Of sick turkeys, kwashiorkor, malaria, perinatal mortality, heroin addicts and food poisoning: research on the influence of aflatoxins on child health in the tropics

Similarities between the geographical and climatic prevalences of kwashiorkor and of exposure to dietary aflatoxins, and between the biochemical, metabolic and immunological derangements in kwashiorkor and those in animals exposed to aflatoxins, prompted investigation of the associations between kwashiorkor and aflatoxins. Studies in Africa in the 1980s indicated a role for these toxins in the pathogenesis of the disease. Paediatric cases of kwashiorkor are less prone to severe Plasmodium falciparum malaria than normal children. In mice infected with P. berghei, aflatoxin exposure inhibits parasite growth and ameliorates morbidity. Aflatoxins occur in < or = 40% of samples of breast milk from tropical Africa, usually as low concentrations of the relatively non-toxic derivatives of aflatoxin B1 (AFB1) but sometimes as high concentrations of the very toxic AFB1. This could explain kwashiorkor in breast-fed babies. Aflatoxin exposure occurs in > or = 30% of pregnancies in tropical Africa and the toxins are often in cord blood, sometimes at extremely high concentrations. Aflatoxins are now incriminated in neonatal jaundice and there is circumstantial evidence that they cause perinatal death and reduced birthweight. Aflatoxin-induced immunosuppresion may explain the aggressive behaviour of HIV infection in Africa. There are similarities between observations on HIV cases in Africa and those on heroin addicts in Europe, where 'street' heroin is frequently contaminated with aflatoxin. Aflatoxins were found in 20% of random urine samples from heroin addicts in the U.K. and the Netherlands. Aflatoxins have also been incriminated in episodes of food poisoning which have been associated with serious morbidity and mortality, particularly among young children.

Of sick turkeys, kwashiorkor, malaria, perinatal mortality, heroin addicts and food poisoning: research on the influence of aflatoxins on child health in the tropics

Similarities between the geographical and climatic prevalences of kwashiorkor and of exposure to dietary aflatoxins, and between the biochemical, metabolic and immunological derangements in kwashiorkor and those in animals exposed to aflatoxins, prompted investigation of the associations between kwashiorkor and aflatoxins. Studies in Africa in the 1980s indicated a role for these toxins in the pathogenesis of the disease. Paediatric cases of kwashiorkor are less prone to severe Plasmodium falciparum malaria than normal children. In mice infected with P. berghei, aflatoxin exposure inhibits parasite growth and ameliorates morbidity. Aflatoxins occur in < or = 40% of samples of breast milk from tropical Africa, usually as low concentrations of the relatively non-toxic derivatives of aflatoxin B1 (AFB1) but sometimes as high concentrations of the very toxic AFB1. This could explain kwashiorkor in breast-fed babies. Aflatoxin exposure occurs in > or = 30% of pregnancies in tropical Africa and the toxins are often in cord blood, sometimes at extremely high concentrations. Aflatoxins are now incriminated in neonatal jaundice and there is circumstantial evidence that they cause perinatal death and reduced birthweight. Aflatoxin-induced immunosuppresion may explain the aggressive behaviour of HIV infection in Africa. There are similarities between observations on HIV cases in Africa and those on heroin addicts in Europe, where 'street' heroin is frequently contaminated with aflatoxin. Aflatoxins were found in 20% of random urine samples from heroin addicts in the U.K. and the Netherlands. Aflatoxins have also been incriminated in episodes of food poisoning which have been associated with serious morbidity and mortality, particularly among young children.

Ochratoxin A and aflatoxins in breast milk samples from Sierra Leone

Breast milk from 113 mothers in two 'Under-Five Clinics' in the Southern Province of Sierra Leone, namely, Njala and Bo, were examined for their mycotoxin content. Only 10 were mycotoxin-free. Eighty-eight per cent of samples contained various aflatoxins and 35% contained ochratoxin A (OTA). Few samples (15%) had a single mycotoxin. Thirty-six (32%) had two mycotoxins and 50 (40%) had three or more. The occurrence of OTA in combination with various aflatoxins was recorded. It is concluded that infants in Sierra Leone are exposed to OTA and aflatoxins at levels which in some cases far exceed those permissible in animal feed in developed countries.

