Randomised controlled trial of zinc supplementation in malnourished Bangladeshi children with acute diarrhoea

OBJECTIVE

To evaluate the impact of zinc supplementation on the clinical course, stool weight, duration of diarrhoea, changes in serum zinc, and body weight gain of children with acute diarrhoea.

DESIGN

Randomised double blind controlled trial. Children were assigned to receive zinc (20 mg elemental zinc per day) containing multivitamins or control group (zinc-free multivitamins) daily in three divided doses for two weeks.

SETTING

A diarrhoeal disease hospital in Dhaka, Bangladesh.

PATIENTS

111 children, 3 to 24 months old, below 76% median weight for age of the National Center for Health Statistics standard with acute diarrhoea. Children with severe infection and/or oedema were excluded.

MAIN OUTCOME MEASURES

Total diarrhoeal stool output, duration of diarrhoea, rate of weight gain, and changes in serum zinc levels after supplementation.

RESULTS

Stool output was 28% less and duration 14% shorter in the zinc supplemented group than placebo (p = 0.06). There were reductions in median total diarrhoeal stool output among zinc supplemented subjects who were shorter (less than 95% height for age), 239 v 326 g/kg (p < 0.04), and who had a lower initial serum zinc (< 14 mmol/l), 279 v 329 g/kg (p < 0.05); a shortening of mean time to recovery occurred (4.7 v 6.2 days, p < 0.04) in those with lower serum zinc. There was an increase in mean serum zinc in the zinc supplemented group (+2.4 v -0.3 mumol/l, p < 0.001) during two weeks of supplementation, and better mean weight gain (120 v 30 g, p < 0.03) at the time of discharge from hospital.

CONCLUSIONS

Zinc supplementation is a simple, acceptable, and affordable strategy which should be considered in the management of acute diarrhoea and in prevention of growth faltering in children specially those who are malnourished.

[Evaluation of the ambulatory treatment of acute diarrhea in infants. Réseau interhospitalier d'evaluation des pratigues médicales dans les affections courantes de l'enfant]

BACKGROUND

Gastroenteritis remains a common and expensive illness. Oral rehydration solutions (ORS) have been shown to be effective in the prevention and treatment of dehydration, the prime cause for diarrhea-related morbidity and mortality.

OBJECTIVE

To evaluate the ambulatory management of acute gastroenteritis in infants, and particularly practices concerning oral fluid therapy.

METHODS

This prospective, multicenter study included 326 infants (mean age: 10 +/- 6 months), examined in a hospital for acute gastroenteritis, with or without dehydration.

RESULTS

Before admission, 81% had previously been examined by a practitioner, and 89% of these practitioners had written a prescription. This prescription included ORS in 35% and was not different according to the age of the infant. Pediatricians prescribed ORS more frequently than general practitioners (respectively 58% vs 29%; P < 0.001). The failure rate of ORS prescription was 25% (two parents did not observe, ten children refused to drink, and eight stopped treatment because of vomiting). Lactose-free milks were prescribed in 46% of infants and the observance was 82%. At least one drug was prescribed in 94% of infants, with a mean of 2.6 drugs per infant; one antibiotic was prescribed in 33% of infants. Infants were admitted to hospital without any previous consultation in 18%, on the parents' initiative but after at least one previous medical examination in 52%, and on the physician's initiative in 30%. Thirty-three percent were dehydrated; one infant died and two had sequellae.

CONCLUSION

The use of ORS remains insufficient. Efforts to improve use of ORS should be expanded beyond physician education.

Grandma ahead of her time: traditional ways of diarrhoea management in Lesotho

The study was aimed at learning about home management of infant and young child diarrhoea in Lesotho. Focus groups and individual interviews were conducted with mothers, grandmothers and nurses during two phases of field work in three geographically different locations. It was found that home management of diarrhoea traditionally had emphasised feeding. While medical advice in the past recommended that, except for breast feeding, food should be withheld during diarrhoea, mothers, grandmothers and even nurses had been reluctant to follow this advice. Mothers and grandmothers saw feeding during diarrhoea as so essential that they would make special efforts to feed a child with diarrhoea. Since most foods contain protein and carbohydrates which stimulate intestinal fluid absorption, feeding during diarrhoea, besides maintaining nutrition, will help maintain hydration. When such beneficial feeding practices are protected and supported there is less need to promote new practices and less risk of producing harmful effects.

Factors determining recovery during nutritional therapy of persistent diarrhoea: the impact of diarrhoea severity and intercurrent infections

The recovery pattern and outcome were analysed in 261 consecutive children (age 6-36 months) with persistent diarrhoea who underwent inpatient nutritional rehabilitation with a rice-lentil (Khitchri) and yoghurt-based diet. Overall, 217 (83%) recovered successfully, as judged by a reduction in stool output and weight gain for a consecutive 3 d. Failures were more commonly febrile at admission [odds ratio (OR) 2.3, 95% confidence interval (CI) 1.1-4.8] and a greater number had culture-proven sepsis (Fisher's exact test, p < 0.001). Logistic regression analysis identified significantly increased risk of treatment failure with several admission characteristics, including stool frequency > 5 d(-1) (OR 2.9, 95% CI 1.6-5.2), vomiting (OR 2.5, 95% CI 1.1-5.7) and sepsis (OR 2.8, 95% CI 1.1-7.5). Survival analysis revealed significantly longer time-to-recovery among children with stool frequency > 5 d(-1) at admission (p < 0.001), suspected sepsis necessitating intravenous antibiotics (p < 0.001) or oral candidiasis (p < 0.05). These findings suggest that severity of diarrhoea and coexisting systemic infections are key determinants of the response to nutritional therapy in children with persistent diarrhoea.

