Nutritional rehabilitation of malnourished children detected by Screening Tool for Assessment of Malnutrition in Pediatric: Urban versus rural settings.

BACKGROUND: Malnutrition presents a major global health burden. In Egypt, it remains an important issue in children under 5 years especially in rural communities. AIM OF THE STUDY: The aim of the study was to screen 2-5 years old children enrolled from Egyptian hospitals in rural and urban areas for the risk of malnutrition using Screening Tool for Assessment of Malnutrition in Pediatric (STAMP) and to evaluate the effectiveness of nutritional intervention programs. SUBJECTS AND METHODS: This cross-sectional study was conducted on 90 patients recruited from two hospitals in urban and rural Cairo, Dietary history and anthropometric measurements were assessed. Patients at intermediate and severe risk of malnutrition according to STAMP were given tailored nutritional programs. RESULTS: In the rural hospital, 4.4% of the screened children were underweight, 22.2% were marginally underweight, and 73.3% had normal weight. Regarding the urban hospital, 15.6% were marginally underweight, 84.4% had normal weight and no underweight patients. Among the rural group 35.6% were at high risk according to STAMP score results compared to 20% in the urban group. Nevertheless, the only significant differences were the more stunting and higher BMI in rural hospital patients. After nutritional intervention, high-risk category patients decreased in both groups coupled by significant improvement in the anthropometric parameters and nutrition data with no significant differences between them. CONCLUSION: Nutritional education and prompt implementation of nutritional rehabilitation program for malnourished children detected by screening tools result in improvement in their nutritional status disregards their location whether urban or rural.

Functional outcome of unstable pelvic ring injuries after iliosacral screw fixation: single versus two screw fixation.

INTRODUCTION: A clinical series of patients was studied to compare the functional score after the use of a single versus two percutaneous iliosacral screws for unstable posterior pelvic ring fractures with or without anterior fixation with the aim to explore if the addition of a second screw would provide better results regarding the functional outcome score. MATERIALS AND METHODS: This case series includes 77 patients with an average of 32.6 years who suffered unstable posterior pelvic ring fractures. Forty-six were Tile type C and 31 were Tile type B. Patients underwent closed reduction and were fixed using percutaneous fluoroscopic-guided iliosacral screws in the supine position with 1 screw in 50 fractures, 2 screws in 37 fractures, 2 fractures were fixed with plates after ORIF, and in 6 cases (out of the bilateral cases) the undisplaced side was unfixed. Postoperatively three patients were lost to follow up and 74 patients (84 posterior fractures fixed with screws) were followed up for a mean of 37.4 months (range 6-151 months) and were evaluated using the Majeed score (1989). RESULTS: Clinical union occurred in all the patients, although in two cases posterior fixation failed and was revised. Radiologically excellent reduction was achieved in 55 patients (71.4%), good in 16 (20.8%), fair in 6 (7.8%) and none had poor reduction. Statistically; among 62 cases that completed the Majeed score evaluation at the last follow-up session, there was no significant difference p value 0.051 between two groups. We also compared Majeed score in Tile B and C fractures fixed with one versus two screws. CONCLUSION: The addition of a second screw for posterior fixation did not show any statistically significant difference regarding functional outcome. LEVEL OF EVIDENCE: Level IV clinical trial.

Effect of dietary fat supplementation during late pregnancy and first six months of lactation on maternal and infant vitamin A status in rural Bangladesh.

