Trajectories of resting energy expenditure and performance of predictive equations in children hospitalized with an acute illness and malnutrition: a longitudinal study

There is scarce data on energy expenditure in ill children with different degrees of malnutrition. This study aimed to determine resting energy expenditure (REE) trajectories in hospitalized malnourished children during and after hospitalization. We followed a cohort of children in Bangladesh and Malawi (2-23 months) with: no wasting (NW); moderate wasting (MW), severe wasting (SW), or edematous malnutrition (EM). REE was measured by indirect calorimetry at admission, discharge, 14-and-45-days post-discharge. 125 children (NW, n = 23; MW, n = 29; SW, n = 51; EM, n = 22), median age 9 (IQR 6, 14) months, provided 401 REE measurements. At admission, the REE of children with NW and MW was 67 (95% CI [58, 75]) and 70 (95% CI [63, 76]) kcal/kg/day, respectively, while REE in children with SW was higher, 79 kcal/kg/day (95% CI [74, 84], p = 0.018), than NW. REE in these groups was stable over time. In children with EM, REE increased from admission to discharge (65 kcal/kg/day, 95% CI [56, 73]) to 79 (95% CI [72, 86], p = 0.0014) and was stable hereafter. Predictive equations underestimated REE in 92% of participants at all time points. Recommended feeding targets during the acute phase of illness in severely malnourished children exceeded REE. Acutely ill malnourished children are at risk of being overfed when implementing current international guidelines.

Detection and absolute quantification of Lactiplantibacillus plantarum ATCC 202195 by quantitative real-time PCR

IMPORTANCE

When administered for seven consecutive days shortly after birth, the probiotic bacterium Lactiplantibacillus plantarum ATCC 202195 plus fructooligosaccharide (FOS) was reported to reduce sepsis and lower respiratory tract infection events during early infancy in a randomized trial in India. Since probiotic effects are often strain specific, strain-level detection and quantification by routine molecular methods enables the monitoring of safety outcomes, such as probiotic-associated bacteremia, and allows for the quality of probiotic interventions to be assessed and monitored (i.e., verify strain identity and enumerate). Despite the potential clinical applications of L. plantarum ATCC 202195, an assay to detect and quantify this strain has not previously been described. Herein, we report the design of primer and probe sequences to detect L. plantarum ATCC 202195 and the development and optimization of a real-time PCR assay to detect and quantify the strain with high specificity and high sensitivity.

Bifidobacterium longum subsp. iuvenis subsp. nov., a novel subspecies isolated from the faeces of weaning infants

The species Bifidobacterium longum currently comprises four subspecies: B. longum subsp. longum , B. longum subsp. infantis , B. longum subsp. suis and B. longum subsp. suillum . Recently, several studies on B. longum suggested the presence of a separate clade containing four strains isolated from infants and one from rhesus macaque. These strains shared a phylogenetic similarity to B. longum subsp. suis DSM 20210T and B. longum subsp. suillum JCM1995T [average nucleotide identity (ANI) of 98.1 %) while showed an ANI of 96.5 % with both B. longum subsp. infantis and B. longum subsp. longum . The current work describes five novel additional B. longum strains isolated from Bangladeshi weaning infants and demonstrates their common phylogenetic origin with those of the previously proposed separated clade. Based on polyphasic taxonomic approach comprising loci multilocus sequence analysis and whole genome multilocus sequence typing, all ten examined strains have been confirmed as a distinct lineage within the species B. longum with B. longum subsp. suis and B. longum subsp. suillum as closest subspecies. Interestingly, these strains are present in weaning infants and primates as opposed to their closest relatives which have been typically isolated from pig and calves. These strains, similarly to B. longum subsp. infantis , show a common capacity to metabolize the human milk oligosaccharide 3-fucosyllactose. Moreover, they harbour a riboflavin synthesis operon, which differentiate them from their closest subspecies, B. longum subsp. suis and B. longum subsp. suillum . Based on the consistent results from genotypical, ecological and phenotypical analyses, a novel subspecies with the name Bifidobacterium longum subsp. iuvenis, with type strain NCC 5000T (=LMG 32752T=CCOS 2034T), is proposed.

Comparisons of the Rome III and Rome IV criteria for diagnosis of irritable bowel syndrome in Indian and Bangladeshi communities and internal shifts in the diagnostic categories of bowel disorders of gut-brain interactions

BACKGROUND

Although the Rome IV criteria are the most recent criteria to diagnose irritable bowel syndrome (IBS), their sensitivity has been shown to be low in Chinese and Western populations. There are scanty data comparing the Rome III and Rome IV criteria in diagnosis of IBS in the Indian and Bangladeshi populations where abdominal pain, an essential component of diagnosis of IBS by the Rome IV criteria, is less in frequency and of lower severity.

METHODS

We analyzed the Indian and Bangladeshi data from the Rome Global Epidemiology Study to compare diagnostic sensitivity of the Rome III and Rome IV criteria for IBS, internal shifts in diagnostic categories of disorders of gut-brain interaction (DGBI), the severity of IBS diagnosed by the Rome III and Rome IV criteria, and consultation patterns in these populations.

KEY RESULTS

The Rome IV criteria were less sensitive than the Rome III criteria to diagnose IBS in these populations, and the subjects with Rome III IBS shifted internally to other DGBI when the Rome IV criteria were applied. Moreover, Rome IV IBS subjects had greater symptom severity than the Rome III IBS. A third of people fulfilling diagnostic criteria for IBS consulted doctors, and those diagnosed using Rome IV criteria, those with higher anxiety and depression symptom score, lower global physical health score, and greater IBS symptom severity score had greater correlation coefficients with doctors' consultation.

CONCLUSIONS AND INFERENCES

The Rome IV diagnostic criteria for IBS are less sensitive than the Rome III criteria in Indian and Bangladesh communities. Application of the Rome IV criteria to people who meet the Rome III IBS criteria selects a subgroup of people with greater severity of symptoms, and hence, Rome IV IBS is more strongly associated with physician consultation. These findings may have important bearing in future iterations of the Rome criteria for a broader global applicability.

Environmental enteric dysfunction and small intestinal histomorphology of stunted children in Bangladesh

There is lack of information on the histological characteristics of the intestinal mucosa in Bangladeshi children. Collection of intestinal biopsy samples and assessment of the histomorphological features is considered to be the traditional gold standard for diagnosis of environmental enteric dysfunction (EED). The purpose of the study was to evaluate the intestinal histological characteristics of stunted children aged between 12-18 months with possible EED. 110 children with chronic malnutrition (52 stunted with length-for-age Z score, LAZ<-2 and 58 at risk of stunting with LAZ <-1 to -2) from the Bangladesh Environmental Enteric Dysfunction (BEED) study protocol who underwent upper gastrointestinal (GI) endoscopy were selected for this study. To explore the association of EED with childhood stunting, upper GI endoscopy was done and the biopsy specimens were studied for histopathology. Villous height and crypt depth were measured and the presence and intensity of inflammatory infiltrates in the lamina propria was investigated. Bivariate analysis was performed to examine the relationship between stunting and histologic morphology. More than 90% children irrespective of nutritional status were diagnosed to have chronic non-specific duodenitis on histopathology. Half of the children from both groups had villous atrophy as well as crypt hyperplasia and lymphocytic infiltration was present in more than 90% children, irrespective of groups. However, no statistically significant difference was observed when compared between the groups. The prevalence of chronic non-specific duodenitis in Bangladeshi children, irrespective of nutritional status, was high. A significant number of these children had abnormal findings in intestinal histomorphology. Trial registration number: ClinicalTrials.gov ID: NCT02812615 Date of first registration: 24/06/2016. https://clinicaltrials.gov/ct2/results?cond=NCT02812615&term=&cntry=&state=&city=&dist.

Bifidobacterium infantis treatment promotes weight gain in Bangladeshi infants with severe acute malnutrition

Disrupted development of the gut microbiota is a contributing cause of childhood malnutrition. Bifidobacterium longum subspecies infantis is a prominent early colonizer of the infant gut that consumes human milk oligosaccharides (HMOs). We found that the absolute abundance of Bifidobacterium infantis is lower in 3- to 24-month-old Bangladeshi infants with severe acute malnutrition (SAM) compared to their healthy age-matched counterparts. A single-blind, placebo-controlled trial (SYNERGIE) was conducted in 2- to 6-month-old Bangladeshi infants with SAM. A commercial U.S. donor-derived B. infantis strain (EVC001) was administered daily with or without the HMO lacto-N-neotetraose for 28 days. This intervention increased fecal B. infantis abundance in infants with SAM, although to levels still 10- to 100-fold lower than in untreated healthy controls. EVC001 treatment promoted weight gain that was associated with reduced intestinal inflammation markers in infants with SAM. We cultured fecal B. infantis strains from Bangladeshi infants and colonized gnotobiotic mice with these cultured strains. The gnotobiotic mice were fed a diet representative of that consumed by 6-month-old Bangladeshi infants, with or without HMO supplementation. One B. infantis strain, Bg_2D9, expressing two gene clusters involved in uptake and utilization of N-glycans and plant-derived polysaccharides, exhibited superior fitness over EVC001. The fitness advantage of Bg_2D9 was confirmed in a gnotobiotic mouse model of mother-to-infant gut microbiota transmission where dams received a pretreatment fecal community from a SAM infant in the SYNERGIE trial. Whether Bg_2D9 is superior to EVC001 for treating malnourished infants who consume a diet with limited breastmilk requires further clinical testing.

