Length of gestation and birthweight in dizygotic twins.

Despite the longer gestation of girls, their birthweight is less than that of boys. Because unlike-sex twins provide a natural situation in which to investigate the influence of sex on gestation, we compared birthweight and gestation of 1929 same-sex and unlike-sex dizygotic pairs. Length of gestation in unlike-sex pairs was similar to that of female same-sex pairs, and significantly (0.4 weeks; p=0.02) longer than that of male same-sex pairs. Birthweight of girls from unlike-sex pairs was similar to that of girls from same-sex pairs, but boys from unlike-sex pairs weighed 78 g more than boys from same-sex pairs (p=0.001). These data show that in unlike-sex pairs it is the girl that prolongs gestation for her brother, resulting in a higher birthweight than that of same-sex boys.

Growth hormone treatment enhances bone mineralisation in children with chronic renal failure.

UNLABELLED: Dual energy X-ray absorptiometry of the whole body and the lumbar spine was performed to study bone mineralisation before and after 1 year of recombinant human growth hormone (rhGH) treatment in ten children with chronic renal failure. At the start, median age was 7.3 years (range 2.0-8.8 years) and median glomerular filtration rate 15 ml/min per 1.73 m2 (range 7-41 ml/min per 1.73 m2). Total body mineral content (TBMC), lumbar spine mineral content (LBMC), total body bone mineral density (TBMD) and lumbar spine mineral density (LBMD) improved significantly (P < 0.05) after 1 year of treatment. Bone mineral data before and after treatment were compared with two groups of controls, i.e. ten healthy children matched for age and ten healthy children matched for height. Patients' TBMC, LBMC, TBMD and LBMD data before treatment were no different from those of height-matched controls; the same was true after 1 year of treatment except for the patients' significantly better LBMD (P < 0.05). When compared with age-matched controls, patients had significantly lower baseline TBMC and LBMC levels before treatment; after treatment LBMC was no longer different. However, there were no differences in TBMD or LBMD between patients and age-matched controls at baseline or after rhGH. CONCLUSION: Recombinant human growth hormone treatment for 1 year results in a significant increase in both growth velocity and bone mineralisation. Comparison with height-matched controls shows a similar bone mineralisation at baseline and a better bone mineral density after treatment.

Fetal growth: boys before girls.

At term birth, boys are heavier than girls. This difference is thought to be generated in part by androgen action; its time course has not been deciphered. Androgen action may not only increase weight gain, but may also alter its time course. We have tested this hypothesis by examining the difference in gestational age of 281,894 boys and girls with weights between 500-4,749 g. The age at which children are born with a given weight was found to depend on gender: boys were consistently younger than girls (p < 0.001), the age difference being most pronounced in the lower birth weight classes. Thus, the gender difference in fetal growth appears to be rather pronounced before the third trimester and relatively less marked towards term. In conclusion, the male conceptus seems to grow not only more, but also earlier than the female. Hence, some critical time windows of development may be slightly different in boys and girls, and this phenomenon may be one of the bases for gender differences in the sensitivity to fetal programming. Copyrightz1999S. KargerAG,Basel

Sacolene in cholera: a double blind randomized controlled trial.

Methylated casein (Sacolene), a diarrhoea remedy used in Europe, has shown an antisecretory effect in cholera-induced secretion in animals and benefit in diarrhoea in humans. In this placebo controlled trial Sacolene was evaluated in 78 male adults with severe cholera who, after initial i.v. therapy received Sacolene or placebo, 4 g at start and 2 g 4 hourly until cessation of diarrhoea, along with oral rehydration therapy and repeat i.v. therapy if indicated. No antibiotics were given during the study. The purging rate and diarrhoea duration were similar in the 2 groups. The proportion of patients requiring repeat courses of i.v. therapy in the study group was 46% compared with 69% in controls (i.e. reduced by 23%, p = 0.04). While the severity of purging was not reduced, the proportion of patients requiring repeat i.v. therapy was reduced by Sacolene therapy. The latter finding may indicate some benefit from Sacolene in cholera, though this requires confirmation.

Fatness and muscularity as risk indicators of child mortality in rural Congo.