[Acute diarrhea: stool water loss in hospitalized infants and its correlation with etiologic agents and lactose content in the diet]

Forty weaned male infants were studied during their first year of life, all hospitalized with acute diarrhea in the Gastroenterology and Metabolism Unit of the Hospital "Umberto I", São Paulo, SP, Brazil. We evaluated and quantified water fecal losses, employing the metabolic bed technique, relating the feeding formula employed with the different causal enteropathogenic agents. 67.5% of the studied infants were under six months and 40% under three months of age. Two groups were randomly assembled to receive, lactose or lactose free feeding formulae. Twenty one patients received a lactose-containing formula (Ninho 10%) and the other 19 children were fed caseine (Portagen) formulae. According to coproculture results and identification of enteropathogenic agents, we divided the studied infants relating feeding formula with the presence or absence of the enteropathogenic Escherichia coli (EPEC): I-13 with positive coproculture for EPEC and diets which included lactose--(L/EPEC+); II--eight with negative coproculture for EPEC and diets which included lactose--(L/EPEC-); III--seven with positive coproculture for EPEC and lactose free diets--(G/EPEC+); IV--12 with negative coproculture for EPEC and lactose free diets. (G/EPEC-). The most frequently isolated agent at coproculture was EPEC, in 20 of the cases (50%), followed by Campylobacter (7.5%). It was also possible to observe that the frequencies of EIEC, Salmonella and Rotavirus were all equal (2.5%). Mixed infections occurred only between EPEC and EIEC, registering a frequency of 5%. The EIEC samples, associated to EPEC 0111 were serotyped as 0 28 ac: H- and 0 152:H-. The use of metabolic bed made the evaluation of fecal volumes possible by a simple and quick technique, thus allowing a closer clinical monitoring, as well as a more reliable evaluation of the patients hospitalized with acute diarrhea. Average acceptance volumes of the formulae--either with or without lactose--were always below the amount recommended by FAO/WHO (100 kcal/day) which shows the impact of acute diarrhea on the decrease of food intake. The average volumes of watery fecal losses found among any of the studied subgroups may be considered quite relevant when compared to standard values. Especially within the L/EPEC+ group fecal losses, both on the first day (83.56 ml/kg/day) and, mainly, on the second (119.44 ml/kg/day) reached exceedingly high levels indicating a disastrous association between the presence of EPEC in the small intestine and lactose offer in the diet. Thus, the results show that there exists a positive and significant association between poor lactose absorption and the presence of EPEC in the feces. WHO's recommendation proposing the use of diluted cow milk, in universal and indiscriminate administration, in the two first days of the disease, may represent a risk factor, not only for malnutrition, but also for the survival rates of children with severe diarrhea, especially those under six months of age and hospitalized with EPEC enteroinfection.

A trial in the Karelian Republic of oral rehydration and Lactobacillus GG for treatment of acute diarrhoea

In a controlled trial in Petrozavodsk, Karelia, the effects of oral rehydration and Lactobacillus strain GG (LGG) on recovery from acute diarrhoea (27% rotavirus, 21% bacterial aetiology) were studied in 123 children aged between 1 and 36 months of age. On admission to hospital, the patients were first randomized to receive either isotonic oral rehydration solution (ORS) with osmolarity 311 mosmol/l and sodium 90 mmol/l (WHO-ORS), or a hypotonic ORS with osmolarity 224 mosmol/l and sodium 60 mmol/l (Light-ORS), and thereafter randomized to receive either 5 x 10(9) colony forming units of LGG or a matching placebo. The two ORS performed equally for acute rehydration, and oral rehydration with either ORS was associated with a shorter duration of diarrhoea than intravenous rehydration (p = 0.036). Patients receiving LGG had a significantly shorter duration of watery diarrhoea [mean (SD) 2.7 (2.2) days] than those receiving the placebo [3.7 (2.8) days, p = 0.03]. LGG significantly shortened the duration of rotavirus diarrhoea but not diarrhoea with confirmed bacterial aetiology.

Comparison of two regimens of feeding and oral electrolyte solutions in infants with diarrhea

BACKGROUND

Glucose-based oral rehydration solutions (ORS) available in the United States do not appear to reduce the severity or duration of diarrhea. The use of cereal-derived ORS and cereal-based feedings appears to diminish the severity of illness in studies conducted in the developing world. To our knowledge, no controlled trials of cereal-derived ORS or cereal-based feedings have been performed in the United States.

METHODS

We performed a randomized, double-blind trial of two ORS feeding regimens in outpatients with diarrhea. Patients aged 2-13 months with acute watery diarrhea were enrolled. Subjects received standard glucose-based ORS in alternation with soy-based, lactose-free infant formula (Group 1) or rice syrup solid containing ORS in alternation with rice-based, lactose-free infant formula (Group 2). Subjects were visited at home daily to determine the severity of illness and characteristics of the stool.

