Nutritional status, exclusive breastfeeding and management of acute respiratory illness and diarrhea in the first 6 months of life in infants from two regions of Indonesia.

BACKGROUND: Infant morbidity and mortality rates remain high in Indonesia, with acute respiratory illnesses (ARI) and diarrhea the leading two health problems in children under 5 years. We aimed to describe the nutritional status, feeding practice and case management of ARI and diarrhea of infants from two regions of Indonesia during the first 6 months of life. METHODS: This study was an observational study conducted in parallel to an immunogenicity and efficacy trial of an oral rotavirus vaccine (RV3-BB) in the Klaten and Yogyakarta regions, Indonesia. Mothers were interviewed at 3 time points: within the first 6 days of their infant's life, and at 8-10 and 22-24 weeks of age. Questions asked included pregnancy history, infant nutritional status, feeding status and health of infants within up to 2 weeks prior to the assessment. RESULTS: Between February 2013 and January 2014, 233 mother-infant pairs were recruited. 60% (136/223) of infants were exclusively breastfed (EBF) until 6 months of age with the strongest support for EBF reported by mothers themselves 70% (101/223) and 25% (36/223) from their partners. At 6 months, 6% (14/223) of infants were underweight and severely underweight; 4% (8/ 223) wasted and severely wasted; and 12% (28/223) were stunted and severely stunted. Non-recommended medication use was high, with 54% (21/39) of infants with reported cough within 2 weeks of an assessment receiving cough medication, 70% (27 /39) an antihistamine, 26% (10/39) a mucolytic and 15% (6 /39) an oral bronchodilator. At age 22-24 week, infants with reported diarrhea within 2 weeks of an assessment had low use of oral rehydration solutions (ORS) (3/21;14%) and zinc therapy (2/ 21;10%). CONCLUSION: In this unique observational study, breastfeeding rates of 60% at 6 months were below the Indonesian national target of >75%. Adherence to WHO guidelines for management of ARI and diarrhea was poor, with high use of non-recommended cough medications and oral bronchodilators in the first 6 months of life and low use of ORS and zinc therapy. Ongoing education of primary health care workers and parents regarding management of common illness is needed in Indonesia.

Bacteria, parasitic agents and rotaviruses associated with acute diarrhoea in hospital in-patient Indonesian children.

Faeces from children (aged from one month to 12 years) with acute diarrhoea admitted to hospital in Yogyakarta, Indonesia, from June 1978 to June 1979, were examined for the presence of enteric pathogens. One or more recognized enteropathogens were identified in 56% of children. Rotaviruses were identified in 38% of all children. Toxigenic coliforms (predominantly Escherichia coli) were isolated from 12% of children. Salmonella sp. (6%), Shigella sp. (4%) and enteropathogenic parasites (predominantly Trichuris trichiura) from 3.5% of children. Mixed infections with two or more enteric pathogens were found in 7.6% of children. The incidence rate of each pathogen was correlated with age of the child, socio-economic level of the family and duration of breast feeding. Toxigenic coliforms were equally common in all age groups from both well-to-do and poor families. Enteropathogenic parasites appeared in increasing frequency with age. They were more common in artificially fed children and in children from families of low socio-economic level. The occurrence of multiple infection with mixtures of enteric pathogens increased with increasing age. Mixtures of parasites and other enteric pathogens only occurred in children with acute diarrhoea. These results provide baseline data about the relative importance of different enteropathogens in Indonesian children.

Maternal antibodies to rotavirus: could they interfere with live rotavirus vaccines in developing countries?

INTRODUCTION: Past experience with live oral vaccines including licensed rotavirus vaccines demonstrates a trend towards reduced vaccine efficacy in developing countries compared with developed countries. The reasons behind this disparity are not well understood. Transplacental transfer of maternal antibodies and breast milk ingestion may attenuate vaccine responses in infants in developing countries where rotavirus infections are endemic, and maternal antibody levels are high. We examined the prevalence and level of rotavirus antibody in maternal and cord serum, colostrum and breast milk in a developing country setting. METHODS: 100 mother-infant pairs were prospectively recruited from December 2008 to February 2009 at Dr. Sardjito Hospital, Yogyakarta, Indonesia. Maternal and cord sera were collected during delivery. Colostrum and transitional breast milk were collected between day 0-3 and day 7-10 postpartum respectively. Rotavirus-specific IgA and IgG were estimated for all specimens and virus neutralization assays were conducted on a subset of milk specimens. RESULTS: All maternal and cord serum samples were positive for rotavirus-specific IgG antibodies with a strong correlation between levels of rotavirus-specific IgG in mothers and levels transferred to infants in cord blood (r=0.86; p=0.001). 78% of colostrum and 67% of transitional breast milk specimens were positive for rotavirus-specific IgA. There was a median 4-fold decrease in rotavirus-specific IgA from colostrum to transitional breast milk. Neutralizing antibodies were present in 56% of colostrum specimens assayed (19/34) and in 41% of transitional milk specimens assayed (14/34). CONCLUSIONS: Maternal serum and breast milk antibodies to rotavirus are highly prevalent in a developing country setting. Evaluation of the impact of maternal anti-rotavirus serum and breast milk antibody upon vaccine immunogenicity would help to inform rotavirus vaccination strategies, especially in developing settings.

