Prevalence, clinical predictors, and outcome of hypocalcaemia in severely-malnourished under-five children admitted to an urban hospital in Bangladesh: a case-control study.

Hypocalcaemia is common in severely-malnourished children and is often associated with fatal outcome. There is very limited information on the clinical predicting factors of hypocalcaemia in hospitalized severely-malnourished under-five children. Our objective was to evaluate the prevalence, clinical predicting factors, and outcome of hypocalcaemia in such children. In this case-control study, all severely-malnourished under-five children (n=333) admitted to the Longer Stay Ward (LSW), High Dependency Unit (HDU), and Intensive Care Unit (ICU) of the Dhaka Hospital of icddr,b between April 2011 and April 2012, who also had their total serum calcium estimated, were enrolled. Those who presented with hypocalcaemia (serum calcium <2.12 mmol/L) constituted the cases (n=87), and those admitted without hypocalcaemia (n=246) constituted the control group in our analysis. The prevalence of hypocalcaemia among severely-malnourished under-five children was 26% (87/333). The fatality rate among cases was significantly higher than that in the controls (17% vs 5%; p < 0.001). Using logistic regression analysis, after adjusting for potential confounders, such as vomiting, abdominal distension, and diastolic hypotension, we identified acute watery diarrhoea (AWD) (OR 2.19, 95% CI 1.08-4.43, p = 0.030), convulsion on admission (OR 21.86, 95% CI 2.57-185.86, p = 0.005), and lethargy (OR 2.70, 95% CI 1.633-5.46, p = 0.006) as independent predictors of hypocalcaemia in severely-malnourished children. It is concluded, severely-malnourished children presenting with hypocalcaemia have an increased risk of death than those without hypocalcaemia. AWD, convulsion, and lethargy assessed on admission to hospital are the clinical predictors of hypocalcaemia in such children. Presence of these features in hospitalized children with severe acute malnutrition (SAM) should alert clinicians about the possibility of hypocalcaemia and may help undertake potential preventive measures, such as calcium supplementation, in addition to other aspects of management of such children, especially in the resource-poor settings.

Frequency of symptomatic zinc deficiency in very low birth weight infants.

Current concepts on zinc requirements for premature infants rely on studies dating back more than 20 years. Given that nowadays more premature infants frequently survive we aimed to obtain recent frequency data on zinc deficiency in very low birth weight (VLBW) infants.226 VLBW infants born between July 2005 and December 2009 were retrospectively included in this study. Mean gestational age (GA) was 28.7 weeks (range 23+0 to 38+0) and mean birth weight 1120g (range 354-1495). All infants received zinc supplementation according to the ESPGHAN guidelines. 26 (11.5%) patients showed clinical signs for zinc deficiency of whom 15 had serum zinc concentrations < 50µg/dl, 9 between 50 and 70 µg/dl and 2 > 70 µg/dl. Infants presenting with dermatitis had significantly lower concentrations (mean 26.7 µg/dl, range 19-31) when compared to infants with diarrhoea or isolated peripheral oedema (35.3 µg/dl and 51.8 µg/dl respectively). Strongest independent risk factors were low GA, being small for GA and suffering from intestinal resection due to necrotizing enterocolitis. Frequency of zinc concentrations <50 µg/dl were calculated to be 6.6% in VLBW infants.Even though current guidelines for zinc supplementation were followed the frequency of zinc deficiency was found to be unexpectedly high in ELBW and SGA infants. Despite the retrospective nature of this single centre study, our data strongly suggest that recommendations on zinc supplementation in ELBW and SGA infants should be reviewed.

Effect of glutamine supplementation on lymphocyte subsets in children with acute diarrhea.

To study the effect of glutamine supplementation on lymphocyte subpopulation counts in children with acute diarrhea, children aged 6-24 months were enrolled in a double-blind randomized study. Cases had received either 0.3 g/kg/day of glutamine or placebo orally for seven days. The counts of blood leukocytes, lymphocytes and lymphocyte subpopulations (CD3+, CD4+, CD8+, CD19+, CD16+CD56+) were determined both on admission and seven days later using a flow cytometry. When adjusting for sex, current breastfeeding status, dehydration, and nutritional status of children, lymphocyte subpopulations did not differ significantly between the glutamine- and placebo-supplemented groups on the 7th day of intervention.