RESULTS

After the first 2 days, significantly more Group 1 subjects continued to have diarrhea than did Group 2 subjects (median duration of diarrhea 3 vs. 2 days) as demonstrated by Kaplan-Meier survival curves (p = 0.04).

CONCLUSION

We conclude that infants fed a regimen consisting of rice syrup solid containing ORS and rice formula resolved their diarrhea sooner than did infants fed a regimen of standard glucose-based ORS and formula. The relative contributions of ORS and formula to this more rapid recovery can be elucidated by further studies.

Lactobacillus reuteri as a therapeutic agent in acute diarrhea in young children

BACKGROUND

Certain strains of lactobacilli may promote recovery from acute diarrhea. Lactobacillus reuteri is of human origin and is a natural colonizer of gastrointestinal tract. In this trial, exogenously administered L. reuteri was studied as a therapeutic agent in acute diarrhea.

METHODS

Forty patients between 6 and 36 months of age hospitalized with acute diarrhea (75% rotavirus) were studied. After parental consent, the patients were randomized to one of two treatment groups to receive either 10(10) to 10(11) colony-forming units of L. reuteri or a matching placebo daily for the length of hospitalization or up to 5 days. The clinical outcome of diarrhea and colonization of L. reuteri were evaluated.

RESULTS

The mean (SD) duration of watery diarrhea after treatment was 1.7 (1.6) days in the L. reuteri group and 2.9 (2.3) days in the placebo group (p = 0.07). On the second day of treatment only 26% of patients receiving L. reuteri had watery diarrhea, compared with 81% of those receiving placebo (p = 0.0005). Cultures of lactobacilli from stool samples demonstrated that administration of L. reuteri resulted in colonization of the gastrointestinal tract. Lactobacillus reuteri accounted for > 75% of the total lactobacilli found in children fed with this product.

CONCLUSIONS

Lactobacillus reuteri is effective as a therapeutic agent in acute rotavirus diarrhea in children. Further studies are warranted to confirm the present finding and to explore the full therapeutic potential of L. reuteri in acute viral diarrhea.

Cross-cultural medicine and diverse health beliefs. Ethiopians abroad

A large number of Ethiopians reside abroad as refugees, immigrants, or students. To provide adequate care, physicians must understand their beliefs about health and medicine. To Ethiopians, health is an equilibrium between the body and the outside. Excess sun is believed to cause mitch ("sunstroke"), leading to skin disease. Blowing winds are thought to cause pain wherever they hit. Sexually transmitted disease is attributed to urinating under a full moon. People with buda, "evil eye," are said to be able to harm others by looking at them. Ethiopians often complain of rasehn, "my head" (often saying it burns); yazorehnyal, "spinning" (not a true vertigo); and libehn, "my heart" (usually indicating dyspepsia rather than a cardiac problem). Most Ethiopians have faith in traditional healers and procedures. In children, uvulectomy (to prevent presumed suffocation during pharyngitis in babies), the extraction of lower incisors (to prevent diarrhea), and the incision of eyelids (to prevent or cure conjunctivitis) are common. Circumcision is performed on almost all men and 90% of women. Ethiopians do bloodletting for moygnbagegn, a neurologic disease that includes fever and syncope. Chest pain is treated by cupping. Ethiopians often prefer injections to tablets. Bad news is usually given to families of patients and not the patients themselves. Zar is a form of spirit possession treated by a traditional healer negotiating with the alien spirit and giving gifts to the possessed patient. Health education must address Ethiopian concerns and customs.

Evaluation of doctors trained at Diarrhoea Training Unit of National Institute of Child Health, Karachi

Diarrhoeal diseases are a major contributory factor for high infant mortality and morbidity in Pakistan. To overcome this, Government of Pakistan launched a National Programme for Control of Diarrhoeal Disease. A Diarrhoea Training Unit (DTU) was established at the National Institute of Child Health, Karachi, where apart from proper case management, 17 training workshops were held between July, 1989 to July, 1991. Eighty-five doctors from various facilities in Sindh were trained in proper management of diarrhoea and establishment of Oral Rehydration Therapy (ORT) units in their regions. Evaluation of DTU training, assessment of the knowledge of trained doctors, case management and function of ORT Units were done between September, 1992 and October, 1993. Two teams each consisting of a doctor and a lady health visitor, visited 30 such facilities. An observation check list was used for assessing the ORT unit and diarrhoea case management and a test questionnaire for the knowledge of facility physician and paramedic. Of the 29 facilities, 17 had DTU trained doctors. ORT corner had been established in 26, weighing scales were used in 21, record keeping in eight and soap and water was available for hand washing in seven centres. The presence of untrained doctors provided an opportunity to compare the two groups. Dehydration assessment was fairly good, weight was recorded in fewer cases than desirable, case management was similar in the two groups, except for infrequent use of antibiotics by the trained group. Prevention was poorly advised. Physicians' knowledge in both groups was similar but deficient in advising the use of ORS, feeding in diarrhoea and nutritional assessment. The trained ones had significantly better knowledge about drugs and this was reflected in their case management. Paramedic case management were similar to those in doctors. The study thus showed positive and beneficial effects of training.