Dietary fat intake is extremely low in most communities with vitamin A deficiency. However, its role in vitamin A status of pregnant and lactating women is poorly understood. The aim of the study was to examine the effect of supplementing women with fat from mid-/late pregnancy until six months postpartum on their vitamin A status and that of their infants. Women recruited at 5-7 months of gestation were supplemented daily with 20 mL of soybean-oil (n = 248) until six months postpartum or received no supplement (n = 251). Dietary fat intake was assessed by 24-hour dietary recall at enrollment and at 1, 3 and 6 months postpartum. Concentrations of maternal plasma retinol, beta-carotene, and lutein were measured at enrollment and at 1, 3 and 6 months postpartum, and those of infants at six months postpartum. Concentration of breastmilk retinol was measured at 1, 3 and 6 months postpartum. The change in concentration of plasma retinol at three months postpartum compared to pregnancy was significantly higher in the supplemented compared to the control women (+0.04 vs -0.07 micromol/L respectively; p < 0.05). Concentrations of plasma beta-carotene and lutein declined in both the groups during the postpartum period but the decline was significantly less in the supplemented than in the control women at one month (beta-carotene -0.07 vs -0.13 micromol/L, p < 0.05); lutein -0.26 vs -0.49 micromol/L, p < 0.05) and three months (beta-carotene -0.04 vs -0.08 micromol/L, p < 0.05; lutein -0.31 vs -0.47 micromol/L, p < 0.05). Concentration of breastmilk retinol was also significantly greater in the supplemented group at three months postpartum than in the controls (0.68 +/- 0.35 vs 0.55 +/- 0.34 micromol/L respectively, p < 0.03). Concentrations of infants' plasma retinol, beta-carotene, and lutein, measured at six months of age, did not differ between the groups. Fat supplementation during pregnancy and lactation in women with a very low intake of dietary fat has beneficial effects on maternal postpartum vitamin A status.

Low-dose beta-carotene supplementation and deworming improve serum vitamin A and beta-carotene concentrations in preschool children of Bangladesh.

Despite the national vitamin A and antihelminthic prophylaxis programmes, both intestinal geohelminths and subclinical vitamin A deficiency continue to be prevalent among children in developing countries. Studies on potential synergistic effects of vitamin A supplementation and deworming on retinol status have inconsistent results. The purpose of the present study was to investigate the impacts of low-dose beta-carotene supplementation and antihelminthic therapy on serum retinol and beta-carotene concentrations in preschool children of Bangladesh. Two hundred and forty-four children, known to be infected with Ascaris lumbricoides, were randomized into four treatment groups: I-IV. Group I and II received two oral doses of 400 mg of albendazole each, the first dose at baseline and the second dose after four months; Group III and IV received placebo in place of albendazole. In addition, Group I and III received 1.2 mg of beta-carotene powder in capsule daily for six months, and Group II and IV received placebo in place of beta-carotene. Serum retinol and beta-carotene levels were measured before and after six months of the interventions. Serum retinol and beta-carotene increased significantly in Group I where both antihelminthic therapy and daily beta-carotene supplementation were given (p<0.05 and p<0.001 respectively). Antihelminthic therapy alone only improved serum beta-carotene concentration (p<0.0001). Low-dose beta-carotene supplementation, along with an antihelminthic therapy, synergistically improved vitamin A status. This finding has public-health implications for improving vitamin A status of children in developing countries.

Arsenic and cadmium in food-chain in Bangladesh--an exploratory study.

Arsenic contamination of tubewell water is a major public-health problem in Bangladesh. In the recent years, the use of shallow and deep tubewell water for irrigation and the use of excess amount of cheap fertilizers and pesticides containing cadmium pose a serious threat of contamination of arsenic and cadmium in food. In an exploratory study, arsenic and cadmium were measured in foods from Matlab, a rural area in Bangladesh, that is extensively affected by arsenic and the economy is agriculture-based. Raw and cooked food samples were collected from village homes (households, n=13) and analyzed to quantify concentrations of arsenic and cadmium using atomic absorption spectrophotometry. Washing rice with water before cooking reduced the concentration of arsenic in raw rice by 13-15%. Rice, when cooked with excess water discarded, showed a significant decrease in arsenic concentration compared to that cooked without discarding the water (p<0.001). In contrast, concentration of cadmium did not decrease in cooked rice after discarding water. Cooked rice with discarded water had significantly lower concentration of arsenic compared to raw rice (p=0.002). Raw rice had higher concentration of arsenic compared to raw vegetables (p<0.001); however, no such difference was found for cadmium. Compared to raw vegetables (e.g. arum), concentration of arsenic increased significantly (p=0.024) when cooked with arsenic-contaminated water. Thus, the practice of discarding excess water while cooking rice reduces the concentration of arsenic but not of cadmium in cooked rice. However, water generally not discarded when cooking vegetables to avoid loss of micronutrients consequently retains arsenic. The results suggest that arsenic and cadmium have entered the food-chain of Bangladesh, and the cooking practices influence the concentration of arsenic but not of cadmium in cooked food.