Neonatal jaundice, aflatoxins and naphthols: report of a study in Ibadan, Nigeria

This study set out to investigate the prevalence of naphthols and aflatoxins in the sera of babies with neonatal jaundice and their mothers in order to determine whether they contribute to the occurrence of unexplained neonatal jaundice in Ibadan. Blood was obtained from 327 jaundiced neonates and 80 of their mothers, and 60 non-jaundiced controls and seven of their mothers admitted to hospital between April 1989 and April 1991. Blood group, bilirubin concentration, erythrocyte G6PD status, aflatoxin and naphthol concentrations in blood were measured. Altogether, 30.9% of the jaundiced neonates were G6PD-deficient, compared with 13.3% of controls (chi 2 = 6.88; p = 0.009). Aflatoxins were detected in 27.4% of jaundiced neonates, 17% of their mothers, 16.6% of controls and 14.4% of control mothers. Naphthols were detected in 7.2% of jaundiced babies, 6.3% of their mothers, 6.25% of control babies and 14.4% of their mothers. Analysis of the data revealed that either G6PD deficiency or the presence of any serum aflatoxin is a risk factor for neonatal jaundice; odds ratio were 2.97 (95%) confidence intervals (CI): 1.31-6.74) and 2.68 (CI: 1.18-6.10), respectively. This study demonstrates that G6PD deficiency and/or the presence of serum aflatoxins are risk factors for neonatal jaundice in Nigeria. Aflatoxins are an additional risk factor not previously reported.

Neonatal jaundice in Zaria, Nigeria--a second prospective study

Of the 587 neonates born in ABUTH, Zaria, Nigeria and successfully followed up, 99 were clinically jaundiced (16.9%). Of these, only 38 (38%) had significant hyperbilirubinaemia (serum bilirubin above 170 umol/L). During the same period, 279 neonates were admitted through Emergency Paediatric Unit (EPU) of whom 70 (25%) were jaundiced and 64 (95%) of them had serum bilirubin above 170 umol/L. Jaundice was more severe and the incidence of kernicterus higher in babies born outside the hospital than in those born in hospital and periodically followed up. The incidence of kernicterus was 20.3% and 2.6% respectively. The pattern of aetiological factors was similar in the two groups of jaundiced neonates. Septicaemia (50%) and G6PD deficiency (40%) were the major aetiological factors. Exposure to traditional herbal medications, oxytocin induced/augmented labour, cephalhaematoma and tribal incidences did not play statistically significant roles. Jaundice due to Rh-incompatibility was not encountered. Results of this double prospective study were compared with the previous findings in this and other centres in Nigeria.

Neonatal jaundice with reference to aflatoxins: an aetiological study in Zaria, northern Nigeria

Two prospective studies were undertaken to determine a possible relationship between perinatal aflatoxin exposure and neonatal jaundice. First, cord blood samples from 37 neonates who subsequently developed jaundice and from 40 non-jaundiced (control) babies were analysed for six major aflatoxins and aflatoxicol. Peripheral blood samples of both groups were also analysed postnatally for aflatoxins. In a second study, serum aflatoxin levels of 64 jaundiced neonates admitted from outside the hospital were compared with levels in 60 non-jaundiced control babies. Aflatoxins were detected in 14 (37.8%) cord blood samples of jaundiced neonates and in nine (22.5%) of the controls. The mean cord aflatoxin concentration was highest in jaundiced neonates with septicaemia, but the difference was not statistically significant. The frequency of detection of aflatoxins in peripheral blood was not significantly different in jaundiced and non-jaundiced babies. Aflatoxins were detected in the blood of over 50% of neonates with jaundice of 'unknown' aetiology. There was no correlation between severity of hyperbilirubinaemia and serum aflatoxin levels. Further studies are needed to determine the extent of pre- and postnatal exposure to aflatoxin in Nigerian infants and the effects of such exposure on fetal and neonatal health.