The Influence of FUT2 and FUT3 Polymorphisms and Nasopharyngeal Microbiome on Respiratory Infections in Breastfed Bangladeshi Infants from the Microbiota and Health Study

Acute respiratory infections (ARIs) are one of the most common causes of morbidity and mortality in young children. The aim of our study was to examine whether variation in maternal FUT2 (α1,2-fucosyltransferase 2) and FUT3 (α1,3/4-fucosyltransferase 3) genes, which shape fucosylated human milk oligosaccharides (HMOs) in breast milk, are associated with the occurrence of ARIs in breastfed infants as well as the influence of the nasopharyngeal microbiome on ARI risk. Occurrences of ARIs were prospectively recorded in a cohort of 240 breastfed Bangladeshi infants from birth to 2 years. Secretor and Lewis status was established by sequencing of FUT2/3 genes. The nasopharyngeal microbiome was characterized by shotgun metagenomics, complemented by specific detection of respiratory pathogens; 88.6% of mothers and 91% of infants were identified as secretors. Maternal secretor status was associated with reduced ARI incidence among these infants in the period from birth to 6 months (incidence rate ratio [IRR], 0.66; 95% confidence interval [CI], 0.47 to 0.94; P = 0.020), but not at later time periods. The nasopharyngeal microbiome, despite precise characterization to the species level, was not predictive of subsequent ARIs. The observed risk reduction of ARIs among infants of secretor mothers during the predominant breastfeeding period is consistent with the hypothesis that fucosylated oligosaccharides in human milk contribute to protection against respiratory infections. However, we found no evidence that modulation of the nasopharyngeal microbiome influenced ARI risk. IMPORTANCE The observed risk reduction of acute respiratory infections (ARIs) among infants of secretor mothers during the predominant breastfeeding period is consistent with the hypothesis that fucosylated oligosaccharides in human milk contribute to protection against respiratory infections. Respiratory pathogens were only weak modulators of risk, and the nasopharyngeal microbiome did not influence ARI risk, suggesting that the associated protective effects of human milk oligosaccharides (HMOs) are not conveyed via changes in the nasopharyngeal microbiome. Our observations add to the evidence for a role of fucosylated HMOs in protection against respiratory infections in exclusively or predominantly breastfed infants in low-resource settings. There is no indication that the nasopharyngeal microbiome substantially modulates the risk of subsequent mild ARIs. Larger studies are needed to provide mechanistic insights on links between secretor status, HMOs, and risk of respiratory infections.

Evaluation of SIMESON, a training program to improve access to quality health care for pregnant women and newborn in different healthcare facilities of northern Bangladesh

Aim

The study aims to explore the current knowledge and skills of healthcare providers already trained by SIMESON (simulation for essential skills for obstetrical and neonatal care), in reviewing perinatal health situations including current status of healthcare facilities and cost estimation.

Design

It was an observational study.

Methods

Cost estimation following both quantitative and qualitative approaches was also attempted.

Result

Knowledge and skills of 88 healthcare providers about the provision of normal delivery and immediate postpartum care, management of postpartum haemorrhage (PPH), retained placenta and use of bag and mask ventilation to help a baby breathe were found to be considerably strengthened following SIMESON training. During the 6 months after training, there were 477 PPH cases managed successfully with only one death; neonatal deaths observed were 6.6/1,000 live births; twice the number of facility deliveries; and 80% use rate of Ambu bag for helping baby breathe. The estimated cost per trainee was 395.68 USD, and 5.85 USD per beneficiary.

Antibiotic exposure among young infants suffering from diarrhoea in Bangladesh

AIMS

Appropriate rehydration has always been significant in treating diarrhoeal diseases in children. Irrational antibiotic use among diarrhoeal children has remained a major public health concern. Information regarding antibiotic use in young infants suffering from diarrhoea is very limited and a unique aspect of research. We aimed to investigate the prevalence of antibiotic use in the community among 2-6 months infants with diarrhoeal illnesses and having different nutritional status.

METHODS

We investigated a total of 5279 infants aged 2-6 months at Dhaka hospital, International Centre for Diarrhoeal Disease Research, Bangladesh, between September 2018 and June 2019. Among them, 257 infants were suffering from severe acute malnutrition (SAM). History of taking antibiotics was ascertained by direct observation of a prescription by a physician, the bottle of antibiotic or asking the caregiver about the name of antibiotic or its price that is very close to the usual market price of an antibiotic.

RESULTS

Overall, 52% of infants received antibiotics before hospital admission. Non-SAM infants had higher odds of receiving antibiotics (adjusted odds ratio [aOR] = 1.52, 95% confidence interval: 1.18, 1.97, P value = 0.003) compared to infants with SAM and use of antibiotics increased with age (aOR = 1.11, 95% confidence interval: 1.06, 1.17, P value<0.001). Commonly used antibiotics were azithromycin (13.3%), ciprofloxacin (7.7%), erythromycin (7.7%) and metronidazole (2.6%). The proportion of receiving ciprofloxacin was significantly lower in infants with SAM compared to their non-SAM counterparts (2.7% vs. 7.97%, P value = 0.004).

CONCLUSIONS

The study underscores the excessive use of antibiotics among diarrhoeal infants, which is already a major public health concern in low- and middle-income countries.

Alterations in the histological features of the intestinal mucosa in malnourished adults of Bangladesh

There is paucity of knowledge on the histological features of the intestinal mucosa in malnourished adults of Bangladesh. The purpose of the study was to explore the histological features of the intestinal mucosa in malnourished adults of Bangladesh and to compare the findings with their well-nourished counterparts. 64 adults (37 malnourished with body mass index, BMI < 18.5 kg/m² and 27 controls with BMI > 18.5 kg/m²) from the Bangladesh Environmental Enteric Dysfunction (BEED) study, who underwent upper-gastrointestinal endoscopy, were selected for this study. With a view to address the association of environmental enteric dysfunction (EED) with malnutrition, upper-gastrointestinal endoscopy was performed and mucosal biopsies from the distal duodenum were studied for histopathology. Villous height, crypt depth, and presence of inflammatory infiltrates in lamina propria were investigated. Bivariate analysis was performed to quantify the relation between malnutrition and the histological features. About 95% adults, irrespective of nutritional status, were diagnosed to have chronic non-specific duodenitis on histopathology. Malnourished adults suffered significantly more from chronic active duodenitis compared to their well-nourished counterparts (p = 0.003). Malnourished adults also had significantly higher frequency of subtotal villous atrophy, crypt hyperplasia and marked cellular infiltration in the lamina propria than the healthy controls (p < 0.05).

Seroprevalence of Helicobacter pylori and its association with metabolic syndrome in a rural community of Bangladesh

BACKGROUND AND AIM

As the interrelationship between Helicobacter pylori, metabolic syndrome (MetS), and non-alcoholic fatty liver disease (NAFLD) is controversial, we undertook a community-based study with the aim to find the seroprevalence of H. pylori and its relationship with MetS and NAFLD.

METHODS

This door-to-door survey was conducted among the adult subjects (≥18 years) of two villages (Charcharia of Dhaka district and Kharrah of Munshiganj district) of Bangladesh. Interviews using a structured questionnaire, clinical examination, anthropometric measurements, ultrasonogram of the liver, and biochemical tests were performed.

RESULTS

Of 1021 subjects, 781 responded (76.49%), and 767 were included in the final analysis (mean age 40.35 ± 15.56 years; female 63.5%). Anti-H. pylori antibodies were found in 418 of 767 (54.5%). There were no H. pylori serostatus association with MetS and diabetes mellitus (DM) in univariate or multivariate analysis (all P > 0.05). However, H. pylori seropositive subjects had lower systolic blood pressure (odds ratio [OR] = -2.95 [-5.58, -0.32]) and low density lipoprotein -cholesterol (OR -7.79 [-15, -0.57]) compared to seronegative subjects in the linear regression model. Seronegativity of H. pylori was associated with NALFD in univariate (P = 0.007) but not multivariate analysis (P = 0.086). There were no differences in the frequency of H. pylori seropositivity among the participants with nonobese compared to obese NAFLD (19/42 [45%] vs 43/99 [43.4%], P = 0.844).

CONCLUSION

In a rural community of Bangladesh, about 55% of the population were H. pylori seropositive, which was more common among the underweight than normal or obese subjects. However, there was no relationship observed between H. pylori seroprevalence and MetS, DM, or NAFLD.

Changing Epidemiology of Acute Respiratory Infections in Under-Two Children in Dhaka, Bangladesh

Objectives: Risk factors for acute respiratory infections (ARIs) in community settings are not fully understood, especially in low-income countries. We examined the incidence and risk factors associated with ARIs in under-two children from the Microbiota and Health study. Methods: Children from a peri-urban area of Dhaka (Bangladesh) were followed from birth to 2 years of age by both active surveillance of ARIs and regular scheduled visits. Nasopharyngeal samples were collected during scheduled visits for detection of bacterial facultative respiratory pathogens. Information on socioeconomic, environmental, and household conditions, and mother and child characteristics were collected. A hierarchical modeling approach was used to identify proximate determinants of ARIs. Results: Of 267 infants, 87.3% experienced at least one ARI episode during the first 2 years of life. The peak incidence of ARIs was 330 infections per 100 infant-years and occurred between 2 and 4 months of age. Season was the main risk factor (rainy monsoon season, incidence rate ratio [IRR] 2.43 [1.92-3.07]; cool dry winter, IRR 2.10 [1.65-2.67] compared with hot dry summer) in the first 2 years of life. In addition, during the first 6 months of life, young maternal age (<22 years; IRR 1.34 [1.01-1.77]) and low birth weight (<2,500 g; IRR 1.39 [1.03-1.89]) were associated with higher ARI incidence. Conclusions: Reminiscent of industrialized settings, cool rainy season rather than socioeconomic and hygiene conditions was a major risk factor for ARIs in peri-urban Bangladesh. Understanding the causal links between seasonally variable factors such as temperature, humidity, crowding, diet, and ARIs will inform prevention measures.

