[The effect of nutritional management on the mortality of malnourished children, uninfected and infected with the human immunodeficiency virus]. / Impact d'une prise en charge nutritionnelle sur la mortalité d'enfants malnutris infectés ou non par le virus de l'immunodéficience humaine.

Weight loss is a major complication in children infected with HIV. Very few studies have focused on the nutritional management of malnourished HIV-positive children, particularly in developing countries, although there have been some studies in adults. Therefore, the aim of this retrospective study was to evaluate, as a function of HIV status, the effect of a nutritional rehabilitation program on the mortality of malnourished children in an Ivory Coast nursery. We studied 193 malnourished children over the age of 15 months from January 1 1994 to December 31 1996; 41 % of these children (80 of 193) were HIV-positive. The nutritional rehabilitation program was introduced in 1995. It had a beneficial effect in HIV-negative children because the setback rate (the number of deaths and transfers x 1,000/the number of child-months at risk) decreased significantly over the three years of the study (1994: 130; 1995: 113; 1996: 26; p < 0.05). The rate in HIV-positive children did fall slightly, but this decrease was not statistically significant. These results demonstrate the difficulties involved in the nutritional management of malnourished HIV-positive children. However, recent studies have suggested that nutritional rehabilitation (by mouth) combined with total vitamin and mineral supplementation may be more effective. Given the frequency of malnutrition in HIV-positive children, clinical studies aimed at improving the nutritional management of these children should be a priority in developing countries.

HIV-related gender biases among malnourished children in Abidjan, Côte D'Ivoire.

This study, conducted in a health centre in Abidjan for malnourished children, shows that there were more girls than boys among children admitted who were HIV seropositive whereas there were more boys than girls among seronegative children. Reasons for this gender bias are investigated.

[Anthropometric characteristics of HIV infected malnourished children in Ivory Coast]. / Caractéristiques anthropométriques d'enfants malnutris infectés par le VIH en Côte d'Ivoire.

Stunting and weight-loss are common complications of HIV infection in children. The aim of this study was to assess whether stunting, assessed using a height-for-age index, is a discriminating factor for HIV in malnourished children. This is a retrospective study of 66 children, all older than 15 months, with marasmus-type malnutrition. They were studied at a nursery in the Côte d'Ivoire from 1994 to 1995. Forty-five percent of the children were HIV-positive. The anthropometric indices (weight-for-age, weight-for-height, height-for-age and body mass index) were lower in seropositive than in seronegative children, but the difference was not significant. The rate of stunting was similar in the two groups, with 66% of seropositive and 58% of seronegative children stunted. Thus, stunting was not a discriminating factor for HIV infection. Studies aimed at increasing our understanding of nutritional disorders associated with HIV are necessary to improve the nutritional management of these children, especially in Africa where malnutrition is endemic.

[Dehydration: an important factor of mortality in human immunodeficiency virus (HIV) seropositive malnourished children]. / Déshydratation: un facteur important de mortalité chez l'enfant malnutri séropositif vis-à-vis du virus de l'immunodéficience humaine (VIH).

A combination of diarrhoea and malnutrition frequently occurs in HIV seropositive children and constitutes a bad prognosis factor. The impact of dehydration induced by diarrhoea in these children has not as yet been assessed and constitutes the aim of this study. This retrospective analysis was conducted on 121 malnourished children monitored in 1994 at an infant home in Cöte d'lvoire. 46.2% of the children were HIV seropositive and their mortality rate was significantly higher than that observed among seronegative children (42.8% vs. 15.3%; p < 0.01). Among the various pathologies observed in these children, diarrhoea and oral candidosis were discriminating factors in seropositive children. Besides, the findings confirmed the effect of dehydration on the mortality of malnourished children as a whole. Studies allowing a better understanding of factors involved in diarrhoea or dehydration among HIV seropositive malnourished children appears to be essential to improve the management of these children.

[Vitamin e supplementation in Senegalese children with kwashiorkor]. / Supplémentation en vitamine E chez des enfants sénégalais présentant un kwashiorkor.

Kwashiorkor continues to be a major cause of infant mortality in the developing world. It has recently been suggesting that this form of malnutrition is due to oxidizing aggression. Vitamin E is a powerful natural anti-oxidant, and we therefore investigated the extent to which its supplementation in the diet contributed to treating child kwashiorkor. Vitamin E was also administered to children suffering from marasmus. The study was conducted from October 1993 to July 1994 and included 79 children (38 cases of kwashiorkor and 41 of marasmus). The treatment resulted in a 76% success rate, with the best results for marasmus (89.5% cure). However, the supplement did not have any effect on the nutritional status for either the kwashiorkor or marasmus patients. In the kwashiorkor group, the weight increase, after disappearance of edema was 15.2 +/- 4.9 g/kg/d in the supplemented group as compared to 16.4 +/- 3.6 g/kg/d in the control group. The duration of edema along treatment was similar for the two groups (supplemented: 8.6 +/- 3.1 days, control group: 7.1 +/- 3.9 days). Possible reasons for vitamin E supplementation having no effect are discussed.