Human fetal exposure to ochratoxin A and aflatoxins

Analysis of 64 cord blood samples from pregnant women in Sierra Leone revealed the presence of ochratoxin A (OTA) and aflatoxins in 25% and 58% of samples, respectively. Of the eight maternal blood samples collected during delivery, one contained OTA and aflatoxins were detected in six. There was no relationship between mycotoxins in maternal and cord blood. The effect these toxins might have had on the birthweight of infants is discussed.

Ultrastructural changes in murine lymphocytes induced by aflatoxin B1

This investigation sought to determine whether splenic lymphocytes obtained from Balb/C mice exposed to aflatoxin B1 (AFB1) showed any ultrastructural changes which could account for the immunodysfunction attributable to aflatoxins. Lymphocytes obtained from Balb/C mice administered aflatoxin B1 in olive oil daily for three weeks were studied using both transmission and scanning electron microscopy. The lymphocytes demonstrated ultrastructural changes primarily in the mitochondria where marked internal dissociation of the cristae was revealed by transmission electron microscopy. All other cellular organelles were unaffected. No significant alterations in external structure were observed under scanning electron microscopy. The findings of this study indicate that AFB1 administration does not affect the surface topography of lymphocytes, but AFB1, by causing extensive mitochondrial damage, may affect the way in which these cells function. This could be a possible explanation for the immunodysfunction associated with AFB1.

Detection of naphthols and aflatoxins in Nigerian cord blood

Widespread use of napthol-containing compounds and frequent contamination of foods by aflatoxins occurs in Nigeria. Napthols cause haemolysis and aflatoxins are hepatotoxic. A study was carried out to determine the extent of fetal exposure to these compounds and their influence on birthweight. Cord blood samples were collected at delivery from 625 babies and their sera were analysed for aflatoxins and naphthols. Mothers' histories and babies' weights were recorded. Naphthols were detected in 6.9% and aflatoxins in 14.6% of serum samples. No correlation was found between the presence of either compound and birthweight. Reported exposure to naphthalene-containing compounds was not related to detection of serum naphthol. Results show considerable fetal exposure to these potentially toxic compounds in Ibadan, Nigeria.

HBsAg and aflatoxins in sera of rural (Igbo-Ora) and urban (Ibadan) populations in Nigeria

The purpose of this study was to screen for the presence of hepatitis B surface antigen and aflatoxins in the sera of 100 non-hospitalized individuals from the rural population of Igbo-Ora and 89 non-hospitalized individuals from the urban population of Ibadan, Nigeria. Hitherto, such a study as this has not been undertaken in this environment. The proportions of hepatitis B surface antigen carriage and serum 'pathologic' levels of aflatoxins were high (47-49%, 8.2-9.0% respectively) but varied very little between the two different populations sampled. These findings indicate that determined efforts should be instituted to reduce or eliminate hepatitis B virus infection and aflatoxin contamination of high risk foodstuffs from this environment.

HBsAg, aflatoxins and primary hepatocellular carcinoma

Nigeria is a very high risk area for primary hepatocellular carcinoma and this is the first study to utilize measurements of both hepatitis B virus status and aflatoxin levels in the same patients to determine the role of these factors in the causation of liver cancer in this environment. We have shown that there is a higher prevalence of hepatitis B surface antigen (P < 0.005) and higher 'pathologic' serum levels of aflatoxins (P < 0.05) in patients with primary hepatocellular carcinoma than in matched controls. It is considered that the results of this study may strengthen the hypothesis that hepatitis B virus may be an important aetiological factor in the development of primary hepatocellular carcinoma. Further work is in progress to correlate the level of aflatoxin serum albumin adducts with liver damage in order to assess the value of the albumin adduct as a marker of risk of liver cancer development.