Supplementing iron and zinc: double blind, randomized evaluation of separate or combined delivery.

BACKGROUND/OBJECTIVES: Many children have diets deficient in both iron and zinc, but there has been some evidence of negative interactions when they are supplemented together. The optimal delivery approach would maximize clinical benefits of both nutrients. We studied the effectiveness of different iron and zinc supplement delivery approaches to improve diarrhea and anemia in a rural Bangladesh population. STUDY DESIGN: Randomized, double blind, placebo-controlled factorial community trial. RESULTS: Iron supplementation alone increased diarrhea, but adding zinc, separately or together, attenuated these harmful effects. Combined zinc and iron was as effective as iron alone for iron outcomes. All supplements were vomited <1% of the time, but combined iron and zinc were vomited significantly more than any of the other supplements. Children receiving zinc and iron (together or separately) had fewer hospitalizations. Separating delivery of iron and zinc may have some additional benefit in stunted children. CONCLUSIONS: Separate and combined administration of iron and zinc are equally effective for reducing diarrhea, hospitalizations and improving iron outcomes. There may be some benefit in separate administration in stunted children.

Effect of micronutrients on morbidity and duration of hospital stay in childhood pneumonia.

A cross-sectional and controlled clinical trial was conducted in under-5 children to compare the effects of supplementation of five micronutrients (vitamin-A, vitamin C, vitamin E, folic acid and zinc) on the morbidity and on the duration of hospital stay in pneumonia. Data were collected from 1150 children. Among them 350 children were excluded for various reasons and finally data from 800 children were analyzed. Among these 800 children 59.00% (475) were male and 41.00% (325) were female. The mean+/-SD age was 6.5+/-5.6 months and 56.25% (450) were infants. The children were divided into two groups-400 in control group and 400 in intervention (case) group. In both the groups, specific treatment was given by ampicillin and gentamycin. In intervention group, five micronutrients were given in 200 children from the day of admission and continued up to discharge. Another 200 children were again divided into 5 sub-groups (40 in each sub-group) and a single micronutrient was given in the same way in each sub-groups. All the subjects were suffering clinically from severe pneumonia and radiologically from bronchopneumonia. Cases and controls were matched by parents' occupation, education level, economic status and family members. All the children were fully vaccinated as per existing EPI schedule of the country, partially breastfed up to six months and after six months weaned by carbohydrate rich diet. All the children were in mild (grade I) PEM according to Gomez's classification. Venous blood was collected for estimation of serum level of five micronutrients from all the samples before starting treatment by standard procedures. The average blood level of all the micronutrients was low. The average duration of hospital staying was 6.75 days in intervention group and 7.75 days in control group (p<0.01). Chest indrawing and fast breathing disappeared earlier in the intervention group (p<0.01) suggesting that supplementation of micronutrients decrease the morbidity and duration of hospital stay of children suffering from pneumonia.

The epidemiology of visceral leishmaniasis and asymptomatic leishmanial infection in a highly endemic Bangladeshi village.

