Intranatal Torsion of Polydactyly: A Rare Event.

Polydactyly is one of the most common anomalies of hand and/or foot. Postnatal torsion of pedunculated polydactyly is a well known complication but intranatal torsion has been infrequently described in published literature. Here, we describe a case of pedunculated ulnar polydactyly which was gangrenous at birth due to intranatal torsion. Controversies surrounding the management of narrow pedicled pedunculated polydactyly by traditional method of suture ligation at base are also discussed.

Anthropometric standards of privileged neonates in Maiduguri, Nigeria.

PIP: The study had been undertaken with an objective to assess the anthropometric values of privileged neonates in Northeastern Nigeria. The subjects for the study are neonates born to physically and nutritionally normal mothers between 15-40 years of age and coming from a better socioeconomic section of various ethnic groups of Nigeria. 1530 full-term singletons, without any antenatal or natal problem have been studied for their weight, length and head circumference. The mean birth weight was observed to be 3.2 +or- 0.59 kg. with higher values in males. There was a tendency for the mean birthweight to increase with increase in parity. Ibo neonates were heavier than other ethnic groups. The overall incidence of low birthweight babies was 5.75%. Mothers 18 years of age had the highest incidence of intrauterine growth retardation. The average values for length were 49.18 +or- 2.9 cm and for head circumference 34.72 +or- 1.77 cm. Though the mean values for weight, length and head circumference are comparable to American standards, the normal range for large-for-date babies was found to be higher, particularly in Ibo neonates. The ethnic groups classified were Ibo, Kanuri, Hausa, Yoruba, Fulani, Shuwa and other.^ieng

Cost effective strategy for promotion of appropriate case management of diarrheal diseases--establishment of DTUs.

Oral rehydration therapy (ORT) is one of the essential components of child survival technologies which are currently being utilised to reduce morbidity and mortality on account of common illnesses. ORT has made it possible to undertake a global effort to reduce deaths from dehydration and diarrhea associated malnutrition. Appropriate case management can also combat deaths from dysentery and persistent diarrhea. During the last decade considerable success has been achieved by incorporating this simple, effective and economic therapeutic intervention in the primary health care package. However, the ultimate objective of improved case management of diarrhea including the use of ORT at all levels of health care system is yet to be achieved. Patients with dysentery need antimicrobial therapy apart from ORT. Clinical experience has shown that with ORT and appropriate dietary therapy, most patients with persistent diarrhea can be managed effectively. Unfortunately, injudicious use of intravenous fluids and irrational prescription of antibiotics and anti-diarrheal agents is quite common even in the hands of pediatricians. The training of mothers visiting health facilities is poor for ORT and feeding. Establishment of diarrhea training and treatment units (DTUs) is aimed to improve current practices in the teaching hospitals and to promote appropriate case management of diarrhea by all health personnel.

Diarrhoea and malnutrition interaction.

Epidemiological studies have demonstrated a marked negative relationship between diarrhoea and physical growth and development of a child. Each day of illness due to diarrhoea produces a weight deficit of 20-40 gms. Poor nutrition is associated with more serious prolonged diarrhoea. 'Catch-up growth' often does not occur in malnourished children. Malnutrition, particularly wasting, is a strong predictor of diarrhoeal duration and the prolonged illness could exacerbate nutritional faltering, thereby increasing the subsequent risk of death. Poor appetite, vomiting, deliberate withholding of food resulting in poor intake; malabsorption of macro and micronutrients; hastening of intestinal transit time; disturbance of metabolic and endocrine functions; and direct loss of protein and other nutrients in gastrointestinal tract are some of the known mechanisms which have an impact on the nutrition during an episode of diarrhea. In addition diarrhoea of infectious origin causes cytokine induced malnutrition which results from the actions of proinflammatory cytokines like tumour necrosis factor and interleukin 1, 6 and 8. Preexisting malnutrition is associated with decreased turnover of epithelial cells resulting in delayed recovery which may prolong an episode of infectious diarrhoea by itself as well as by promoting tissue invasion by other enteropathogens. Malnutrition may also alter protective host factors and thereby favour intestinal colonization by the pathogenic microbes. Mucosal damage varying from moderately severe changes to flat lesions indistinguishable from those of celiac disease may occur in kwashiorkar. Diarrhoea malnutrition interaction represents a dangerous web which can be distangled by prevention of disease transmission by promoting exclusive breast feeding, hygienic weaning practices, safe drinking water and handwashing, improved host defences by breast feeding, improved nutrition, measles vaccine and other vaccines against enteropathogens in the offing; and promotion of standard case management with special emphasis on nutritional support and rehabilitation.