Depression of the Ca2+-ATPase activity of the rat liver endoplasmic reticulum by the liver tumour promoters 1,1,1-trichloro-2,2-bis(p-chlorophenyl)- ethane and phenobarbital

The effects of a short-term in vivo administration of two liver tumour promoters (phenobarbital and 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane on rat liver endoplasmic reticulum Ca(2+)-ATPase were investigated. The specific activity values of this membrane-bound enzyme significantly decreased (P less than 0.01) by 51% for phenobarbital-treated rats and by 48% for 1,1,1-trichloro-2,2-bis(p-chlorophenyl)ethane-treated rats compared with control animals. The depression of liver endoplasmic reticulum Ca(2+)-ATPase appears to be a manifestation of the toxicological effect of tumour promoters.

Clinical implications of food contaminated by aflatoxins

Aflatoxins have been incriminated, mainly on circumstantial evidence, in hepatocellular carcinoma, acute hepatic failure and Reye's syndrome, but other possible effects of continuous or intermittent dietary exposure to aflatoxins, which occurs widely in the tropics, have received little study. Over the past 10 years evidence has steadily accumulated that incriminates aflatoxins in the aetiology of kwashiorkor, a widespread and serious disorder of children in the tropics, previously believed to be caused by protein deficiency. Investigation of human breast milk, undertaken initially to elucidate the pathogenesis of kwashiorkor in breastfed infants, has revealed widespread and serious exposure to aflatoxins from this source. Extension of these studies to pregnant women, in turn, revealed widespread and serious prenatal aflatoxin exposure. In laboratory and farm animals, such exposure has serious implications for immune and hepatic functions, and is detrimental to growth and development. Recent analysis of heroin samples show that heroin addicts may also be exposed to these toxins. These findings show that human exposure to aflatoxins may begin prenatally, persist during breastfeeding, and continue into adult life. It is postulated that aflatoxins (i) play a role in the aetiology of kwashiorkor, (ii) increase neonatal susceptibility to infection and jaundice, (iii) increase childhood susceptibility to infections and malignant disease, (iv) compromise immune responses to prophylactic immunisations and (v) may play a role in the pathogenesis of diseases in heroin addicts. There are indications also that acute, fatal aflatoxin poisoning which masquerades as 'hepatitis' may occur more frequently than is currently appreciated.

Aflatoxin excretion in children with kwashiorkor or marasmic kwashiorkor--a clinical investigation

A group of five children with kwashiorkor, seven with marasmic kwashiorkor and one underweight child were given an aflatoxin-free diet consisting of maize meal and milk powder. Blood specimens were collected on admission; on day 4 and 10, 24 hour urine and stool samples were collected for the first ten days. Serum, urine and stool samples were analysed for aflatoxins using high performance liquid chromatography with fluorescent detection, after various extraction and clean-up procedures. The children with kwashiorkor and marasmic kwashiorkor excreted aflatoxins in stools for up to 9 and 6 days after admission respectively. No aflatoxins were detected in the stools or urine of the underweight child. In kwashiorkor, urinary excretion ceased after 2 days, while in marasmic kwashiorkor urinary excretion persisted for 4 days. In stools, B1 was the type of aflatoxin detected most frequently in kwashiorkor and least frequently in marasmic kwashiorkor. Aflatoxin M2 was frequently detected in the stools of both groups of children. Estimates of the total amount of aflatoxin excreted by kwashiorkor and marasmic kwashiorkor indicate that these children were harbouring up to 4 micrograms/kg body weight at the time of admission. These findings establish that aflatoxins accumulate in body fluids and tissues in kwashiorkor and marasmic kwashiorkor which is only slowly eliminated.