We examined the epidemiology of kala-azar and asymptomatic leishmanial infection measured by serologic and leishmanin skin test results in a Bangladeshi community. In a subset, we measured serum retinol, zinc and C-reactive protein (CRP). Kala-azar and seroconversion incidence were 15.6 and 63.1 per 1,000 person-years, respectively. Proximity to a previous kala-azar case increased the likelihood of both kala-azar and asymptomatic infection. Bed net use protected against kala-azar (rate ratio = 0.35, P < 0.01), but not subclinical infection (rate ratio = 1.1, P = 0.82). Kala-azar patients were younger (P < 0.001) and reported lower red meat consumption (P < 0.01) than asymptomatic seropositive individuals. Retinol and zinc levels were lower in current kala-azar patients and those who later developed kala-azar compared with uninfected and asymptomatically infected subjects. The CRP levels were higher in kala-azar patients compared with the other two groups. Low red meat intake and poor zinc and retinol status may characterize a group at higher risk of symptomatic disease.

A modified routine analysis of arsenic content in drinking-water in Bangladesh by hydride generation-atomic absorption spectrophotometry.

The high prevalence of elevated levels of arsenic in drinking-water in many countries, including Bangladesh, has necessitated the development of reliable and rapid methods for the determination of a wide range of arsenic concentrations in water. A simple hydride generation-atomic absorption spectrometry (HG-AAS) method for the determination of arsenic in the range of microg/L to mg/L concentrations in water is reported here. The method showed linearity over concentrations ranging from 1 to 30 microg/L, but requires dilution of samples with higher concentrations. The detection limit ranged from 0.3 to 0.5 microg/L. Evaluation of the method, using internal quality-control (QC) samples (pooled water samples) and spiked internal QC samples throughout the study, and Standard Reference Material in certain lots, showed good accuracy and precision. Analysis of duplicate water samples at another laboratory also showed good agreement. In total, 13,286 tubewell water samples from Matlab, a rural area in Bangladesh, were analyzed. Thirty-seven percent of the water samples had concentrations below 50 microg/L, 29% below the WHO guideline value of 10 microg/L, and 17% below 1 microg/L. The HG-AAS was found to be a precise, sensitive, and reasonably fast and simple method for analysis of arsenic concentrations in water samples.

Antioxidant vitamins E and C as adjunct therapy of severe acute lower-respiratory infection in infants and young children: a randomized controlled trial.

OBJECTIVE: To evaluate the effect of antioxidant Vitamins E and C as adjunct therapy of severe acute lower respiratory infection (ALRI) in children. DESIGN: Randomized double-blind placebo-controlled clinical trial. SETTING: A large childrens' hospital serving the urban poor in Kolkata, India. SUBJECTS: Children aged 2-35 months admitted with severe ALRI. INTERVENTION: In total, 174 children were randomly assigned to receive alpha-tocopherol 200 mg and ascorbic acid 100 mg twice daily or placebo for 5 days. All children received standard treatment for severe ALRI. Outcome measures were: time taken to recover from a very ill status, fever, tachypnoea, and feeding difficulty; and improvement in oxidative stress and immune response indicated by thiobarbituric acid reacting substances (TBARS) and response to skin antigens, respectively. RESULTS: Recovery rate ratios (95% CI) using proportional hazards model were 0.89 (0.64-1.25), 1.01 (0.72-1.41), 0.86 (0.57-1.29), and 1.12 (0.77-1.64) for very ill status, feeding difficulty, fever, and tachypnoea, respectively. TBARS values were high and similar in the two groups at admission, discharge, and at 2 weeks follow-up. Serum alpha-tocopherol significantly increased in treated group at discharge. Immune response to skin antigens were very poor at admission and after 2 weeks, in both groups. CONCLUSION: Infants with severe ALRI failed to benefit from two antioxidant nutrients as adjunct therapy. Severe ALRI in infants may cause cell-mediated immune dysfunction. We need a better understanding of oxidative processes in growing infants to help us better design interventions with antioxidant therapy.

Increased food intake after the addition of amylase-rich flour to supplementary food for malnourished children in rural communities of Bangladesh.