Helicobacter pylori infection in Indian children.

Current epidemiological scenario of Hp in India does not very clearly predict the natural history of this infection in children as they grow old. Positive serology does not seem to be of much clinical significance. Colonization by Hp in the stomach or duodenum per se does not predict a potential ulcer disease in all the cases. Most case control studies from India do not suggest any significant relationship of Helicobacter pylori (Hp) infection and recurrent abdominal pain. A significant relationship has been observed between Hp infection and antral gastritis and duodenitis. Hp related gastric or duodenal ulcers are infrequently reported in children probably because children between 12-18 years of age are not included in most of these studies. Scarce information is available regarding the relationship of Hp infection with failure to thrive, persistent diarrhea, disabled and neurodevelopmentally retarded children and the implications of acquiring infection in infancy. There is an urgent need to have guidelines for management of children with variable spectrum of gastroduodenal disease who are detected to have Hp colonization without any evidence of mucosal inflammation. Since a large number of children fall in this group, treating all of them in the absence of knowing their PCR amplified DNA sequence in Hp genome is impractical and may not be necessary. The ones detected to have evidence of mucosal inflammation attributed to Hp infection may need to be treated since it is not justified to leave these children untreated even after making a definite diagnosis. Secondly, eradication therapy may provide them the much desired symptomatic relief which is the patient's primary concern. For older children with peptic ulcer disease, using adult model for clinical significance and therapeutic options is justified. However, at present, there are no definite guidelines regarding the combinations and duration of antibacterial therapy for children in our setting due to lack of available data.

Integrated Management of Childhood Illness (IMCI): a robust strategy.

Integrated Management of Childhood Illness (IMCI), a strategy fostering holistic approach to child health and development, is built upon successful experiences gained from effective child health interventions like immunization, oral rehydration therapy, management of acute respiratory infections and improved infant feeding. The core intervention of IMCI is integrated management of the five most important causes of childhood deaths-acute respiratory infections, diarrheal diseases, measles, malaria and malnutrition. Using a set of interventions for the integrated treatment and prevention of major childhood illnesses, the IMCI strategy aims to reduce death as well as the frequency and severity of illness and disability, thus contributing to improved growth and development. In health facilities, the IMCI strategy promotes the accurate identification of childhood illness (es) in the outpatient settings, ensures appropriate combined treatment of all major illnesses, strengthens the counselling of caretakers and the provision of preventive services, and speeds up the referral of severely ill children. The strategy also aims to improve the quality of care of sick children at the referral level. It also creates a scientifically sound link between the management guidelines at the community level and the management approach in a referral centre. The strategy also envisages actual situations when referral is not possible and offers the best possible options in such circumstances. In the home setting, it promotes appropriate early home care and care-seeking, improved nutrition and prevention, and the correct implementation of prescribed care. In addition to its focus on treatment of illness in the health facility as well as at home, it also provides an opportunity for important preventive interventions such as immunization and improved infant and child nutrition including breastfeeding. The IMCI strategy reduces wastage of resources and avoids duplication of efforts that may occur in a series of separate disease control programs. The essential pillars include improvement in the case management skills of health personnel, improvement in health systems, and improvement in family and community practices. IMCI has been introduced in more than 80 countries and 19 of them have already scaled up IMCI implementation Even though it is too early to relate the decrease in childhood mortality with the introduction of IMCI in these countries, there are several indirect indicators which endorse its validity as a comprehensive and effective strategy. IMCI has helped countries to revise and update their child health policies, streamline the essential drug lists for children, increase service utilization, improve quality of care and nutritional counselling, improve health systems and improved family and community practices.