Foetal and neonatal exposure to aflatoxins

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

The effects on malaria of treatment of iron-deficiency anaemia with oral iron in Gambian children

In order to determine whether giving iron to iron-deficient children increases their susceptibility to malaria, 213 Gambian children aged between 6 months and 5 years with iron-deficiency anaemia were randomized to receive either oral iron or placebo during the rainy season when malaria transmission is maximal. Haematological and iron measurements improved significantly in the group given iron. Regular morbidity surveys showed that fever associated with parasitaemia occurred more frequently in the iron-treated group than in the placebo group. This difference was not significant for all parasitaemias grouped together, but became significant and progressively larger for parasitaemias of ten or more positive fields per 100 high power fields (P less than 0.025), and for parasitaemias of 50 or more positive fields per 100 high power fields (P less than 0.01). Three children in the iron-treated group but none in the placebo group had more than one episode of fever and parasitaemia. Splenomegaly rates rose appreciably during the study in both groups, but in children at age 2 years the splenomegaly rate at the end of the study was significantly greater in the iron-treated group. We concluded that there is a significantly increased risk of fever associated with severe malarial parasitaemia for children with iron-deficiency anaemia given iron during the season of maximal malaria transmission in this part of The Gambia.

Iron-deficiency anaemia and its response to oral iron: report of a study in rural Gambian children treated at home by their mothers

Haematological and iron parameters, measured in 907 children aged from 6 months to 5 years in rural Gambia at the start of the rainy season, differed from those in American reference populations as follows: mean haemoglobin levels were much lower at ages 1 and 2 years and mean levels of mean corpuscular volume (MCV) were lower at all ages (at age 1 year mean haemoglobin was 11.2 g/dl and mean MCV 68.2 fl); in a sample of 249 children randomly selected from the whole study population, mean serum iron levels were similar but mean transferrin saturation and mean serum ferritin levels were lower, especially at ages 1-3 years (at age 1 year mean serum iron was 11.1 mumol/l, mean transferrin saturation 16.9%, and geometric mean serum ferritin 8.8 ng/ml. A total of 213 children (23%) whose haemoglobin and mean corpuscular volume were both less than the 3rd percentile of the reference population received oral iron or placebo from their mothers during the rainy season when malaria transmission is maximal. Mean levels of haemoglobin, mean corpuscular volume, serum iron, transferrin saturation and serum ferritin rose in the iron-treated group and fell in the placebo group at all ages, except under 1 year for serum ferritin, to produce significant differences between the groups by the end of the study. Total iron-binding capacity showed no significant changes during the study. We concluded that oral iron given by the mother during the rainy season can be used to treat iron-deficiency anaemia in Gambian children who would otherwise become more anaemic.

Climatic conditions and kwashiorkor in Mumias: a retrospective analysis over a 5-year period

Hospital records from a rural hospital in Kenya were retrospectively analysed for the total monthly admissions for kwashiorkor and all other forms of malnutrition over a 5-year period. These figures were related to the climatic conditions that prevailed during the year as derived from the records of a meteorological station in the area. The peak prevalence for kwashiorkor coincided each year with the season during which relative humidity was highest. The prevalence of kwashiorkor is discussed in relation to variable aflatoxin formation, which is influenced by seasonal changes in weather conditions.

Protein-energy malnutrition in northern Sudan: clinical studies

The medical history, clinical features and investigations of 145 children with kwashiorkor were compared with 113 marasmic kwashiorkor, 158 marasmic children and 186 nutritionally normal controls of similar age admitted to hospital in Khartoum. Factors in the group with protein-energy malnutrition (PEM) which could relate to aetiology include: a history of prolonged illness and anorexia, frequent and prolonged episodes of diarrhoea and recent measles. The delay in achievement of developmental milestones in PEM children probably reflects the frequent and chronic illnesses in this group. An episode of previous oedema was reported in 22 per cent of marasmic kwashiorkor, 12 per cent of kwashiorkor and 12 per cent of marasmic children. Though hair and mucosal changes and enlarged liver were more common in the marasmic kwashiorkor and kwashiorkor groups, they were also common in marasmic children. There was no significant difference in behaviour (apathy, irritability, anorexia) between kwashiorkor and marasmic children. The classical skin changes of kwashiorkor were only seen in the oedematous children. The mortality was 19 per cent in kwashiorkor, 35 per cent in marasmic kwashiorkor, and 14.5 per cent in the marasmic group. The major differences between marasmus and kwashiorkor children were that the kwashiorkor children were reported larger at birth, achieved more normal developmental milestones, were taller and had larger head circumference than the marasmic children. The implications of these findings in relation to aetiology are discussed.

