Indigenous child health: are we making progress?

We identified 244 relevant articles pertinent to indigenous health (4% of the total) with a steady increase in number since 1995. Most Australian publications in the journal (with a small Indigenous population) have focussed on conditions such as malnutrition, diarrhoeal disease, iron deficiency, rheumatic fever, acute glomerulonephritis and respiratory and ear infections, and in settings where nearly all affected children are Indigenous. In contrast, New Zealand publications (with a large Maori and Pacific Islander population) have addressed important health issues affecting all children but emphasised the over-representation of Maori and Pacific Islanders. Publications in the journal are largely descriptive studies with relatively few systematic reviews and randomised trials. Our review attempts to cover the important Indigenous health issues in our region as represented by articles published in the Journal. The studies do document definite improvements in indigenous child health over the last 50 years.

Efficacy of Lactobacillus GG in aboriginal children with acute diarrhoeal disease: a randomised clinical trial.

OBJECTIVE: The effectiveness of probiotic therapy for acute rotavirus infectious diarrhoea in an indigenous setting with bacterial/parasitic diarrhoea is unclear. In the present study, we assessed the efficacy of probiotics in Australian Aboriginal children in the Northern Territory admitted to hospital with diarrhoeal disease. PATIENTS AND METHODS: A randomised double-blind placebo-controlled study was conducted in Aboriginal children (ages 4 months-2 years), admitted to hospital with acute diarrhoeal disease (>3 loose stools per day). Children received either oral Lactobacillus GG (5 x 10(9) colony-forming units 3 times per day for 3 days; n = 33) or placebo (n = 31). Small intestinal functional capacity was assessed by the noninvasive 13C-sucrose breath test on days 1 and 4. RESULTS: Both groups showed mean improvement in the sucrose breath test after 4 days; however, there was no difference (mean, 95% confidence interval) between probiotic (2.9 [cumulative percentage of dose recovered at 90 minutes]; 1.7-4.2) and placebo (3.7; 2.3-5.2) groups. Probiotics did not change the duration of diarrhoea, total diarrhoea stools, or diarrhoea score compared with placebo. There was a significant (P < 0.05) difference in diarrhoea frequency on day 2 between probiotics (3.3 [loose stools]; 2.5-4.3) and placebo (4.7; 3.8-5.7) groups. CONCLUSIONS: Lactobacillus GG did not appear to enhance short-term recovery following acute diarrhoeal illness in this setting.

Enteric pathogens, intestinal permeability and nitric oxide production in acute gastroenteritis.

BACKGROUND: Aboriginal children hospitalized with diarrheal disease in northern Australia have high rates of acidosis, hypokalemia and osmotic diarrhea, as well as abnormal small bowel permeability and elevated nitric oxide (NO) production. METHODS: In a study of 291 diarrheal admissions and 84 controls, we examined the relationship of diarrheal severity outcomes with specific enteric pathogens. NO production was measured by urine nitrate plus nitrite excretion on a low nitrate diet, small bowel permeability by the lactulose:rhamnose ratio on a timed blood specimen and stool pathogens by standard microbiologic investigations and PCR. RESULTS: The addition of diagnostic tests for diarrheagenic Escherichia coli to standard stool microbiologic testing increased the rate of specific diagnoses from 53% to 75%, but with multiple pathogens isolated from 34%. The most frequently isolated pathogens from diarrheal patients were enteroaggregative E. coli (28.9%), rotavirus (26.5%), enteropathogenic E. coli (17.2%), Salmonella spp. (10.7%), Cryptosporidium parvum (7.2%) and Strongyloides stercoralis (7.2%). High geometric mean permeability ratios (95% confidence intervals) occurred with rotavirus (19.6; 15.3 to 25.1), enteroaggregative E. coli (21.2; 15.3 to 29.3) and Cryptosporidium (23.0; 15.1 to 35.1) compared with 9.4 (6.8 to 13.1) for no pathogens. NO production was highest for Cryptosporidium (3.7; 2.3 to 6.1) compared with 0.6 (0.4 to 1.1) for no pathogens. Multiple regression analysis revealed significant associations (P < 0.001) for rotavirus with acidosis and osmotic diarrhea, for Strongyloides with wasting and hypokalemia and for Cryptospoidium with severe and prolonged diarrhea. CONCLUSIONS: Cryptosporidium, Strongyloides, rotavirus and enteroaggregative E. coli are important contributors to the severe manifestations of acute gastroenteritis in Australian Aboriginal children.