Iron supplementation in children with celiac disease.

OBJECTIVE: To evaluate the effect of iron supplementation, in addition to gluten free diet (GFD), on hematological profile of children with Celiac Disease (CD). METHODS: Children diagnosed as CD as per modified ESPGAN criteria were prospectively evaluated for their hematological profile at the time of their enrolment and after consuming GFD for at least one year. The results were compared with age and sex matched controls. Evaluation of hematological profile included hemoglobin estimation, complete blood counts, peripheral blood smear examination, serum iron, total iron binding capacity (TIBC), and serum ferritin estimation. All the enrolled cases were given iron supplementation in addition to exclusion of gluten from their diet. Repeat intestinal biopsy was performed in all the cases after completing 1 year on GFD. RESULTS: Twenty one children (mean age 6.67 years, range 4-11 years) diagnosed as CD who completed at least one year of regular follow up on GFD (mean 1.5 years, range 1-2 years) were analysed for their hematological profile at the time of enrolment and after consuming GFD and iron supplementation. At the time of enrolment all the children had hemoglobin level <11 gm%, 78% had microcytic hypochromic anemia and 22% had dimorphic anemia, with lower mean MCV, MCH and serum ferritin levels, and a significantly higher mean TIBC as compared to controls (p<0.001). In the follow up evaluation of these cases on GFD, mean hemoglobin levels were comparable with controls but the cases continued to have lower mean MCV, MCH serum ferritin levels (p<0.05) and higher mean TIBC (p<0.05). Seven children had mild anemia. Serum ferritin levels showed a negative correlation with the grade of villous atrophy and lamina propria infiltrate. CONCLUSION: Our results suggest that iron deficiency anemia (IDA) is commonly associated with CD and iron deficiency state continues for a longer time even after excluding gluten from the diet and iron supplementation. Apart from offering them GFD rich in iron, early detection and treatment of IDA and prophylactic iron folic acid supplementation will go a long way to optimize their mental and psychomotor functions.

Brush cytology: an adjunct to diagnostic upper GI endoscopy.

Endoscopic brush cytology (EBC) was performed in antral and duodenal brushings of children subjected to upper GI endoscopy for the detection of H. pylori (Hp) and trophozoites of Giardia lamblia (Glt) in addition to routine endoscopic grasp biopsy (EGB). It was hospital based prospective study. EBC was performed in children subjected to upper GI endoscopy with a sheathed cytology brush. Mucosal brushings were collected from antrum, body of the stomach and second or third part of duodenum by gently rubbing the surface of the brush with the mucosal wall in all the directions, brush withdrawn and brushings performed on a glass slide. The smears were placed in 95% ethyl alcohol and later examined for Glt and Hp using Giemsa and Hematoxylin & Eosin stain. EGB was taken from antrum, body of the stomach and duodenum from sites other than those used for brushings. One hundred and seventy children between 1-13 years (median age = 5 years) were subjected to upper GI endoscopy for malabsorption (n = 94), recurrent abdominal pain (n = 49), failure to thrive (n = 16) and recurrent vomiting/regurgitation (n = 11) and EBC was performed in addition to routine EGB. Thirty five children (20.4%) were colonized by Hp, 14 (8.2%) were detected to have Glt and in 6 cases (3.5%) both Hp as well as Glt were detected. Out of 41 cases colonized by Hp, 24 cases (58.5%) were detected by EGB and 27 cases (65.8%) were detected by EBC. Out of 20 children in whom Glt were detected from their duodenum, the detection was by EBG in 12 cases (60%) and by EBC in as many as 19 cases (95%). Comparison of EGB and EBC suggested that detection rates with EBC were higher than EGB. Detection by EBC was significantly higher for Glt than Hp. There were no complications attributed to EBC and procedure time for endoscopy was not significantly prolonged. On the contrary, detection of Hp and particularly Glt in higher proportion of cases with the help of EBC was helpful in their appropriate management. Our results suggest that EBC is a safe and useful tool to enhance the value of diagnostic endoscopic procedure when used in combination with routine EGB.

