[Better medicines for children]

The European Regulation incenting pharmaceutical companies to develop drugs in children will have substantial consequences for all partners involved. Children and parents will be asked to participate in clinical trials, paediatricians to monitor these investigations, industry to be creative and propose adapted formulations, ethical committees to deliver advices and public health authorities to assist the system in order to bring to a good end a full set of paediatric indications.

Study design in osteoporosis: a European perspective

The advent of effective agents for the treatment of osteoporosis has led to the view that placebo-controlled trials to test new agents for efficacy are no longer appropriate. Rather, studies of superiority, equivalence, or non-inferiority have been recommended. Such studies require very large sample sizes, and the burden of osteoporotic fracture in a trial setting is substantially increased. Studies of equivalence cannot be unambiguously interpreted because the variance in effect of active comparator agents is too large in osteoporosis. If fracture studies are required by regulatory agencies, there is still a requirement for placebo-controlled studies, although perhaps of shorter duration than demanded at present.

The molar ratio of serum retinol-binding protein (RBP) to transthyretin (TTR) is not useful to assess vitamin A status during infection in hospitalised children

OBJECTIVE

To assess the usefulness of the molar ratio of serum retinol-binding protein (RBP) to transthyretin (TTR) to determine vitamin A (VA) status during infection.

DESIGN

We took advantage of previously collected data during a randomised double-blind, placebo-controlled clinical trial to conduct a secondary analysis of the RBP/TTR ratio and its relationship to infection and VA status. In this clinical trial, children were randomly assigned to one of three groups and received either one single oral high dose of VA (200 000 IU) on the day of admission and subsequently a placebo daily until discharge or daily oral low doses of VA (5000 IU) from admission until discharge or a placebo daily from admission until discharge.

SETTING

Lwiro pediatric hospital, Province of South Kivu, Democratic Republic of Congo.

SUBJECTS

A total of 900 children aged 0-72 months hospitalised consecutively between March 1994 and March 1996.

MAIN OUTCOME MEASURES

RBP/TTR molar ratio after 7 days hospitalisation.

RESULTS

After 7 days hospitalisation, molar RBP:TTR ratio (mean+/-s.d.) of infected children (C-reactive proteins>10 mg/l) was 0.67+/-0.31 in the high-dose group (n=81), 0.74+/-0.44 in the low dose group (n=71) and 0.73+/-0.39 in the placebo group (n=81). These values did not differ significantly (one-way ANOVA P=0.472). In patients with baseline serum retinol concentrations<0.70 micromol/l, changes in RBP:TTR ratio between admission and day 7 were not statistically different in the three groups (one-way ANOVA P=0.548).

CONCLUSIONS

In this population of malnourished hospitalised children, molar RBP:TTR ratio does not appear to be useful to assess VA status during infection.

SPONSORSHIP

Our research was partially supported by a grant from the Fonds de la Recherche Scientifique et Médicale (contract 3.4505.94) and the David and Alice Van Buuren Foundation.

[The food pyramid battle]

Two hundred years after Napoleon, nutritionists of the world are fighting against each other in front of the pyramids. In 1995, the USAD (US Agriculture Department) started the battle by publishing "new food recommendations" that should not be confounded with the recommended dietary allowances (RDA). The food choices proposed by the USAD aimed at improving the health of the general population and avoiding chronic diseases. Implicitly these proposals should also meet the RDA. In order to reach its target, the Committee has proposed two pre-requisites: to balance food consumption and energy expenditure and therefore control body weight and to eat among various food items.

[Excessive dietetic restrictions in children]

Children have specific and increased nutritional requirements in comparison with adults. A rapid growth and an enhanced energy expenditure explain these main differences. Any diet deviation will expose more rapidly to a risk of nutritional deficiency with health consequences. Whenever a diet restriction is required for medical reasons, a particular attention must be paid to the feeding regimen in order to avoid any health problem and mainly growth retardation.

