Role of a probiotic (Saccharomyces boulardii) in management and prevention of diarrhoea.

AIM: To assess the efficacy and safety of Saccharomyces boulardii (S. boulardii) in acute watery diarrhoea and its role in reducing the frequency of episodes of diarrhoea in subsequent two months. METHODS: Children from 2 mo to 12 years of age, with acute diarrhoea were selected according to inclusion criteria and randomised in S. boulardii group (treated with ORS, nutritional support and S. boulardii, 250 mg bid) and in control group (treated with ORS and nutritional support only). Active treatment phase was 5 d and each child was followed for two months afterwards. Frequency and consistency of stools as well as safety of drug was assessed on every visit. A comparison of two groups was done in terms of number of diarrhoeal episode in subsequent two months. RESULTS: There were fifty patients in each group. Baseline characteristics such as mean age and the average frequency of stools were comparable in S. boulardii and control group at the time of inclusion in the trial. By d 3 it reduced to 2.7 and 4.2 stools per d respectively and by d 6 it reduced to 1.6 (S. boulardii Group) and 3.3 (control group). The duration of diarrhoea was 3.6 d in S. boulardii group whereas it was 4.8 d in control group (P = 0.001). In the following two months, S. boulardii group had a significantly lower frequency of 0.54 episodes as compared to 1.08 episodes in control group. The drug was well accepted and tolerated. There were no reports of the side effects during treatment period. CONCLUSION: S. boulardii significantly reduces the frequency and duration of acute diarrhoea. The consistency of stool also improves. The drug is well-tolerated.

Association between iron deficiency anemia and febrile seizures.

OBJECTIVE: To find the association between iron deficiency anemia and febrile convulsions among children presenting at the Aga Khan University Hospital, Karachi. DESIGN: Case control study. PLACE AND DURATION OF STUDY: Paediatric Department of the Aga Khan University Hospital, Karachi, from January 2001 to December 2001. PATIENTS AND METHODS: A total of 60 patients fulfilled the study criteria of febrile seizure or any febrile illness. These were divided into two groups with children having febrile seizures comprised the cases while those having only febrile illness with no seizures comprised the controls. Both groups had equal number of children matched for age and gender. Workup for seizures and iron deficiency anemia was done and data was analyzed using SPSS version 10. RESULTS: The mean age for cases (group A) was 22.97+/-9.52 months while that for controls (group B) was 22.77+/-11.33. There was also no significant difference in the gender distribution in the two groups. Iron deficiency anemia was significantly more frequent among the cases as compared to the controls as evident from parameters studied i.e. hemoglobin <10 g/dl (p-value= <0.000), hematocrit <30% (p= <0.01), MCV <70 fL (p=<0.002), MCH<24 pg (p= <0.001) and serum ferritin <10 ng/ml (p= <0.000). CONCLUSION: Plasma ferritin level was significantly lower in cases as compared to controls suggesting that iron deficient children are more prone to febrile seizures. A follow-up study of patients found to be iron-deficient at the time of a first febrile seizure to determine the incidence of subsequent febrile seizures after treatment for iron deficiency would be of great interest.

Profile of children with congenital adrenal hyperplasia--a hospital study.

OBJECTIVE: To collect baseline information on congenital adrenal hyperplasia (CAH) and to identify relevant issues specific to this disease in Pakistan. METHODS: A retrospective analysis of medical records of pediatric patients registered for serum 17 hydroxyprogesterone (17-OHP) measurement and documented to have CAH in the period 1987 to 1998 was carried out at The Aga Khan University, Karachi (AKU). The clinical notes were reviewed for documentation of CAH as the diagnosis. RESULTS: Of the 152 children registered for 17-OHP testing, sixty-three were diagnosed with CAH. Salt wasting, simple virilization and non-classical CAH was found in 40 (63%), 18 (29.0%) and 5 (8.0%) patients respectively. Twenty-one (33.9%) patients were incorrectly assigned sex and of these, 20 (32.2%) patients were females who were either considered males or just not assigned gender. Parental consanguinity was found in 33 (52.3%) cases. No case had a history of similar features in either parent but in 19 (30.6%) cases similar features were present in siblings. Sixteen cases (25.4%) had a history of sibling death in the neonatal period and 7 had a history of sibling death in infancy. Maternal obstetric histories identified 3 (4.8%) cases with a history of still birth(s) and 4 (6.4%) with a history of abortion(s). CONCLUSION: Children with CAH should be diagnosed early as a rational and judicious choice of sex assignment is a critical aspect of treatment. The high rate of consanguinity emphasized the need to establish the true incidence of the defect in Pakistani population.

Impact of socioeconomic conditions on perinatal mortality in Karachi.

