Aflatoxins and kwashiorkor: clinical studies in Sudanese children

Human Breast Milk Contamination with Aflatoxins, Impact on Children's Health, and Possible Control Means: A Review

Aflatoxins are natural toxicants produced mainly by species of the Aspergillus genus, which contaminate virtually all feeds and foods. Apart from their deleterious health effects on humans and animals, they can be secreted unmodified or carried over into the milk of lactating females, thereby posing health risks to suckling babies. Aflatoxin M1 (AFM1) is the major and most toxic aflatoxin type after aflatoxin B1 (AFB1). It contaminates human breast milk upon direct ingestion from dairy products or by carry-over from the parent molecule (AFB1), which is hydroxylated in the liver and possibly in the mammary glands by cytochrome oxidase enzymes and then excreted into breast milk as AFM1 during lactation via the mammary alveolar epithelial cells. This puts suckling infants and children fed on this milk at a high risk, especially that their detoxifying activities are still weak at this age essentially due to immature liver as the main organ responsible for the detoxification of xenobiotics. The occurrence of AFM1 at toxic levels in human breast milk and associated health conditions in nursing children is well documented, with developing countries being the most affected. Different studies have demonstrated that contamination of human breast milk with AFM1 represents a real public health issue, which should be promptly and properly addressed to reduce its incidence. To this end, different actions have been suggested, including a wider and proper implementation of regulatory measures, not only for breast milk but also for foods and feeds as the upstream sources for breast milk contamination with AFM1. The promotion of awareness of lactating mothers through the organization of training sessions and mass media disclosures before and after parturition is of a paramount importance for the success of any action. This is especially relevant that there are no possible control measures to ensure compliance of lactating mothers to specific regulatory measures, which can yet be appropriate for the expansion of breast milk banks in industrialized countries and emergence of breast milk sellers. This review attempted to revisit the public health issues raised by mother milk contamination with AFM1, which remains undermined despite the numerous relevant publications highlighting the needs to tackle its incidence as a protective measure for the children physical and mental health.

One-carbon metabolism in children with marasmus and kwashiorkor

BACKGROUND

Kwashiorkor is a childhood syndrome of edematous malnutrition. Its precise nutritional precipitants remain uncertain despite nine decades of study. Remarkably, kwashiorkor's disturbances resemble the effects of experimental diets that are deficient in one-carbon nutrients. This similarity suggests that kwashiorkor may represent a nutritionally mediated syndrome of acute one-carbon metabolism dysfunction. Here we report findings from a cross-sectional exploration of serum one-carbon metabolites in Malawian children.

METHODS

Blood was collected from children aged 12-60 months before nutritional rehabilitation: kwashiorkor (N = 94), marasmic-kwashiorkor (N = 43) marasmus (N = 118), moderate acute malnutrition (N = 56) and controls (N = 46). Serum concentrations of 16 one-carbon metabolites were quantified using LC/MS techniques, and then compared across participant groups.

FINDINGS

Twelve of 16 measured one-carbon metabolites differed significantly between participant groups. Measured outputs of one-carbon metabolism, asymmetric dimethylarginine (ADMA) and cysteine, were lower in marasmic-kwashiorkor (median µmol/L (± SD): 0·549 (± 0·217) P = 0·00045 & 90 (± 40) P < 0·0001, respectively) and kwashiorkor (0·557 (± 0·195) P < 0·0001 & 115 (± 50) P < 0·0001), relative to marasmus (0·698 (± 0·212) & 153 (± 42)). ADMA and cysteine were well correlated with methionine in both kwashiorkor and marasmic-kwashiorkor.

INTERPRETATION

Kwashiorkor and marasmic-kwashiorkor were distinguished by evidence of one-carbon metabolism dysfunction. Correlative observations suggest that methionine deficiency drives this dysfunction, which is implicated in the syndrome's pathogenesis. The hypothesis that kwashiorkor can be prevented by fortifying low quality diets with methionine, along with nutrients that support efficient methionine use, such as choline, requires further investigation.

FUNDING

The Hickey Family Foundation, the American College of Gastroenterology, the NICHD, and the USDA/ARS.