OBJECTIVES: To examine the relationship of anthropometrical indicators of fatness and muscularity with mortality in children in a rural African community. BACKGROUND: A prospective cohort study was carried out in the rural health zone of Bwamanda, Northern Congo using a random cluster sample of 5167 children, aged 0-5 years. MAIN OUTCOME MEASURES: Short- and long-term mortality rates, being deaths within 3 months and deaths in 3-month periods observed 3-30 months after enrolment. Rates of all cause mortality and of mortality from kwashiorkor or marasmus, by level of baseline fatness and muscularity. Indicators of fatness and muscularity were obtained by correcting anthropometric arm fat and arm muscle areas for age, sex, weight and height. RESULTS: The relationship of both the fatness and muscularity scores with short-term mortality was marked by a clear threshold (-0.5 SDS) below which there was a significant rise in mortality from all causes as well as from kwashiorkor and marasmus. These excess mortalities were also found in normal weight children. Fatness and muscularity scores remained significant determining factors of short-term mortality in a multiple logistic regression analysis with sex, age, season and weight-for-age. A ROC curve analysis showed that fat and muscularity scores had better predictive abilities than weight-for-age. Low fat status had a bad prognosis on the long-term in underweight children. CONCLUSIONS: Measures of current nutritional status should not be based on weight indices alone. Objective and/or clinical evaluation of fat and muscle status (also in normal weight children) should be added in order to detect a higher proportion of malnourished children and to more accurately evaluate mortality risk.

Respiratory syncytial virus bronchiolitis: a double-blind dexamethasone efficacy study.

The efficacy of dexamethasone therapy for primary respiratory syncytial virus bronchiolitis was studied in a double-blind placebo design in 29 previously healthy infants (median age, 194 days). No significant differences were found between the groups in evolution of respiratory rate, oxygen saturation, clinical score, or pulmonary function tests on day 3.

Maternal determinants of child survival in a rural African community.

BACKGROUND: The aim was to determine maternal factors related to child survival in the rural area of Bwamanda, Northern Zaire. METHODS: A prospective study of 30-months mortality was carried out in a cohort of 776 children aged 0-3 months, obtained by random cluster sampling. Inclusion criteria were exclusive breastfeeding, no severe prematurity and absence of severe protein-energy malnutrition, diarrhoea or acute respiratory infection. Mortality was recorded by regular home visits and inspection of hospital and funeral registers. Maternal factors that remain stable during follow-up were studied. RESULTS: Factors associated with excess mortality in bivariate and multiple logistic regression analysis were: (i) mother has parity > 5 (relative risk [RR] = 1.5-4.2); (ii) distance from the health centre > 5 km (RR = 0.9-2.9); (iii) invaliding maternal diseases (RR = 1.2-9.0). Maternal school education (conditional odds ratio [OR] = 1.0-5.0) was significant in the multiple regression. In contrast to the other risk factors, mother-child separation or problems with breastfeeding were rare and did not significantly increase mortality. CONCLUSIONS: Chronic stress situations created by maternal invalidity, high parity and distance from health care facilities, increase child mortality. Acute stress in the mother-child dyad seemed to be efficiently compensated for. In subsistence economy areas, maternal school education can be a disadvantage.

PIP: During August 1989-April 1992 in northern Zaire, random cluster sampling was taken of 16 villages in the health zone of Bwamanda. Health workers visited 766 exclusively breastfed infants, 0-3 months old, every 3 months for a total of 6 visits. This prospective study aimed to identify maternal determinants of child survival. The mortality rate was about 7.5%. More than 3% of the mothers suffered from chronic illness. 28.2% had at least 2 children. 86.1% were illiterate. 55% had already experienced at least 1 child death. Four variables were interrelated and, together, increased the risk of mortality: parity, number of surviving children, maternal age, and number of dead children. The multiple logistic regression analysis found the risk factors for mortality to include parity greater than 5 (conditional odds ratio [COR] = 4.9; p 0.01), more than 5 km distance from the health center (COR = 1.9; p = 0.06), at least 2 signs or symptoms of maternal chronic disease (COR = 4.8; p = 0.03), and any education for mothers (COR = 2.2; p = 0.05). Contrary to findings of other studies, mother-child separation and problems with breast feeding, rare in this area of northern Zaire, did not contribute significantly to mortality, but higher levels of maternal education were associated with increased levels of child mortality. These findings show that, in this rural area of subsistence farming, high parity, and illiteracy, chronic maternal stress situations (e.g., previous child deaths, maternal invalidity, high parity, great distance from health care facilities, and high child mortality) hamper child survival.