Evaluation of an Australian indigenous housing programme: community level impact on crowding, infrastructure function and hygiene.

BACKGROUND AND AIM: Housing programmes in indigenous Australian communities have focused largely on achieving good standards of infrastructure function. The impact of this approach was assessed on three potentially important housing-related influences on child health at the community level: (1) crowding, (2) the functional state of the house infrastructure and (3) the hygienic condition of the houses. METHODS: A before-and-after study, including house infrastructure surveys and structured interviews with the main householder, was conducted in all homes of young children in 10 remote Australian indigenous communities. RESULTS: Compared with baseline, follow-up surveys showed (1) a small non-significant decrease in the mean number of people per bedroom in the house on the night before the survey (3.4, 95% CI 3.1 to 3.6 at baseline vs 3.2, 95% CI 2.9 to 3.4 at follow-up; natural logarithm transformed t test, t=1.3, p=0.102); (2) a marginally significant overall improvement in infrastructure function scores (Kruskal-Wallis test, χ(2)=3.9, p=0.047); and (3) no clear overall improvement in hygiene (Kruskal-Wallis test, χ(2)=0.3, p=0.605). CONCLUSION: Housing programmes of this scale that focus on the provision of infrastructure alone appear unlikely to lead to more hygienic general living environments, at least in this study context. A broader ecological approach to housing programmes delivered in these communities is needed if potential health benefits are to be maximised. This ecological approach would require a balanced programme of improving access to health hardware, hygiene promotion and creating a broader enabling environment in communities.

13C-sucrose breath test: novel use of a noninvasive biomarker of environmental gut health.

OBJECTIVE: Environmental enteropathy syndrome may compromise growth and predispose to infectious diseases in children in the developing world, including Australian Aboriginal children from remote communities of the Northern Territory. In this study, we described the use of a biomarker (13)C-sucrose breath test (SBT) to measure enterocyte sucrase activity as a marker of small intestinal villus integrity and function. METHODS: This was a hospital-based prospective case-control study of Aboriginal and non-Aboriginal children with and without acute diarrheal disease. Using the SBT, we compared 36 Aboriginal case subjects admitted to a hospital (18 diarrheal and 18 nondiarrheal disease), with 7 healthy non-Aboriginal control subjects. Intestinal permeability using the lactulose/rhamnose (L/R) ratio on a timed 90-minute blood test was performed simultaneously with the SBT. The SBT results are expressed as a cumulative percentage of the dose recovered at 90 minutes. RESULTS: Aboriginal children with acute diarrheal disease have a significantly decreased absorptive capacity, as determined by the SBT, with a mean of 1.9% compared with either Aboriginal children without diarrhea (4.1%) or non-Aboriginal (6.1%) control subjects. The mean L/R ratio in the diarrhea group was 31.8 compared with 11.4 in Aboriginal children without diarrhea. There was a significant inverse correlation between the SBT and the L/R ratio. CONCLUSIONS: The SBT was able to discriminate among Aboriginal children with diarrhea, asymptomatic Aboriginal children with an underlying environmental enteropathy, and healthy non-Aboriginal controls. This test provides a noninvasive, easy-to-use, integrated marker of the absorptive capacity and integrity of the small intestine and could be a valuable tool in evaluating the efficacy of interventions aimed at improving gut health.

Critical appraisal of the management of severe malnutrition: 1. Epidemiology and treatment guidelines.

Hospital case-fatality rates for severe malnutrition in the developing world remain high, particularly in Africa where they have not changed much over recent decades. In an effort to improve case management, WHO has developed treatment guidelines. The aim of this review is to critically appraise the evidence for the guidelines and review important recent advances in the management of severe malnutrition. We conclude that not only is the evidence base deficient, but also the external generalisability of even good-quality studies is seriously compromised by the great variability in clinical practice between regions and types of health facilities in the developing world, which is much greater than between developed countries. The diagnosis of severe wasting is complicated by the dramatic change in reference standards (from CDC/WHO 1978 to CDC 2000 in EpiNut) and also by difficulties in accurate measurement of length. Although following treatment guidelines has resulted in improved outcomes, there is evidence against the statement that case-fatality rates (particularly in African hospitals) can be reduced below 5% and that higher rates are proof of poor practice, because there is wide variation in severity of illness factors. The practice of prolonged hospital treatment of severe malnutrition until wasting and/or oedema has resolved is being replaced by shorter hospital stays combined with outpatient or community follow-up because of advances in dietary management outside of hospital.