Aflatoxin M1 in Africa: Exposure Assessment, Regulations, and Prevention Strategies - A Review

Aflatoxins are the most harmful mycotoxins causing health problems to human and animal. Many acute aflatoxin outbreaks have been reported in Africa, especially in Kenya and Tanzania. When ingested, aflatoxin B1 is converted by hydroxylation in the liver into aflatoxin M1, which is excreted in milk of dairy females and in urine of exposed populations. This review aims to highlight the AFM1 studies carried out in African regions (North Africa, East Africa, West Africa, Central Africa, and Southern Africa), particularly AFM1 occurrence in milk and dairy products, and in human biological fluids (breast milk, serum, and urine) of the populations exposed. Strategies for AFM1 detoxification will be considered, as well as AFM1 regulations as compared to the legislation adopted worldwide and the assessment of AFM1 exposure of some African populations. Egypt, Kenya, and Nigeria have the highest number of investigations on AFM1 in the continent. Indeed, some reports showed that 100% of the samples analyzed exceeded the EU regulations (50 ng/kg), especially in Zimbabwe, Nigeria, Sudan, and Egypt. Furthermore, AFM1 levels up to 8,000, 6,999, 6,900, and 2040 ng/kg have been reported in milk from Egypt, Kenya, Sudan, and Nigeria, respectively. Data on AFM1 occurrence in human biological fluids have also shown that exposure of African populations is mainly due to milk intake and breastfeeding, with 85-100% of children being exposed to high levels. Food fermentation in Africa has been tried for AFM1 detoxification strategies. Few African countries have set regulations for AFM1 in milk and derivatives, generally similar to those of the Codex alimentarius, the US or the EU standards.

Aflatoxins in organs and biological samples from children affected by kwashiorkor, marasmus and marasmic-kwashiorkor: A scoping review

Originally, the kwashiorkor is a pathology justified by the low consumption of proteins and high carbohydrates in weaned children. However, today, it can appear due to multifactorial causes, one of the hypotheses being the presence of aflatoxins in foods consumed by the child population and detected in biological fluids. The objective of this work is to scoping review the presence of aflatoxins in kwashiorkor, marasmus and marasmic-kwashiorkor from organs and biological samples in children. Results reflected that the presence of aflatoxins in kwashiorkor is greater compared to marasmic-kwashiorkor and marasmus in the organs and biological samples analyzed. The relationship of this mycotoxin with the pathology shows that it can affect both genders, even up to 12 years, in addition they are detected in eight biological samples and organs, except in the spleen, and in ten African countries and in the Philippines. The appearance of this pathology has been associated in children when after weaning they consume foods with low protein content and rich in carbohydrates, but coincidentally coincides with foods where the growth of aflatoxigenic fungi is more prevalent, and even the presence of other fungi that can generate other mycotoxins, such as ochratoxin A and fumonisin B1.

Chronic and Acute Toxicities of Aflatoxins: Mechanisms of Action

There are presently more than 18 known aflatoxins most of which have been insufficiently studied for their incidence, health-risk, and mechanisms of toxicity to allow effective intervention and control means that would significantly and sustainably reduce their incidence and adverse effects on health and economy. Among these, aflatoxin B1 (AFB1) has been by far the most studied; yet, many aspects of the range and mechanisms of the diseases it causes remain to be elucidated. Its mutagenicity, tumorigenicity, and carcinogenicity-which are the best known-still suffer from limitations regarding the relative contribution of the oxidative stress and the reactive epoxide derivative (Aflatoxin-exo 8,9-epoxide) in the induction of the diseases, as well as its metabolic and synthesis pathways. Additionally, despite the well-established additive effects for carcinogenicity between AFB1 and other risk factors, e.g., hepatitis viruses B and C, and the hepatotoxic algal microcystins, the mechanisms of this synergy remain unclear. This study reviews the most recent advances in the field of the mechanisms of toxicity of aflatoxins and the adverse health effects that they cause in humans and animals.