Validity of single-weight measurements to predict current malnutrition and mortality in children.

In this cross-sectional study of a random cluster sample of 4238 rural Zairian children aged 0-5 y, we assessed underweight and wasting, defined as weight-for-age < 75%, and weight-for-height < 80% of the U.S. National Center for Health Statistics reference median, respectively. We determined the diagnostic validity of underweight and wasting for protein-energy malnutrition, taking a low arm circumference and clinical signs of muscle loss as criteria. Both underweight and wasting had low sensitivity in recognizing low arm circumference, any clinical muscle loss and even severe marasmus, especially in the weaning period of 12-30 mos. Receiver operating characteristic (ROC) analysis showed that the diagnostic validity of weight-for-height can be improved by using a cutoff for wasting at Z-score -0.75 instead of Z-score -2 or 80% of reference median. ROC analysis of 30-mo mortality revealed a poor prognostic validity of weight-for-height and weight-for-age and better performances of arm circumference (cm) and of age. These data suggest that nutritional intervention programs targeted at wasted or underweight children can have only a limited effect on the prevalence of protein-energy malnutrition in the community or on the long-term mortality associated with it.

Hyperimmune cow colostrum reduces diarrhoea due to rotavirus: a double-blind, controlled clinical trial.

The therapeutic efficacy of hyperimmune bovine colostrum (HBC) from cows immunized with four serotypes of human rotavirus was evaluated in a double-blind, randomized trial in 75 boys, aged 6-24 months, infected with rotavirus diarrhoea. The treatment group received 100 ml of HBC three times a day for 3 consecutive days, while the controls received the same amount of bovine colostrum from significantly shorter duration of diarrhoea than the controls (median 56 versus 72 h (p<0.001); confidence interval of median difference (CI) 8-32 h). Total stool output (g/kg) between admission and cessation of diarrhoea was reduced by 29% in the HBC-treated group compared with controls (median 205 versus 290 g (p=0.04); CI = 1-154 g). In 50% of the children in the study group, diarrhoea stopped by 48 h, whereas 100% of the controls were still suffering from diarrhoea. No untoward effects were noted in either group. Colostrum from cows immunized with rotavirus antigen is clinically effective in reducing the duration and severity of childhood diarrhoea due to rotavirus.

Outcome after right middle lobe syndrome.

The long-term pulmonary consequences of right middle lobe syndrome (RMLS) in childhood are not known. Therefore, outcome was evaluated in 17 children with RMLS diagnosed in early childhood (mean age, 3.3 years; SD, 1.1 year). Mean age at follow-up was 10.1 years (SD, 2.6 years). RMLS was defined as atelectasis of the right middle lobe (RML) of at least 1 month's duration and visible on the lateral view of the chest radiograph as a wedge-shaped density extending from the hilum anteriorly and downward. Seventeen children without personal history of allergy or respiratory tract disease were studied as control group. Five of 17 study group children had ongoing respiratory problems: symptoms of asthma were present in 4 patients, and cylindrical bronchiectasis was present in one patient. Chest radiograph at follow-up was abnormal in six patients. Pulmonary function tests, including mean and SEM for vital capacity (VC) (82% of predicted +/- 7 vs 94% predicted +/- 3), FEV1 (77% of predicted +/- 12 vs 96% of predicted +/- 4) and their ratio (75 +/- 5 vs 85 +/- 3) were significantly lower in patients with ongoing respiratory symptoms than in the control children. The provocative dose causing a 20% decrease in FEV1 (PD20) of methacholine was significantly lower in patients with ongoing symptoms at follow-up than in control children and in patients without symptoms at follow-up (2.8[2.2 to 3.1] vs 4.5[2.2 to 8.8] and 9.2[2.3 to 24] mg/mL; median and P25-75, p < 0.05). Age at initial diagnosis tended to be younger in patients with ongoing symptoms at follow-up (2.3 +/- 0.7 years vs 3.8 +/- 0.4 years; p < 0.08).

Nutritional assessment: the problem of clinical-anthropometrical mismatch.

