentrations in detecting changes in maternal vitamin A status. OBJECTIVE: We used receiver operating characteristic analyses and standardized differences to compare the ability of these indicators to detect a response to postpartum vitamin A supplementation in lactating Bangladeshi women. DESIGN: At 2 wk postpartum, women were randomly assigned to receive either a single dose of vitamin A [200000 IU (60000 retinol equivalents); n = 74] or placebo (n = 73). Data from maternal serum and breast milk collected 3 mo postpartum and from infant serum collected 6 mo postpartum were used to examine the ability of serum retinol, the MRDR ratio, and breast-milk vitamin A to discriminate between individuals in the supplemented and unsupplemented groups. Breast milk was collected by expressing the entire contents of one breast that had not been used to feed an infant for > or =2 h (full samples) or without controlling the time since the last breast-feeding episode (casual samples). RESULTS: Casual breast-milk samples performed better than full breast-milk samples in detecting a response to maternal supplementation. The MRDR ratio performed better than serum retinol in both the women and their infants. Overall, the most responsive indicator was the measurement of breast-milk vitamin A per gram of fat in casual breast-milk samples. CONCLUSIONS: Breast-milk vitamin A and the MRDR ratio are responsive indicators of vitamin A status, especially in women with mild vitamin A deficiency.

Prenatal screening in rural Bangladesh: from prediction to care.

The role of antenatal care is being increasingly questioned, particularly in resource poor environments. The low predictability of antenatal markers for adverse maternal outcomes has led some to reject antenatal care as an efficient strategy in the fight against maternal and perinatal mortality. Few studies, however, have assessed the predictability of adverse outcomes other than dystocia or perinatal death, and most studies have been hospital based. This population-based cohort study was undertaken to assess whether prenatal screening can identify women at risk of severe labour or delivery complications in a rural area in Bangladesh. Antenatal risk markers, signs and symptoms were assessed for their association with severe maternal complications including dystocia, malpresentation, haemorrhage, hypertensive diseases, twin delivery and death. The results of the study suggest that antenatal screening by trained midwives fails to adequately distinguish women who will need special care during labour and delivery from those who will not need such care. The large majority of the women with dystocia or haemorrhage had no warning signs during pregnancy. A single blood pressure measurement and the assessment of fundal height, on the other hand, may detect a substantial number of women with hypertensive diseases and twin pregnancies. In addition, women who had an antenatal visit were four times more likely to deliver with a midwife than women who had no antenatal visit. Antenatal care may not be an efficient strategy to identify those most in need for obstetric service delivery, but if promoted in concurrence with effective emergency obstetric care, and delivered in skilled hands, it may become an effective instrument to facilitate better use of emergency obstetric care services.

Neonatal mortality in a rural area of The Gambia.

Childhood mortality in Upper River Division, The Gambia is high, 99 per 1000 mid-year population, and 27% of deaths occur is the neonatal period. The aims of the present study were to describe patterns of neonatal death and to identify risk factors. Cause of death was investigated using a neonatal post-mortem questionnaire, and a population-based, matched case-control study was conducted to identify potential risk factors. The neonatal mortality rate in Upper River Division was 39 per 1000 live births (95% CI 36.8-41.2). The rates in the early and late neonatal periods were 21.0 (19.4-22.6) and 18.0 (16.5-19.5), respectively. Infection accounted for 57% of all deaths. In the early neonatal period, 30% of deaths were due to prematurity. Only 55% of babies who died presented for treatment and 84% died at home. Risk factors for neonatal death were primiparity (OR 2.18), previous stillbirth (OR 3.19), prolonged labour (OR 2.80) and pre-lacteal feeding (OR 3.38). A protective effect was seen in association with delivery by a trained traditional birth attendant (OR 0.34) and the application of shea nut butter, a traditional medicine, to the cord stump (OR 0.07). This study has identified the need to understand the reasons underlying the widespread use of pre-lacteal feeds and the barriers to health service use in this community in order to plan effective interventions.