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

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

Detection of cow's milk protein intolerance by an enzyme-linked immunosorbent assay

Circulating IgG antibodies to cow's milk proteins have been quantified in 182 children using an enzyme-linked immunosorbent assay (ELISA). Antibody levels in children with cow's milk protein intolerance (CMPI) were compared with those in control groups comprising other diarrhoeal diseases, atopic children, and a "normal" sample including children with toddler diarrhoea. Mean IgG antibody levels in children with CMPI were significantly higher than in any of the control groups. There were clear differences in peak antibody levels between CMPI and all other groups for each of the protein fractions tested. There was some overlap in titres between CMPI and other enteropathies but the assay gave 88% sensitivity and specificity for the diagnosis of CMPI overall and was 100% specific against the combination of non-enteropathic controls in this study. These findings indicate that the assay could be applied as an outpatient screening test for CMPI and would be particularly useful in differentiating "toddler" diarrhoea from CMPI.

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

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

Loperamide in acute diarrhoea in childhood: results of a double blind, placebo controlled clinical trial

Fifty-three young children with acute diarrhoea were included in a hospital-based, double-blind trial of loperamide at two dose levels (0.4 and 0.8 mg/kg/day), given with standard oral rehydration therapy versus placebo plus oral rehydration therapy. The differences in the overall recovery rate were significant (P less than 0.05), the fastest being in the group given 0.8 mg/kg and slowest in the placebo group. Comparison between weights on admission and weights by day 3 showed that more children in the loperamide groups gained weight than in the placebo group (P less than 0.05). No serious side effects of loperamide were observed. The drug was withdrawn in one child because of excessive lethargy and sleep. The results indicate that loperamide in the doses employed is safe and may be a useful adjunct to oral rehydration in certain children.

Aflatoxins in the livers of children with kwashiorkor in Ghana

Autopsy liver specimens from 22 kwashiorkor children in Ghana were analysed for the presence of aflatoxins using both high performance liquid chromatography and thin layer chromatography. Aflatoxin B1 was found in the livers of 20 subjects and aflatoxicol in the livers of the remaining two subjects. These results confirm previous findings of aflatoxin B1 and aflatoxicol in the livers of children with kwashiorkor and provide further evidence of associations between these toxic compounds and kwashiorkor which might have relevance to the aetiology and pathogenesis of this disease which as yet remain mysterious.

Aflatoxins in liver biopsies from Sudanese children

Aflatoxin analysis of 40 percutaneous needle liver biopsies in 27 children with protein-energy malnutrition and 13 children with miscellaneous liver disease in The Sudan is reported. Aflatoxins B1, B2 and aflatoxicol were detected in 5 of the 16 biopsies from kwashiorkor but in none of 11 biopsies from marasmus or marasmic kwashiorkor. Aflatoxins G1, G2 and M2 were detected in 5 of 12 children with chronic liver disease. A very high concentration of aflatoxicol was found in a breast-fed infant with neonatal hepatitis of unknown etiology.

Aflatoxins and kwashiorkor: clinical studies in Sudanese children

Aflatoxin analysis of blood and urine by high performance liquid chromatography in 584 Sudanese children is reported. The results in 404 malnourished children comprising 141 kwashiorkor, 111 marasmic kwashiorkor and 152 with marasmus are compared with 180 age-matched controls and correlated with clinical findings. The aflatoxin detection rate and mean concentration were higher in serum of children with kwashiorkor than the other groups. The difference between the detection rate in kwashiorkor and controls was significant (p less than 0.05). The aflatoxin detection rate in urine was highest in the marasmic kwashiorkor group and the mean concentration was higher in the marasmic kwashiorkor and marasmic groups than in the kwashiorkor and control groups. There were important differences in the detection of certain aflatoxins between the groups. Aflatoxicol was detected in the sera of 16 (11.6%) kwashiorkor, in six (6.1%) marasmic kwashiorkor, but in none of the controls and only once in marasmus. These differences are highly significant (p less than 0.0001). The ratio of AFB1 to AFM1 was higher in the sera and urines of kwashiorkors than in controls, suggesting that the normal transformation of AFB1 to AFM1 may be impaired in kwashiorkor with consequent increase in transformation of AFB1 to aflatoxicol. The study therefore provides evidence of differences in the metabolism of aflatoxins in children with kwashiorkor compared with children with other forms of malnutrition and normally nourished children and confirms the association between aflatoxins and kwashiorkor contained in a preliminary report on this work.