Plasma homocysteine concentration in a Belgian school-age population

BACKGROUND

Total plasma homocysteine (tHcy) is an independent risk factor for cardiovascular disease in adults. Data for children and adolescents are lacking.

OBJECTIVE

The aim of this study was to provide a reference range for tHcy and to explore the relation between tHcy and nutritional indexes in a Belgian pediatric population.

DESIGN

tHcy, folate, and vitamin B-12 were measured in 647 healthy children (353 girls and 294 boys) aged 5-19 y.

RESULTS

The tHcy distribution was, as in adults, skewed to the right [geometric mean (-1 SD, +1 SD): 7.41 micromol/L (5.51, 9.96)]. Concentrations were lowest in younger children and increased with age. After the tHcy distribution was examined according to age, 3 age ranges were distinguished: 5-9 y [6.21 micromol/L (5.14, 7.50)], 10-14 y [7.09 micromol/L (5.69, 8.84)], and 15-19 y [8.84 micromol/L (6.36, 12.29)]. We observed no significant differences in tHcy values between girls and boys in children aged < 15 y; in postpubertal children, however, concentrations were higher in boys than in girls. In the 3 age groups, folate was inversely correlated with tHcy; the negative relation between tHcy and vitamin B-12 was less strong. Familial cardiovascular disease was more frequent in children who had hyperhomocysteinemia.

CONCLUSIONS

These observations suggest that in children, as in adults, genetic, nutritional, and endocrine factors are determinants of the metabolism of homocysteine. The significance of tHcy values in childhood and young adulthood in terms of predicting cardiovascular risk in adulthood should be investigated.

Randomized placebo-controlled clinical trial of the effect of a single high dose or daily low doses of vitamin A on the morbidity of hospitalized, malnourished children

The effect of high-dose vitamin A supplementation on recovery from morbidity and on recovery from nosocomial morbidity of hospitalized children has been poorly studied and results are conflicting. The effect of daily, low doses has never been assessed. We investigated the effect of a single high dose and daily, low doses of vitamin A on diarrhea, acute lower respiratory tract infections (ALRIs), and all-cause fevers in 900 hospitalized preschool-age children in the Democratic Republic of Congo in a randomized, double-blind, placebo-controlled clinical trial. The high-dose treatment group received 200,000 IU vitamin A (100,000 IU if aged <12 mo) orally on the day of admission, the low-dose treatment group received 5000 IU vitamin A/d until discharge. Data on all-cause morbidity were collected daily. Mortality rates were not significantly different among the 3 groups. High-dose vitamin A supplementation had no significant effect on the duration of moderate or severe diarrhea nor on the duration and incidence of ALRIs and all-cause fevers. Children in the high-dose group with no edema had an increased risk of severe nosocomial diarrhea (relative risk: 2.42; 95% CI: 1.15, 5.11). Low-dose vitamin A supplementation significantly reduced the incidence of severe diarrhea in severely malnourished children (relative risk: 0.21; 95% CI: 0.07, 0.62) but showed no significant effect on the duration of moderate or severe diarrhea or on the duration and incidence of ALRIs and all-cause fevers. Supplementation with high doses of vitamin A did not reduce morbidity in this population of malnourished and subclinically vitamin A-deficient children; daily, low doses appeared more beneficial for severely malnourished children.

Vitamin A supplementation but not deworming improves growth of malnourished preschool children in eastern Zaire

