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.

Zinc supplementation in the management of shigellosis in malnourished children in Bangladesh.

OBJECTIVE: To assess the impact of zinc supplementation on clinical recovery, weight gain and subsequent growth and morbidity in moderately malnourished children with shigellosis. DESIGN: A randomized, double-blind, controlled trial. SETTING: Dhaka hospital of ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh. SUBJECTS: Fifty-six moderately malnourished children, aged 12-59 months with culture-proven shigellosis. METHODS: Subjects were randomly allocated to receive zinc (20 mg/day elemental) in multivitamin syrup (intervention) or multivitamin syrup without zinc (control) in two equally divided doses daily for 2 weeks. All children received pivmecillinam in a dose of 15 mg/kg every 6 h for 5 days. After supplementation, children were followed in their respective homes every 2 weeks for 6 months. RESULTS: Children receiving zinc recovered from acute illness significantly faster than the control children (P<0.05). The medians time (days) to recovery and disappearances of blood and mucous were significantly 50% shorter in the zinc-supplemented group compared to the control group. The mean body weight of zinc supplemented children increased significantly from 8.8 kg on admission to 9.2 kg (P<0.01) at recovery, which was not observed in the control children (from 9.3 to 9.6 kg; P=0.12). During the 6-month follow-up period, zinc-supplemented children had significantly fewer mean episodes of diarrhoea compared to the control children (2.2 vs 3.3; P=0.03). CONCLUSION: Zinc supplementation significantly shortens the duration of acute shigellosis, promotes better weight gain during recovery and reduces diarrhoeal morbidity during the subsequent 6 months.

Day-care management of children with severe malnutrition in an urban health clinic in Dhaka, Bangladesh.

Management of severely malnourished children with associated complications relies on hospital-based treatment. Implementation of a standardized protocol at the Dhaka Hospital, ICDDR,B reduced case fatality approximately 50%. We developed and prospectively evaluated a day-care clinic approach that provided antibiotics, micronutrients and feeding during the day with continued care by parents at home at night as an alternative to hospitalization. Severely malnourished children aged 6-23 months denied admission to hospital were enrolled at Radda Clinic, Dhaka and received protocolized management with antibiotics, micronutrients and milk-based diet from 8:00 am to 5:00 pm each day, while mothers were educated on continuation of care at home. They were transitioned to the day-care nutrition rehabilitation (NR) unit of Radda Clinic following resolution of acute illness, received NR diet (Khichuri, halwa and milk-based) daily until children attained 80% weight-for-length. From February 2001 to November 2003, 264 children were enrolled; 52% were boys and 78%, 21% and 1% had marasmus, marasmus-kwashiorkor and kwashiorkor, respectively. Only 13% had severe malnutrition alone while 35% had pneumonia, 35% had diarrhea and 17% had both pneumonia and diarrhea. The mean (SD) duration of acute and NR phases were 8 (4) and 14 (13) days, respectively. Children gained weight [mean (SD) g/kg day] more rapidly during acute 10 (7) than NR phase 6 (5). Successful management was possible in 82% (95% CI 77-86%) children, 12% discontinued treatment and 6% referred to hospitals. Only one child died during NR phase. Severely malnourished children can be successfully managed at existing day-care clinics using a protocolized approach.

Milestones in endoscope design for minimally invasive urologic surgery: the sentinel role of a pioneer.

Endoscopically based techniques have revolutionized the entire field of surgical specialties over the past 50 years. Currently, minimal access surgery is commonplace for considerable segments of surgical procedures across specialty lines. Central to this revolution, and arguably foremost in its impact on the development of minimally invasive endoscopic surgery, was the development of the rod-lens optical system by Professor Harold H. Hopkins and the almost simultaneous development of the fiberoptic cold-light light source by Karl Storz. It was George Berci who acted as the catalyst in bringing these two men together in the early 1960s, and from that meeting ensued one of the most successful cooperations in the design of endoscopic equipment. Innovative surgeons quickly recognized the enormous potential of these inventions, and in this context, George Berci's work and vision provided the hallmark events leading to the clinical applications from which surgeons and their patients so greatly benefit currently. In urology, Berci's early work has been recognized as a sentinel event bringing endoscopic endoluminal surgery from the lower urinary tract (urethra, bladder, prostate) to the upper urinary tract (ureter, kidney), and eventually to extraluminal laparoendoscopic surgery. This work has been recognized by the Journal of Urology as a "milestone in urology" leading to the clinical application in the field of endoscopic surgery currently referred to as endourology. In this article, the current state-of-the-art urologic surgery for the management of stone disease, urologic tumors, and anatomic abnormalities is presented, which to a great extent has its roots in George Berci's contributions to the field of innovative endoscope design.