Asymptomatic Duodenitis and Helicobacter pylori associated Dyspepsia in 2-Year-Old Chronic Malnourished Bangladeshi Slum-Dwelling Children: A Cross-Sectional Study

AIM

There is insufficient knowledge on the * duodenal histology and Helicobacter pylori infection in malnourished Bangladeshi children. Therefore, we attempted to explore the prevalence of H. pylori infection and duodenal histopathology in 2-year-old chronic malnourished Bangladeshi slum-dwelling children and investigate their association with dyspeptic symptoms.

METHODS

This cross-sectional study was conducted using the data of the Bangladesh Environmental Enteric Dysfunction study in an urban slum of Dhaka, Bangladesh. With a view to address the association of environmental enteric dysfunction (EED) with stunting, upper gastrointestinal endoscopy was performed on 54 chronic malnourished children {31 stunted [length-for-age Z-scores (LAZ) <-2] and 23 at risk of stunting (LAZ <-1 to -2)} aged between 12-24 months and the mucosal biopsies were subjected to histopathological examination after obtaining proper clinical history. Stool antigen for H. pylori (HpSA) was assessed to determine H. pylori status.

RESULTS

In all, 83.3% (45/54) of the children had histopathological evidence of duodenitis. Chronic mild duodenitis was found to be the most prevalent form of duodenitis (53.7%) in the children. Only 8.9% (4/45) of the children with duodenitis had dyspepsia (p < 0.05). The 14.8% (8/54) of the children were found positive for H. pylori infection. Logistic regression analysis revealed children positive for HpSA had significant association with dyspepsia (OR 9.34; 95% CI 1.54-56.80).

CONCLUSIONS

The number of chronic malnourished children suffering from duodenitis was found to be very high. Majority of these children was asymptomatic. Children positive for HpSA had significant association with dyspeptic symptoms.

Duodenal Microbiota in Stunted Undernourished Children with Enteropathy

BACKGROUND

Environmental enteric dysfunction (EED) is an enigmatic disorder of the small intestine that is postulated to play a role in childhood undernutrition, a pressing global health problem. Defining the incidence of this disorder, its pathophysiological features, and its contribution to impaired linear and ponderal growth has been hampered by the difficulty in directly sampling the small intestinal mucosa and microbial community (microbiota).

METHODS

In this study, among 110 young children (mean age, 18 months) with linear growth stunting who were living in an urban slum in Dhaka, Bangladesh, and had not benefited from a nutritional intervention, we performed endoscopy in 80 children who had biopsy-confirmed EED and available plasma and duodenal samples. We quantified the levels of 4077 plasma proteins and 2619 proteins in duodenal biopsy samples obtained from these children. The levels of bacterial strains in microbiota recovered from duodenal aspirate from each child were determined with the use of culture-independent methods. In addition, we obtained 21 plasma samples and 27 fecal samples from age-matched healthy children living in the same area. Young germ-free mice that had been fed a Bangladeshi diet were colonized with bacterial strains cultured from the duodenal aspirates.

RESULTS

Of the bacterial strains that were obtained from the children, the absolute levels of a shared group of 14 taxa (which are not typically classified as enteropathogens) were negatively correlated with linear growth (length-for-age z score, r = -0.49; P = 0.003) and positively correlated with duodenal proteins involved in immunoinflammatory responses. The representation of these 14 duodenal taxa in fecal microbiota was significantly different from that in samples obtained from healthy children (P<0.001 by permutational multivariate analysis of variance). Enteropathy of the small intestine developed in gnotobiotic mice that had been colonized with cultured duodenal strains obtained from children with EED.

CONCLUSIONS

These results provide support for a causal relationship between growth stunting and components of the small intestinal microbiota and enteropathy and offer a rationale for developing therapies that target these microbial contributions to EED. (Funded by the Bill and Melinda Gates Foundation and others; ClinicalTrials.gov number, NCT02812615.).

Cholera and Pancreatic Cholera: Is VIP the Common Pathophysiologic Factor?

Background: Cholera remains a major global health problem, causing high output diarrhea leading to severe dehydration and shock in developing countries. We aimed to determine whether vasoactive intestinal polypeptide (VIP), the mediator of pancreatic cholera syndrome, has a role in the pathophysiology of human cholera. Methods: We conducted a prospective observational study of cholera cases hospitalized with severe dehydration. Plasma and stool water levels of VIP were measured just after admission, after complete rehydration (3–4 h), at 24 h post-rehydration and at discharge after diarrhea ceased. Results: In total, 23 cholera patients were examined between January and August 2018. The geometric mean of stool VIP (sVIP) and plasma VIP (pVIP) on admission were 207.67 and 8.34 pmol/L, respectively. pVIP values were all within the normal range (</= 30 pcmol/L); however, sVIP levels were very high at all timepoints, though less so just after rehydration. In multivariable GEE models, after adjustment for covariates, sVIP levels were significantly associated with duration of hospitalization (p = 0.026), total stool volume (p = 0.023) as well as stool output in the first 24 h (p = 0.013). Conclusions: The data suggest that VIP, which is released by intestinal nerves, may play an important role in human choleragenesis, and inhibitors of intestinal VIP merit testing for potential therapeutic benefits.

Achieving Optimal Gestational Weight Gain, Birth Weight, and Perinatal Outcomes Among Pregnant Women at Risk of Hypertension: Protocol for a Pilot Randomized Controlled Trial

Background

Hypertensive disorders, including preeclampsia, complicate 10% of all pregnancies, causing maternal and fetal morbidity and mortality. In Bangladesh, 24% of all maternal deaths are directly attributed to hypertensive disorders. Conventional antenatal care practices often delay or miss detecting hypertensive disorders in pregnancy, which may allow some women to become vulnerable to the adverse consequences of the hypertensive disorders. Regular self-monitoring of blood pressure and weight gain may improve maternal and fetal outcomes among pregnant women at risk of developing hypertensive disorders during pregnancy through early diagnosis, prompt referral, and timely clinical management; however, to undertake a randomized controlled trial of an intervention to reduce adverse consequences of hypertensive disorders in pregnancy, its feasibility must first be determined.

Objective

The objectives of this study are to evaluate the accuracy of a wearable blood pressure monitoring device (Health Gauge) in order to test the design and methods of a future definitive randomized controlled trial, and to examine the feasibility, acceptability, and fidelity of an intervention focusing on regular monitoring of weight gain and self-monitoring of blood pressure for pregnant women at risk of developing hypertensive disorders and their associated complications.

Methods

The study is located in Matlab, Bangladesh will be conducted in two phases. First, a wearable blood pressure device (Health Gauge) will be validated in accordance with the European Society of Hypertension International Protocol (revision 2010). Second, a prospective, two-arm, parallel, and nonblinded randomized controlled external pilot trial will be conducted. In the pilot trial, 70 eligible participants will be individually randomized to the intervention arm, in which pregnant women will self-monitor their blood pressure daily using a wearable device (Health Gauge) and be evaluated monthly by trained health workers for weight gain from 20 weeks of gestation until delivery, or the control arm, in which pregnant women will be assessed for weight gain every two months from 20 weeks of gestation until delivery (1:1 intervention to control allocation ratio using a permuted block randomization method with concealment). All women will receive standard antenatal care.

Results

A validation study of the wearable blood pressure device has successfully been conducted among the general adult population in Matlab, Bangladesh. As of September 2019, the pilot trial has completed enrollment of women who are pregnant (N=70; intervention: n=35; control: n=35) and follow-up of the participants is ongoing. Data analysis is expected to be completed by June 2020, and results are expected to be submitted for publication in August 2020.

Conclusions

The findings of this study will help us to design a comprehensive, full-scale randomized controlled trial to test the efficacy of regular self-monitoring of blood pressure and weight gain during pregnancy, a simple and inexpensive intervention to help to achieve optimal maternal and fetal outcomes in pregnant women at risk of developing hypertensive disorders and their associated complications during pregnancy.

Trial Registration

ClinicalTrials.gov NCT03858595; https://clinicaltrials.gov/ct2/show/NCT03858595

International Registered Report Identifier (IRRID)

DERR1-10.2196/16676

Helicobacter pylori infection is associated with fecal biomarkers of environmental enteric dysfunction but not with the nutritional status of children living in Bangladesh

Background

Because Helicobacter pylori (H. pylori) infection and Environmental Enteric Dysfunction (EED) follow a similar mode of transmission, there can be a complex interplay between H. pylori infection and EED, both of which can influence childhood growth. We sought to investigate the factors associated with H. pylori infection and identify its relationship with the fecal biomarkers of EED including Myeloperoxidase (MPO), Neopterin (NEO), Calprotectin, Reg1B and Alpha-1 antitrypsin (AAT), and nutritional status of the children.

Methodology

Data from an on-going community-based nutrition intervention study was used for this analysis. Total 319 children aged between 12–18 months were evaluated at enrolment and at the end of a 90-day nutrition intervention. Multivariable linear regression with generalized estimating equations was done to examine the association of H. pylori infection with stool biomarker of EED and nutritional status of the children.

Principal findings

One-fifth of the participants had H. pylori infection at both the time points, with 13.8% overall persistence. Children living in crowded households had higher odds of being infected by H. pylori (AOR = 2.02; 95% CI = 1.02, 4.10; p-value = 0.045). At enrolment, 60%, 99%, 69% and 85% of the stool samples were elevated compared to the reference values set for MPO, NEO, AAT and Calprotectin in the non-tropical western countries. The proportions reduced to 52%, 99%, 67%, and 77% for the same biomarkers after the nutrition intervention. Infection with H. pylori had significant positive association with fecal AAT concentrations (Coefficient = 0.26; 95% CI = 0.02, 0.49; p-value = 0.03) and inverse relationship with Reg1B concentrations measured in the stool samples (Coefficient = -0.32; 95% CI = -0.59, -0.05; p-value = 0.02). However, H. pylori infection was not associated with the indicators of childhood growth.