A randomized controlled trial was conducted in eastern Zaire to assess the effects of high dose vitamin A supplementation and regular deparasitation on the growth of 358 moderately malnourished preschool children, discharged from the hospital. The treatment groups received either vitamin A (60 mg of oily solution of retinyl palmitate, 30 mg if aged <12 mo) every 6 mo or mebendazole (500 mg) every 3 mo; the control group received no supplementation. Anthropometric data were gathered at baseline and after 6 and 12 mo of follow-up. Serum retinol concentrations were measured at baseline and after 3 mo. The three groups did not differ in sociodemographic indicators, age and sex composition, nutritional status and serum retinol concentrations at baseline. In children who were vitamin A deficient at baseline, adjusted mean weight and mid-upper arm circumference (MUAC) increments were higher in the vitamin A-supplemented group than in the control group [annual increment in weight and MUAC in vitamin A vs. control group: 2.088 vs. 1.179 kg (P = 0.029) and 2.24 vs. 0.95 cm (P = 0.012), respectively], whereas growth increment did not differ between the dewormed group and the control group. In children who were not vitamin A deficient at baseline, growth increment did not differ between the vitamin A-supplemented and control groups, whereas weight gain was lower in the dewormed group than in the control group. Vitamin A-supplemented boys gained more weight and height than control boys, whereas vitamin A-supplemented girls gained less height than control girls. Dewormed boys and girls gained less weight than control boys and girls. Programs to improve vitamin A status by high dose vitamin A supplementation may improve growth of preschool children who are vitamin A deficient, whereas deworming does not.

Effects of cow's milk supplementation on milk output of protein deficient lactating mothers and on their infants' energy and protein status

A cow's milk supplement providing 500 kcal (2093 kJ) and 18 g of protein a day was given during 2 months to 83 lactating Zairian mothers suffering from protein malnutrition. The mothers' nutritional status improved significantly after 2 months. The initial 24-hour mother's milk output was on average 607 ml (s.d.: 182) and did not change significantly after 2 months (604 ml; s.d.: 178). Initial milk output and change in milk output did not differ according to mothers' nutritional status at inclusion. Breast-fed infants showed a significant improvement of their mean serum albumin concentration while their growth was similar to the mean growth of children of the same age.

Vitamin A deficiency and protein-energy malnutrition in a sample of pre-school age children in the Kivu Province in Zaire

OBJECTIVE

To assess pre-school age children's vitamin A status in a population where protein-energy malnutrition is endemic and serum retinol binding protein and transtyretin concentrations are low.

DESIGN

A cross-sectional study.

SETTING

Health district of Katana, South-Kivu, Zaire.

SUBJECTS

415 pre-school age children.

METHODS

Three methods were used to assess vitamin A status: ophtalmological examination, retinol serum concentration and Relative Dose Response (RDR) test.

RESULTS

The only ophthalmological signs of vitamin A deficiency appeared in two cases of night blindness, which represents a prevalence of 0.7%. Deficient serum retinol concentration (< 0.35 mumol/l) was found in 19.7% of the whole study population and in 10.4% of non-infected children in good nutritional status. RDR test carried out on a reduced sample of 79 subjects was abnormal for 7.6% of the children but showed a low sensitivity when compared with serum retinol concentration.

CONCLUSION

This survey suggests that in this population of the South-Kivu Province in Zaire, vitamin A deficiency co-exists with protein-energy malnutrition and is a public health problem even with non-malnourished and non-infected children.

Prognostic indices for mortality of hospitalized children in central Africa

A hospital-based follow-up study was conducted between 1986 and 1988 at Lwiro (South Kivu Province, Zaire). Of 1,129 children in the study, three of four were severely malnourished, and 17.4% died. This study analyzes the mortality in hospital; its objectives are to evaluate the prognostic power of edema and anthropometric and biologic indicators and to seek indices that perform better. Receiver operating characteristic curves were established for each parameter under study and for each index constructed. Areas under receiver operating characteristic curves were highest for biologic indicators, and simple indices, obtained by counting the number of risk factors present, performed best. In the absence of biologic parameters, the authors suggest classifying children as at risk of dying when they present with edema and/or with arm circumference of less than 115 mm. When biologic measurements are possible, in addition to edema and arm circumference, the authors suggest taking serum albumin and transthyretin into account. For serum albumin and transthyretin, mortality risk is defined in terms of values of less than 16 g/liter and 6.5 mg/dl, respectively. Children will be classified as at risk of dying when they present with at least two of the four risk factors. The resulting diagnostic test has a high sensitivity (91.2%) and positive and negative predictive values of 40.8% and 97.9%, respectively.