Efficacy of zinc in young infants with acute watery diarrhea.

BACKGROUND: Recent studies reported that zinc significantly reduced the duration and volume of acute watery diarrhea in children aged > or = 4 mo, but there were no data specifically on infants aged < 6 mo. OBJECTIVE: This study investigated the effect of zinc on the duration of illness and the stool quantity in acute watery diarrhea of infants aged 1-6 mo by comparing a 20 mg Zn/d dose with a 5 mg Zn/d dose. DESIGN: Infants hospitalized with at least some dehydration (by World Health Organization classification) were enrolled in a double-blind, randomized, placebo-controlled trial. Infants were randomly assigned to receive 20 mg Zn (acetate)/d, 5 mg Zn/d, or placebo for the duration of illness. RESULTS: Two hundred seventy-five infants were enrolled between 20 September 1998 and 18 December 2000. Neither diarrhea duration nor mean stool volume differed between groups. There were no significant differences in fluid intake, the need for unscheduled intravenous fluid, weight gain, or vomiting rates between the groups. CONCLUSIONS: Zinc supplementation did not affect diarrhea duration or stool volume in young infants. Young infants tolerated both zinc doses. A beneficial effect on subsequent illness cannot be ruled out.

Management of Lithuanian children's acute diarrhoea with Gastrolit solution and dioctahedral smectite.

OBJECTIVE: Acute gastroenteritis represents a major cause of morbidity and mortality worldwide among children, and rehydration treatment has been one of the cornerstones in the management strategy. The natural clay dioctahedral smectite (Smecta) increases intestinal barrier function and is effective against infectious diarrhoea in children. The purpose of this work was to compare the efficacy and tolerance of Lithuanian children's diarrhoea treatment with dioctahedral smectite combined with hypotonic oral rehydration solution (ORS)--Gastrolit--versus Gastrolit alone to establish the influence of Smecta on serum electrolyte balance in young children with diarrhoea and mild or moderate dehydration. METHODS: Smecta combined with ORS (study group) and ORS alone (control group) were evaluated in a multicentre, open, randomized trial in 54 children aged 6-48 months hospitalized for acute diarrhoea (mostly rotavirus aetiology) and signs of mild and moderate dehydration. The main outcomes examined were duration of diarrhoea, fever, number of vomiting episodes, and serum electrolyte balance before and after treatment. RESULTS: The mean duration of diarrhoea was significantly shorter in the study group (42.3 +/- 24.7 h) than in the control group (61.8 +/- 33.9 h). No side effects of Smecta were observed. The changes of sodium, potassium, chloride and calcium concentrations after treatment were minimal and in the normal range. CONCLUSIONS: Smecta significantly reduced the duration of diarrhoea, was safe and well tolerated, and had no impact on the adsorption of electrolytes. Smecta could be used together with ORS in children suffering from acute gastroenteritis (without uncontrollable vomiting) with mild and moderate dehydration.

Impact of zinc supplementation on persistent diarrhoea in malnourished Bangladeshi children.