Dietary mycotoxins exposure and child growth, immune system, morbidity, and mortality: a systematic literature review

The aim of this study was to systematically review associations between dietary mycotoxins exposure and child growth and morbidity of children aged 5 years or younger. Peer-reviewed literature was searched in MEDLINE, EMBASE, COCHRANE, CINAHL, Web of Science, and PsycINFO. Experimental and observational studies were considered. The exposures were dietary mycotoxins during pregnancy, lactation and childhood, and mycotoxins concentrations in the diet, breast milk, urine, and blood. From a total of 4869 references, 86 full-text papers were extracted of which 50 were included in this review. The methodological quality and risk of bias were evaluated and quality of the collective evidence was assessed using GRADE. Uncertainty remains whether mycotoxins exposure affects child growth, immunity and mortality and the overall quality of the evidence is very low. Overall however, we cannot rule out a possible association between dietary mycotoxins, in particular, AF and FUM and child malnutrition. Our analyses were limited by the reporting quality, difference in findings, heterogeneity of outcomes, mycotoxins detection methods, and the observational nature of most studies. Robust study designs with adequate sample size, use of validated biomarkers of exposure and assessment of co-occurrence of mycotoxins and their synergistic effects are required to provide the further evidence regarding a potential effect of dietary mycotoxins exposure on child growth and immunity.

Effectiveness of hermetic maize grain storage technology in limiting aflatoxin exposure in women and children from smallholder farming areas

The longitudinal study assessed the effectiveness of hermetic storage technology in limiting aflatoxin exposure among women aged 15-45 years and children under five years of age from households in selected smallholder farming areas of Zimbabwe. Exposure levels were determined by measuring aflatoxin M1 (AFM1) in urine samples from women and children every three months during the 2015/2016 storage season for nine months. After extraction and immunoaffinity column clean up, AFM1 was determined by high performance liquid chromatography. Generally, the proportion of AFM1 positive urine samples from women increased throughout the grain storage season from 5.4% (n=23) (geometric mean (GM) 1.62 μg/l) at harvest to 75% (n=315) (GM 48.35 μg/l) nine months later (range <limit of quantification (LOQ)-217.29 μg/l). In urine samples from children, AFM1 positive samples increased from 2.2% (n=4) (GM 0.78 μg/l) at harvest to 72.5% (n=98) (GM 22.81 μg/l) nine months later (range <LOQ- 135.00 μg/l). Urinary AFM1 was significantly higher in samples from participants using conventional storage (GM 62.28 μg/l; range <LOQ-217.29 μg/l) compared with samples from participants using hermetic technology (GM 31.95 μg/l; range <LOQ-157.71 μg/l. There was no significant difference in AFM1 concentrations in urine samples from participants consuming grain from metal silos and hermetic bags (P>0.05) hence the two technologies are equally effective in limiting exposure to aflatoxins in humans. The study concluded that aflatoxin exposure levels among women and children from small-holder farming areas increase throughout the postharvest season and the use of hermetic storage technology resulted in up to 33.2% decrease in frequency of detection and 48.7% decrease in levels of AFM1 compared to conventional storage technologies. Thus hermetic grain storage can be an effective technology recommended for limiting aflatoxin exposure in smallholder farming populations.

Aflatoxin exposure in Nigerian children with severe acute malnutrition

Aflatoxin exposure is an important public health concern in sub-Saharan Africa as well as parts of Latin America and Asia. In addition to hepatocellular carcinoma, chronic aflatoxin exposure is believed to play a role in childhood growth impairment. The most reliable biomarker of chronic aflatoxin exposure is the aflatoxin-albumin adduct, as measured by ELISA or isotope dilution mass spectrometry (IDMS). In this report, we have used high resolution LC-MS/MS with IDMS to quantitate AFB₁-lysine in an extremely vulnerable population of Nigerian children suffering from severe acute malnutrition. To increase the sensitivity and reliability of the analyses, a labelled AFB₁-¹³C₆¹⁵N₂-lysine internal standard was synthesized. AFB₁-lysine concentrations in this population ranged between 0.2 and 59.2 pg/mg albumin, with a median value of 2.6 pg/mg albumin. AFB₁-lysine concentrations were significantly higher in stunted children (median = 4.6 pg/mg) compared to non-stunted (1.2 pg/mg), as well as in children with severe acute malnutrition (4.3 pg/mg) compared to controls (0.8 pg/mg). The median concentrations were also higher in children with kwashiorkor (6.3 pg/mg) compared to those suffering from marasmus (0.9 pg/mg). This is the first report of the use of high-resolution mass spectrometry to quantitate AFB₁-lysine in humans.