BACKGROUND: In Bangladesh, as in other developing countries, protein-energy malnutrition is mostprevalent among children during weaning. After weaning, children are often fed cereal-based diluted low-calorie porridge, resulting in growth-faltering. OBJECTIVE: To assess the effect on food intake of adding amylase-rich flour (ARF) from germinated wheat to supplementary food among children in nine rural Community Nutrition Centers under the Bangladesh Integrated Nutrition Project (BINP). METHODS: A total of 166 malnourished children of either sex, aged 6 to 24 months, received one of three diets randomly allocated to the Community Nutrition Centers. The composition of the diets was the same; however, the consistency and calorie density were altered by adding either ARF or water. Thirty-five children received the standard supplementary food of the BINP (S-SF), 65 received supplementaryfood with added ARF (ARF-SF), and 66 received supplementary food with added water (W-SF). The children were studied for six weeks. Results. The mean +/- SD intake of supplementaryfood from a single meal by children completing six weeks on the diets was higher for children receiving ARF-SF (33.91 +/- 8.25 g) than for those receiving S-SF (25.66 +/- 6.73 g) or W-SF (30.26 +/- 8.39g) (p < .05 for both comparisons). The weight of vomited food was significantly higher for children receiving W-SF than for children in the other two groups. Weight gain and increments in length and weight-for-height were higher for children who received ARF-SF than for children in the other two groups, but the differences were not statistically significant. The acceptability ofARF-SF was higher than that of the two other diets. The additional cost of adding 2 g of ARF to the diet was about Taka 0.25 (U.S. dollar 1 = Taka 48). CONCLUSIONS: Addition of ARF to existing standard supplementary food, as used under the BINP program, is a simple and effective means to increase the intake of food by changing its consistency, thus making it easier for malnourished children to ingest.

Zinc for severe pneumonia in very young children: double-blind placebo-controlled trial.

BACKGROUND: Pneumonia is a leading cause of morbidity and mortality in young children. Early reversal of severity signs--chest indrawing, hypoxia, and tachypnoea--improves outcome. We postulated that zinc, an acute phase reactant, would shorten duration of severe pneumonia and time in hospital. METHODS: In a double-blind placebo-controlled clinical trial in Matlab Hospital, Bangladesh, 270 children aged 2-23 months were randomised to receive elemental zinc (20 mg per day) or placebo, plus the hospital's standard antimicrobial management, until discharge. The outcomes were time to cessation of severe pneumonia (no chest indrawing, respiratory rate 50 per min or less, oxygen saturation at least 95% on room air) and discharge from hospital. Discharge was allowed when respiratory rate was 40 per minute or less for 24 consecutive hours while patients were maintained only on oral antibiotics. FINDINGS: The group receiving zinc had reduced duration of severe pneumonia (relative hazard [RH]=0.70, 95% CI 0.51-0.98), including duration of chest indrawing (0.80, 0.61-1.05), respiratory rate more than 50 per min (0.74, 0.57-0.98), and hypoxia (0.79, 0.61-1.04), and overall hospital duration (0.75, 0.57-0.99). The mean reduction is equivalent to 1 hospital day for both severe pneumonia and time in hospital. All effects were greater when children with wheezing were omitted from the analysis. INTERPRETATION: Adjuvant treatment with 20 mg zinc per day accelerates recovery from severe pneumonia in children, and could help reduce antimicrobial resistance by decreasing multiple antibiotic exposures, and lessen complications and deaths where second line drugs are unavailable.

Effect of zinc supplementation between 1 and 6 mo of life on growth and morbidity of Bangladeshi infants in urban slums.