OBJECTIVE: To study and compare the perinatal mortality (PNM) in hospitals located in various socio-economic areas of Karachi. DESIGN: A prospective review of all births was done from May 1996 to April 1997. Precoded proformas were provided to each hospital and the birth and details of each mother and baby delivered recorded. SETTING: All mothers and their newborn delivered during the time period mentioned. OUTCOME MEASURES: Comparison of PNM in hospitals located in various socio-economic areas of Karachi. RESULTS: A total of 4957 proformas were filled, 63.5% by doctors, 32% by LHVs, 2.9% by administrator and 2.3% by paramedics. Overall 92.3% mothers were housewives, less than 45% of the mothers received primary/secondary education; 42% mothers were of the age 21 to 25 years. More than 52.3% fathers were unskilled labourers. Only 27% mothers were booked while the rest were unbooked or came to deliver on walk in basis. Majority (62%) of the mothers had a > 37 week duration of pregnancy and 51% newborns were male and 49% female. Twenty three percent of the newborns weighed < 2500 grams, remaining weighed > 2500 grams but less than 4500 grams; 24.5% newborns died on day one of birth. The PNM per 1000 births in the high, middle and low socioeconomic hospital was 16.4 +/- 23.6, 24.9 +/- 51.20 and 80.4 +/- 177.78 respectively. A statistical significance (p < 0.0000) by the Chi-square for several proportions was seen between the high middle and low socioeconomic hospitals of Karachi. CONCLUSION: The present socioeconomic conditions will take some time to change. However, this study indicates that perinatal mortality rate may be changed by an improvement in antenatal care of the mother, hence the fetus.

Cefixime: an oral option for the treatment of multidrug-resistant enteric fever in children.

BACKGROUND: Enteric fever is a serious public health problem in Pakistan, where multidrug-resistant salmonellosis causes enteric fever with increased morbidity and mortality. Costly parenteral therapy and lack of an established safety profile for the use of quinolones in children necessitate evaluation of an oral treatment option. This study is meant to assess the efficacy, safety, and cost effectiveness of an oral third-generation cephalosporin (cefixime) in the treatment of multidrug-resistant enteric fever. METHODS: Between November 1993 and October 1994, 85 patients, 15 years of age or less, with culture-proven enteric fever were randomly assigned to two groups. Group A (n = 41) received cefixime at a dosage of 10 mg/kg to 12 mg/kg per day in two divided doses. Group B (n = 44) received chloramphenicol at a dosage of 100 mg/kg daily in four divided doses. Both groups were treated for 2 weeks. RESULTS: In group A, 95% (39/41) of the patients receiving cefixime responded favorably, whereas in group B, 30% (14/45) responded to chloramphenicol. The 31 patients not cured in group B were then successfully treated with cefixime. Overall, cefixime was well tolerated. Subsequent antibiogram data showed an overall multidrug-resistance rate of 78% (66/85). CONCLUSIONS: Cefixime is a safe, effective, and cheaper oral option for the treatment of multidrug-resistant enteric fever. Further studies are needed, however, to validate this observation.

Detection and management of pneumonia by community health workers--a community intervention study in Rehri village, Pakistan.

This community based, case management intervention study was done to assess the effectiveness of Community Health Workers (CHWs) in case detection and management of pneumonia in children under five years of age. Twenty-two volunteers (school teachers and students) were selected as CHWs from Rehri village, in Sindh, Pakistan and trained on World Health Organization (WHO) recommended National/Acute Respiratory Tract Infection (ARI) guidelines at the Department of Paediatrics, Dow Medical College, Civil Hospital, Karachi. The CHWs had no prior health education. The intervention was the use of CHWs to detect and manage pneumonia in children under five years of age in Rehri village. Two medical officers supervised the post-training activities of CHWs in the village during the study period. Between December, 1992 and May, 1993, 442 episodes of pneumonia (very severe disease 10, severe pneumonia 54 and simple pneumonia 378) were detected and managed by trained CHWs. The medical officers agreed with the CHWs for classification and treatment in 356 (81%) cases. This study suggests that in areas where there is a shortage of trained health care professionals, educated community members such as school teachers can be trained to detect and manage pneumonia in their community.

Rehabilitation of grade III protein energy malnutrition on out patients basis.

Malnutrition is an important yet preventable and curable cause of morbidity and mortality. One hundred and thirty-five children suffering from grade III Protein Energy Malnutrition (PEM) from a poor urban population of Karachi city were enrolled for rehabilitation by health education and growth monitoring as out patient. Of these, 89% showed satisfactory recovery during a mean follow-up period of 3.2 months. Mainstay of this study was simple health messages adapted according to local cultural practices in native language. This simple strategy can go a long way in prevention and treatment of PEM in all the developing countries.

Risk factors of persistent diarrhoea in children below five years of age.