Modelling the dynamics of toxicity associated with aflatoxins in foods and feeds

In this paper, we developed a mathematical model to describethe dynamics of Aflatoxins in plants, animals, and humans. Fourequilibrium points were found, and their stability analyses wereconducted using threshold quantities. If both are less than one, thestandardized toxic limit is not exceeded, while if both are greater thanone it is exceeded in both animals and humans. Standardized toxic limitis exceeded in a relevant host (animals or humans) when their respectivethreshold quantity is greater than one. Numerical simulations werecarried out to support the analytic results. The need to use experimentaldata in the model is also shown. This could ease satisfactoryharmonization of acceptable standards and facilitate international tradeof food and feeds.

Innovative technologies to manage aflatoxins in foods and feeds and the profitability of application - A review

Aflatoxins are mainly produced by certain strains of Aspergillus flavus, which are found in diverse agricultural crops. In many lower-income countries, aflatoxins pose serious public health issues since the occurrence of these toxins can be considerably common and even extreme. Aflatoxins can negatively affect health of livestock and poultry due to contaminated feeds. Additionally, they significantly limit the development of international trade as a result of strict regulation in high-value markets. Due to their high stability, aflatoxins are not only a problem during cropping, but also during storage, transport, processing, and handling steps. Consequently, innovative evidence-based technologies are urgently required to minimize aflatoxin exposure. Thus far, biological control has been developed as the most innovative potential technology of controlling aflatoxin contamination in crops, which uses competitive exclusion of toxigenic strains by non-toxigenic ones. This technology is commercially applied in groundnuts maize, cottonseed, and pistachios during pre-harvest stages. Some other effective technologies such as irradiation, ozone fumigation, chemical and biological control agents, and improved packaging materials can also minimize post-harvest aflatoxins contamination in agricultural products. However, integrated adoption of these pre- and post-harvest technologies is still required for sustainable solutions to reduce aflatoxins contamination, which enhances food security, alleviates malnutrition, and strengthens economic sustainability.

Interventions targeting child undernutrition in developing countries may be undermined by dietary exposure to aflatoxin

Child undernutrition, a form of malnutrition, is a major public health burden in developing countries. Supplementation interventions targeting the major micronutrient deficiencies have only reduced the burden of child undernutrition to a certain extent, indicating that there are other underlying determinants that need to be addressed. Aflatoxin exposure, which is also highly prevalent in developing countries, may be considered an aggravating factor for child undernutrition. Increasing evidence suggests that aflatoxin exposure can occur in any stage of life, including in utero through a trans-placental pathway and in early childhood (through contaminated weaning food and family food). Early life exposure to aflatoxin is associated with adverse effects on low birth weight, stunting, immune suppression, and the liver function damage. The mechanisms underlying impaired growth and aflatoxin exposure are still unclear but intestinal function damage, reduced immune function, and alteration in the insulin-like growth factor axis caused by the liver damage are the suggested hypotheses. Given the fact that both aflatoxin and child undernutrition are common in sub-Saharan Africa, effective interventions aimed at reducing undernutrition cannot be satisfactorily achieved until the interactive relationship between aflatoxin and child undernutrition is clearly understood, and an aflatoxin mitigation strategy takes effect in those vulnerable mothers and children.