BACKGROUND: Evidence for an effect of zinc supplementation on growth and morbidity in very young infants in developing countries is scarce and inconsistent. OBJECTIVE: We assessed the effect of zinc supplementation on growth and morbidity in poor Bangladeshi infants aged 4-24 wk. DESIGN: Infants from Dhaka slums were enrolled at 4 wk of age and randomly assigned to receive 5 mg elemental Zn/d (n = 152) or placebo (n = 149) until 24 wk of age. They were followed weekly for information on compliance and morbidity; anthropometric measurements were performed monthly. Serum zinc was assessed at baseline and at 24 wk of age. RESULTS: At 24 wk of age, serum zinc concentrations were higher in the zinc than in the placebo group (13.3 +/- 3.8 and 10.7 +/- 2.9 micro mol/L, respectively; P < 0.001). Significantly greater weight gains were observed in the zinc than in the placebo group for 43 infants who were zinc deficient (< 9.18 micro mol/L) at baseline (3.15 +/- 0.77 and 2.66 +/- 0.80 kg, respectively; P < 0.04). In the other infants, no significant differences were observed in mean weight and length gains during the study period. Zinc-deficient infants showed a reduced risk of incidence of acute lower respiratory infection after zinc supplementation (relative risk: 0.30; 95% CI: 0.10, 0.92); among the non-zinc-deficient infants there were no significant differences between treatment groups. CONCLUSIONS: Zinc-deficient Bangladeshi infants showed improvements in growth rate and a reduced incidence of acute lower respiratory infection after zinc supplementation. In infants with serum zinc concentrations > 9.18 micro mol/L, supplementation improved only biochemical zinc status.

Differential modulation of interleukin-6 and interleukin-10 by diclofenac in patients undergoing major surgery.

BACKGROUND: Prostaglandins modulate cytokine release though increases in cAMP, regulating interleukin (IL) 6 and IL-10. Diclofenac inhibits cyclo-oxygenase activity and hence prostaglandin production. We hypothesized that diclofenac would affect release of IL-6 and IL-10 and modulate the immune response. METHODS: In a randomized, double-blind, placebo-controlled study, we investigated the effect of diclofenac in patients undergoing major urological surgery. Patients were randomized to receive either diclofenac (50 mg orally every 8 h the day before surgery and 75 mg i.m. every 12 h on the day of surgery, n = 23) or placebo (n = 23). Standardized combined general anaesthesia and epidural analgesia was administered. Serum IL-6, IL-10 and cortisol were measured before surgery and 30 min and 2, 6, 12 and 24 h after skin incision. Temperature, leucocyte count and C-reactive protein concentration were measured before surgery and after 24 h. RESULTS: IL-6 and IL-10 concentrations increased, reaching peak levels at 12 and 6 h respectively in both groups. At 12 h, the IL-6 concentration was significantly lower in patients receiving diclofenac than in those receiving placebo (P = 0.003). In contrast, IL-10 concentration at 6 h was higher in diclofenac-treated patients (P = 0.008), and this was associated with less pyrexia (P = 0.03), a lower leucocyte count (P = 0.0002) and a lower C-reactive protein concentration (P = 0.0039). Serum cortisol concentration was similar in the two groups of patients until 24 h, when the concentration was lower in patients who received diclofenac (P = 0.002). Cortisol concentration correlated with IL-6 concentration at 24 h. CONCLUSIONS: Administration of diclofenac was associated with lower IL-6 and higher IL-10 concentrations, and lower leucocyte count, C-reactive protein concentration and temperature. Diclofenac may have an anti-inflammatory role in major surgery.

Folic acid supplementation on red kidney bean-induced diarrhoea and enteric bacterial translocation into mesenteric lymph nodes in rats: a pilot study.