Breast milk immune factors in Bangladeshi women supplemented postpartum with retinol or beta-carotene.

BACKGROUND: Vitamin A supplementation of mothers postpartum may improve infant health, not only by increasing vitamin A delivery to the infant through breast milk but also by increasing delivery of milk immune factors. Our hypothesis was that postpartum supplementation with vitamin A increases milk concentrations of certain soluble immune factors. DESIGN: In a double-blind trial conducted in Matlab, Bangladesh, women at 1-3 wk postpartum were randomly assigned to receive until 9 mo postpartum 1) a single dose of 60 mg retinol as retinyl palmitate followed by daily placebos (n = 69), 2) daily doses of 7.6 mg beta-carotene (n = 72), or 3) daily placebos (n = 71). Milk samples collected at baseline and 3 mo postpartum were analyzed by enzyme-linked immunosorbent assay for secretory immunoglobulin A, lactoferrin, lysozyme, and interleukin 8; by HPLC for total retinol; and by atomic absorption spectroscopy for sodium and potassium. RESULTS: After mammary epithelial permeability (defined as an elevated Na:K) and baseline immune factor concentrations were controlled for, there were no significant treatment effects on immune factors at 3 mo. Increased mammary permeability was common (25% of women at baseline and 12% at 3 mo) and was associated with higher concentrations of milk immune factors. Low body vitamin A stores at baseline, as assessed by the modified-relative-dose-response test, were associated with a higher Na:K, but neither retinol nor beta-carotene supplementation affected the prevalence of increased mammary permeability. CONCLUSIONS: Postpartum vitamin A supplementation does not increase milk concentrations of immune factors. The causes of increased mammary epithelial permeability in this population require further study.

Serum interleukin-6 in renal osteodystrophy: relationship with serum PTH and bone remodeling markers.

Interleukin-6, synthesized by osteoblasts in response to PTH, stimulates osteoclastogenesis and bone resorption in vitro, and it has been implicated in the pathogenesis of bone loss in several clinical situations. The aim of this study was to evaluate whether serum levels of interleukin-6 were increased in patients with renal osteodystrophy, and to investigate the possible relationships between serum interleukin-6 and PTH levels on one hand, and serum interleukin-6 and bone remodeling markers on the other. Serum interleukin-6 (IL-6), intact PTH, osteocalcin, bone alkaline phosphatase (BAP) and carboxyterminal telopeptide of Type 1 collagen (ICTP) were measured in 86 uremic patients. IL-6 (median [range] 16.5 [1.0-430] pg/ml), PTH (279.8 [11-2004] pg/ml), osteocalcin (143.8 [8-921] ng/ml), BAP (20.9 [6-169] U/I) and ICTP (38.8 [1.5-181.5] microg/l) were higher than normal. IL-6 levels correlated with PTH (r= 0.22, p = 0.04) and with ICTP (r = 0.31, p = 0.004). A stronger correlation was found between PTH and circulating bone remodeling markers (r = 0.66 for osteocalcin, r = 0.56 for BAP, and r = 0.39 for ICTP). The correlation between PTH and IL-6 was stronger in those patients (n = 15) with severe secondary hyperparathyroidism (r= 0,71, p = 0.003). On the other hand, in the group of patients (n = 41) with PTH lower than 250 pg/ml, there was no correlation between IL-6 and PTH, while IL-6 correlated with ICTP (r = 0.44, p = 0.006). Serum IL-6 correlates with ICTP which suggests that it may mediate bone resorption in renal osteodystrophy.

Maternal vitamin A or beta-carotene supplementation in lactating bangladeshi women benefits mothers and infants but does not prevent subclinical deficiency.