Diarrhea training and treatment unit: experience from a teaching hospital.

Case management of children with diarrhea has been evaluated after the establishment of a Diarrhea Training and Treatment Unit (DTU) in Kalawati Saran Children's Hospital, New Delhi. Our one year experience has shown a decrease in hospital admissions on account of diarrhea by 13%. With the help of proper treatment protocol, 69.5% of total cases have been managed with home available fluids/ORS after educating the mothers on home management of diarrhea. Majority of admitted cases (80.7%) were managed in the ORT area and rehydrated under proper monitoring and supervision between 3-8 hours (mean duration of stay 4.28 +/- 1.8 hours). Out of 1951 cases with dehydration, 1585 patients (81.2%) were rehydrated with ORS and only 366 cases (18.8%) received intravenous fluids. In more than 85% of cases with associated vomiting, successful oral rehydration was achieved with ORS. Use of ORS and early feeding even in those patients who initially received intravenous fluids for rehydration significantly reduced the average duration of stay in the diarrhea ward (P = less than 0.001). During the first year of its inception the average cost of rehydrating one patient of diarrhea in the DTU came down to Rs. 18.54 from Rs. 31.69 in the preceding year. Rationalising drug therapy in the case management helped to significantly reduce the consumption of antibiotics (P = less than 0.001) and antiemetics (P = less than 0.001), which has helped to reduce the expenditure on drugs on an average from Rs. 17.60 to Rs. 4.92 per patient.

Cladosporium bantianum meningitis in a neonate.

Cladosporium bantianum meningitis has been reported mostly in adult farmers between 20 and 30 years of age. We report a 6-day-old male neonate who was admitted with fever, focal seizures and not accepting feeds. Initial investigations suggested a diagnosis of pyogenic meningitis but antibiotic therapy for 14 days did not result in any significant clinical improvement. Repeat CSF examination after 14 days suggested a diagnosis of C. bantianum meningitis which was supported by presence of multiple abscesses in the cerebral cortex on CT scan of the head and confirmed by CSF culture. Clinical response to antifungal therapy remained unsatisfactory.

Goldenhar syndrome with rare associations.

Goldenhar syndrome is a malformation complex involving the structures arising from first and second branchial arches, the first pharyngeal pouch, first branchial cleft and primordia of the temporal bone. Though the syndrome itself is not very rare, the presence of polydactyly and hydrocephalus, which are rare associations, prompted us to report this case.

Diagnostic modalities for gastroesophageal reflux.

OBJECTIVE: To evaluate commonly utilized diagnostic modalities to detecting Gastroesophageal Reflux (GER). METHODS: Sixty children aged 1-72 months (mean age 14.7 months) with symptoms suggestive of Gastroesosphageal Reflux (GER) were investigated and subjected to upper gastrointestinal endoscopy and esophageal biopsy (EB), gastroesophageal scintiscanning (GS) and 24 hour ambulatory pH monitoring. RESULT: GER was detected in 28 (46.7%) cases by one or more diagnostic modalities. Ambulatory 24 hour pH monitoring was positive in higher proportion (43.3%) of cases in comparison to other modalities, followed by EB (38.3%) and GS (30%). Considering 24 hour pH monitoring as the gold standard, esophageal biopsy was positive in 22/26 cases (84.6%) detected by 24 hour pH monitoring with a specificity of 97.1% as compared to 17/26 cases (65.4%) by gastroesophageal scintiscanning with a specificity of 97.1%. When compared with EB results, amongst various parameters measured during 24 hour pH monitoring, Reflux index (RI) ranked highest (sensitivity 95.6 % and specificity 89.2 %) followed by duration of longest episode > 20 minutes and Euler Byrne score. Oscillatory index, calculated from tracings of pH monitoring, even though ranked lower because of its low sensitivity helped to pick up 2 cases missed by EB and RI. CONCLUSION: Our results suggest that a combination of diagnostic modalities may be required to diagnose GER in young children. Ambulatory 24 hour pH monitoring appears to be the single best investigation and combining it with EB and/or GS can help to detect maximum number of cases.