Conclusions

The study findings affirmed that the acquisition and persistence of H. pylori infection in the early years of life may exert an adverse impact on intestinal health, induce gut inflammation and result in increased intestinal permeability.

Infection with H. pylori, a substantial public health burden in the tropical countries, follows the similar mode of transmission analogous to Environmental Enteric Dysfunction (EED). There can be a complex interplay between H. pylori infection and EED–both of which can influence childhood growth–but the definite role of H. pylori infection contributing to EED and subsequent growth failure is poorly understood. In this study, the authors present data from an ongoing community-based nutrition intervention study and investigated the factors associated with H. pylori infection and identify its relationship with fecal biomarkers of EED and indicators of the nutritional status of the children hailing from a resource-poor urban settlement. They demonstrated the acquisition and persistence of H. pylori infection during early childhood. The study results also corroborate that infection with H. pylori had significant positive association with fecal Alpha-1 antitrypsin concentrations and an inverse relationship with Reg1B concentrations measured in stool samples of the children. The findings revealed in this study may contribute to a better understanding of the role of H. pylori infection in contributing to EED as well as alteration of gut function in the early years of life.

Efficacy of a Green Banana-Mixed Diet in the Management of Persistent Diarrhea: Protocol for an Open-Labeled, Randomized Controlled Trial

Background

Diarrhea is the second-leading cause of death in children under 5 years of age. In low- and middle-income countries, 3%-20% of acute diarrheal episodes become persistent diarrhea (PD) (ie, duration ≥14 days), which results in 36%-56% of all diarrheal deaths. In Bangladesh, PD causes >25% of diarrhea-related deaths. Commensal gut microbiota dysbiosis is increasingly recognized in the pathogenesis of PD. Hospital-based management of PD requires a hospital stay, which increases the risk of infection and hospital costs. The higher cost of treatment and high case-fatality rates reiterate PD as an important public health problem. At the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), for the last two decades, a consensus-based guideline has been followed for PD. Observation has revealed that green banana helps in the resolution of diarrhea. However, no larger prospective study has been conducted to evaluate the efficacy of green banana in the management of PD among children older than 6 months of age.

Objective

Our objective is to assess the efficacy of full-strength rice suji (semolina) with and without green banana compared to three-quarter-strength rice suji in the management of PD in children aged 6-36 months at the Dhaka Hospital of the icddr,b.

Methods

This open-labeled, randomized controlled study aims to enroll a total of 145 children with PD who have not been improving on a diet of milk suji. Children will be randomized into three different diet-specific groups: full-strength rice suji containing green banana, full-strength rice suji alone, and three-quarter-strength rice suji. The primary outcome is the percentage of children who recovered from diarrhea by day 5.

Results

Recruitment and data collection began in December 2017 and were completed in November 2019. Results are expected by April 2020.

Conclusions

This study is expected to provide insights into the incorporation of green banana into the dietary management of PD. This would be the first study to investigate the role of microbiota and metabolomics in the pathogenesis of PD.

Trial Registration

ClinicalTrials.gov NCT03366740; https://clinicaltrials.gov/ct2/show/NCT03366740

International Registered Report Identifier (IRRID)

DERR1-10.2196/15759

Study protocol to assess the impact of an integrated nutrition intervention on the growth and development of children under two in rural Bangladesh

Background

The period from birth to two years is the “critical window” for achieving optimal growth and development. An inadequate quality and quantities of complementary foods, poor child-feeding practices and infection negatively impact the growth of under-twos. Approximately one-third of under-fives in developing countries are stunted; many are also micronutrient deficient. An estimated 6% of mortalities among under-fives can be prevented by ensuring optimal complementary feeding. The objective of the study was to assess the ability of a 12-month integrated nutrition intervention to improve the nutritional status (length-for-age Z-score) of 6 to 12-month-old children in rural Bangladesh.

Methods

In this community-based randomized controlled trial, the intervention group received a package of interventions that includes, food vouchers; to prepare egg-based nutritious snacks (suji firni for < 1-year-olds, suji halwa for > 1-year-olds), micronutrient powder to fortify children’s food at home, child feeding counselling and water, sanitation and hygiene (WASH), behaviour change communication. The control group received routine health messages provided by the government. Baseline and endline surveys were conducted; Data collection was performed monthly on children’s growth, food voucher utilization, child feeding and morbidity. In addition, we assessed the cognitive development of the children after 12 months of intervention.

Conclusion

This trial aims to explore whether an integrated nutrition intervention can mitigate childhood stunting during the critical window of opportunity in rural Bangladesh. The results may provide robust evidence to improve the linear growth of children in developing countries.

Trial registration

The study was retrospectively registered on August 17, 2018 and is available online at ClinicalTrials.gov (ID: NCT02768181).

Impact of Small Intestine Bacterial Overgrowth on Response to a Nutritional Intervention in Bangladeshi Children from an Urban Community

Small intestine bacterial overgrowth (SIBO) is prevalent among children living in low-income settings, leading to impaired growth and development. The aim of this study was to assess linear and ponderal growth parameters between malnourished SIBO-positive and SIBO-negative children aged 12-18 months who prospectively underwent a nutritional intervention. A glucose hydrogen breath test to detect SIBO was performed in 194 stunted (length-for-age Z score [LAZ] < -2 standard deviations) or at-risk of stunting (LAZ score between < -1 and -2 standard deviations) children. Participants received nutritional supplementation (egg and milk) in addition to their regular family meals 6 days per week for 90 days. Small intestine bacterial overgrowth was defined as a ≥ 12-ppm rise in breath hydrogen over the patient's baseline during the 3-hour test. Small intestine bacterial overgrowth status before intervention was forced into a multivariable linear regression model to examine its effects on anthropometric changes in response to the intervention. Sociodemographic data at enrollment was analyzed through multivariable logistic regression in an attempt to predict SIBO positivity. Overall, 14.9% (29/194) children were diagnosed with SIBO before the nutritional intervention. No statistically significant difference was observed among SIBO-positive and SIBO-negative groups in terms of their response to the nutritional intervention (SIBO-positive coefficient [95% confidence interval (CI)], P-value for ∆length-for-age Z score -0.003 [-0.14, 0.13], 0.96; ∆weight-for-age Z score -0.05 [-0.20, 0.09], 0.46; and ∆weight-for-length Z score -0.10 [-0.31, 0.10], 0.33). This study demonstrated that a noteworthy proportion of malnourished children living in a disadvantaged urban community were SIBO positive; however, it failed to reveal an association between SIBO status and response to nutritional intervention.

Effects of microbiota-directed foods in gnotobiotic animals and undernourished children

To examine the contributions of impaired gut microbial community development to childhood undernutrition, we combined metabolomic and proteomic analyses of plasma samples with metagenomic analyses of fecal samples to characterize the biological state of Bangladeshi children with severe acute malnutrition (SAM) as they transitioned, after standard treatment, to moderate acute malnutrition (MAM) with persistent microbiota immaturity. Host and microbial effects of microbiota-directed complementary food (MDCF) prototypes targeting weaning-phase bacterial taxa underrepresented in SAM and MAM microbiota were characterized in gnotobiotic mice and gnotobiotic piglets colonized with age- and growth-discriminatory bacteria. A randomized, double-blind controlled feeding study identified a lead MDCF that changes the abundances of targeted bacteria and increases plasma biomarkers and mediators of growth, bone formation, neurodevelopment, and immune function in children with MAM.

Impact of Routine Counseling on Breastfeeding Status in Hospitalized Infants Below 6 Months: Observation From a Large Diarrheal Disease Hospital in Bangladesh

Background. Breastfeeding counseling (BFC) plays a crucial role in improving infant and young child feeding practices. To evaluate the impact of activities of BFC unit (BFCU) on breastfeeding practices of infants who were hospitalized for diarrheal illness through their regular counseling, assistance and support, and motivation. Methods. In this retrospective chart analysis conducted at Dhaka Hospital of icddr,b using an electronic database, data were collected from mothers of infants younger than 6 months of age who visited the BFCU from 2011 to 2015. Results. Among a total of 3420 infants enrolled during study period, 429 (12.5%) were predominantly breastfed, 2457 (71.8%) partially breastfed, 531 (15.5%) non-breastfed, and 3 (0.1%) exclusively breastfed (EBF) at home. Through counseling of BFCU (following 24-hour recall technique), 2212 (65%) infants became EBF and 1186 (35%) failed to be EBF during discharge. Logistic regression analysis after adjusting for potential covariates, such as maternal age <18 years and receiving breast milk with other liquid at home, revealed that infants having severe underweight, maternal perception of “baby does not suck,” and “there is not enough milk” were less likely to be associated with EBF during discharge. Among 531 non-breastfed infants, 455 (85.7%) became partial breastfeeding and only 23 (4.3%) became EBF. Conclusion. Counseling of mothers even during acute illness of infants in the hospital can help promote breastfeeding. Therefore, there is great importance of robust counseling on breastfeeding practices and may help establish re-lactation of acutely ill babies.

Screening for coeliac disease in children and adults living in a slum of Dhaka, Bangladesh

Background and objective

Serological screening with a confirmation through biopsy has improved the understanding of coeliac disease (CD) epidemiology worldwide. Prevalence of CD in Bangladesh is not yet explored and therefore, we aimed to assess the seroprevalence of CD in slum-dwelling malnourished children and adults in Dhaka.