Detection of trace aflatoxin M1 in human urine using a commercial ELISA followed by HPLC

Aflatoxin is a liver carcinogen, and rapid, inexpensive methods to detect its urinary biomarkers are needed. We used a commercial enzyme-linked immuno-sorbent assay (ELISA) for aflatoxin M1 in urine (Helica Biosystems) to test 52 Haitian samples. Using this ELISA, we detected traces above the limit of detection (0.2 ng/ml urine) but below the limit of quantitation (0.4 ng/ml) in 14 samples. Liquid chromatography of all 52 Haitian urine samples revealed that only 11 had quantifiable AFM1 (mean: 29.5 pg/ml, standard error: 10.8, range: 2.94-96.5 pg/ml). The Helica ELISA may have detected forms of aflatoxin other than AFM1 in the Haitian samples, or matrix enhancement may have affected results at low AFM1 concentrations. This ELISA may serve as an initial, qualitative indicator of aflatoxin exposure for epidemiological purposes. But this method's utility as a precise and specific indicator of AFM1 concentrations will require additional refinement and validation.

The molecular epidemiology of chronic aflatoxin driven impaired child growth

Aflatoxins are toxic secondary fungal metabolites that contaminate dietary staples in tropical regions; chronic high levels of exposure are common for many of the poorest populations. Observations in animals indicate that growth and/or food utilization are adversely affected by aflatoxins. This review highlights the development of validated exposure biomarkers and their use here to assess the role of aflatoxins in early life growth retardation. Aflatoxin exposure occurs in utero and continues in early infancy as weaning foods are introduced. Using aflatoxin-albumin exposure biomarkers, five major studies clearly demonstrate strong dose response relationships between exposure in utero and/or early infancy and growth retardation, identified by reduced birth weight and/or low HAZ and WAZ scores. The epidemiological studies include cross-sectional and longitudinal surveys, though aflatoxin reduction intervention studies are now required to further support these data and guide sustainable options to reduce the burden of exposure. The use of aflatoxin exposure biomarkers was essential in understanding the observational data reviewed and will likely be a critical monitor of the effectiveness of interventions to restrict aflatoxin exposure. Given that an estimated 4.5 billion individuals live in regions at risk of dietary contamination the public health concern cannot be over stated.

Aflatoxin M1in breast-milk of UAE women

A study was undertaken to determine whether breast-milk of mothers from the United Arab Emirates (UAE) contained aflatoxins. One hundred and forty lactating mothers, 55 who had delivered premature infants (<2500 g, </=37 wk gestational age) and 85 who had full-term infants, agreed to participate in the study. Breast-milk was collected during regular feeding of infants in the special care baby unit and postnatal wards using an electric breast pump and ten ml of milk was siphoned off into a zinc-free plastic container for analysis. Aflatoxin M(1) concentration in the breast-milk samples was measured by HPLC. Samples were collected between January 1999 and December 2000. Approximately 66% of the mothers were expatriates and 34% were UAE nationals. Babies' weight, postnatal age, sex, birthweight and gestational age, and mothers' nationality, age and parity were recorded. Overall, 92% of the breast-milk samples contained aflatoxin M(1). Both univariate and multivariate logistic regression analysis failed to show significant correlation between aflatoxin M(1) and gestational age, postnatal age, gender, nationality and clinical condition. Levels of lactose, protein and lipids did not correlate significantly with levels of aflatoxin M(1). The public should be educated about storing food and the hazards of aflatoxin ingestion to reduce the unacceptably frequent presence of aflatoxin in breast-milk.

Mycotoxins and child health: the need for health risk assessment

The occurrences of mycotoxins as food contaminants in different localities particularly in developing countries and the inevitable exposure of populations and children to these toxins with probable adverse outcomes need be scientifically and systematically assessed. Health risk assessment developed in the 1980s is separate from risk management, both with risk communication form the risk analysis framework adopted by the World Health Organization. The process contributes increasingly to policy development, public health decision making, the establishment of mycotoxin regulations and research planning. However, the exercise of the risk assessment structured approach is not simple and is faced up to lack of data, capable infrastructure facilities and need for trained personnel and resources. Furthermore, adopted methodologies need be developed focusing on child characteristics and health concerns.