Extended-interval gentamicin administration in malnourished children.

Malnourished children have several physiologic abnormalities that can affect drug distribution and elimination. The aim of this study was to determine the efficacy, safety and pharmacokinetics of a once-daily dose of gentamicin compared with conventional thrice-daily dosing in malnourished children. To our knowledge, it has not been investigated in this population so far. A total of 310 malnourished children of either gender aged 6 months to 5 years with diarrhea and pneumonia were randomized to receive intramuscular gentamicin 5 mg/kg/day once-daily (OD) (n=148) or the same total daily amount given in three divided doses (TD) (n=162) in addition to ceftriaxone 75 mg/kg/day. After 48 h at steady state, gentamicin pharmacokinetics was assessed by fluorescence polarization immunoassay in a subgroup of 59 children and 43 children in the OD and TD groups, respectively. The groups were equivalent in baseline demographic, clinical and laboratory characteristics. Good and partial clinical responses occurred in 64 per cent vs. 54 per cent and 25 per cent vs. 27 per cent in the OD and the TD children, respectively (p=NS for both comparisons). Five patients in each treatment group died. Renal toxicity defined by change in serum creatinine was not observed in any patient from either group. In the OD group, mean+/-SD serum gentamicin concentrations at 1 (peak), 3, 5, 8, 23, and 24 (trough value) hours after the dose were 11.7+/-4.1, 4.4+/-1.2, 2.08+/-0.9, 1.01+/-0.6, 0.31+/-0.09 and 0.29+/-0.07 mg/l respectively. In the TD group, mean +/-SD serum gentamicin concentration at 1 hour (peak) was 4.7+/-1.8 mg/l and the trough concentration was 0.48+/-0.21 mg/l. In OD group, the gentamicin trough concentration was significantly lower (p<0.001) and the peak concentration was significantly higher (p<0.001) compared to TD group. The results of this study indicate that once-daily gentamicin is effective and safe in malnourished children. Widespread implementation of once-daily dosing in malnourished children is appropriate and will reduce number of intramuscular injections and hospital costs.

Low osmolar oral rehydration salts solution in the treatment of acute watery diarrhoea in neonates and young infants: a randomized, controlled clinical trial.

To compare the efficacy and safety of low osmolar oral rehydration salts solution (ORS-75) (mmol/L: Na+ 75, osmolarity 245) with that of World Health Organization-recommended ORS (ORS-90) (mmol/L: Na+ 90, osmolarity 311 ) in the treatment of acute watery diarrhoea in neonates and very young infants, a randomized double-blind, controlled clinical trial was carried out at the Clinical Research and Service Centre of ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh, during January 1998-December 1999. Infants, aged < or = 2 months, presenting with a history of watery diarrhoea of < or = 72 hours, with no or some dehydration and without any systemic illness, were randomly assigned to receive either ORS-75 or ORS-90 for the correction and subsequent prevention of dehydration. Infants were studied for a maximum of five days. Total stool output, stool frequency, and requirement for ORS were outcome measures. Serum electrolytes were measured at 24 hours after admission to monitor serum sodium imbalance. Seventy-three infants received ORS-75, and 71 received ORS-90. Both the groups were comparable in their baseline characteristics. Diarrhoea resolved within five days in 53% and 66% of infants receiving ORS-75 and ORS-90 respectively (p = 0.3). Total stool volume [median (inter-quartile range) 132 (65-280) vs 139 (70-259) g/kg, p = 0.9], during the study period, was not significantly different between the two groups. Total stool frequency [31 (16-51) vs 35 (16-53), p = 0.9] and total ORS intake [192 (96-374) vs 209 (134-317) mL/kg, p = 0.7] were similar between the groups. No infants developed late evidence of hypernatraemia, irrespective of treatment. The results of the study indicate that ORS-75 is as safe as standard ORS-90 in the treatment of acute watery diarrhoea in neonates and very young infants and is effective in correcting and preventing dehydration.