Acute diarrhea in under five-year-old children admitted to King Mongkut Prachomklao Hospital, Phetchaburi province

A prospective epidemiological and clinical study of acute diarrhea in children under 5 years old was done at King Mongkut Prachomklao Hospital in order to provide baseline data for health officers to make a strategic plan to reduce the diarrheal mortality and morbidity, which is one of the mid-decade goals for children. There were 105 cases of acute diarrhea patients admitted to the Pediatric ward between May 1995 and April 1996. Seventy-six per cent of them were in the younger age group (> 1 month-2 years old) while 23.8 per cent were in the older age group (2-5 years old). Causative pathogens were identified in 64 patients (61%). Younger patients had a higher percentage of identifiable pathogens (66.7%) than older patients (44.4%). Rotavirus was the most common pathogen isolated (17.2%). The other common pathogens identified were Eschericia coli (14.1%), Campylobacter jejuni (14.1%), Shigella (12.5%), Entamoeba histolytica (7.8%) and Salmonella (3.1%). Mixed infections were reported in 31.3 per cent of these patients. Clinical presentations and stool characteristics were difficult to distinguish from most of the pathogens. However, Rotavirus was highly suspected if a younger child presented with fever, watery to loose stool with the predominant symptom of vomiting. Mucous, mucous-bloody stool gave a clue to the diagnosis of Shigella and Entamoeba histolytica. Most cases had at least mild to moderate dehydration, so oral rehydration solution (ORS) was successfully given in only 31.4 per cent of patients. Antibiotics were prescribed to 51.4 per cent of patients in this study. Healthcare personnel should emphasize to parents and caretakers about good hygienic behavior to reduce the episodes of diarrhea and the use of ORS every time when their children have diarrheal episodes to reduce the disease severity.

[Evaluation of pediatric patients hospitalized for acute diarrhea from 1990 to 1996]

Infectious diarrhea is a common disorder in children in Italy, which may lead to hospitalization especially during infancy. In order to obtain data about epidemiology and clinic pictures of acute diarrhea, the carts of 1295 paediatric outpatients, hospitalized for this pathology in the time between 1990-1996 at the Children's Hospital "Meyer" of Florence, were analyzed. An offending organism could be isolate in 43.3% of patients; Rotaviruses are the leading cause of diarrhea, followed by salmonella spp. Furthermore the role of Campylobacter as common bacterial pathogen worldwide has been clarified.

A controlled trial comparing the efficacy of rice-based and hypotonic glucose oral rehydration solutions in infants and young children with gastroenteritis

A prospective randomized trial was conducted to compare the efficacy of a rice-based oral rehydration solution (ORS) with glucose ORS in infants and children under 5 years of age with acute diarrhoea and mild to moderate dehydration (< 10%). One hundred children presenting to a large metropolitan teaching hospital were eligible for entry to the study and were randomized to receive rice ORS or glucose ORS. Outcome measures were stool output (SO), duration of illness (DD) and recovery time to introduction of other fluids (RTF) and diet (RTD). Significant differences were found for all outcome measures in favour of the rice ORS group. Mean SO was lower (160 vs 213 mL; P < 0.02), mean DD was reduced (17.3 vs 24.3 h; P = 0.03) and median RTF was decreased (12.7 vs 18.1 h; P < 0.001) in the rice ORS group compared with the glucose ORS group. The median time to introduction of diet and mean length of hospital stay showed similar significant reductions. Our study has shown rice ORS to be an acceptable alternative to glucose ORS in young children and have shown that it is significantly more effective in reducing the course of diarrhoeal illness and the time taken to return to normal drinking and eating habits.

Mothers' health-seeking behaviour in acute diarrhoea in Tlaxcala, Mexico

This study, a cross-sectional survey, was conducted to assess how mothers take care of their children with diarrhoea and to develop a model of health-care seeking behaviour. Multistage sampling was used. Mothers whose children aged less than five years had suffered from diarrhoea in the last fortnight were included. Nurses interviewed the mothers to collect data. Variables included in the interview were: mothers' characteristics, children's characteristics, clinical data, treatment given by the mother, maternal health-seeking behaviour and mothers' information about diarrhoea and dehydration. Variables corresponding to the clinical data were grouped to identify dehydration signs and the need for medical care. Dehydration was defined as the presence of two or more of the following reported signs: thirst, sunken eyes, sunken fontanelle, or scanty urine. The need for medical care was defined as the presence of one or more of the following characteristics: illness lasting more than three days, vomiting, fever, bloody diarrhoea or dehydration. A sample of 747 mothers was obtained. Household treatments consisted of herbal teas to stop diarrhoea (52.3%), liquids to prevent dehydration (92.2%), symptomatic drugs (35.2%) and changes in feeding patterns (36.3%), which consisted in suppressing milk and dairy products and interrupting breast feeding (12.2%). Mothers sought medical assistance when they perceived a worsening of clinical conditions. Clinical signs statistically associated with their decision were: bloody diarrhoea, vomiting, illness longer than three days, weight loss, and fever. The signs of dehydration were not associated with health care-seeking because the mother did not recognise them. It is concluded that maternal educational programmes should emphasise, besides the proper use of oral rehydration therapy, teaching mothers to identify signs of dehydration as an indication to seek timely medical care.