The effects of aflatoxin B1 on the development of kwashiorkor in mice

Seventy Swiss albino mice (6-week-old male) were selected for the investigation into aflatoxin B1's role in the cause of kwashiorkor. The mice were divided randomly into four groups. They were grouped within each group by being fed either low or normal protein level diets supplemented with very small amounts of aflatoxin B1 (0.5 microg/day). The control groups were fed aflatoxin B1-free diets containing either normal or low protein levels. All groups were monitored for 7 weeks. The increase in body weight was found to be low in groups I and II, given diets contaminated with aflatoxin B1. Although groups II and IV, which were given low dietary protein, showed remarkable decreases in serum total protein and albumin levels (group II: total protein 4.1 +/- 0.1 g/dL, albumin 2.6 +/- 0.8 g/dL and group IV: total protein 4.6 +/- 1.3 g/dL, albumin 2.8 +/- 0.82 g/dL) when compared with the groups fed a normal dietary protein level (group I: total protein 5.9 +/- 1.3g/dL, albumin 3.4 +/- 0.7g/dL and group III: total protein 5.4 +/- 1.6g/dL, albumin 3.5 +/- 1.2g/dL; P < 0.05). The statistical difference between these two groups was found not to be significant (P > 0.05). However, decreases in total protein and albumin levels were a little more prominent in group II. In addition, histopatological changes of the liver was remarkable in the group fed a low protein diet and aflatoxin B1 when compared with the group fed only a low protein diet and no aflatoxin B1. More significantly, however, was the increase in liver weight in both groups fed a low protein diet (groups II and IV). Our conclusion is that aflatoxin B1 could not have contributed to the development of kwashiorkor.

Seasonal variation in exposure frequency and concentration levels of aflatoxins and ochratoxins in urine samples of boys and girls

Urine samples from children in Sierra Leone (134 boys and 110 girls), were collected during the dry season. During the rainy season samples were collected from 97 boys and 93 girls. Analysis of the dry season samples, revealed that, with the exception of one boy, all children had detectable amounts of aflatoxins and/or ochratoxins in their urine. Similarly, with the exception of four children (two from each sex), rainy season urine samples also contained these two mycotoxins. There were significant differences in the frequency of exposure to some mycotoxins: ochratoxin A (OTA), p < 0.01; 4-hydroxyochratoxin A (4R-OTA), p < 0.002; aflatoxin M1 (AFM 1), p < 0.04; aflatoxicol (AFL), p < 0.03; aflatoxin B2 (AFB2), p < 0.04. There were also significant differences in the levels of aflatoxin B1 (AFB1), (p < 0.05) and AFB2, (p < 0.02) detected in dry season samples. Stratification of these results according to season and sex, has indicated significant differences with respect to 4R-OTA (p < 0.04) and AFB1 (p < 0.02). The results of this study show that in Sierra Leone, children are frequently and constantly exposed to both aflatoxins and ochratoxins.

Aflatoxin: is it a neglected threat for formula-fed infants?

In the present study, the risk of exposure to aflatoxin in infants fed breast milk and formula was investigated. For this purpose, aflatoxin B1 (AFB1) was determined in the serum of both breast-fed and formula-fed infants. Serum AFB1 positivity was significantly higher in the formula-feeding (F) group than the breast-feeding (B) group (42.8 vs 8.5%, P < 0.01). The AFB1 concentration in different commercial formulas was also determined. Aflatoxin B1 was found in seven of the eight newly opened packages of different brands of formula. The concentrations showed a statistically significant increase at the 30th day after opening the packages (P < 0.01). Although AFB1 concentrations in the formulas were found to be within acceptable limits for most countries, still, its existence must be carefully evaluated because future influences of very small amounts of aflatoxin on the growing organism have not been fully elucidated. Therefore, it was again concluded that for infants, human milk is safer than commercial formulas because of the lower contamination risk of aflatoxin. Also, commercial formulas must be regularly examined by authorities for the possible risk of aflatoxin contamination.