Intensive nutrition education with or without supplementary feeding improves the nutritional status of moderately-malnourished children in Bangladesh.

This prospective randomized trial was carried out to test the efficacy of a specific intervention for reducing the extent of their malnutrition and to change behaviour of mothers relating to child-feeding practices, care-giving, and health-seeking practices under the Bangladesh Integrated Nutrition Project (BINP). The study was conducted in rural Bangladesh among 282 moderately-malnourished (weight-for-age between 61% and 75% of median of the National Center for Health Statistics standard) children aged 6-24 months. Mothers of the first intervention group received intensive nutrition education (INE group) twice a week for three months. The second intervention group received the same nutrition education, and their children received additional supplementary feeding (INE+SF group). The comparison group received nutrition education from the community nutrition promoters twice a month according to the standard routine service of BINP. The children were observed for a further six months. After three months of interventions, a significantly higher proportion of children in the INE and INE+SF groups improved (37% and 47% respectively) from moderate to mild or normal nutrition compared to the comparison group (18%) (p < 0.001). At the end of six months of observation, the nutritional status of children in the intervention groups improved further from moderate to mild or normal nutrition compared to the comparison group (59% and 86% vs 30%, p < 0.0001). As the intensive nutrition education and supplementation given were highly effective, more children improved from moderate malnutrition to mild or normal nutritional status despite a higher incidence of morbidity. The frequency of child feeding and home-based complementary feeding improved significantly (p < 0.001) in both the intervention groups after three months of interventions and six months of observation. Body-weight gain was positively associated with age, length-for-age, weight-for-length, frequency of feeding of khichuri, egg, and potato (p < 0.05). Ability of mothers to identify malnutrition improved from 15% to 99% in the INE group and from 15% to 100% in the INE+SF group, but reduced from 24% to 21% in the comparison group. Use of separate feed pots, frequency of feeding, and cooking of additional complementary feeds improved significantly in the INE and INE+SF groups compared to the comparison group after three months of interventions and six months of observation. It can be concluded from the findings of the study that intensive nutrition education significantly improves the status of moderately-malnourished children with or without supplementary feeding.

Plesiomonas shigelloides-associated diarrhoea in Bangladeshi children: a hospital-based surveillance study.

Little is known about clinical and epidemiological features of Plesiomonas shigelloides-associated diarrhoea in children. We reviewed hospital-based surveillance records of 38 children with diarrhoea having P. shigelloides as the only pathogen isolated from their faecal specimen. Of those 38 children, 29 (76 per cent) were below 2 years of age and 28 (74 per cent) were male. Thirty-two (84 per cent) children presented with watery diarrhoea and six (16 per cent) had dysenteric stools. Vomiting was a feature in 27 (71 per cent) children and clinically significant dehydration was observed in nine (23 per cent) children. Fever was present in three (8 per cent) children and five (13 per cent) had diarrhoea 14 days. Thirty-three (87 per cent) children were successfully treated with ORS alone and only five (13 per cent) required intravenous fluid in addition to ORS. Plesiomonas shigelloides was isolated throughout the year. The findings may be of public health importance for creating awareness among physicians about the clinical profile and management strategy of P. shigelloides-associated diarrhoea in children.

Efficacy and tolerability of racecadotril in the treatment of cholera in adults: a double blind, randomised, controlled clinical trial.