Critical appraisal of the management of severe malnutrition: 3. Complications.

The high case-fatality of severe malnutrition is due to infections, dehydration, electrolyte disturbances and heart failure. We focus on the evidence about managing these complications of severe malnutrition. Signs of circulatory collapse in severely malnourished children should be treated with intravenous or bone marrow infusion of Ringer's lactate with additional dextrose and potassium at a rate 20-40 mL/kg fast with close monitoring of vital signs. Recommendations for slow or restricted fluids in the face of shock are unsafe, and hypotonic or maintenance solutions must be avoided to prevent hyponatraemia. However, the evidence that severely malnourished children do not tolerate excessive fluid administration is good, so caution must be exercised with regards to fluids in the initial phase of treatment. There is also good evidence that wide spectrum antibiotics need to be given empirically for severe malnutrition to prevent the otherwise unavoidable early mortality. There is a need for improved protocols for tuberculosis diagnosis, HIV management and treatment of infants under 6 months with severe malnutrition. The contribution of environmental enteropathy to poor growth and nutrition during the weaning period means that there should be more priority on improving environmental health, particularly better hygiene and less overcrowding. A T-cell mediated enteropathy contributes to growth failure and malnutrition, and it is related to environmental contamination of enteric organisms in the weaning period rather than allergic responses.

Critical appraisal of the management of severe malnutrition: 2. Dietary management.

In the dietary management of severe acute malnutrition in children, there is evidence to support the WHO Manual's protocol of cautious feeding of a low energy and protein formula with small frequent feeds in the initial phase of treatment, particularly in kwashiorkor. However, this initial milk diet (WHO F-75) might benefit from increasing the sulphur amino acid, phosphorus and potassium content and reducing the lactose content, but further studies are needed. Careful tube-feeding results in faster initial recovery and weight gain, but has a significant risk of aspiration in poorly supervised settings. Ready-to-use therapeutic food is an important recent advance in the dietary management of malnutrition in ambulatory settings, allowing more effective prevention programmes and earlier discharge from hospital where community follow-up is available. It should be included in future protocols. There is very good evidence on the use of micronutrients such as zinc, and preliminary evidence suggests that smaller doses of daily vitamin A are preferable to a single large dose on admission for severe malnutrition.

Critical appraisal of the management of severe malnutrition: 4. Implications for Aboriginal child health in northern Australia.

The main implications of this review for the treatment of malnourished Australian Aboriginal children in northern Australia are that the emphasis needs to change from hospital case management with enteral tube-feeding to improved community management with a focus on environmental health (e.g. housing, hygiene and overcrowding) and child care issues.

Small bowel intestinal permeability in Australian aboriginal children.

OBJECTIVE: To show that the severity of diarrheal disease in Aboriginal children in tropical Australia is a consequence of underlying small intestinal mucosal damage. STUDY DESIGN: A prospective study of 338 Aboriginal admissions compared to 37 non-Aboriginal children, both diarrhea cases and controls. Intestinal permeability was measured by lactulose-rhamnose (L/R) ratios on a timed 90-minute blood test. RESULTS: For diarrheal admissions, significantly more Aboriginal (vs. non-Aboriginal children) had hypokalemia (70 vs. 10%), acidosis (65 vs. 29%), moderate to severe dehydration (52 vs. 19%) and a longer mean length of stay (mean 8.9 vs. 3.9 days). Mean L/R ratios (95% confidence intervals) in Aboriginal children (diarrhea vs. controls) were 16.5 (14.6-18.7) vs. 4.5 (3.8-5.3) compared to 7.7 (4.4-13.3) vs. 2.5 (1.8-3.4), respectively, in non-Aboriginals. Abnormal permeability ratios (> 5.6) consistent with tropical-environmental enteropathy syndrome were found in 36% (27/75) of Aboriginal controls compared to none of the non-Aboriginal controls. On multiple regression, the factors associated with high L/R ratios were diarrheal severity ( < 0.001), acidosis ( = 0.007) and hypokalemia ( = 0.04). CONCLUSIONS: An underlying tropical-environmental enteropathy contributes to the severity of acute gastroenteritis in Aboriginal children. Diarrheal complications, such as acidosis, hypokalemia, and osmotic diarrhea are associated with high L/R ratios, reflecting greater small intestinal mucosal damage.