The effects of maternal postpartum vitamin A or beta-carotene supplementation on maternal and infant serum retinol concentrations, modified relative dose-response (MRDR) ratios and breast milk vitamin A concentrations were assessed during a community-based trial in Matlab, Bangladesh. At 1-3 wk postpartum, women were randomly assigned to receive either (1) a single dose of 200,000 international units [60,000 retinol equivalents (RE)] vitamin A followed by daily placebos (n = 74), (2) daily doses of beta-carotene [7.8 mg (1300 RE)] (n = 73) or (3) daily placebos (n = 73) until 9 mo postpartum. Compared to placebos, vitamin A supplementation resulted in lower maternal MRDR ratios (i.e., increased liver stores) and higher milk vitamin A concentrations at 3 mo, but these improvements were not sustained. The beta-carotene supplementation acted more slowly, resulting in milk vitamin A concentrations higher than the placebo group only at 9 mo. Irrespective of treatment group, over 50% of women produced milk with low vitamin A concentrations (/=0. 06. We conclude that while both interventions were beneficial, neither was sufficient to correct the underlying subclinical vitamin A deficiency in these women nor to bring their infants into adequate vitamin A status.

Adherence to cotrimoxazole treatment for acute lower respiratory tract infections in rural Bangladeshi children.

This study evaluates compliance with taking oral cotrimoxazole in an ALRI control programme in rural Bangladesh. Health workers administered the first dose to children with moderate disease and entrusted relatives to give the remaining doses. A team of medical assistants visited the families of cases 3 to 5 days after initiating treatment and counted the remaining tablets. Medical assistants undertook 367 visits to families of children under treatment at a mean (SD) of 4.4 (0.99) days after treatment began. All children appeared to have been given the antibiotic, but one-quarter were being under-dosed on the day of the visit. Under-dosing did not correlate with any of the socio-demographic variables studied, and seemed to be homogeneously distributed in the community. Under-dosed children did not seem to have a higher risk of subsequent ALRI episodes during the study period. There was no indication of progression to severe disease or death in home-managed cases of moderate pneumonia in this study. These findings raise a question about the need for 5 days of oral antibiotic in the management of moderate pneumonia. Careful studies of the effect on subsequent morbidity, mortality and antibiotic resistance of providing briefer treatment for moderate episodes of ALRI are required. If a briefer course proves effective, this would have important implications for funding programmes of control of ALRI in the community.

[Fluorescence microscopy for detection of frauds in ground coffee]. / Microscopía de fluorescencia para detectar fraudes en café tostado y molido.

Currently, frauds in ground coffee are detected with traditional microscopy, which is a tedious and not very precise method. Therefore, a more efficient and rapid microscopical method based on fluorescence, was proposed. For the microscopy analysis, pure coffee was compared to coffee samples adulterated with rye, barley, corn and wheat at 2.5, 5.0, and 10.0% levels. Starch granules were detected and identified immediately with fluorescence microscopy, in the adulterated coffee mixtures, quite different from optical microscopy where no frauds were detected with certainty. The suggested fluorescence method for the detection of cereal frauds in coffee was found to be more efficient and precise than the current official one.

Acute lower respiratory infections in rural Bangladeshi children: patterns of treatment and identification of barriers.

A study conducted in rural Bangladesh examined the patterns of health seeking behavior, mothers' recognition of symptoms, the perceived causes and barriers to timely treatment of acute lower respiratory infections (ALRI). A total of 194 children under 5 years of age suffering from ALRI in an intensive maternal child health and family planning area was prospectively followed. About 62% of the mothers sought allopathic treatment for their children within 24 hours of case detection. No treatment of any kind was sought in 45 (23.2%) cases. Most of the mothers could recognize the different symptoms of ALRI. Cold was reported as the most common cause of ALRI. No significant difference was observed in the reported symptoms or perceived cause of the disease between those who sought no treatment and those who sought allopathic, homeopathic, spiritual or combined treatments. Failure to recognize severity followed by work loss were the most common reasons identified for not seeking any medical care. Whether or not a mother sought allopathic treatment was not associated with the child's age, sex, mother's age, mother's education, duration of illness, birth order, housing type or distance from the health center. The study indicates the potential value of giving parents clear guidelines on recognition of severity of symptoms of ALRI and motivating them to seek treatment quickly when these symptoms present. Health service providers should be aware of the heavy work loads which rural women have and the severe time constraints which deter them from seeking timely treatment from the appropriate sources.