Effect of iron prophylaxis on morbidity due to infectious disease: report on clinical studies in Papua New Guinea

A controlled trial of iron prophylaxis (3 ml intramuscular iron dextran) to two-month-old infants was carried out on the north coast of Papua New Guinea where there is high transmission of malaria. The initial hypothesis was that iron deficiency increased susceptibility to infections and thus iron supplementation in a situation of actual or potential iron deficiency would diminish this susceptibility. Findings detailed elsewhere indicate that the placebo control group became relatively iron deficient and that the iron dextran group had adequate iron stores and a higher mean haemoglobin; however, prevalence of malaria recorded in the field was higher in the iron dextran group. Analysis of field and hospital infectious morbidity in the trial indicated a deleterious effect of iron dextran for all causes and for respiratory infections (the main single reason for admission). Total duration of stay in hospital was significantly increased in the iron dextran group. Analysis of other factors showed a deleterious effect of low weight for height at the start of the trial; a significant positive correlation between birth haemoglobin and hospital morbidity rates and a positive interaction between haemoglobin and iron dextran on hospital morbidity. A possible association between malarial experience and other infectious morbidity is discussed.

Iron and infection in infancy--report on field studies in Papua New Guinea: 1. Demographic description and pilot surveys

Madang district was selected for a longitudinal study of the effects of iron prophylaxis on infectious morbidity in infancy and the topography, climate, domicile, ethnology, demography, disease patterns, nutrition and health services of the district are described. The area has a tropical, humid climate and a mixed economy. Pneumonia was the main killing disease at all ages, and malaria was endemic. A base hospital and well organized maternal and child health services ensured that morbidity surveillance would be optimal. Pilot haematological surveys confirmed a high incidence of anaemia in infancy. Mean haemoglobin between nine and 52 weeks of age was 8.6 g/dl. Results suggested that malaria and iron deficiency were important causes of this anaemia.

Iron and infection in infancy--report on field studies in Papua New Guinea: II. Protocol and description of study cohort

The protocol for a prospective, randomized, double-blind, placebo controlled trial of iron prophylaxis in infants is described. Specific design points discussed include (i) control and "blind", (ii) dose, preparation and age of administration of iron, (iii) standardization of morbidity recording, (iv) data analysis and (v) ethics. The study cohort at birth is described and rationale for exclusions and reasons for withdrawals are discussed. An initial descriptive comparison is made of treatment and control groups entering the trial at two months of age.

Aflatoxins in human breast milk

Breast milk from 99 Sudanese mothers was analysed for aflatoxins. Aflatoxins M1 and/or M2 were detected in 37 of the milks. No other aflatoxin was detected. M1 occurred alone in 13 milks, (mean 19.0 pg/ml), M2 in 11 milks (mean 12.2 pg/ml), and in 13 samples both M1 and M2 were detected. There appeared to be a linear relationship between M1 and M2 where both were excreted. No aflatoxin was detected in subcutaneous abdominal wall fat removed during Caesarian section from 15 women, but was present in three out of 14 bloods taken during anaesthesia. The presence of aflatoxins in mothers' milk showed no correlation with duration of lactation, the infants' nutrition, presence of aflatoxin in mothers' blood, or the infant's blood and urine. It is concluded that some Sudanese women excrete aflatoxins in breast-milk at levels similar to or higher than those considered safe in animal milk, for human consumption.