Significance of very low retinol levels during severe protein-energy malnutrition

In developing countries, severe vitamin A deficiency is associated with increased child mortality. In Kivu, Zaïre, child mortality rate is approximately 50 per 1000 per year and protein calorie malnutrition is endemic. To evaluate vitamin A status in this population, we measured plasma retinol levels in 28 severely malnourished hospitalized children (plasma albumin level below 3 g/dl), and in 153 outpatients (mean plasma albumin level: 3.19 +/- 0.7 g/dl) as controls. Sixty percent of inpatients and 37 percent of out-patients had retinol levels below 10 micrograms/dl (P = 0.02) suggesting a high prevalence of severe vitamin A deficiency in this population. We found that plasma retinol levels were correlated with low retinol binding protein plasma levels (r = 0.77). We conclude that although vitamin A deficiency probably exists in this malnourished population, low retinol levels could at least partly be related to decreased levels of its carrier protein.

Biological risk factors for fatal protein energy malnutrition in hospitalized children in Zaire

Biological markers were used in an attempt to predict mortality in children admitted to the hospital in Kivu, Zaire, for protein energy malnutrition. Data for 39 children who died (16.4%) showed significantly lower levels of albumin (1.61 vs. 2.53 g/dl; p < 0.001), transferrin (82.1 vs. 167.7 mg/dl; p < 0.001), and transthyretin (6.49 vs. 9.87 mg/dl; p < 0.001), but not or retinol-binding protein, than for the 199 survivors. Since albumin and transferrin were correlated, a Cox model was used to see whether albumin or transferrin has a significant predictive value independent of transthyretin. The relative risk predicted by each indicator was of the same order of magnitude, approximately 4. We conclude that specific biological markers help to discriminate among hospitalized subjects at risk and to identify those in need of more intensive nutritional support to prevent early death.

Serum albumin concentration, arm circumference, and oedema and subsequent risk of dying in children in central Africa

OBJECTIVE

To measure the prognostic value of clinical, anthropometric, and biological indicators of protein energy malnutrition in hospitalised children.

DESIGN

Hospital based follow up study from admission to discharge or death of a cohort of children. SETTING-Paediatric hospital in Zaire.

SUBJECTS

1129 children consecutively admitted between August 1986 and October 1988.

MAIN OUTCOME MEASURES

Height, weight, arm circumference, skinfold thicknesses, serum albumin concentration, and mortality.

RESULTS

Mortality was higher in wasted children and in those with a mid-upper arm circumference < 125 mm, a serum albumin concentration < 16 g/l, and oedema. After multivariate analysis, serum albumin concentration was the best predictor of subsequent risk of dying. Mid-upper arm circumference and oedema, however, still contributed considerably to evaluation of mortality.

CONCLUSIONS

In this specific environment of central Africa an isolated clinical sign such as oedema is not enough to detect children with a high risk of dying among those admitted to paediatric wards with severe protein energy malnutrition. Measurement of additional indicators such as arm circumference and serum albumin concentration seems to be of crucial importance.

[Enzymes and histology of the intestinal mucosa of breast-fed African infants]

Weight gain and statural growth are slow in the Kivu area (Zaïre), as compared with international reference curves. One hypothesis put forward to explain this well-documented but poorly understood fact is inadequate breast-feeding with early intake of foods responsible for the introduction of microorganisms with deleterious effects on the digestive tract. A study of intestinal mucosa specimens from 90 at least partially breast-fed infants (4 to 22 months) showed that the appearance of the jejunal mucosa was consistently abnormal, as compared with histologic standards used in Europe. Furthermore, intestinal disaccharidase activities were always abnormal; lactase activities were extremely low and alpha-glucosidase activities were reduced by one-third to one-half as compared with European reference values. Age apparently influenced the magnitude of these modifications, whereas the correlation with nutritional status was less clear; only a correlation between the serum albumin level and the microscopic appearance of jejunal biopsy specimens was found. Intestinal alpha-glucosidase levels were lower in those patients with giardiasis. These findings demonstrate that in Kivu early atrophy of the intestinal mucosa contributes, together with the protein-calory malnutrition, to the lower growth rates in infants.