Why did maternal mortality decline in Matlab?

In 1991, an article on the Maternity Care Program in Matlab, Bangladesh, reported a substantial decline in direct obstetric deaths in the intervention area, but not in the control area. The decline was attributed primarily to the posting of midwives at the village level. In this article, data are presented from the same period and area on a variety of intermediate events. They indicate that the decline in deaths was probably due to the combined efforts of community midwives and the physicians at the Matlab maternity clinic. Their ability to refer patients to higher levels of care was important. The data further indicate that the decline in deaths depended upon the functioning of the government hospital in Chandpur, where cesarean sections and blood transfusions were available. Midwives might also have made a special contribution by providing early termination of pregnancy, which is legal in Bangladesh.

PIP: Data were collected during 1993 from the Matlab Demographic Surveillance System, midwives' cards, the Matlab maternity clinic record book, and records at the government's district hospital. This study analyzed these data in order to determine why maternal mortality declined in the intervention area. Direct obstetric deaths declined from 20 deaths during the 3 years before the Maternity Care Program was implemented to 6 deaths during the 3 years after program implementation. In the control area, mortality remained stable at 20 deaths during the same time period. The declines were apparent among diagnoses for induced abortion, eclampsia and pre-eclampsia, and prolonged obstructed labor. There were few changes in causes of death in the control area. During the intervention period, midwives in villages administered services to 49 women with preeclampsia, of whom 6 later developed eclampsia. There were 20 referrals to the maternity clinic for a variety of complications including eclampsia. The Matlab clinic received 54 patients during the intervention period with a primary diagnosis of pre-eclampsia or eclampsia. Midwives provided care for 77 women with prolonged labor. Matlab clinic received 116 patients due to prolonged labor. 4% of the 2364 midwives' cards indicated referral. 83% of referrals were to the Matlab clinic. The Matlab maternity clinic had 300 admissions during the study period, of which 65% (194 women) were from the intervention area. Women from the intervention area were 2.3 times more likely to be treated at the Matlab clinic than women from the control area. 69% of admissions at Chandpur District Hospital were from the Matlab intervention area. Case fatality rates in the hospital did not differ among intervention and control populations. The authors conclude that greater use of midwives, referrals and proper transport, and better service conditions significantly contributed to maternal mortality decline.

Bulging fontanelle after supplementation with 25,000 IU of vitamin A in infancy using immunization contacts.

To evaluate the safety of vitamin A supplementation in early infancy using DPT/OPV immunization contracts, a double-blind, randomized, placebo-controlled trial was conducted in Bangladesh. One hundred and sixty-seven infants received three doses of either 25,000 IU of vitamin A or a placebo at about 6.5, 11.8 and 17.0 weeks of age. Trained physicians examined each of the infants on days 1, 2, 3 and 8 after supplementation. Nine infants (10.5%) supplemented with vitamin A had episodes of bulging of the fontanelle compared with two infants (2.5%) in the placebo group (p < 0.05). Twelve of the 14 episodes occurred in infants supplemented with vitamin A. Of these 12 episodes, none occurred with the first dose, 3 occurred with the second and 9 with the third dose. The higher incidence of bulging of the fontanelle in the vitamin A group relative to the placebo group and its temporal association with the vitamin A doses are suggestive of a causal association. The finding that increased numbers of vitamin A doses were associated with a higher probability of bulging of the fontanelle suggests a cumulative effect.

Comparison of mortality between villages with and without Primary Health Care workers in Upper River Division, The Gambia.

Health services utilization was analysed in a rural area of the The Gambia. In general, health workers were consulted frequently. However, verbal autopsies showed that children who died had rarely consulted health workers, particularly if they came from villages where such workers were not posted. Traditional healers were consulted frequently, independently of the presence of a village health worker. The relationship between cause specific mortality and the utilization of health services is discussed. Childhood mortality was similar in villages with or without a primary health care worker at the time of the study.