Cerebrospinal fluid osmolal changes in bacterial meningitis.

Sixty children with acute bacterial meningitis (ABM) were prospectively studied for their serum sodium values and cerebrospinal fluid (CSF), serum and urinary osmolality. The results have been compared with 20 age and nutritionally matched controls. Even though mean serum osmolality (283.2 +/- 13.84 mOsm/kg) and serum sodium levels (130.5 +/- 8.15 mEq/L) were significantly lower in ABM in comparison to controls (p < 0.05 and < 0.001, respectively), the overall mean CSF osmolality in patients with ABM (282.5 +/- 12.3 mOsm/kg) was not significantly different as compared to controls (288.2 +/- 7.89 mOsm/kg). As expected, cases of ABM with syndrome of inappropriate secretion of antidiuretic hormone (SIADH) had significantly lower CSF osmolality (272 +/- 9.42 mOsm/kg) as compared to those without SIADH (288.5 +/- 9.34 mOsm/kg) and controls (288.2 +/- 7.89 mOsm/kg). However, our observations indicate that whereas the mean CSF osmolality was lower than the serum osmolality in the control group as well as in ABM without SIADH, it was greater than serum osmolality in ABM with SIADH (p < 0.05). Our results suggest that in the presence of SIADH, hypo-osmolality of serum may eventually result in hypo-osmolality of CSF, but the fall in CSF osmolality is not of the same degree as that of serum. Low CSF osmolality was observed to be associated with an unfavorable prognosis (p < 0.05).

Serum sodium and osmolal changes in tuberculous meningitis.

Twenty children from 2 months to 7 years (mean age 2.74 years +/- 1.62) diagnosed to have tuberculous meningitis (TBM) were evaluated for serial serum sodium levels and osmolality of cerebrospinal fluid (CSF), serum and urine on admission and the results compared with 20 age and nutritionally matched controls, and these investigations repeated on day 3 and day 10. Mean serum sodium levels (130.7 +/- 6.26 mEq/L), and osmolality of CSF (272.0 +/- 7.0 mOsm/kg) and serum (275.5 +/- 6.09 mOsm/kg) were significantly lower (p < 0.001) than in controls. Hyponatremia was detected in 65% of cases on admission, 47% on day 3 and in 30.8% on day 10. All the patients with hyponatremia had biochemical evidence of syndrome of inappropriate secretion of antidiuretic hormone (SIADH) on admission. Incidence of SIADH gradually decreased to 41.2% on day 3 and 15.4% on day 10. In some of the cases serum sodium levels and osmolality of serum and CSF took about 3 weeks to return to normal. CSF osmolality was lower than concomitant serum osmolality in patients as well as in controls. In patients with SIADH, CSF osmolality followed the same trend as serum values and returned to normal in 2-3 weeks. Overall mortality was 25%. Two out of 3 patients who expired during first 3 days had SIADH but in those cases who survived there was no correlation with degree of meningeal inflammatory changes or ultimate outcome. SIADH is commonly associated with TBM and should be diagnosed early in order to modify the fluid therapy in these cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Breastfeeding among urban women of low-socioeconomic status: factors influencing introduction of supplemental feeds before four months of age.

PIP: This study assessed characteristics of women who exclusively breast feed infants during the first 4 months and women who introduce early supplementation of foods in India. Data were obtained from interviews with 75 randomly selected mothers. 73.3% of mothers were 20-30 years old. 49.3% of birth weights were under 45 kg. 20% were under 145 cm in length. 55 mothers (73.3%) received prenatal care. 26 mothers were informed about breast feeding. 76% of mothers resumed full household and/or professional work within 45 days of delivery. 61.3% of births were males. 97.3% were normal vaginal deliveries. 98.7% roomed with their mother after delivery. 62.7% were breast fed within the first day of life. The rest were breast fed by the 3rd day. 51.3% were started on supplementary feeding within 6 weeks. 72% were started on supplementary feeding within 2 months. Duration of exclusive breast feeding was unrelated to maternal education or nutrition, socioeconomic status, family support, motivation for breast feeding, birth order, or gender of the infant. The most common reason for early food supplementation was insufficient breast milk (49.4%). 6 of 13 mothers related work resumption as the reason for artificial feeding. Most mothers used cow or buffalo milk. Most used bottles, and few had proper hygiene. Most diluted the supplements with water.^ieng

Knowledge and perceptions of residents regarding case management of acute diarrhea.