Influence of location and staff knowledge on quality of retail pharmacy prescribing for childhood diarrhea in Kenya

BACKGROUND

Retail pharmacies are important sources of advice on pharmaceuticals in developing countries, where many purchasing decisions are unmediated by medical professionals. For childhood diarrhea, choice of drug sales in pharmacies has been found to be consistently poor, whether with or without prescription, as evidenced by a low use of effective oral rehydration salts (ORS) and high use of marginally effective or ineffective products such as antimotility agents, adsorbents, and antimicrobials. Little information is available about factors influencing prescribing by pharmacy personnel in these settings. This paper reports results of an analysis which examined the influence of rural versus urban location, neighborhood socio-economic status (SES), and clinical knowledge of pharmacy assistants on quality of prescribing in retail pharmacies in Kenya.

METHODS

Using WHO treatment guidelines, we measured quality of prescribing in childhood diarrhea as: (1) the proportion of client encounters in which ORS is prescribed (indicating higher quality practice); and (2) the proportion of visits in which an antidiarrheal product is prescribed (lower quality practice). We obtained data on prescribing in a simple case of childhood diarrhea using surrogate patient visits to 91 pharmacies located in the major urban area of Kenya (Nairobi) and four rural towns. Multivariate logistic regression was used to examine the association between pharmacy predictor variables and the quality of prescribing.

RESULTS

No consistent relationship was found between the clinical knowledge of pharmacy assistants and quality of prescribing. Controlling for number of products prescribed, gender of the assessor, and level of knowledge, multivariate analyses indicated that in comparison to rural pharmacies, the odds of prescribing ORS were significantly higher in pharmacies located in high SES (OR = 4.7; 95% CI = 1.4,16.1) or middle SES (OR = 4.5; CI = 1.9,10.6) urban neighborhoods; the odds in low SES urban pharmacies were similar to those in rural areas (OR = 2.0; CI = 0.6,6.2). The odds of prescribing antidiarrheal products did not differ significantly in any geographic area.

CONCLUSIONS

Location of a retail pharmacy in a rural area or in a low-income urban neighborhood was associated with suboptimal quality of prescribing as evidenced by lower use of ORS. No relationship between clinical knowledge and quality of practice was detected. Future research is needed to examine such factors as the influence of intra-pharmacy authority structure, perceived efficacy of pharmaceuticals, local patterns of physician practice, and economic incentives on the quality of prescribing.

Oral rehydration therapy--a dental perspective

Sugar-based Oral Rehydration Therapy (ORT) is still the conventional treatment for diarrhoeal diseases. The WHO/UNICEF, and other groups endorse and actively promote its use for all cases of diarrhoea. Despite the deleterious effects of sugars promotion on dental health, and the incontrovertible role of sugars as the major factor responsible for the present upsurge in dental caries prevalence in the developing countries, the search for an ideal Oral Rehydration Solution (ORS) has so far completely ignored any dental considerations. Of the presently available rehydration solutions, the cereal or food-based solutions offer greater advantages over the sugar based solutions. Further research efforts must be directed at non-sugar based ORT, and funding organisations should give support to researchers and research institutions working to replace sugars with cereal flours, improve food-based ORS, or develop novel approaches to ORT that are based on non-cariogenic ingredients. Policy makers, researchers and health care workers generally must always consider, in addition to other factors, the dental implications of their recommendations on ORT.

[Pathogenesis and intensive care of infants with toxic-dystrophic syndrome]

Eighty-two children with the toxic dystrophic syndrome coursing in the presence of acute enteric infection were examined. A number of pathogenetically significant disorders were revealed: salt-deficient exsicosis, exsication, hypopotassemia, anemia, hypoproteinemia, stable metabolic acidosis, protein and energy insufficiency. Among the causes of protein and energy insufficiency associated with progressive weight loss the principal were impaired cavitary digestion, decrease of the absorption capacity of the intestine for proteins, fats, and carbohydrates, and long inadequate nutrition because of protracted diarrhea. Newly developed three-staged intensive care protocol with correction of homeostasis, provision with energy and nutrients, and repair of cavitary digestion and absorption capacity of the intestine helped reduce the mortality in this patient population from 13.4 to 4.8%.

[Clinical assessment of a new oral bacterial treatment for children with acute diarrhea]

This study was carried out to evaluate the efficacy of a new oral bacteriotherapeutic drug in 63 children under 4 years old affected by infective diarrhoea or by extraintestinal infective pathology caused by oral antibiotic therapy. The patients were divided into three groups: the first and the second included subjects affected by acute diarrhoea enrolled in a comparative and controlled study; the third included subjects in chemotherapeutic treatment because suffering from infective extraintestinal pathologies, these patients were enrolled in a not controlled study. The first group underwent the rehydratant treatment for the acute enteritis together with the therapy with inactivated Lactobacillus acidophilus LB to value its antidiarrheic activity. To the second group (control group) was administered a no bacteriotherapeutic drug, while to the third group was administered the antibiotic therapy for extra-intestinal pathologies together with inactivated Lactobacillus acidophilus to avoid possible phenomena due to intestinal dysmicrobism. For all the patients included in the study, were reported; the number, the characteristics, the consistency of the motions and the description of the symptomatology during the treatment and daily. The greater part of the patients affected by the intestinal infective pathology subdued bacteriologic tests by coproculture. The obtained results showed a statistically significant clinical improvement of the first group patients compared with those of the second group, while those of the third group showed that the drug activity prevents the intestinal dysmicrobism affections due to the antibiotic therapy.