UNLABELLED: Deaths following childhood diarrhoea, a major health problem in developing countries, are often associated with malnutrition and septicaemic complications. Folic acid has been used in the treatment of acute and chronic diarrhoea in the tropics. Using a rat model, we evaluated the protective effect of large doses of folic acid on diarrhoea, small intestinal bacterial overgrowth and translocation of enteric bacteria into mesenteric lymph nodes induced by a raw red kidney bean-based diet containing lectin (phytohemagglutinin). Long-Evans rats in 2 groups of 5 each (60 g to 70 g in weight, 28 d old) were used. All 10 rats, individually kept in metabolic cages, received a raw red kidney bean-based diet for 10 d, and 5 of them also received a daily folic acid supplement (160 microg/g feed) both during and for 10 d before the experiment. The faecal weight was measured and a quantitative aerobic bacterial culture of the small intestinal mucosal scrapings and of the mesenteric lymph nodes was made. Folic acid supplementation did not reduce faecal output nor did it prevent loss of body weight associated with lectin-induced diarrhoea. However, the mean total count of enteric bacteria translocated to the mesenteric lymph nodes was significantly reduced in the supplemented rats (1.27 +/- 0.61 vs 2.66 +/- 0.84, p = 0.028) and a trend towards reduced bacterial count in the small intestinal mucosal scrapings (0.40 +/- 0.89 vs 1.42 +/- 1.31, p = 0.16) was documented. A significant positive correlation was also seen between the bacterial count in the jejunal mucosal scrapings and in the mesenteric lymph nodes. CONCLUSION: Although large-dose folic acid supplementation did not prevent diarrhoea and malnutrition induced by a lectin-based diet, it substantially reduced the count of enteric bacteria translocated into the mesenteric lymph nodes and showed a trend towards a reduction in indigenous bacteria adhering to jejunal mucosa. These findings could be of relevance in the prevention of septicaemic complications following many clinical conditions, including diarrhoea with malnutrition in children known to have bacteraemic and septicaemic complications.

Simultaneous zinc and vitamin A supplementation in Bangladeshi children: randomised double blind controlled trial.

OBJECTIVE: To evaluate the effect of simultaneous zinc and vitamin A supplementation on diarrhoea and acute lower respiratory infections in children. STUDY DESIGN: Randomised double blind placebo controlled trial. SETTING: Urban slums of Dhaka, Bangladesh. PARTICIPANTS AND METHODS: 800 children aged 12-35 months were randomly assigned to one of four intervention groups: 20 mg zinc once daily for 14 days; 200 000 IU vitamin A, single dose on day 14; both zinc and vitamin A; placebo. The children were followed up once a week for six months, and morbidity information was collected. RESULTS: The incidence and prevalence of diarrhoea were lower in the zinc and vitamin A groups than in the placebo group. Zinc and vitamin A interaction had a rate ratio (95% confidence interval) of 0.79 (0.66 to 0.94) for the prevalence of persistent diarrhoea and 0.80 (0.67 to 0.95) for dysentery. Incidence (1.62; 1.16 to 2.25) and prevalence (2.07; 1.76 to 2.44) of acute lower respiratory infection were significantly higher in the zinc group than in the placebo group. The interaction term had rate ratios of 0.75 (0.46 to 1.20) for incidence and 0.58 (0.46 to 0.73) for prevalence of acute lower respiratory infection. CONCLUSIONS: Combined zinc and vitamin A synergistically reduced the prevalence of persistent diarrhoea and dysentery. Zinc was associated with a significant increase in acute lower respiratory infection, but this adverse effect was reduced by the interaction between zinc and vitamin A.

A randomized controlled clinical trial of zinc, vitamin A or both in undernourished children with persistent diarrhea in Bangladesh.

UNLABELLED: In a double-blind randomized controlled clinical trial, moderately malnourished Bangladeshi children (61-75% of the median weight/age) were studied for the effect of zinc and/or vitamin A supplementation on the clinical outcome of persistent diarrhea. Children 6 mo to 2 y of age with diarrhea for more than 14 d were randomly allocated into 4 groups of 24 receiving a multivitamin syrup and (i) zinc (20 mg elemental), (ii) vitamin A, (iii) both zinc and vitamin A, or (iv) neither, in 2 doses daily for 7 d. Clinical data on recovery and on stool output, consistency and frequency were recorded for 7 d, and weight change from day 1 to day 7 was assessed. The baseline characteristics of the four study groups were comparable. The mean daily stool outputs from days 2 to 7 of therapy were significantly less in the zinc and zinc plus vitamin A groups, but not in the vitamin A group, in comparison with the control group. In children receiving zinc, the cumulative stool weight in the 7 d was 39% less than in the control group (p < 0.001) and 32% less than in the vitamin A group (p = 0.006). The cumulative stool weight in the zinc plus vitamin A group was 24% less than in the control group (p < 0.001), but the 14% lower output than in the vitamin A group was not statistically different. The change in body weight over the 7 d study period was significantly different between the group receiving zinc and the control group (+111 g vs -90 g, p = 0.045). The rate of clinical recovery of children within 7 d was significantly greater in the zinc group (88%) compared with the control group (46%, p = 0.002) or vitamin A group (50%, p = 0.005), but not statistically different from the zinc plus vitamin A group (67%, p = 0.086). CONCLUSION: The results indicate that zinc, but not vitamin A, supplementation in persistent diarrhea reduces stool output, prevents weight loss and promotes earlier recovery.