The knowledge and perceptions about case management of acute diarrhea were studied amongst 330 resident doctors working in Pediatric Departments of various Medical Colleges in the country. Our observations highlight the inadequacies in the medical curriculum and deficient clinical training in the management of acute diarrhea in the teaching institutions. Knowledge of signs of dehydration was correctly perceived by only 79.8% interns, 80.9% house physicians and 81.1% postgraduate students. It was appalling to observe that despite spending 1-3 years in pediatric wards, the knowledge and perceptions of postgraduate students had not significantly improved. On the contrary, the responses of postgraduate students were poorer as compared to interns in their perceptions of use of ORT in moderate dehydration (p less than 0.005) and in presence of vomiting (p less than 0.05). Adequate thrust on diarrhea and its management during undergraduate as well as during postgraduate teaching and proper training in diarrhea case management with "hands on training" needs to be viewed as a priority in the teaching institutions.

PIP: 114 interns, 126 house physicians, and 90 postgraduate medical students working in pediatric departments of 24 medical colleges in India completed and returned a questionnaire on diarrhea, oral rehydration therapy (ORT), and case management to the Diarrhea Training and Treatment Centre in New Delhi. 20.2%, 19.1%, and 18.9% respectively did not know the signs of dehydration. Further only 19.3%, 23.8%, and 35.5% respectively knew the particulars of the National Control of Diarrheal Diseases Programme. Overall knowledge of ORT was limited. For example, only 68.4%, 66.6%, and 71.1% respectively knew the composition of oral rehydration solution (ORS). Further only 21%, 23.8%, and 23.3% respectively knew how much and what to feed children during and after diarrhea. Moreover only 63.1%, 57.1%, and 62.2% respectively knew how to calculate how much ORS to give to replace fluids. Significantly more interns knew that ORS should be used to treat moderate diarrhea (82.4% vs. 64.4%; p.005) and in cases with vomiting (64.9% vs. 51.1%; p.05) than postgraduate students. Furthermore only 29.8% of interns and 36.5% of house physicians did not favor prescribing medications to satisfy mothers. On the other hand, most postgraduate students (60%) did not favor this. These results reflect the deficiency in training of proper diarrhea case management in undergraduate and postgraduate settings. Therefore medical schools and teaching hospitals need to incorporate correct diarrhea case management into their curricula as well as give it high priority, especially since diarrhea related morbidity and mortality among children 5 years old is so high in India.

Clinical and nutritional profile of children with celiac disease.

This prospective study was aimed to evaluate the clinical and nutritional profile of children diagnosed as celiac disease (CD) as per the modified ESPGAN criteria, at the time of diagnosis and after institution of gluten free diet. Out of 65 enrolled cases of CD, 7 (10.8%) children did not follow a strict dietary compliance. Only 41 children with satisfactory dietary compliance on gluten free diet (GFD) who regularly attended the follow up for at least 6 months were evaluated for their nutritional and hematological status. Results were compared with age and sex matched controls. The mean age of diagnosis was 8.7 +/- 3.3 years. Diarrhea and failure to thrive were the most common presenting symptoms. At diagnosis, the nutritional and hematological indices were significantly lower in patients than in controls. Mean duration of follow up on GFD was 22 months (range 6-48 +/- 5.6 months). On follow up, height for age Z score was significantly lower, mean BMI was significantly higher, and weight for age Z score, weight for height Z score (%), mean triceps and biceps skin fold thickness, and mid arm circumference were comparable to controls. At diagnosis, 80% cases had microcytic hypochromic anemia and 20% had dimorphic anemia. On GFD for at least a period of more than 6 months, 19% had microcytic anemia and in 81% the hematological picture was normocytic normochromic. 60% cases had thrombocytosis at diagnosis in comparison to 2.3% after treatment. Institution of GFD leads to rapid improvement in clinical picture as well as most of the nutritional and hematological parameters.