Feeding children with diarrhea.

PIP: This study was designed to test early and rapid feeding of children with diarrhea. The daily weight, the time to reach the normal diet or hospitalization duration, relapse, or prolongation of diarrhea were evaluated. The sample of 40 Indonesian babies with diarrhea was randomly divided into group A and Group B. The age range was from 4 to 24 months, and the body weight range was from 5.7 to 9.6 kg with 2 out of 40 cases malnourished and weighing less than 60% Harvard standard for age. Rehydration with intravenous fluid drip or glucose oral electrolyte solution was completed within 4-6 hours. Continued fluid losses were replaced. Refeeding was initiated immediately upon completion of rehydration. Group A refeeding followed the classic schedule to reintroduce foods slowly, starting with dilute formula and working up to a full diet in 9-11 days. Group B was scheduled to reach full strength formula by the 3rd day and normal diet in the 4th. The mean of daily weight gain of group A was 6 g per day and group B was 49 g per day. This was a highly significant difference. There was a clear association between calorie intake and daily weight gain, and this difference was significant. The mean of time to reach the normal diet or hospitalization time from group A was 10 days and group B was 5 days. This was a statistically significant difference. The duration of diarrhea in both groups was 3 days. Relapse of diarrhea occurred in 2 cases from group A and 1 case from group B. Those who were given rapid, early and adequate refeeding had a weight gain 8 times greater than the other group who followed the classic schedule of reintroducing foods slowly. Study findings indicate that rapid adequate calorie intake is acceptable for refeeding, showing no significant prolongation or relapse of diarrhea.^ieng

Epidemiology of rotavirus diarrhea in Yogyakarta, Indonesia, as revealed by electrophoresis of genome RNA.

Nine different electropherotypes of rotaviruses occurred among 85 children with rotavirus diarrhea in Yogyakarta, Indonesia. Eighty percent of the electropherotypes had a "long" RNA pattern characteristic of human subgroup 2.

Rotavirus serotypes causing acute diarrhoea in hospitalized children in Yogyakarta, Indonesia during 1978-1979.

Rotavirus strains in stool specimens from 111 children aged 3-24 months admitted to hospital in Yogyakarta, Indonesia for treatment of acute diarrhoea were serotyped using VP7 serotype specific monoclonal antibodies in a double sandwich enzyme immunoassay. A serotype could be assigned to 59 of 111 specimens (53%). Inability to assign a serotype to 47% of specimens was probably due to loss of the outer capsid during transport of specimens from Indonesia to Australia. All four major human rotavirus serotypes were detected during the 15 month survey from June 1978 to August 1979, including one serotype 1, 5 serotype 2, 31 serotype 3, and 21 serotype 4 strains. One additional strain reacted with serotype 3 and 4 Mabs. Serotype 3 strains showed intratypic variation. The relative frequency of serotypes 2, 3, and 4 varied during the 15 months and appeared to be influenced by climatic changes associated with dry and wet seasons. Vaccine strategies must take account of comparatively rapid changes of predominant serotypes in a community and are only likely to be successful if comprehensive immunity can be established simultaneously against the four major human serotypes.

Acute diarrhea and rotavirus infection in newborn babies and children in Yogyakarta, Indonesia, from June 1978 to June 1979.

A longitudinal study of acute diarrhea in children in Yogyakarta, Indonesia (June 1978 to June 1979), showed little variation throughout most months of the year in numbers of children admitted to hospital and in numbers infected with rotaviruses. Both decreased during November and December coincidentally with seasonal change from dry to wet conditions. Rotavirus particles were identified by electron microscopy in fecal specimens from 126 of 334 (38%) infants and children with acute diarrhea. Nosocomial rotavirus infections occurred in 11% of control children admitted to hospital for other reasons. Socioeconomic level and preexisting nutritional status did not influence the incidence of rotavirus excretion. Rotavirus infections were most common in children aged 6 to 24 months. There was a low incidence of infection in infants less than 6 months old. Rotavirus infection was seldom observed in newborn babies delivered in an urban hospital nursery, in a rural health center, or at home. One of 72 newborn babies with diarrhea excreted rotavirus. One of 53 healthy newborn babies excreted rotavirus. It is concluded that, in Indonesia, rotavirus infection is a major cause of childhood diarrhea throughout the year, but is an uncommon cause of diarrhea in newborn babies.