[Infections caused by enteropathogenic Escherichia coli]

Escherichia coli strains currently recognized to cause human diarrhea can be distinguished on the basis of pathogenic mechanism and separated into five categories: enterotoxigenic (ETEC), enteroinvasive (EIEC), enterohemorrhagic (EHEC), enteroaggregative (EAggEC) and enteropathogenic (EPEC). EPEC is a bacterial pathogen that causes diarrhea in infants, particularly in developing countries. The purpose of this review is to summarize recent advances in the understanding of EPEC pathogenesis and the contribution of Mexican investigators to the knowledge of this pathogen.

A lamb-meat-based formula for infants allergic to casein hydrolysate formulas

Ten infants with colitis due to milk protein allergy, presenting as hematochezia, whose symptoms did not resolve with the use of hydrolyzed cow-milk-based formulas, were treated with a modular lamb-meat-based formula (LOP). The patients were followed up for 3 months to 5 years. Prompt resolution of symptoms was achieved. In three patients, increased levels of creatinine and blood urea nitrogen and mild metabolic acidosis were noted, all returning to normal after the protein intake was lowered. All patients had normal growth. Seven patients were able to tolerate cow milk protein or soy at age 9-15 months. The LOP formula is well tolerated and is a safe alternative formula for infants allergic to cow milk hydrolysate formula.

Hypo-osmolar sucrose oral rehydration solutions in acute diarrhoea: a pilot study

Based on studies showing improved absorption of hypo-osmolar oral rehydration solutions (ORS) with reduced glucose and sodium concentration, a hypo-osmolar ORS with sucrose replacing glucose (sodium 60, potassium 15, chloride 60, citrate 5, sucrose 58 mmol l-1, calculated osmolality 198 mOsm kg-1) was compared with mildly hyperosmolar glucose ORS (WHO) in 46 children aged 6-30 months with acute diarrhoea and dehydration. In the hypo-osmolar sucrose ORS group (n = 18) faecal output was less by 30% during the initial 24 and 48 h compared with controls, suggesting better absorption. Sucrose may be a suitable alternative to glucose in an absorption-efficient hypo-osmolar ORS.

[Acute infectious diarrhea in children]

Diarrhoea is defined either clinically or pathophysiologically. Some epidemiological issues are considered in a global as well as in a national perspective. The main etiologies and pathophysiological mechanisms are referred. Some important natural defenses against intestinal infection are pointed out. Clinical manifestations are briefly described. The main therapeutical guidelines are discussed. Breast milk is referred to as one of the most important preventive measures against acute infectious diarrhoea.

Maternal perception of cause, signs and severity of diarrhoea in a suburban west African community

With the aim of investigating perceived morbidity and care seeking behaviour, a household survey was conducted, where 319 episodes of diarrhoea were followed by interviews every second day. The chance of consultation increased with the number of symptoms reported by the mother. The appearance of the eyes and how the child breastfed were early warnings that mothers recognized best. By contrast, there was an 80% reduction in the likelihood of seeking consultation when the mother perceived the diarrhoea as caused by teeth eruption (n = 96). Children with "teething diarrhoea" were, however, just as likely to develop signs of dehydration as children with non-teething diarrhoea. We conclude that health education concerning diarrhoea should emphasize early signs of dehydration and the discouragement of "teething" as an explanation of natural diarrhoea.

Oral IgA-IgG treatment of chronic non-specific diarrhoea in infants and children

The effect of orally administered immunoglobulin (IgAbulin) on chronic non-specific diarrhoea of infancy was studied in seven children, median age 26 (21-36) months and duration of diarrhoea 32 (18-84) weeks. Routine laboratory tests for malabsorption and small bowel biopsies were taken in all children before and after 3 weeks of IgAbulin treatment. The biopsy specimens were analysed with regard to histopathology, electronmicroscopy, immunohistochemistry and microbiology. The number of stools decreased from a median of 4.0 (3.0-5.0) to 1.5 (1.0 3.5) (p < 0.05) stools per day over the study period.

[Nosocomial rotavirus infections in children]

BACKGROUND

Worldwide rotaviruses cause in young children one third of diarrhoeal diseases which call for hospital admission. Rotaviruses are also considered the most frequent etiological agent of nosocomial diarrhoeal infections. The objective of the present work was an analysis of the etiology of diarrhoea and nosocomial infection, in particular of rotavirus etiology in children under three years of age.

METHODS AND RESULTS

In 1990-1994 a total of 2002 children under three years were admitted to hospital, incl. 1480 (73.9%) on account of diarrhoeal diseases. A rotavirus etiology was proved in 25.4%, adenovirus etiology in 3.3%. As to bacterial infections, salmonellosis was most frequent (24.4%), less frequent campylobacteriosis (8.4%), shigellosis (1.7%), colibacillary infection (1.3%) or yersiniosis (0.2%). In 36.4% cases of gastroenteritis the etiology was not elucidated. Nosocomial infection with rotaviruses was proved in 59 of 1480 patients with diarrhoea (4.0%) and in 4.5% of the total number of 2002 sick children resp. Nesocomial infection developed most frequently between the 4th and 6th day of hospitalization; the clinical picture is not very different, as a rule isoosmolal dehydration which in cca 50% called for parenteral rehydration. About three quarters of the patients have temporarily elevated aminotransferases. As far as the seasonal character of the disease is concerned, the highest incidence was recorded in the following months of the year: I, II, III, IV, X and XI. This two-phase rotaviral incidence of enteritis does, however, not correspond with the incidence of nosocomial infections. Symptomatic treatment is successful. The prognosis is favourable. Nosocomial rotavirus infection protracted hospitalization on average by five days.