Exposure of infants to aflatoxin M1 from mothers' breast milk in Abu Dhabi, UAE

During a survey of the occurrence of aflatoxins in mothers' breast milk carried out in Abu Dhabi, involving 445 donors at the Cornich Hospital and the Al Nehyan Clinic for Maternity and Childhood, 99.5% of samples were found to contain aflatoxin M1 at concentrations ranging from 2 pg ml-1 to 3 ng ml-1. The mothers represented a wide range of nationalities, ages and health status and the opportunity was used to seek any correlation between these factors and the concentration of aflatoxin M1 in breast milk. The protein, fat and lactose contents of milk samples were also determined and the possibility of any correlation between any of these and aflatoxin M1 was studied.

Aflatoxin, kwashiorkor, and morbidity

Children suffering from kwashiorkor could be grouped as those in whom aflatoxin was detectable in both serum and urine, and those in whom this mycotoxin was undetectable. Examination of the clinical records of the aflatoxin-positive and -negative children (58% and 42% of the sample, respectively) showed several other differences between the two groups. Compared with the aflatoxin-negative group, the children scored as aflatoxin-positive showed a significantly lower haemoglobin level (P = 0.02), a longer duration of oedema (P = 0.057), an increased number of infections (P = 0.037), and a longer duration of hospital stay (P = 0.008). The present findings suggest that the consumption of a staple food such as maize that is contaminated with the fungus Aspergillus flavus exposes susceptible kwashiorkor children to the metabolic hazards of aflatoxins, resulting in a greater risk of frequent infections.

Foetal and neonatal exposure to aflatoxins

Studies on 125 primigravidae in rural Kenya revealed aflatoxins in the blood of 54 prenatally. At delivery re-examination of 34 showed aflatoxins in 12 previously negative. The overall detection rate was 53%. Blood from additional 59 women collected at delivery showed aflatoxins in 53%. Aflatoxins were detected in 37% of 101 cord bloods. There was no relationship between aflatoxins in maternal and cord bloods. The frequency of detection was significantly higher in maternal and cord bloods during the 'wet' than 'dry' months. The mean birth weights of females born to aflatoxin positive mothers was significantly lower (255 g) than those born to aflatoxin free mothers. Two stillbirths were recorded, in both cases maternal and cord blood showed aflatoxins. These findings and the adverse effects of prenatal aflatoxin exposure recorded in animal experiments indicate the need for further study of the effects of aflatoxins on the human foetus and newborn.

Protein-energy malnutrition in northern Sudan: prevalence, socio-economic factors and family background

The socio-economic and family background and the nutrition of 145 children with kwashiorkor admitted to hospital in Khartoum over a 2-year period were compared with 113 marasmic kwashiorkor, 158 marasmic, and 186 nutritionally normal controls of similar age. Peak admissions for kwashiorkor were in the wet and post-wet season and the mean (SD) age was 1.6 (0.6) months. Mothers of malnourished children were more likely to be pregnant, and had poorer housing, sanitation and water supply, a lower income and food expenditure and less education than controls. Mothers of controls breastfed their children longer, introduced mixed feeding earlier, offered a wider variety of foods, and were more likely to have had their infants immunized. Neither family instability nor cultural practices which result in separation of children from their mothers appear to have an important role in protein-energy malnutrition in the Sudan. Families of kwashiorkor children had a higher food expenditure and better maternal education than marasmic children. There was no significant difference between the two groups in duration of breastfeeding or in the age of introduction of mixed diet. However, kwashiorkor children appeared to be offered more meat. Differences in food availability could account for the relative retardation of growth and lack of subcutaneous fat in marasmus compared to kwashiorkor.

Aflatoxins and kwashiorkor in Kenya: a hospital based study in a rural area of Kenya

Aflatoxin analyses were undertaken on sera and urines of 41 children admitted to a rural hospital in Kenya with kwashiorkor, marasmus, marasmic kwashiorkor or normal nutrition (Wellcome Classification). Aflatoxins were detected most frequently and at highest concentrations in the sera of kwashiorkors who, conversely, showed aflatoxins least frequently in their urine and in concentrations that were disproportionately low compared with serum/urine aflatoxin levels in other groups. These findings indicate altered aflatoxin metabolism in kwashiorkor and support the hypothesis that there are special relationships between aflatoxins and kwashiorkor.