PIP: The study aim was to evaluate the impact of mortality and primary health care (PHC) services utilization prior to death, based on data from the mortality surveillance system in the Upper River Division (URD) of The Gambia. The sample of villages with greater than 400 persons included 355 villages with a voluntary village health workers (VHW) and/or a trained traditional birth attendant (TBA), and 9 villages without. Recording of births and deaths was accomplished by one registrar for every 200 children or under, and totaled 373 village registrars and 8 field workers covering a population of 133,000. Cause of death for children aged 5 years was determined by 3 physicians and collected for senior field assistants. Morbidity data for children was gathered from monthly forms completed by VHWs and BAs. VHWs and TBAs were trained 6=8 weeks at Basse Hospital and 4-6 weeks at Bansang Regional Hospital, respectively, with periodic retraining. Local PHC centers provided health education, environmental health education, immunization, nutrition, treatment and referral. There were 6 health centers in URD, which was the base of operations for travel to 5-6 sites 1-2 times per month for running clinics, evaluation of referred patients, and supervision of PHC activities. There were 16, 216 episodes of malaria, 6111 episodes of respiratory infection (ALRI), and 6380 episodes of acute gastroenteritis reported through the PHC system. That means .63, .23, and .25 episodes per person per year, respectively. More than 50% of cases of ALRI involved consultation with VHWs. There were 915 deaths among children aged 5 years in one year. Of the 94% reports on the deaths made by relatives, there were 85% dying at home, and 8% dying at a health center or hospitals. 13% (117) were inpatients during a portion of the precipitating illness. Survivors of illnesses were higher among those children receiving consultation with the VHW. Only 33% of children who died had consulted a VHW during the final illness. TBAs reported 50% of deaths recorded by the surveillance system. TBAs are selectively consulted.

Acute toxicity of vitamin A given with vaccines in infancy.

A double-blind, randomised, placebo-controlled trial was conducted to evaluate the safety and toxicity of vitamin A supplementation within the Expanded Programme on Immunisation (EPI) in rural Bangladesh. 191 infants received 3 doses of either 50,000 IU of vitamin A or placebo at about 1.5, 2.5, and 3.5 months and were examined on days 1, 2, 3, and 8 after supplementation. 11 infants (11.5%) supplemented with vitamin A had episodes of bulging of the fontanelle as opposed to 1 (1%) in the placebo group. 16 of the 17 events occurred in the vitamin A supplemented group. No other side effects were noted. There was a tendency towards a cumulative effect of toxicity with increasing doses.

PIP: The International Center for Diarrhoeal Disease Research, Bangladesh, conducted a double-blind, randomized, placebo-controlled trial in the Matlab to examine the possibility of side effects in 191 infants who received 3 doses of either 50,000 IU vitamin A or a placebo at 1.5, 2.5, and 3.5 months within the Expanded Program of Immunization. Physicians examined the infants on the day of supplementation on days 1,3 and 8 after supplementation. The fontanelles bulged in 12 infants. The incidence of fontanelle bulging was more common in the vitamin A group than in the placebo group (11.5 vs. and 1%). There were 17 fontanelle bulging episodes, 16 taking place after vitamin A supplementation (5.5 vs. 0.3% after placebo supplementation). 8 (50%) of the vitamin A induced bulged fontanelle episodes occurred after the 3rd dose. 3 infants had fontanelle bulging episodes after the 2nd and 3rd doses. 2 other infants had these episodes after the 1st and 3rd doses. The bulging episodes persisted for 24-48 hours in all but 2 cases (48-72 hours) and returned to normal without treatment. No infant with a bulging fontanelle died. No other side effects occurred. The increased incidence of bulging fontanelles among infants receiving vitamin A supplementation and the fact that almost all episodes occurred after vitamin A supplementation suggested that vitamin A supplementation caused the bulging fontanelles. Increased intracranial pressure caused by vitamin A toxicity was responsible for the bulging fontanelles.