CONCLUSIONS

Nosocomial rotavirus gastroenteritis is a serious problem in particular in departments with young children. So far we are unable to influence their occurrence. They are not seasonal, they do not have a different clinical picture or course. Luckily they have a favourable prognosis. However, they prolong the period of hospitalization.

Symptoms and perceived severity of illness as predictive of treatment for diarrhea in six Asian and African sites

This paper examines associations between symptoms, judgement of severity and treatments given for episodes of childhood diarrhea. Using data from ten large sample surveys conducted in six research sites in Asia and Africa, the paper addresses three main questions. One, to what extent are judgments of severity of diarrhea among young children a function of the symptoms observed during an episode of diarrhea? Two, what is the relative importance of symptoms observed vs judgments of severity in the treatments given for diarrhea? And three, what do the results imply for programs promoting the use of ORT for diarrhea? The study found that mothers, perception of severity of illness is linked most closely to three symptoms: vomiting, fever and lassitude. These symptoms are associated with (a) treating the child at all and (b) taking the child to a health facility. These conclusions take on particular significance since they are based on a comparison of ten data sets from six sites differing widely in population density, ecology, access to medical services, educational level and financial resources.

[The effect of energy density and viscosity of porridges on the energy intake of infants]

It has been known for at least 25 years that high energy density and low viscosity are desirable attributes of complementary foods. However, the effects of increasing energy density and reducing viscosity of gruels on infant energy intake have only been studied in the last 10 years. Works published between 1986 and 1992 were carried out with infants randomly selected in urban slums or rural areas in India and Tanzania. When gruels are given in a single meal, all of them showed higher energy intake with both high energy-dense and low viscosity gruels. But these studies do not give information about the effects of these gruels on daily energy intake from gruels and on total daily energy intake when they are given with feeding frequencies corresponding to traditional weaning practices. Works published since 1992 were conducted among infants suffering from or recovering from acute diarrhoea or severe malnutrition. A positive effect of increasing energy density of gruels was observed not only on energy intake from gruels but also on total energy intake. On the other hand, effectiveness of reducing viscosity was not clearly demonstrated. Further studies are required, particularly to identify the conditions for which high energy dense gruels prepared from bulk-reduced starchy staples are able to significantly improve infant energy intake.

Chronic diarrhea: causes, presentation, and management

Important inroads are being made into understanding the pathophysiology of diarrhea. Clear understanding of key mechanisms should suggest new approaches to combat disease. Exciting developments are occurring in terms of super-ORS solutions, particularly with the promise of short chained glucose polymers and glutamine. Perhaps the most important development is the prospect of a good rotavirus vaccine being available before the end of the decade. Chronic diarrhea seems to be on the increase globally, probably because of the success of ORS. The mechanisms that lead to mucosal injury are elusive, and therapy still largely supportive and empiric. Celiac disease continues to be a puzzle, because of the uncomfortable feeling that a majority of cases may be missed because of atypical presentations. The successful use of long term parenteral nutrition has allowed survival and better characterization of cases that otherwise would have perished as 'lethal protracted diarrhea'. Microvillus inclusion disease may be the commonest congenital secretory diarrhea. The role of the recently reported high prevalence of glucoamlase deficiency may be important. Lastly, attention to micronutrients, particularly low vitamin A and probably zinc may prove to be important in prevention and amelioration of diarrhea and growth failure.

[Educational intervention for preventing dehydration in diarrheal diseases in Tlapacoyan, Mexico]

OBJECTIVES

To deliver an educational intervention to teach mothers self-care measures to manage children's diarrhea and dehydration.

MATERIAL AND METHODS

A controlled community trial intervention was designed (with control group) consisting of 180 mothers of children aged under five. The study was conducted in the city of Tlapacoyan, Veracruz, Mexico. Differences were measured for 17 main concepts and compared between the experimental group and the control group. Comparisons before and after the intervention were controlled for mother's age, education and previous training.

RESULTS

All 17 concepts showed per cent changes that ranged between 30% and 100% for the intervention group, and between 13% to 41% for the control group. Chi square values were used to test statistical significance, to ensure that differences were due to the intervention and not to chance.

CONCLUSIONS

A multichannel educational intervention is a culturally sensitive intervention that shows better results than a face-to-face intervention. It should be used for those groups that are at high risk of death due to dehydration associated to diarrhea, even when oral rehydration salts are available.

[Urban-rural variations in medical care of children with diarrhea in Mexico]

OBJECTIVE

To study the urban and rural variations of medical care for acute diarrhea among children under five years old.

MATERIAL AND METHODS

Data from the 1993 Effective Household Treatment National Survey were analyzed. A number of 338 children from urban areas and 300 from rural areas were included in the study. Variables included were: household treatment, health-seeking behavior, mothers' previous training to manage acute diarrhea, use of oral rehydration salts (ORS) and availability of and access to health care.