Effect of an energy-dense diet on the clinical course of acute shigellosis in undernourished children.

To date there have been few reports on the impact of dietary intervention on the clinical course of acute shigellosis. Current management of acute shigellosis is primarily focused on antibiotic therapy with less emphasis on nutritional management. In a randomised clinical trial, we examined the role of an energy-dense diet on the clinical outcome in malnourished children with acute dysentery due to shigellosis. Seventy-five children aged 12--48 months with acute dysentery randomly received either a milk--cereal formula with an energy density of 4960 kJ/l (test group) or a milk-cereal formula with energy of 2480 kJ/l (control group) for 10 d in hospital. In both milk-cereal formulas, protein provided 11 % energy. In addition, the standard hospital diet was offered to all children and all children received an appropriate antibiotic for 5 d. The mean food intakes (g/kg per d) in the test and control groups were: 112 (SE 2.28) and 116 (SE 3.48) on day 1; 118 (SE 2.72) and 107 (SE 3.13) on day 5; 120 (SE 2.25) and 100 (SE 3.83) on day 10. The mean energy intakes (kJ/kg per d) in the test and control groups respectively were: 622 (SE 13.2) and 315 (SE 11.3) on day 1; 655 (SE 15.1) and 311 (SE 7.98) on day 5; 672 (SE 14.7) and 294 (SE 11.1) on day 10. The food and energy intakes were mostly from the milk-cereal diet. There was no difference between two groups in resolution of fever, dysenteric (bloody and or mucoid) stools, stool frequency and tenesmus. However, vomiting was more frequently observed among the test-group children during the first 5 d of intervention (67 % v. 41 %, There was an increase in the mean weight-for-age (%) in the test group compared with the control group after the 10 d of dietary intervention (6.2 (SE 0.6) v. 2.7 (SE 0.4), In addition, resolution of rectal prolapse was better (26 % v. 8 %, in the test group v. control group after 5 d, and 13 % v. 6 %, after 10 d of dietary intervention. Supplementation with a high-energy diet does not have any adverse effect on clinical course of acute shigellosis and reduces the incidence of rectal prolapse in malnourished children.

Simultaneous vitamin A administration at routine immunization contact enhances antibody response to diphtheria vaccine in infants younger than six months.

A randomized, double-blind, placebo-controlled trial was conducted to evaluate the effect of simultaneous vitamin A supplementation and diphtheria, pertussis and tetanus (DPT) vaccination on the antibody levels. Infants aged 6-17 wk (n = 56) were randomly given 15 mg oral vitamin A or placebo at the time of their DPT immunization. Three such doses were given at monthly intervals. Immunoglobulin (Ig) G antibodies to diphtheria, pertussis and tetanus were assayed on enrollment and 1 mo after the third dose. Baseline antibody concentrations to diphtheria, pertussis and tetanus did not differ between the vitamin A-supplemented and placebo-treated groups. The postdose antibody to diphtheria level was significantly greater in the vitamin A than in the placebo-treated group. The geometric mean +/- SEM antibody levels (mg/L) were 22.9 +/- 1.2 and 11.0 +/- 1.3 in the vitamin A and placebo groups, respectively (P = 0.029). The postsupplementation concentrations of antibodies to pertussis and tetanus did not differ between the two groups. These results suggest that antibody response to diphtheria vaccination was potentiated by simultaneous vitamin A administration and DPT immunization.