To evaluate the impact of zinc supplementation on the clinical recovery and body weight of children with persistent diarrhoea, a randomized, double-blind, controlled trial was conducted in 190 children with persistent diarrhoea aged between 3 and 24 months. Children were randomly allocated to receive either zinc (20 mg d(-1)) syrup with multivitamin (2 x RDA) or multivitamin alone in three divided daily doses for 2 weeks. The trial was conducted in a diarrhoeal disease hospital in Dhaka, Bangladesh. Duration until clinical recovery (d), impact on body weight and serum zinc level after 2 weeks of zinc supplementation were recorded. The duration of illness was significantly reduced (33%) with zinc supplementation among children who were underweight (< or =70% wt/age, p = 0.03). Supplemented male children also had a significant reduction (27%) in duration for recovery compared with unsupplemented children (p = 0.05). From baseline to convalescence, zinc-supplemented children maintained their serum zinc concentration (13.4 vs 13.6 micromol l(-1)), whereas unsupplemented children had a decrease in serum zinc after the 2 weeks of diarrhoea (13.6 vs 11.8 micromol l(-1),p < 0.03). The mean body weight of the children in the supplemented group was maintained (5.72 vs 5.70 kg, p = 0.62) during hospitalization, unlike that of the control group, in which there was a reduction in body weight (5.75 vs 5.67 kg, p = 0.05). Five children in the unsupplemented group and one child in the zinc-supplemented group died during the 2 weeks of supplementation (p = 0.06). Zinc supplementation in persistent diarrhoea significantly reduced the length of the recovery period in malnourished children and prevented a fall in body weight and serum zinc concentration, indicating that zinc is a beneficial therapeutic strategy in this high-risk childhood illness.

Plasma vitamin A, zinc and selenium concentrations in children with acute and persistent diarrhoea.

Plasma zinc, selenium, and vitamin A concentrations in 25 children with persistent diarrhoea (PD) and acute diarrhoea (AD) were determined and compared with 25 age-matched control children. Plasma retinol concentrations (PRC) and plasma zinc concentrations (PZC) (3.92 micrograms/dL and 79.4 micrograms/dL respectively) were found to be significantly lower (p < 0.05) in children with PD. PZCs were also significantly reduced (p < 0.05) in children with AD. However, reduction in PZC was more in PD than that in AD. There was no significant difference in PSC in children with either types of diarrhoea as compared with the control group. The results of the study showed that there was deficiency of vitamin A and zinc in diarrhoeas which needs to be correlated for proper nutritional management.

Young coconut water for home rehydration in children with mild gastroenteritis.

Coconut water was evaluated as a home glucose electrolyte solution for well-nourished children with mild diarrhoea. We describe the chemical composition of coconut water by type and age of coconut (Cocos nucifera). Our results suggest that young coconut water can be used, together with early refeeding, as a home glucose electrolyte oral rehydration solution in the early stages of mild diarrhoeal disease, despite not having a balanced electrolyte composition. However, it should not be used in patients with severe cholera, or in patients who are dehydrated and/or in whom renal function is impaired.

Risk factors for death in complicated diarrhoea of children.

A total of 1330 children with complicated diarrhoea who were admitted to the general ward of the International Centre for Diarrhoeal Diseases Research, Bangladesh Health Complex, during 1979 were examined. The risk of death by complication of diarrhoea, aetiology, age, and nutritional state was analysed by a logit regression model. Serum sodium concentration and coma were found to be significant predictors of death, death being related directly to coma and inversely to serum sodium concentration. An earlier study had shown that the incidence of hyponatraemia was directly related to the degree of malnutrition, but the results of logit regression analysis did not show the nutritional state to be a predictor of death. Owing to lack of data, however, serum albumin concentration could not be taken as a variable in the logit regression analysis. To determine the relation of serum albumin concentration to hyponatraemia and the cause of death in hyponatraemia further prospective studies would be necessary.

[Nutrition in infant enteritis]. / Ernährung bei Säuglings-Enteritis

The effects of two different formulas in the treatment of acute diarrhea were tested in a prospective study with 40 infants. The formulas differ in content of lactose, fructose, starch, sodium and potassium. Both groups reached normal food intake at the same time and could be discharged from clinical observation. The patients were divided into two groups with equal degrees of diarrhea. During nutrition with lactose-reduced formula, body-weight was rising and the water-binding capacity of chymus seemed to be better. From significant higher percentages of prae-beta-liproproteins in electrophoresis better endogenous metabolic efficiency could be derived. Phospholipids were also significantly increased when lactose-reduced formula was given. The comparative formula led, due to the higher content of potassium to significantly higher serum levels. The results of this investigation indicate, that reduction of lactose in the formula for infants with diarrhea has some advantages. Whether more effectiveness of formulas in diarrhea could be expected from addition of medium chain triglycerides (Gracey et al. 1970, Schreier und Porath 1971) requires further investigations.