RESULTS

Oral rehydration therapy (ORT) as part of the household treatment and feeding the regular diet were more frequently found in rural areas. Less than 50% of children received medical care in both settings. In urban areas most children were cared for by private physicians. About 30% of children needed medical care but they were not taken to medical facilities. Physicians in rural areas prescribed ORS more frequently, while those from urban areas prescribed medication and restrictive diets in a greater proportion. Physicians working in public facilities prescribed ORT in greater proportions than private ones. Mothers from rural areas had received more training to manage diarrhea but they had restricted access to medical care in comparison to mothers from urban areas.

CONCLUSIONS

It is necessary to improve health care education of urban populations, to increase access and coverage of health services in rural areas and to strength activities to improve the quality of medical care provided by private physicians and by those working in urban areas.

Chronic diarrhea and malabsorption

Diarrhea is one of the major causes of infant morbidity and mortality worldwide. Major advances in understanding the pathophysiology of chronic diarrhea and malabsorption have taken place during the past three decades. Analysis of absorptive and secretory functions of the intestine has provided some insight into the possible causes of diarrhea. This article summarizes some of the specific causes of malabsorptive diarrhea in infancy and childhood, with emphasis on pathophysiology and approaches to therapy.

Biotherapeutic agents. A neglected modality for the treatment and prevention of selected intestinal and vaginal infections

OBJECTIVE

To evaluate the potential of biotherapeutic agents (microorganisms with therapeutic properties) for the prevention and/or treatment of selected intestinal and vaginal infections.

DATA SOURCES

The MEDLINE database was searched for all relevant articles published between 1966 and September 1995. Search terms used were biotherapeutic agent, probiotic, Lactobacillus, Saccharomyces, Bifidobacterium, Candida, gastrointestinal- system, vaginitis, vaginosis-bacterial, and related terms. The bibliographies of obtained articles were also reviewed.

STUDY SELECTION AND DATA EXTRACTION

All placebo-controlled human studies on biotherapeutic agents were reviewed. English-language open trials, case series and reports, and animal studies were reviewed only if they were especially relevant to providing information on the potential efficacy, adverse effects, or mechanisms of action of these agents.

DATA SYNTHESIS

Placebo-controlled studies have shown that biotherapeutic agents have been used successfully to prevent antibiotic-associated diarrhea (Lactobacillus caseiGG, bifidobacterium longum, B longum with L acidophilus, and Saccharomyces boulardii), to prevent acute infantile diarrhea (Bifidobacterium bifidum with Streptococcus thermophilus), to treat recurrent Clostridium difficile disease (S boulardii), and to treat various other diarrheal illnesses (Enterococcus faecium SF68, L caseiGG, and S boulardii). There is also evidence for Lactobacillus acidophilus in the prevention of candidal vaginitis. Few adverse effects have been reported. However, many of the studies tested only small numbers of patients or volunteers.

CONCLUSIONS

There is now evidence that administration of selected microorganisms is beneficial in the prevention and treatment of certain intestinal and, possibly, treatment of vaginal infections. In an effort to decrease the reliance on antimicrobials, the time has come to carefully explore the therapeutic applications of biotherapeutic agents.

[Infantile diarrhea: knowledge and attitudes of mothers at a primary care center]

OBJECTIVE

To study the knowledge and attitudes of mothers at a health centre to babies' diarrhoea.

DESIGN

A crossover, observational and prospective study.

SETTING

Paediatrics clinic at a health centre in the city of Valencia.

PARTICIPANTS

142 mothers who attended the clinic of their own accord.

MEASUREMENTS AND MAIN RESULTS

The mothers themselves filled out a questionnaire on what diarrhoea was, its causes, hygiene measures to prevent it and their response when it appeared. 80.3% accurately defined diarrhoea. 94.4% recognised that micro-organisms were the cause. All mothers of unweaned babies not being breast-fed sterilised the feeding bottle adequately and had a proper water-supply. 89.4% said they washed correctly both hands and food before handling food. Although 89.4% knew they should give more liquid to their babies during diarrhoea, only 24.6% used an adequate oral rehydrating solution and 24.2% said they made their babies fast for long periods. Most said they would consult the doctor if their baby had diarrhoea (79.6%) and would go back to the doctor if they noticed complications (96.5%).

CONCLUSIONS

Mothers attending a health centre in Valencia had a good attitude to diarrhoea prevention. They often committed errors in oral rehydration and feeding of a baby with diarrhoea, which might cause problems. However their frequent attendance at the doctor's may help avoid these problems.

Comparison of oral rehydration solutions made with rice syrup solids or glucose in the treatment of acute diarrhea in infants

An oral electrolyte solution made with rice syrup solids was found to reduce fecal output more effectively than a comparable glucose-based solution in the early hours of treatment of infantile diarrhea. Administration of the rice syrup solids solution was also more effective in promoting absorption of fluid, sodium, and potassium. In some infants, the rapid, effective rehydration offered by this solution may prevent the need for hospitalization.

[Autoimmune enteropathy]

Autoimmune enteropathy was initially described in young male infants presenting as severe secretory diarrhea. The disease is characterized by an inflammatory reaction which may involve several organs (bowel, pancreas, thyroid, kidneys, liver) with the presence of various circulating antibodies. The disease may also be observed in older children and in females with usually less bowel involvement. In view of the autoimmune basis of the disease, treatment requires immunosuppressive agents in addition to parenteral nutrition.