BACKGROUND: The enkephalins, endogenous opiate substances, act as neurotransmitters along the entire digestive tract where they elicit intestinal antisecretory activity without affecting intestinal transit time or motility. Racecadotril, through inhibition of enkephalinase, reinforces the physiological activity of endogenous enkephalins and, therefore, shows intestinal antisecretory activity. AIM: We conducted the study to determine the role of racecadotril as an adjunct to the standard treatment of cholera in adults. METHODS: The study was a double blind, randomised, placebo controlled clinical trial involving 110 adult male cholera patients who received either racecadotril or placebo in addition to standard cholera treatment. The major outcome measures (stool output, oral rehydration solution (ORS) intake, requirements for unscheduled intravenous fluid infusion, and duration of diarrhoea) were compared between the groups. RESULTS: Of 110 patients enrolled, 54 received racecadotril and 56 received placebo. Admission clinical characteristics were comparable between the groups. There was no significant difference in (mean (SD)) total stool output (racecadotril v placebo 315 (228) v 280 (156) g/kg), total ORS intake (390 (264) v 369 (240) ml/kg), or duration of diarrhoea (35 (15) v 32 (13) hours) between the groups. Clinical success, defined as resolution of diarrhoea within 72 hours of initiation of study intervention, was similar in both groups (racecadotril v placebo 96% v 89%). The number of patients receiving unscheduled intravenous infusions was not significantly different between the groups (racecadotril v placebo 22% v 14%). No drug related adverse effect was noted. CONCLUSION: The study demonstrated that racecadotril therapy, although found to be safe, does not provide additional benefit in the treatment of severe cholera in adults.

Energy stress during pregnancy and lactation: consequences for maternal nutrition in rural Bangladesh.

OBJECTIVE: To assess the relationship of energy stress during pregnancy and lactation to maternal body stores in marginally nourished rural Bangladeshi women. SUBJECTS AND METHODS: Two-hundred and fifty-two women were followed from 5-7 months of pregnancy until 6 months postpartum. Energy intake was estimated during pregnancy and at 1, 3 and 6 month(s) postpartum using 24 h dietary recall. Body weight was measured on enrollment, another once or twice during pregnancy, and at 1, 3 and 6 month(s) postpartum. The weekly rates of pregnancy weight gain and postpartum weight changes were determined. Weight and length of the infants were measured at birth and at approximately 1, 3 and 6 month(s). RESULTS: Maternal energy intake at 5-7 months of gestation was 1464+/-416 kcal/day (mean+/-s.d.). Women gained a mean of 200 g/week or a total of 4 kg during the second half of pregnancy. An analysis of maternal weight showed no indication of accrual of fat stores during pregnancy. Dietary energy during lactation exceeded the intake during pregnancy by 248-354 kcal/day. Mothers lost an estimated average of 1 kg of weight during the first 6 months of lactation. The mean (+/-s.d.) birth weight was 2.55+/-0.38 kg, and the prevalence of low birth weight (<2500 g) was 48%. Infants exhibited some catch-up growth only during the first 3 months but overall growth during the first 6 months did not change from their relative status at birth when compared with NCHS reference. CONCLUSIONS: These rural Bangladeshi women failed to gain sufficient weight during the last half of pregnancy to maintain body weight during lactation when the energy demand is high. Poor growth of their primarily breastfed infants raises concern about the adequacy of lactation in this community.

Persistent diarrhoea: associated infection and response to a low lactose diet.

Children aged 4-23 months with persistent diarrhoea received a low lactose diet, multivitamins, minerals and antibiotics for infection. Sixty-one (57 per cent) children improved with low lactose diet while 46 (43 per cent) failed. Children who failed were younger (8.9 +/- 3.5 vs. 11.3 +/- 4.4 months), had higher initial purging rate (146 +/- 102 vs. 109 +/- 102 g/kg/day) and consumed more ORS (138 +/- 77 vs. 95 +/- 79 g/kg/day). A higher proportion of children in the failure group needed unscheduled intravenous fluid (48 vs. 20 per cent) and lost body weight (24 vs. 0 per cent). Single and multiple stool pathogen were isolated from 44 and 45 per cent cases, respectively. Diarrhoeagenic Escherichia coli (66 per cent) was the most common pathogen isolated. Half of all pathogens including Campylobacter, rotavirus, cholera and non-typhoidal Salmonella were nosocomially acquired. Sixty four per cent of children had extraintestinal infections including acute lower respiratory infection (50 per cent), urinary tract infection (29 per cent) and septicaemia (11 per cent). The presence of extraintestinal infections were significantly associated with failure. Overall, 91 per cent of children had either intestinal and/or extraintestinal infections.