Methods

Serum samples were collected from three different cohorts: stunted (length-for-age Z-scores (LAZ) <−2) and at risk of stunting children (LAZ <−1 to −2) and malnourished adults (body mass index <18.5 kg/m²). Samples from all the participants were assessed for anti-tissue transglutaminase antibody (tTG-IgA) and total serum IgA by ELISA. Positive tTG-IgA and randomly selected low IgA values were reconfirmed using anti-tTG-IgG and gliadin IgG ELISA. CD was diagnosed when second screening tests were found positive and the participants were further investigated by small bowel biopsy.

Results

A total of 818 participants (240 stunted, 272 at risk of stunting children and 306 malnourished adults) were enrolled in the study. Overall, anti-tTG-IgA was positive in 5/818 (0.6%; 95% CI 0.25% to 1.46%). Of the five positive cases, anti-tTG-IgG and gliadin IgG were found positive in only one participant. Duodenal biopsy of positive participant revealed characteristic lesions of CD. Randomly selected low IgA values were found negative in tTG-IgG and gliadin IgG for all the participants. No participant was found total IgA deficient.

Conclusion

The incidence of coeliac autoimmunity is low in malnourished slum dwellers regardless of age in Bangladesh. It is important to investigate the nationwide prevalence to reveal the definite picture.

Long-Term Gastrointestinal Consequences are Frequent Following Sporadic Acute Infectious Diarrhea in a Tropical Country: A Prospective Cohort Study

BACKGROUND

Postinfection irritable bowel syndrome (PI-IBS) and functional dyspepsia (PI-FD), though reported from the temperate countries, have not been studied in the tropics; PI-malabsorption syndrome (MAS), which mimics PI-IBS, is reported from the tropics. No report till date on PI-IBS excluded PI-MAS. We studied: (i) the frequency of continuing bowel dysfunction after acute gastroenteritis (AG), (ii) its predictors, and (iii) PI-MAS among patients with PI-IBS.

METHODS

345 consecutive subjects each, with AG and age- and gender-matched healthy controls were followed up 3-monthly for 12 months using a translated-validated questionnaire and functional gastrointestinal disorders (FGIDs) were diagnosed by Rome III criteria. Symptom duration >3 months but <6 months was diagnosed as chronic bowel dysfunction (CBD) and dyspeptic symptoms, respectively. MAS was diagnosed if 2/3 tests (D-xylose H₂ breath test, Sudan III-stained stool microscopy, and duodenal histology) were abnormal. Fecal microbiological studies were performed in 245/345 (71%) patients.

RESULTS

AG patients more often developed PI-IBS and PI-FD than controls (16.5 vs. 2.6% and 7.4 vs. 0.6%, respectively; p<0.001). Presence of FD was a risk factor for PI-IBS and IBS for PI-FD. On multivariate analysis, dyspeptic symptoms, CBD, and weight loss were the risk factors for PI-FGIDs. The frequency of PI-IBS following Vibrio cholera and other bacterial infection was comparable. Malabsorption was present among 2/23 (9%) patients with PI-IBS.

CONCLUSION

FGIDs are common after AG; dyspeptic symptoms, CBD, and weight loss were risk factors for PI-FGIDs. Vibrio cholerae infection caused PI-FGID, which was never reported. About 9 % patients fulfilling the criteria for PI-IBS had PI-MAS.

Transferring knowledge into practice: a multi-modal, multi-centre intervention for enhancing nurses' infection control competency in Bangladesh

BACKGROUND

Nurses are considered as the key to infection prevention as they play a major role in treatment as well as taking care of patients.

AIM

To assess the role of a multi-modal intervention (MMI) in improving nurses' competency and adherence to standard infection control practices in Bangladesh.

METHODS

The study adopted a pretest-post-test intervention approach, in three different periods (from 2012 to 2017) in five hospitals (two public, two private, and one autonomous) in Bangladesh. Each study period was divided into three phases: pretest, MMI, and post-test. Data were collected on 642 nurses using direct observation method through a structured checklist.

FINDINGS

After implementing the MMI, overall hand hygiene compliance significantly increased before patient contact (from 1.3% to 50.2%; P < 0.000) and after patient contact (from 2.8% to 59.6%; P < 0.000). Remarkable improvements were also achieved in adherence to use of gloves (from 14.6% to 57.6%; P < 0.000), maintaining sterility of equipment during aseptic techniques (from 34.9% to 86%; P < 0.000), biomedical waste segregation (from 1.8% to 81.3%; P < 0.000) and labelling of procedural sites (from 0% to 85.7%; P < 0.000). Moreover, needlestick injury rate notably decreased (from 6.2% to 0.6%; P < 0.000).

CONCLUSION

MMI can play a vital role in improving nurses' compliance with the standard infection control practices. Such context-specific interventions, which are crucial for preventing healthcare-associated infections and for decreasing occupational hazards, should be replicated in resource-poor countries for achieving universal health coverage by 2030.

The management of persistent diarrhoea at Dhaka Hospital of the International Centre for Diarrhoeal Disease and Research: a clinical chart review

BACKGROUND

Persistent diarrhoea (PD) is poorly recognised and it requires proper assessment and early intervention to ensure effective treatment. The International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) has been managing children with PD for more than two decades. This review focuses on different aspects of the management of PD in a hospital setting.

AIM

To estimate the prevalence, socio-demographic and clinical characteristics, treatment outcome and hospital course in under-5 children with persistent diarrhoea (PD).

METHODS

The hospital records of all children under 5 years admitted with PD to Dhaka Hospital of the International Centre for Diarrhoeal Disease Research between January 2012 and December 2013 were reviewed. Data were retrieved from the hospital's electronic database.

RESULTS

Of 8638 children under 5 years of age admitted with diarrhoea, 551 (6.4%) had PD and one-third had developed PD during their hospital stay. The incidence of PD was highest (228, 41.4%) in summer (April-June). Half (51%) of the children with PD had dehydration on admission. Fifty-seven (10.3%) had never been breastfed, 138 (25.1%) were severely wasted and 21 (3.8%) had bipedal oedema. Following the steps of a dietary algorithm, 224 (40.6%) patients responded to a milk-based low-lactose diet, 235 (42.6%) to a lactose-, sucrose- and milk-free diet, 48 (8.7%) to a comminuted chicken and glucose-based diet, 41 (7.4%) to exclusive breastfeeding, and 3 (0.5%) required a partially hydrolysed, semi-elemental diet. Major stool pathogens were Campylobacter species (23/59, 39%), Salmonella (10/59, 16.9%) and Shigella (10/59, 16.9%). The overall recovery rate from PD was 95.6% (527/551) and the duration of treatment until resolution of diarrhoea was 6 (3-9) days. The case-fatality rate was 2% (11/551).

CONCLUSION

Persistent diarrhoea remains an important public health problem in children under-5 in Bangladesh. Algorithm-based dietary management with simple clinical guidelines was effective in most cases. This treatment is appropriate in low-income settings where resources are limited.

Treatment outcome of children with persistent Diarrhoea admitted to an Urban Hospital, Dhaka during 2012-2013

BACKGROUND

Despite availability of treatment guidelines, persistent diarrhoea (PD) has been a major contributor of diarrhoeal deaths in low and middle income countries. We evaluated the outcome of children under the age of 5 years who were treated for PD using management algorithm with locally available foods in a diarrhoeal disease hospital in Dhaka.

METHODS

We extracted retrospective data from electronic database for all the under-five children admitted for PD in the Longer Stay Ward and Intensive Care Unit of the Dhaka hospital at icddr,b between 2012 and 2013. Descriptive analysis was done to explore available baseline socio-demographic, nutritional, and co-morbid statuses, pathogens from stool isolates, duration of treatment, use of antibiotics, duration of hospital stay and treatment success rates. We sought to investigate above mentioned descriptive features in addition to associated factors with time to recover from PD using survival analysis with Cox proportional hazard model.

RESULTS

A total number of 426 children with a median age of 7.46 (inter-quartile range IQR; 5.39, 9.43) months were admitted for PD during the study period. Of these, 95% of children were recovered from PD and discharged from the hospital. The median duration of treatment response was 6 (IQR 4, 9) days. The case fatality rate was 1.17%. Multivariate analysis among the children of 6 months or less showed that the rate of recovery from PD was 57% lower in children with severe stunting compared to those without severe stunting (HR 0.43, 95% CI 0.22, 0.88, p < 0.05), 42% lower in children with severe wasting (HR 0.58, 95% CI 0.36, 0.95, p < 0.05), and 81% reduced in children who developed hospital acquired infection (HAI) compared to those without HAI (HR 0.19, 95% CI 0.06, 0.62, p < 0.05). Among the children who were more than 6 months old, age in months (HR 1.05, 95% CI 1.02, 1.09) and female gender (HR 1.41, 95% CI 1.09, 1.84) had better rates of recovery from PD (p < 0.05). Moreover, among children more than 6 months of age, HAI (HR 0.44, 95% CI 0.26, 0.75), and antibiotic use (HR 0.40, 95% CI 0.28, 0.56) were associated with impeded recovery rates from PD (p < 0.05).

CONCLUSION

The treatment guideline for persistent diarrhoea patients followed at icddr,b Dhaka hospital was found to be successful and can be used in other treatment facilities of Bangladesh and other developing countries where any treatment algorithm for PD is unavailable. More emphasis is required to be given for the prevention of hospital acquired infection that may help to limit the use of antibiotic in order to enhance the recovery rate from PD.