[Validation of fast nutritional scoring. Application to 80 cases of "homing" diarrhea]

Pediatricians often have to assess the nutritional status of their patients from unprecise anamnestic information, unreliable clinical signs or biological data difficult to interpret. None of these parameters can be used alone to establish the nutritional status of a sick child. The validity of a simple and rapid nutritional score was tested. The score consisted of 3 anthropometric parameters (weight, height, triceps skinfold) and 4 biological analyses frequently used in pediatric practice (albumin, transferrin, alkaline phosphatase and ferritin serum determinations). The usefulness of the score was established through the important nutritional deficiencies observed in 80 children admitted for "homing diarrhea" requiring early nutritional support.

Safe oral rehydration of hypertonic dehydration

Eighteen infants with severe hypernatremic dehydration secondary to acute gastroenteritis were rehydrated during the 1st day with an oral glucose electrolyte solution containing 60 mmol sodium/L at a mean rate of 120 ml/kg/24 h. These 18 children were safely treated with oral therapy alone. No convulsions were observed during treatment. The mean decrease in natremia was 0.32 mmol/L/h, which compared favorably with the mean fall in natremia of 26 other infants in similar initial conditions who were treated intravenously. The present study lends additional support to the opinion that a slow decrease in plasma sodium (less than 0.5 mmol/L/h) helps to avoid seizures during treatment. As no other untoward effects were observed, this study also confirms that oral solutions given at a slow rate can effectively replace intravenous fluids in the majority of such children.

Tick-borne relapsing fever in a premature infant

Relapsing fever is caused by the Borrelia species of spirochetes. Louse-born epidemics of the disease may occur but the endemic disease is usually transmitted to humans by the bite of an infected tick (Ornithodorus). Transplacental infection was suggested more than 75 years ago (1) but has been rarely documented (2). We describe a case of neonatal relapsing fever where maternal infection was the probable cause of the premature delivery and infection in the infant.

Copper deficiency in infants with active celiac disease

Celiac disease was diagnosed in two unrelated infants aged 7 and 7.5 months with severe malnutrition. They showed typical clinical, biological, and histological signs of the disease. Moreover, accompanying copper deficiency was suggested by severe hypocupremia and persistent neutropenia; bone radiographs were also compatible with this diagnosis. Rapid and complete correction of these anomalies could only be obtained after addition of oral copper sulfate to the gluten-free diet. Mechanisms possibly involved in the development of copper deficiency in young infants with celiac disease are: chronic malabsorption; high copper needs in rapidly growing infants; and possibly increased biliary and digestive losses. It is therefore suggested that young children with severe celiac disease should be monitored for their copper status.

Enteropathogenic agents in children with diarrhoea in rural Zaire

A systematic study of enteropathogenic agents in the stools of children was carried out in a rural area of Kivu Province in Zaire in June, 1979. 84 inpatients and 271 outpatients with diarrhoea were investigated together with 117 inpatient and 203 outpatient controls without diarrhoea. Campylobacter jejuni was the most frequently recovered pathogen in both inpatients (24%) and outpatients (13.7%). Enterotoxigenic Escherichia coli was the next most common among children presenting as outpatients with diarrhoea (10.3%). Yersinia enterocolitica was isolated for the first time in this region. Rotaviruses were found only in outpatients with diarrhoea, and usually in children under two years of age. C. jejuni and Vibrio cholerae could also be isolated from the faeces of domestic animals living in close contact with these village families. Analysis of the clinical features did not lead to the recognition of a pattern typical of any particular pathogen. Salmonella, Shigella, and enteropathogenic E. coli did not play a significant role in the cases studied.

Shigella and shigellaemia

Two cases of bacteraemia with Shigella flexneri 2a in children are described. They illustrate the wide variety of clinical manifestations of shigellosis, ranging from benign gastroenteritis to septicaemia associated with severe extra-intestinal manifestations.