Persistent diarrhoea has been identified as a major source of morbidity in the developing world. This study was conducted to evaluate the risk factors of persistent diarrhoea in children below five years of age. The data used is from a prospective analytical case control study carried out in the Department of Paediatrics, Dow Medical College and Civil Hospital, Karachi, during 1993-94. A total of 50 cases of persistent diarrhoea and 50 acute diarrhoeal controls (matched for age and sex) under 5 comprised the study subjects in this analysis. The maximum incidence of persistent diarrhoeal episodes occurred in children below one year of age. Male to female ratio was 3:2. The seasonal variation showed a peak incidence in summer rainy season. Risk factors for persistent diarrhoea recorded were young age, poor nutritional status, irrational use of antibiotics during acute diarrhoea, lack of exclusive breast feeding, incomplete vaccination, lack of tap water supply and sanitation facility at home and income < Rupees 2000/month of the earning members of the family. Thus, it is concluded that discouraging the irrational use of antibiotics and other drugs for the treatment of diarrhoea, promotion of breast feeding and Expanded Programme of Immunization (EPI), Standard Diarrhoea Case Management courses for doctors, medical students and paramedical staff and provision of safe drinking water and sanitation facility are important for the prevention of persistent diarrhoea.

Expanded programme of immunization in Karachi.

Immunization status of children and their mothers and reasons for their failure to be immunized were studied. The study lasted for two months, i.e., August and September, 1993 at the Paediatric Outpatient Department of Civil Hospital, Karachi. Three groups of patients were targeted. Six hundred and twenty-four children under 1 year of age, 955 children between the ages of 1 to 5 years and 1579 mothers were registered. These women were questioned regarding their immunization status and that of their children. In the group below 1 year of age, BCG, DPT and polio (3 doses) and measles were given to 75%, 35% and 23% respectively. Tetanus toxoid (2 doses) was given to 47% of their mothers. In the group of children between 1-5 years, BCG, DPT and polio 3 doses and measles were given to 84%, 63% and 58% respectively. Tetanus toxoid (2 doses) were given to 64% of their mothers. The main reasons for not vaccinating were lack of information and lack of motivation.

A change of Plasmodium species infecting children in Karachi over the last decade.

Febrile children of both sexes, aged between 0-15 years coming to the Civil Hospital over the last 12 years had their blood tested for malarial parasite. Five hundred and twenty-six slides positive for Plasmodium were analysed for species and stage identification. Of the total 59.3% children with malaria were between 5-15 years of age. Applying the test of proportion, Plasmodium vivax was the predominant species (P < 0.01) between 1981-1985 and plasmodium falciparum between 1986-1990. This trend persisted upto 1992. As malaria due to Plasmodium falciparum is more severe with multiple complications accurate and easier methods of its diagnosis are needed at primary health care level.

A traditional diet as part of oral rehydration therapy in severe acute diarrhoea in young children.

Recently, the role of feeding as treatment of acute diarrhoea has received increasing attention. To assess the efficacy of early feeding in acute diarrhoea, we conducted a randomised, clinical trial of a traditional legume-based weaning diet khitchri in boys 9 to 48 months old with moderate to severe dehydration. Khitchri is composed of rice and lentils cooked with cottonseed oil. Children were randomly allocated to 2 groups: group A received only WHO ORS but no food for the first 24 hours and then khitchri and half-strength cow's milk formula freely; group B received khitchri and the half-strength formula in addition to ORS after the initial rehydration period of 4 to 6 hours. The mean period of evaluation was 3 days. 69 patients were admitted into the study, 33 in group A and 36 in group B. The initial mean purging rate for the children was greater than 200 g/kg/day. Six children did not complete the study because they developed intercurrent infections or were removed by their parents for non-medical reasons. Of the 63 patients who were evaluated, 44 (70%) were successfully treated, 21 in group A and 23 in group B. There were no significant differences in the 2 groups in mean stool output, number of stools, or weight gain, although a trend toward earlier improvement was seen in group B. These data indicate that early feeding of khitchri and WHO/ORS may be as well tolerated as WHO/ORS alone in the first 24 hours treatment of severe acute diarrhoea in young children.

Efficacy of co-trimoxazole in infantile gastro-enteritis.

A comparative, randomized trial was carried out in 105 children, aged between 2 months and 2 years and who were suffering from acute gastro-enteritis, to assess the effectiveness of co-trimoxazole with that of streptomycin and neomycin. Patients were treated in hospital for 5 days or longer and received daily doses either of 50 mg/kg streptomycin or neomycin, or of 6 mg trimethoprim plus 30 mg sulphamethoxazole/kg. Clinical and bacteriological assessments of response to treatment showed that better results were achieved in the co-trimoxazole group, and the duration of illness was also shorter in this this group. In the 3 patients on neomycin and the 12 on streptomycin who did not respond clinically, symptoms were controlled in all of them within 2 to 3 days of being changed over to co-trimoxazole treatment.