Results with Complementary Food Using Local Food Ingredients

Appropriate complementary food is a must for optimum growth of infants and children. The food should be diverse and be given in sufficient quantities 2-4 times a day depending upon age. Poverty, food insecurity, and lack of awareness regarding the choice of nutritious food ingredients are deterrents to optimum complementary feeding. In Bangladesh, 77% of children do not receive appropriate complementary food and, hence, the high prevalence of childhood malnutrition. We developed ready-to-use complementary foods (RUCFs) using locally available food ingredients, rice/lentil and chickpea, which conform to standard specifications. These foods were found to be acceptable by children and their mothers compared to the Pushti packet, the cereal-based supplement used in the erstwhile National Nutrition Program of Bangladesh. In a cluster-randomized community-based trial in rural Bangladesh among more than 5,000 children, the efficacy of rice/lentil- and chickpea-based RUCFs was compared with another commonly used supplementary food called wheat-soy blend++ (WSB++) and a commercial product called Plumpy'doz. Deceleration in length for age was significantly lower (by 0.02-0.04/month) in the rice/lentil, Plumpy'doz, and chickpea groups compared to the control group at 18 months of age. Weight-for-length z-score decline was lower only in Plumpy'doz and chickpea groups. WSB++ was not different from the control group. In children who received chickpea RUCF or Plumpy'doz, the prevalence of stunting was 5-6% lower at 18 months. These foods can be used to prevent or treat malnutrition among children, particularly those from food-insecure households.

Evaluation of a Smartphone Decision-Support Tool for Diarrheal Disease Management in a Resource-Limited Setting

The emergence of mobile technology offers new opportunities to improve clinical guideline adherence in resource-limited settings. We conducted a clinical pilot study in rural Bangladesh to evaluate the impact of a smartphone adaptation of the World Health Organization (WHO) diarrheal disease management guidelines, including a modality for age-based weight estimation. Software development was guided by end-user input and evaluated in a resource-limited district and sub-district hospital during the fall 2015 cholera season; both hospitals lacked scales which necessitated weight estimation. The study consisted of a 6 week pre-intervention and 6 week intervention period with a 10-day post-discharge follow-up. Standard of care was maintained throughout the study with the exception that admitting clinicians used the tool during the intervention. Inclusion criteria were patients two months of age and older with uncomplicated diarrheal disease. The primary outcome was adherence to guidelines for prescriptions of intravenous (IV) fluids, antibiotics and zinc. A total of 841 patients were enrolled (325 pre-intervention; 516 intervention). During the intervention, the proportion of prescriptions for IV fluids decreased at the district and sub-district hospitals (both p < 0.001) with risk ratios (RRs) of 0.5 and 0.2, respectively. However, when IV fluids were prescribed, the volume better adhered to recommendations. The proportion of prescriptions for the recommended antibiotic azithromycin increased (p < 0.001 district; p = 0.035 sub-district) with RRs of 6.9 (district) and 1.6 (sub-district) while prescriptions for other antibiotics decreased; zinc adherence increased. Limitations included an absence of a concurrent control group and no independent dehydration assessment during the pre-intervention. Despite limitations, opportunities were identified to improve clinical care, including better assessment, weight estimation, and fluid/ antibiotic selection. These findings demonstrate that a smartphone-based tool can improve guideline adherence. This study should serve as a catalyst for a randomized controlled trial to expand on the findings and address limitations.

Diarrhea-associated pneumococcal meningitis with complicating hydrocephalus in a child in a resource-limited setting

INTRODUCTION

Streptococcus pneumonia is the most common and intimidating cause of childhood meningitis. Its delayed diagnosis may be associated with hyponatremia and hypernatremia with fatal outcome.

CASE PRESENTATION

A previously healthy nine-month-old Bangladeshi female infant was diagnosed with diarrhea, pneumonia, and convulsion due to hypernatremia. Pneumonia was confirmed by respiratory distress and radiological findings. Routine cerebrospinal fluid study detected pneumococcal meningitis. Ampicillin, gentamicin, and dexamethasone were promptly started. On day three of hospitalization, convulsion re-appeared with worsening of consciousness level. Antibiotics were switched to ceftriaxone and vancomycin, although ultrasonography of the brain revealed no abnormality. Contrast-enhanced computed tomography scan of the head was performed and revealed dilated ventricles with diffused enhancement of meninges and basal cisterns, demonstrating meningitis with ventriculomegaly. Ceftriaxone was replaced by meropenem to control fever. Magnetic resonance imaging (MRI) of the brain confirmed the progression of hydrocephalus. An emergency ventriculo-peritoneal (VP) shunt operation was performed with continuation of antibiotics for 21 days. After three months, follow-up MRI showed reduction of ventricular size with functioning VP shunt in situ with no neurological deficits.

CONCLUSIONS

Childhood pneumococcal meningitis may be associated with diarrhea, pneumonia, and other related complication. Appropriate antibiotic therapy alone may not be sufficient to avert complications. Communicating hydrocephalus is potentially an ominous ramification of meningitis even when the ultrasonography result is normal. Rapid diagnosis is imperative to attain good outcome. Evidence advocates further research into the risk factors of meningitis in diarrheal children that may help in early diagnosis and management to reduce meningitis-related fatal outcome.

Hypernatremia in Children With Diarrhea: Presenting Features, Management, Outcome, and Risk Factors for Death

We sought to investigate the magnitude, clinical features, treatment, and outcome of children suffering from hypernatremic diarrhea and to identify risk factors for fatal outcome among them. We reviewed 2 data sets of children <15 years admitted to the in-patient ward of the Dhaka Hospital of International Centre for Diarrhoeal Disease Research, Bangladesh (icddr, b) with diarrhea and hypernatremia (serum sodium ≥150 mmol/L): (a) March 2001 to March 2002 (n = 371) and (b) March 2009 to August 2011 (n = 360). We reviewed their records and collected relevant information for analyses. The prevalence of hypernatremia was 5.1% (371/7212) and 2.4% (360/15 219), case fatality rate was 15% and 19%, respectively. In logistic regression analysis, the risk for death significantly increased in association with serum sodium ≥170 mmol/L, nutritional edema, hypoglycemia, respiratory distress, and absent peripheral pulses and reduced with the sole use of oral rehydration salts (ORS) or ORS following intravenous fluid, if indicated (for all, P < .05). Thus, managing children with hypernatremia using only ORS or ORS following intravenous fluid may help reduce the number of deaths.

Oral Phage Therapy of Acute Bacterial Diarrhea With Two Coliphage Preparations: A Randomized Trial in Children From Bangladesh

Background

Antibiotic resistance is rising in important bacterial pathogens. Phage therapy (PT), the use of bacterial viruses infecting the pathogen in a species-specific way, is a potential alternative.

Method

T4-like coliphages or a commercial Russian coliphage product or placebo was orally given over 4 days to Bangladeshi children hospitalized with acute bacterial diarrhea. Safety of oral phage was assessed clinically and by functional tests; coliphage and Escherichia coli titers and enteropathogens were determined in stool and quantitative diarrhea parameters (stool output, stool frequency) were measured. Stool microbiota was studied by 16S rRNA gene sequencing; the genomes of four fecal Streptococcus isolates were sequenced.

Findings

No adverse events attributable to oral phage application were observed (primary safety outcome). Fecal coliphage was increased in treated over control children, but the titers did not show substantial intestinal phage replication (secondary microbiology outcome). 60% of the children suffered from a microbiologically proven E. coli diarrhea; the most frequent diagnosis was ETEC infections. Bacterial co-pathogens were also detected. Half of the patients contained phage-susceptible E. coli colonies in the stool. E. coli represented less than 5% of fecal bacteria. Stool ETEC titers showed only a short-lived peak and were otherwise close to the replication threshold determined for T4 phage in vitro. An interim analysis after the enrollment of 120 patients showed no amelioration in quantitative diarrhea parameter by PT over standard care (tertiary clinical outcome). Stool microbiota was characterized by an overgrowth with Streptococcus belonging to the Streptococcus gallolyticus and Streptococcus salivarius species groups, their abundance correlated with quantitative diarrhea outcome, but genome sequencing did not identify virulence genes.

Interpretation

Oral coliphages showed a safe gut transit in children, but failed to achieve intestinal amplification and to improve diarrhea outcome, possibly due to insufficient phage coverage and too low E. coli pathogen titers requiring higher oral phage doses. More knowledge is needed on in vivo phage–bacterium interaction and the role of E. coli in childhood diarrhea for successful PT.

Funding

The study was supported by a grant from Nestlé Nutrition and Nestlé Health Science. The trial was registered with Identifier NCT00937274 at ClinicalTrials.gov.

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Coliphages given orally to children with bacterial diarrhea appeared in the stool, but did not improve clinical outcome.

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In microbiologically diagnosed E. coli diarrhea, pathogen titers were close to the replication threshold of coliphages.

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Acute bacterial diarrhea displayed a marked dysbiosis with fecal streptococci that stabilized with recovery from diarrhea.

Antibiotic resistance of bacterial infections reached alarming levels. Phage therapy is a potential alternative antimicrobial. We demonstrated that two different oral phage preparations did not improve acute bacterial diarrhea in children from Bangladesh. We observed fecal excretion of the oral phage, but no major phage amplification in the gut. E. coli pathogen levels were low and the fecal microbiota showed a transient overgrowth with streptococci. Future phage trials should first verify the titer and association of the targeted pathogen with the disease.