Persistent diarrhea: management in a diarrhea treatment unit.

Five hundred ninety two children (6.0%) were diagnosed as persistent diarrhea (PD) out of a total attendance of 9795 cases in the Diarrhea Training and Treatment Unit (DTU) over a period of 1 year. Most of the cases were initially managed as outpatients on dietary advice and treatment of associated infections. Eighty eight per cent of the cases followed as outpatients from the DTU responded to treatment and only 11.5% of them had to be hospitalized. A total of 49/592 cases (8.3%) required to be hospitalized on account of treatment failure from outpatients and other indications. Clinical spectrum of hospitalized children included severe malnutrition (40.8%), pneumonia (40.8%), urinary tract infection (32.7%), lactose intolerance (32.7%), anemia (28.6%), septicemia (16.3%), dysentery (8.2%) and neck flop due to hypokalemia (4.1%). Dietary management included modifications in the diet already offered to hospitalized patients. Thirty eight children were fed on one of these diets. Of these 13/35 children (37.1%) were successfully managed with lactose reduced diet., 18/22 cases (81.8%) with lactose free diet and only in 2 cases carbohydrate free diet was given. In 3 cases, normal feeding was continued. Eleven cases were too sick to be offered any oral feeding. Eleven of forty nine cases (22.4%) expired. Mortality was highest in infants <6 months (31.6%). The causes of death included severe malnutrition (14.3%), septicemia (14.3%) and pneumonia (12.2%). Screening and treating cases of PD for associated infections like septicemia, pneumonia and urinary tract infection seems to be a key factor which determines morbidity and mortality in these cases. Feeding on a hospital food modified as lactose reduced/free diet can benefit majority of cases with PD and a very small proportion of cases may require carbohydrate free diet.

A randomized controlled trial of vitamin A supplementation in acute diarrhea.

Effect of vitamin A supplementation on duration of diarrhea was evaluated in 108 cases between 6 months to 5 years of age suffering from acute diarrhea of less than 3 days duration and results were compared with equal number of age and sex matched controls having comparable feeding pattern, nutritional and socio-economic status and clinical profile who did not receive vitamin A supplementation. There was no significant difference in the mean duration of diarrhea in cases who received vitamin A and the controls. However, on subgroup analysis of the study and control groups a significant (p = 0.009) beneficial effect of vitamin A supplementation was noticed in cases who had a pre-existing vitamin A deficiency with CIC stage 3/5 and above. Even though vitamin A supplementation in malnourished children did not significantly alter the duration of diarrhea, a beneficial effect was observed in children who had CIC state 3 and above in association with malnutrition (p = 0.025). Our results indicate that vitamin A supplementation does not significantly reduce the duration of a diarrheal episode. However, in children with pre-existing vitamin A deficiency particularly those who have associated malnutrition it may have a beneficial effect.

Duodenal string test in typhoid fever.

Twenty five children between 4-12 years of age hospitalized with a clinical diagnosis of enteric fever were studied for evaluating the practicality and sensitivity of duodenal string-capsule culture (DSCC) and compared with conventional cultures from blood (BC), urine (UC) and stool (SC). Duodenal string capsule (DSCC) was successfully inserted in 18 patients (72%). Insertion of DSCC failed in 7 patients (28%) and all of them were below 6 years of age. Salmonella typhi was isolated from DSCC and/or BC in 13 cases (72.2%). DSCC was positive in 11 out of 13 confirmed cases of typhoid fever (84.6%). BC was positive in 8 cases (61.5%). DSCC was successful in isolating the organism in about 30% more cases than BC. Duodenal string test was a simple, non-invasive and a reliable test which when used in combination with BC could identify almost all cases of enteric fever irrespective of duration of fever and prior use of antibiotics.