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.

Local production of anti-vibrio cholerae mucosal antibody in reproductive tract tissues after cholera.

To investigate whether intestinal presentation of an antigen by Vibrio cholerae, a noninvasive organism, could induce an anatomically distant mucosal immune response in reproductive tract tissues, the endocervical immune responses of women in Bangladesh were evaluated after cholera. Endocervical secretions were analyzed for secretory IgA (sIgA) antibody against the B subunit of cholera toxin (CtxB) in 9 women with cholera and 8 women with diarrhea caused by neither V. cholerae nor heat labile enterotoxin-producing Escherichia coli. Women infected with V. cholerae developed significant sIgA anti-CtxB responses in endocervical samples (P< or =.02). Antibody subtype analysis of endocervical IgA was consistent with local mucosal production (P< or =.001). Women with cholera did not develop sIgA anti-CtxB responses in serum. The ability to generate specific mucosal immune responses in reproductive tract tissues after intestinal presentation of antigen could facilitate development of vaccines effective against reproductive tract pathogens.

Randomized controlled trial of the effect of zinc supplementation on the mental development of Bangladeshi infants.

BACKGROUND: Zinc deficiency is thought to be common in young children in developing countries and some data suggest that it may detrimentally affect children's development. OBJECTIVE: Our goal was to assess the effect of zinc supplementation on the developmental levels and behavior of Bangladeshi infants. DESIGN: This was a randomized, double-blind, controlled trial conducted in Dhaka, Bangladesh. Three hundred one infants aged 1 mo were randomly assigned to receive either 5 mg elemental Zn or placebo daily for 5 mo, and subsequent growth and morbidity were observed. For the present study, developmental levels were assessed in a subsample of 212 infants at 7 and 13 mo of age with use of the Bayley Scales of Infant Development, and the infants' behavior during the tests was observed. The children's social backgrounds, weights, and lengths were also recorded. RESULTS: The children's nutritional status was generally poor. The zinc-treated group had slightly lower scores on the mental development index of the Bayley Scales than did the placebo group (beta = 3.7, SE = 1.3, P < 0.005). This effect remained significant when nutritional status and social background were controlled for. No other significant differences between groups were noted. CONCLUSIONS: The mental development index scores of the zinc-treated group were slightly but significantly lower than those of the placebo group. This finding may have been due to micronutrient imbalance. Caution should be exercised when supplementing undernourished infants with a single micronutrient.

Clinical studies in persistent diarrhea: dietary management with green banana or pectin in Bangladeshi children.

BACKGROUND & AIMS: Because of the beneficial intestinal effects of dietary fibers, we have evaluated the therapeutic effects of green banana or pectin in children with persistent diarrhea. METHODS: In a double-blind trial, 62 boys, age 5-12 months, were randomly given a rice-based diet containing either 250 g/L of cooked green banana (n = 22) or 4 g/kg pectin (n = 19) or the rice-diet alone (control, n = 21), providing 54 kcal/dL daily for 7 days. Stool weight and consistency, frequency of vomiting and purging, and duration of illness were measured. RESULTS: Most children (60%) had no pathogens isolated from stools, 17% had rotavirus, 5% Vibrio cholerae, 4% Salmonella group B, and 11% had enterotoxigenic Escherichia coli infections. By day 3 posttreatment, significantly (P < 0.001) more children recovered from diarrhea receiving pectin or banana than controls (59%, 55%, and 15%, respectively). By day 4, these proportions correspondingly increased to 82%, 78%, and 23%, respectively, the study diet groups being significantly (P < 0.001) different than controls. Green banana and pectin significantly (P < 0.05) reduced amounts of stool, oral rehydration solution, intravenous fluid, and numbers of vomiting, and diarrheal duration. CONCLUSIONS: Green banana and pectin are useful in the dietary management of persistent diarrhea in hospitalized children and may also be useful to treat children at home.