Bacterial Isolates from Tracheal Aspirates and their Anti-microbial Susceptibility in Mechanically-Ventilated Children with Pneumonia Admitted to an Urban Critical Care Ward

Background and Aims: Data on Bacterial isolates from tracheal aspirates in children with severe pneumonia requiring intubation and mechanical ventilation especially in developing countries are very limited. We examined the microbial spectrum of bacteria isolated from tracheal aspirate of those children. The antibiotic susceptibility profiles of those bacteria were also examined.Methods: We evaluated the data of all mechanically ventilated children aged 0-59 months admitted to Intensive Care Unit (ICU) of “Dhaka Hospital” of the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) between August 2009 and July 2013 having their tracheal aspirate culture done. Data were extracted from electronic medical records of the Dhaka Hospital.Results: Among 836 admitted pneumonia children in the ICU, we identified 35 children who fulfilled the inclusion criteria. Among them 34 (97%) had positive bacterial growths: Klebseilla species in 14 (40%), Escherichia coli in 11 (31%), Acinetobacter in 8 (23%) and Streptococcus species in 8 (23%). Additionally, Enterococcus, Staphylococcus aureus, Pseudominas and Proteus species were identified in 6 (17%), 4 (11%), and 2 (6%) of the children respectively. The susceptibility of the gram-negatives, except Klebseilla, to ampicillin, cotrimoxazole, gentamycin, ciprofloxacin, azithromycin, and ceftriaxone ranged from 0- 54%, while that for ceftazidime and amikacin ranged from 12-80%. The sensitivity of Klebseilla to these antibiotics ranged from 0-100%.Conclusions: Our data suggests that gram-negative bacteria, Klebseilla followed by Escherichia coli, and Acenetobacter are the predominant bacteria associated with severe pneumonia in ventilated children. The increased number of infections caused by Gram-negative bacteria is being accompanied by rising rates of multi-drug resistance which underscores the importance of aggressive antimicrobial therapy in the management of such children.Bangladesh Crit Care J September 2014; 2 (2): 60-64

Extreme hypernatremic dehydration due to potential sodium intoxication: consequences and management for an infant with diarrhea at an urban intensive care unit in Bangladesh: a case report

Introduction

Hypernatremia (serum sodium ≥150mmol/L) is one of the most life-threatening complications of childhood diarrhea, and its management remains challenging, even in a highly advanced critical care setting. This case report describes the acute clinical course and 3-month neurological follow-up after discharge of an infant with extreme hypernatremia in an intensive care unit in Dhaka, Bangladesh.

Case presentation

A 6-month-old Asian Bangladeshi girl of middle-class socioeconomic status was admitted to the intensive care unit of our institution in 2012 with acute watery diarrhea, lethargy and hypernatremia (208mmol/L serum sodium). She had a history of taking excess oral rehydration salt: five packets each, inappropriately prepared, rice-based, properly diluted, glucose-based oral rehydration salt. Her hypernatremia was treated exclusively with oral rehydration salt solution. She experienced seizures on the third day of her hospitalization and was treated with anticonvulsant drugs. Later in the course of her hospitalization, Enterobacter spp bacteremia was detected and successfully treated with ciprofloxacin. Although magnetic resonance imaging of her brain at discharge showed cerebral edema, brain magnetic resonance imaging appeared normal at a follow-up examination 3 months after discharge. Electroencephalograms taken at discharge and at her 3-month follow-up examination also appeared normal.

Conclusions

Successful management of extreme hypernatremia with only oral rehydration salt did not result in observable neurological consequences, which emphasizes the importance of the use of oral rehydration salt for the clinical management of childhood hypernatremia.

Safety analysis of a Russian phage cocktail: from metagenomic analysis to oral application in healthy human subjects

Phage therapy has a long tradition in Eastern Europe, where preparations are comprised of complex phage cocktails whose compositions have not been described. We investigated the composition of a phage cocktail from the Russian pharmaceutical company Microgen targeting Escherichia coli/Proteus infections. Electron microscopy identified six phage types, with numerically T7-like phages dominating over T4-like phages. A metagenomic approach using taxonomical classification, reference mapping and de novo assembly identified 18 distinct phage types, including 7 genera of Podoviridae, 2 established and 2 proposed genera of Myoviridae, and 2 genera of Siphoviridae. De novo assembly yielded 7 contigs greater than 30 kb, including a 147-kb Myovirus genome and a 42-kb genome of a potentially new phage. Bioinformatic analysis did not reveal undesired genes and a small human volunteer trial did not associate adverse effects with oral phage exposure.

Oral T4-like phage cocktail application to healthy adult volunteers from Bangladesh

The genomic diversity of 99 T4-like coliphages was investigated by sequencing an equimolar mixture with Illumina technology and screening them against different databases for horizontal gene transfer and undesired genes. A 9-phage cocktail was given to 15 healthy adults from Bangladesh at a dose of 3×10(9) and 3×10(7) plaque-forming units and placebo respectively. Phages were detected in 64% of the stool samples when subjects were treated with higher titer phage, compared to 30% and 28% with lower-titer phage and placebo, respectively. No Escherichia coli was present in initial stool samples, and no amplification of phage was observed. One percent of the administered oral phage was recovered from the feces. No adverse events were observed by self-report, clinical examination, or from laboratory tests for liver, kidney, and hematology function. No impact of oral phage was seen on the fecal microbiota composition with respect to bacterial 16S rRNA from stool.

Efficacy of partially hydrolyzed guar gum-added oral rehydration solution in the treatment of severe cholera in adults

BACKGROUND

Partially hydrolyzed guar gum (PHGG) is a water-soluble fiber if added to oral rehydration solution (ORS) and undergoes fermentation in the colon liberating short chain fatty acids (SCFAs). SCFAs potentiate the effect of ORS, reducing the severity of diarrhea.

AIM

To examine the effect of PHGG-added ORS in reducing the stool output and duration of diarrhea in adult cholera.

METHODS

195 male patients were studied in a randomized controlled trial: (a) 65 received ORS + 25 g PHGG; (b) 65 received ORS + 50 g PHGG, and (c) 65 received ORS alone (control). Major outcomes were stool weight and duration of diarrhea.

RESULTS

No significant differences were found in mean +/- SD stool weight (g/kg b.w.) during the first and second 24 h. In the subgroup analysis (excluding very high purging patients, stool weight in the first 24 h was >10 kg), the stool weight (g/kg b.w.) was significantly reduced in the first 24 h in both groups receiving PHGG (PHGG 25 g, 136 +/- 68 vs. PHGG 50 g, 144 +/- 49 vs. control, 176 +/- 43, p = 0.01).

CONCLUSION

PHGG-added ORS might have a beneficial effect in moderately purging adult cholera. However, further studies are warranted to confirm the preliminary findings.

Evidence of intra-familial transmission of Helicobacter pylori by PCR-based RAPD fingerprinting in Bangladesh

Helicobacter pylori is a genetically diverse bacterial species, which has facilitated adaptation to new hosts and persists worldwide. The main objective of this study was to explore intra-familial transmission of H. pylori in Bangladesh. We characterized H. pylori in 35 families including 138 family members using random amplified polymorphic DNA (RAPD) fingerprinting. Forty-six percent of H. pylori isolated from the mother shared a related genotype with strains isolated from their children. Twenty-nine percent of H. pylori isolates of the mother are related to the youngest children. Only 6% of the parents shared related genotype of H. pylori. These findings suggest that mother-to-child transmission occurs in early childhood and is the most probable route of transmission of H. pylori in Bangladesh.

Micronutrients and anaemia

Micronutrient deficiencies and anaemia remain as major health concerns for children in Bangladesh. Among the micronutrient interventions, supplementation with vitamin A to children aged less than five years has been the most successful, especially after distribution of vitamin A was combined with National Immunization Days. Although salt sold in Bangladesh is intended to contain iodine, much of the salt does not contain iodine, and iodine deficiency continues to be common. Anaemia similarly is common among all population groups and has shown no sign of improvement even when iron-supplementation programmes have been attempted. It appears that many other causes contribute to anaemia in addition to iron deficiency. Zinc deficiency is a key micronutrient deficiency and is covered in a separate paper because of its importance among new child-health interventions.

Reduction in morbidity of rotavirus induced diarrhoea in mice by yeast produced monovalent llama-derived antibody fragments

Apart from the use of oral rehydration solution, there are currently no treatment modalities for rotavirus induced diarrhoea, which is particularly relevant to developing countries. Fragments derived from llama heavy chain antibodies were previously shown to be highly stable, efficiently produced in yeast and exhibiting high epitope specific affinity. We now aim to demonstrate that these antibody fragments are capable of reducing morbidity of rotavirus induced diarrhoea. Here we show the isolation of rotavirus specific antibody fragments and their capability of reducing the morbidity of rotavirus induced diarrhoea in vivo in mice. They could provide a treatment modality for the moderation of human rotavirus infections having a significant impact on the course of an often fatal childhood disease.

Low osmolar oral rehydration salts solution in the treatment of acute watery diarrhoea in neonates and young infants: a randomized, controlled clinical trial

To compare the efficacy and safety of low osmolar oral rehydration salts solution (ORS-75) (mmol/L: Na+ 75, osmolarity 245) with that of World Health Organization-recommended ORS (ORS-90) (mmol/L: Na+ 90, osmolarity 311 ) in the treatment of acute watery diarrhoea in neonates and very young infants, a randomized double-blind, controlled clinical trial was carried out at the Clinical Research and Service Centre of ICDDR,B: Centre for Health and Population Research, Dhaka, Bangladesh, during January 1998-December 1999. Infants, aged < or = 2 months, presenting with a history of watery diarrhoea of < or = 72 hours, with no or some dehydration and without any systemic illness, were randomly assigned to receive either ORS-75 or ORS-90 for the correction and subsequent prevention of dehydration. Infants were studied for a maximum of five days. Total stool output, stool frequency, and requirement for ORS were outcome measures. Serum electrolytes were measured at 24 hours after admission to monitor serum sodium imbalance. Seventy-three infants received ORS-75, and 71 received ORS-90. Both the groups were comparable in their baseline characteristics. Diarrhoea resolved within five days in 53% and 66% of infants receiving ORS-75 and ORS-90 respectively (p = 0.3). Total stool volume [median (inter-quartile range) 132 (65-280) vs 139 (70-259) g/kg, p = 0.9], during the study period, was not significantly different between the two groups. Total stool frequency [31 (16-51) vs 35 (16-53), p = 0.9] and total ORS intake [192 (96-374) vs 209 (134-317) mL/kg, p = 0.7] were similar between the groups. No infants developed late evidence of hypernatraemia, irrespective of treatment. The results of the study indicate that ORS-75 is as safe as standard ORS-90 in the treatment of acute watery diarrhoea in neonates and very young infants and is effective in correcting and preventing dehydration.