OBJECTIVE: To study risk factors for and prevalence and validity of clinical-anthropometrical mismatch (CAM) defined as the presence of clinical signs of protein-energy malnutrition despite normal weight-for-age (WFA). DESIGN: A semi-longitudinal study of nutrition and morbidity with a longitudinal assessment of mortality. SETTING: The rural health zone of Bwamanda in Northern Zaire. SUBJECTS: 4238 children of age 0-6 years enrolled by random cluster sampling. INTERVENTION: Clinical nutritional staging, anthropometry, diagnosis of diarrhoea and severe respiratory infection in the rainy (first survey) and the subsequent dry season (second survey). Recording of mortality during 27 months after the second survey. RESULTS: Prevalence of CAM was high above various cut-off levels of WFA and was accompanied by increased morbidity and long-term mortality. Of all the children with clinical signs of malnutrition, a high proportion had normal WFA. CAM was associated with weight loss within the limits of the international reference. CONCLUSIONS: If a child has a normal weight but clinical malnutrition signs are present, the clinical diagnosis should prevail. Weight charts are not fully appropriate for nutritional classification purposes. The clinical nutritional staging used in this study is sufficiently reproducible and capable of identifying children with functional malnutrition.

Persistent diarrhoea: efficacy of a rice-based diet and role of nutritional status in recovery and nutrient absorption.

A diet based on rice powder, soya-bean oil, glucose, egg-white and salts was given to twenty-six patients of different nutritional status aged 4-18 months with persistent diarrhoea and twenty-five age-matched controls without diarrhoea. Clinical response was monitored during 1 week of dietary treatment and absorption of macronutrients was estimated during a 72 h balance study. Twenty-one patients (81%) recovered from diarrhoea within 7 d. There were significant relationships between nutritional indices, recovery, and absorption of total energy, fat and N. The absorption of fat, protein and carbohydrate in the better nourished controls without diarrhoea was significantly higher than in patients with persistent diarrhoea with better nutrition or malnutrition. The duration of diarrhoea was significantly longer in lighter patients (weight-for-age < 65% NCHS (1976) standard), in wasted patients (weight/height < 80% of NCHS) and those with mid upper arm circumference (MUAC) less than 110 mm. There were negative relationships between the period of recovery and the coefficient of absorption of fat (P < 0.001), total energy intake (P < 0.01) and MUAC (P < 0.05). Weight-for-age and MUAC showed most effective discriminative power for absorption of nutrients. However, the coefficients of absorption for carbohydrate were not different for any pair of nutritional groups. Absorption of all nutrients was also correlated negatively with severity of persistent diarrhoea on admission. The results of the present study indicate that a rice-based diet is highly effective in the management of persistent diarrhoea and less malnutrition aggravates nutrient malabsorption, increases duration and severity of diarrhoea and less severely malnourished patients do not absorb nutrients as well as healthy controls. Malnutrition and the initial severity of diarrhoea are significant determinants of clinical prognosis and nutrient absorption in persistent diarrhoea.

Child morbidity patterns in two tropical seasons and associated mortality rates.

Cross-sectional morbidity recorded during two successive quarterly survey rounds and subsequent 27-months mortality were studied in a random sample of 4238 preschool children in a rural Zairian area. Analysis focuses on morbid patterns, i.e. any combination of the principal signs and symptoms encountered in tropical areas (oedema, marasmus, cough, fever, diarrhoea and tachypnoea). Almost half the children (45-48%) had signs of morbidity, a very high rate. The 3-6 month age group emerged as particularly vulnerable with the highest prevalences of all morbid patterns except for isolated fever. Isolated cough was more prevalent in the dry season probably as an effect of nightly indoor woodburning. All other morbid patterns were significantly more prevalent in the rainy season. Diarrhoea with cough was found to constitute half of all cases of diarrhoea. The results show that with a few simple questions on major symptoms and a brief examination by paramedical health workers, children with an increased risk of death can be identified. The method can be applied at under-5 clinics. Prognosis is particularly bad in severe malnutrition, especially when associated with diarrhoea, in diarrhoea with cough, cough with fever/tachypnoea and for children who are found sick both in the rainy and the subsequent dry season.