Characteristics of children hospitalized with severe dehydration and persistent diarrhoea in Bangladesh.

The study analyzed data from a systematic sample of children, aged less than five years, who presented with persistent diarrhoea (diarrhoea of more than 14 days duration). It aims to differentiate (a) non-severe persistent diarrhoea (with no or mild dehydration) and (b) severe persistent diarrhoea (with moderate or severe dehydration), and to identify individual characteristics associated with severe persistent diarrhoea. In total, 7,505 patients, who represented a 4% systematic sample of the patient population, were seen during January 1993-December 1995. Of them, 297 (4%) presented with persistent diarrhoea. The male:female ratio was 2:1. Eighty-three percent of them had mild or no dehydration, and 17% had moderate or severe dehydration. Severe malnutrition of the study patients defined as weight-for-age z-score < -3, weight-for-length z-score < -3 and length-for-age z-score < -3 were 33.9%, 9.7%, and 22.7% respectively. Only 3% had oedematous malnutrition, and 11% had xerophthalmia. Factors independently associated with severe persistent diarrhoea by logistic regression analyses were: number of watery stool > 10 times during the last 24 hours prior to admission (OR, 10.0; CI, 1.2-87, p = 0.03), lower respiratory tract infection (OR, 111; CI, 4.2-2955, p = 0.004), and lack of mothers' education (OR, 7.8; CI, 1.4-41.9, p = 0.016) after controlling for confounders. Awareness and health education of mothers or caregivers and better case management during acute diarrhoeal episode might prevent the development of severe persistent diarrhoea in young children. In addition, children with severe persistent diarrhoea might need special attention to have adequate rehydration and control of extraintestinal infections, including respiratory tract infection.

Production of safe therapeutic feeds from contaminated water supplies.

We have assessed the effectiveness of using an osmotic sachet for safe rehydration of therapeutic milk from contaminated water supplies in a poor urban area of Bangladesh. 35 women were given sachets to hydrate in their homes and comparison of the hydration water and the reconstituted milk showed that the high bacterial contamination reported in the domestic water supply was removed by use of the sachet. The mean rehydration time was 4.5 h (range 3.4-5.5). This rehydration method could have a role in the preparation of therapeutic feeds where microbiological contamination of the environment is a serious problem and availability of adequate water is not a limiting factor.

Zinc supplementation during pregnancy and effects on growth and morbidity in low birthweight infants: a randomised placebo controlled trial.

BACKGROUND: Infant malnutrition and mortality rates are high in less-developed countries especially in low-birthweight infants. Zinc deficiency is also widely prevalent in these circumstances. We aimed to assess the effect of daily zinc supplements given to pregnant mothers on their infants' growth and morbidity. METHODS: We did a double-blind, placebo controlled, randomised trial in 199 and 221 Bangladeshi infants whose mothers took 30 mg daily elemental zinc or placebo, respectively, from 12 to 16 weeks' gestation until delivery. Infants were followed up until 6 months of age. We obtained data for morbidity every week by mothers' recall. Infants' anthropometric measurements were done every month, and their serum zinc was assessed at 1 and 6 months of age. FINDINGS: Infants of mothers who received zinc during pregnancy had at age 6 months reduced risks compared with those in the placebo group for acute diarrhoea (risk ratio 0.84; 95% CI 0.72-0.98), dysentery (0.36; 0.25-0.84), and impetigo (0.53; 0.34-0.82). These reductions were seen in low-birthweight infants but not in those with normal birthweight. There were no differences in infant growth or serum zinc concentrations between treatment groups. INTERPRETATION: Maternal zinc supplementation during pregnancy resulted in a reduction of the health risks in Bangladeshi low-birthweight infants, although this intervention did not improve birthweight. Whether zinc should be added to usual antenatal supplements in regions with high rates of low birthweight should be reviewed.