High prevalence of cagA and vacA seropositivity in asymptomatic Bangladeshi children with Helicobacter pylori infection

AIM

To evaluate the prevalence of antibodies against two major markers of virulence of Helicobacter pylori--cytotoxin-associated gene A (cagA) and the vacuolating cytotoxin gene (vacA)--among children in a peri-urban community of Bangladesh, and to evaluate Western blot (WB) assay for detection of H. pylori infection diagnosed by 13C urea breath test (UBT) in such children.

METHODS

One hundred and eighty-two children aged 18-60 mo, of the peri-urban community of Dhaka, were screened for H. pylori infection using UBT, and the serum samples were analysed for antibody against cagA and vacA by Western blot.

RESULTS

The overall prevalence of H. pylori infection by 13C-urea breath test was 80%. The seroprevalence of cagA with or without vacA, vacA with and without cagA, and both cagA and vacA were 82%, 82% and 81%, respectively. Among children with a positive UBT, 95% were seropositive for both cagA and vacA, indicating that the products of these genes are frequently co-expressed in H. pylori infection in this community. The sensitivity, specificity, positive and negative predictive value of the Western blot test for H. pylori infections, compared to UBT, were 94%, 68%, 92% and 76%, respectively.

CONCLUSION

Compared to UBT, Western blot test is reliable for the detection of H. pylori infection. The high seroprevalence of cagA- and vacA-positive virulent H. pylori strains in an asymptomatic paediatric population indicate that such strains are common in this population and may cause characteristic H. pylori infection in Bangladesh.

High prevalence of cagA and vacA seropositivity in asymptomatic Bangladeshi children with Helicobacter pylori infection

AIM

To evaluate the prevalence of antibodies against two major markers of virulence of Helicobacter pylori--cytotoxin-associated gene A (cagA) and the vacuolating cytotoxin gene (vacA)--among children in a peri-urban community of Bangladesh, and to evaluate Western blot (WB) assay for detection of H. pylori infection diagnosed by 13C urea breath test (UBT) in such children.

METHODS

One hundred and eighty-two children aged 18-60 mo, of the peri-urban community of Dhaka, were screened for H. pylori infection using UBT, and the serum samples were analysed for antibody against cagA and vacA by Western blot.

RESULTS

The overall prevalence of H. pylori infection by 13C-urea breath test was 80%. The seroprevalence of cagA with or without vacA, vacA with and without cagA, and both cagA and vacA were 82%, 82% and 81%, respectively. Among children with a positive UBT, 95% were seropositive for both cagA and vacA, indicating that the products of these genes are frequently co-expressed in H. pylori infection in this community. The sensitivity, specificity, positive and negative predictive value of the Western blot test for H. pylori infections, compared to UBT, were 94%, 68%, 92% and 76%, respectively.

CONCLUSION

Compared to UBT, Western blot test is reliable for the detection of H. pylori infection. The high seroprevalence of cagA- and vacA-positive virulent H. pylori strains in an asymptomatic paediatric population indicate that such strains are common in this population and may cause characteristic H. pylori infection in Bangladesh.

Partially hydrolysed guar gum supplemented comminuted chicken diet in persistent diarrhoea: a randomised controlled trial

BACKGROUND

Partially hydrolysed guar gum (Benefiber) added to a diet is fermented in the colon, producing short chain fatty acids, which improve intestinal function, including colonic salt and water absorption.

AIMS

To evaluate the effect of Benefiber supplemented comminuted chicken diet in the treatment of persistent diarrhoea.

METHODS

One hundred and sixteen children (aged 5-24 months), presenting to Dhaka Hospital with a history of watery diarrhoea for more than 14 days (persistent diarrhoea), were randomised to receive either: (1) comminuted chicken diet with Benefiber (study diet); or (2) comminuted chicken diet without Benefiber (control diet). The study period was seven days.

RESULTS

Of 116 children, 57 received the study diet and 59 received the control diet. Diarrhoea resolved in a greater number of children with the study than with the control diet (46/55 (84%) v 36/58 (62%); odds ratio 3.12, 95% CI 1.19 to 8.4). Survival analysis for the duration of diarrhoea also showed a reduced duration of diarrhoea in children receiving the study diet. There was also a trend in daily stool reduction in children receiving the study diet, significant on days 4-7.

CONCLUSION

Results show that Benefiber supplemented comminuted chicken diet enhances recovery of children with persistent diarrhoea, indicating its therapeutic potential.

Isolation of Escherichia coli bacteriophages from the stool of pediatric diarrhea patients in Bangladesh

A 3-week coliphage survey was conducted in stool samples from 140 Bangladeshi children hospitalized with severe diarrhea. On the Escherichia coli indicator strain K803, all but one phage isolate had 170-kb genomes and the morphology of T4 phage. In spot tests, the individual T4-like phages infected up to 27 out of 40 diarrhea-associated E. coli, representing 22 O serotypes and various virulence factors; only five of them were not infected by any of these new phages. A combination of diagnostic PCR based on g32 (DNA binding) and g23 (major capsid protein) and Southern hybridization revealed that half were T-even phages sensu strictu, while the other half were pseudo-T-even or even more distantly related T4-like phages that failed to cross-hybridize with T4 or between each other. Nineteen percent of the acute stool samples yielded T4-like phages, and the prevalence was lower in convalescent stool samples. T4-like phages were also isolated from environmental and sewage water, but with low frequency and low titers. On the enteropathogenic E. coli strain O127:K63, 14% of the patients yielded phage, all of which were members of the phage family Siphoviridae with 50-kb genomes, showing the morphology of Jersey- and beta-4 like phages and narrow lytic patterns on E. coli O serotypes. Three siphovirus types could be differentiated by lack of cross-hybridization. Only a few stool samples were positive on both indicator strains. Phages with closely related restriction patterns and, in the case of T4-like phages, identical g23 gene sequences were isolated from different patients, suggesting epidemiological links between the patients.

Antimicrobial susceptibility of Helicobacter pylori strains isolated in Bangladesh

Antimicrobial susceptibility of 120 Helicobacter pylori isolates to metronidazole, tetracycline, clarithromycin, and amoxicillin was determined, and 77.5, 15, 10, and 6.6% of the isolates, respectively, were resistant. Only rdxA inactivation and both rdxA and frxA inactivation were responsible for metronidazole resistance in 66% (8 of 12) and 33% (4 of 12) of the isolates, respectively.

Reduced osmolarity oral rehydration solution for persistent diarrhea in infants: a randomized controlled clinical trial

OBJECTIVE

We evaluated and compared the efficacy of the World Health Organization (WHO) oral rehydration solution (ORS) and 2 different formulations of reduced osmolarity ORSs in infants with persistent diarrhea.

STUDY DESIGN

Infants with persistent diarrhea (n = 95) were randomized to 1 of the 3 ORSs: WHO-ORS (control, n = 32), a glucose-based reduced osmolarity ORS (RORS-G, n = 30), or a rice-based reduced osmolarity ORS (RORS-R, n = 31) for replacement of ongoing stool losses for up to 7 days. Major outcome measures were stool volume and frequency, ORS intake, and resolution of diarrhea.

RESULTS

Although there were variations from one study day to another, the stool volume was approximately 40% less in the reduced osmolarity ORS groups; consequently, these children required less ORS (22% for RORS-G and 27% for RORS-R groups). A higher proportion of children in the RORS-R groups also had resolution of diarrhea during the study period. No children in any of the treatment groups had hyponatremia.

CONCLUSION

Reduced osmolarity ORS is clinically more effective than WHO-ORS and may thus be advantageous for use in the treatment of children with persistent diarrhea.

Characteristics of children hospitalized with severe dehydration and persistent diarrhoea in Bangladesh

The study analyzed data from a systematic sample of children, aged less than five years, who presented with persistent diarrhoea (diarrhoea of more than 14 days duration). It aims to differentiate (a) non-severe persistent diarrhoea (with no or mild dehydration) and (b) severe persistent diarrhoea (with moderate or severe dehydration), and to identify individual characteristics associated with severe persistent diarrhoea. In total, 7,505 patients, who represented a 4% systematic sample of the patient population, were seen during January 1993-December 1995. Of them, 297 (4%) presented with persistent diarrhoea. The male:female ratio was 2:1. Eighty-three percent of them had mild or no dehydration, and 17% had moderate or severe dehydration. Severe malnutrition of the study patients defined as weight-for-age z-score < -3, weight-for-length z-score < -3 and length-for-age z-score < -3 were 33.9%, 9.7%, and 22.7% respectively. Only 3% had oedematous malnutrition, and 11% had xerophthalmia. Factors independently associated with severe persistent diarrhoea by logistic regression analyses were: number of watery stool > 10 times during the last 24 hours prior to admission (OR, 10.0; CI, 1.2-87, p = 0.03), lower respiratory tract infection (OR, 111; CI, 4.2-2955, p = 0.004), and lack of mothers' education (OR, 7.8; CI, 1.4-41.9, p = 0.016) after controlling for confounders. Awareness and health education of mothers or caregivers and better case management during acute diarrhoeal episode might prevent the development of severe persistent diarrhoea in young children. In addition, children with severe persistent diarrhoea might need special attention to have adequate rehydration and control of extraintestinal infections, including respiratory tract infection.