PIP: Cross-sectional morbidity in 2 successive quarterly survey rounds and subsequent 27-months mortality were studied in a random sample of 4238 preschool children in the rural health zone of Bwamanda in northern Ubangi, Zaire. 45-48% of the subjects displayed signs of morbidity such as oedema, marasmus, cough, fever, diarrhea, and tachypnoea. Being particularly vulnerable, children aged 3-6 months exhibited the highest prevalences of all morbid patterns except for isolated fever. Further, while isolated cough was more prevalent in the dry season and probably attributable to nightly indoor woodburning, all other morbid patterns were significantly more prevalent in the rainy season. Diarrhea with cough constituted half of all diarrhea cases. The authors continue by concluding that children at increased risk of death may be readily identified by posing a few simple questions on major symptoms and a brief examination by paramedical health workers. The method could be employed at under-5 clinics. Prognosis, however, is particularly bad in severe malnutrition, especially when associated with diarrhea, in diarrhea with cough, cough with fever/tachypnoea, and for children who are found sick both in the rainy and the subsequent dry season.

Posterior fossa dermoid cyst associated with dermal fistula: report of 2 cases and review of the literature.

Two cases of dermoid cysts of the posterior fossa in association with a dermal fistula and with different clinical presentations are reported. The patient in case 1 is a 14-month-old girl with a history of recurrent bacterial meningitis. Case 2, a 7-year-old girl, presented with a skin "granuloma" at the inion. Both cases, and a review of the literature, demonstrate the need for a thorough exploration of the cranial and spinal midline skin areas in every newborn and argue for widespread use of nuclear magnetic resonance imaging whenever a suspected midline lesion is found.

Influence of nutritional status on child mortality in rural Zaire.

Although the association between nutritional status and mortality risk is obvious for extreme malnutrition, the issue is not so clear for mild to moderate undernutrition. We have investigated this association in children of 0-5 years in the rural area of Bwamanda, Zaire, where an integrated development project, with good medical facilities, has operated for 20 years. A random cluster sample of 5167 children was taken; newborn infants and immigrants were included at six quarterly survey rounds from October, 1989, until February, 1991. All surveys included clinical and anthropometric assessment of nutritional status. Deaths were recorded up to April, 1992; there were 246 deaths. Marasmus, kwashiorkor, and other causes of death were defined by the verbal autopsy method and checked against medical records kept at the central hospital and the peripheral dispensaries. As expected, we found an increased risk of death in severe malnutrition. When deaths directly attributed to marasmus or kwashiorkor were excluded, mild to moderate stunting or wasting were not associated with higher mortality in the short term (within 3 months of the previous study round) or in the long term (from 3-30 months after study entry). The commonest causes of death were malaria and anaemia. Extreme marasmus and kwashiorkor caused 16% of deaths, and are important causes of death even in this favoured area with an integrated development project. Nutritional interventions should be targeted more selectively so that children with moderate malnutrition can be protected from progression to marasmus or kwashiorkor.

Growth of children in a iodine-deficient area in northern Zaïre.

In a case-control study all preschool children of 50 villages in an iodine-deficient area in northern Zaïre were examined for the absence or presence of a goitre. Children with goitre but without obvious signs of cretinism (cases) were maximally matched with a goitre-free child of the same ethnic group, village, sex and age (controls). Anthropometry of cases and controls was compared in order to investigate if endemic goitre is associated with any growth impairment. Surprisingly, between ages 2 and 4 years, children with goitre are taller and heavier, and have a smaller triceps skinfold thickness. Arm circumferences did not differ between cases and controls. Stunting is more prevalent in controls. If manifest cretinism is excluded, goitre is not associated with growth retardation. The higher anthropometric figures in goitrous children remain unexplained. In the absence of any data on the hormonal status of these two groups of children, it can only be surmised that, in iodine-deficient areas, some degree of hypothyroidism negatively influencing growth might be more frequent in non-goitrous children than in goitrous ones.

An initiation codon mutation as a cause of beta-thalassemia in a Belgian family.

Nine asymptomatic members of a family of Belgian origin, spanning three generations, present typical features of heterozygous beta-thalassemia. Since no mutation was detected with a large panel of oligonucleotide probes, the thalassemia gene was investigated by direct sequencing of DNA segments amplified by the polymerase chain reaction. A T-->C transition was detected in the translation initiation codon (ATG). The mutation, which abolishes an Nco I restriction site, was further confirmed by enzymatic digestion as well as by dot-blot hybridization of the amplified products with allele-specific oligonucleotide probes. It produced a beta zero-thalassemia phenotype characterized by marked microcytosis and hypochromia, as well as by an in vitro beta/alpha chain synthesis ratio close to O.5. Search for haplotype linkage showed the mutation to be associated with haplotype IX [- + - + + + +].