PIP: 38 children with kwashiorkor and 41 with marasmus participated in a study of vitamin E supplementation in a nutritional rehabilitation center in the Dakar suburb of Pikine. Kwashiorkor, or edematous malnutrition, is a major factor in infant mortality in Senegal. Vitamin E supplementation was undertaken to test the hypothesis that kwashiorkor results from aggressive oxidation linked to excess free radicals, vitamin E being a major antioxidant in humans. The children attended the center daily, accompanied by their mothers, until they were cured, defined as disappearance of edema and achievement of 80% of the international standard of weight for height. All children were treated for parasites and malaria prevention. Children with kwashiorkor were given ampicillin, metronidazole and supplements of particular minerals. Between October 1993 and July 1994, 17 children with kwashiorkor and 19 with marasmus were given the vitamin E supplements, the other 43 children serving as controls. The cure rate was slightly higher for the groups receiving supplements, but the difference was not statistically significant. The highest cure rate, 89.5%, was in children with marasmus receiving the supplement, and the lowest cure rate, 68.2%, was in control children with marasmus, but the difference was not statistically significant. Among children with kwashiorkor, weight gain after disappearance of edema was 15.2 +or- 4.9 g/kg/d in the vitamin E group and 16.4 +or- 3.6 g/kg/d in the control group. Several factors may explain the absence of a favorable effect of vitamin E. The hypothesized relationship between aggressive oxidation and kwashiorkor may not exist, or the low plasma levels of vitamin E may not truly reflect deficiencies at the tissue level. The treatment dose of 10 mg/d of vitamin E may have been too low, or the existence of multiple deficiencies may have masked the possible beneficial effect of vitamin E.

Efficacy of measles vaccines after controlling for exposure.

The clinical efficacy of measles vaccines was investigated in Niakhar, a rural area of Senegal under demographic surveillance in 1987-1990. Three measles vaccines were tested: a standard Schwarz, a high-titer Edmonston-Zagreb, and a high-titer Schwarz. The two high-titer vaccines were administered at 5 months of age and the standard Schwarz vaccine at 10 months. In addition to a formal randomized vaccine trial, data from national campaigns using the standard Schwarz vaccine were also analyzed. Clinical efficacy was estimated after controlling for exposure. In the randomized trial, the estimate of the efficacy of the standard Schwarz vaccine was 97.2% (95% confidence interval (CI) 91.3-98.1). In the 1986-1987 national campaign, the efficacy of the standard Schwarz vaccine was lower: 92.5% (95% CI 88.8-94.6). In the randomized trial, the efficacy of the high-titer vaccines was lower than that of the standard vaccine. High-titer vaccines were not used in national campaigns. Other factors associated with vaccine efficacy were age at exposure, intensity of exposure, and age at vaccination. Controlling for the intensity of exposure did not change the relative ranking of the efficacy of the three vaccination strategies. The theoretical efficacy of the standard measles vaccine for a single unit of exposure was estimated at 98.0%.

International differences in clinical patterns of diarrhoeal deaths: a comparison of children from Brazil, Senegal, Bangladesh, and India.

Population-based data on deaths due to diarrhoea among children less than 5 years of age were obtained from areas of Brazil (227 deaths), Senegal (531), Bangladesh (236) and India (146). Fatal episodes of diarrhoea were classified as either acute diarrhoea, dysentery, or persistent diarrhoea based on their duration and on the presence or absence of blood in the stools. Persistent diarrhoea accounted for over 60% of infant diarrhoeal deaths in Brazil, 47% in India, 36% in Senegal, and 26% in Bangladesh. In the latter two studies, over one-half of infant diarrhoeal deaths were due to acute watery episodes. Among children 1-4 years old dying from diarrhoea, persistent episodes were the most common in Senegal and India, whereas dysentery was the leading pattern in Bangladesh. These differences may be related to the use of oral rehydration therapy and the utilisation of health care, as well as to environmental characteristics, and are relevant for planning control strategies. Further data are required from other parts of the less developed world.

Child mortality after high-titre measles vaccines: prospective study in Senegal.

The use of Edmonston-Zagreb high-titre (EZ-HT) vaccine at age 6 months has been recommended for countries in which measles before the age of 9 months is a substantial cause of death, but little is known about the long-term effects of high-titre live measles vaccines given early in life. In a randomised vaccine trial in a rural area of Senegal, children were randomly assigned at birth to three vaccine groups: EZ-HT at 5 months (n = 336); Schwarz high-titre (SW-HT) at 5 months (n = 321); and placebo at 5 months followed by standard low-titre Schwarz vaccine at 10 months (standard: n = 358). All children were prospectively followed for 24-39 months in a well-established demographic surveillance system. Child mortality after immunisation was significantly higher in the two groups which received high-titre vaccines than in the group given the standard vaccine. The relative risk of death was 1.80 (95% confidence interval [CI] 1.18-2.74; p = 0.007) in the EZ-HT group and 1.51 (0.97-2.34; p = 0.07) in the SW-HT group compared with the standard group. The three vaccine groups were comparable as regards various social, family, and health characteristics, and there was no difference in mortality between children who received the standard vaccine and those who were eligible for the trial but did not take part for various reasons. The higher risk of death in the two high-titre vaccine groups remained significant in multivariate analyses. These findings suggest a need to reconsider the use of high-titre measles vaccines early in life in less developed countries.

Management of malnourished children with acute diarrhoea and sugar intolerance.

A protocol of nutritional rehabilitation using fermented milk, vegetable oil and caster sugar has been tested on 54 Senegalese children, aged 6-36 months, admitted with acute diarrhoea and malnutrition. At the time of admission, 39 per cent of children were dehydrated and 26 per cent had sugar intolerance. In the course of treatment three went home against medical advice and one died from acute pneumonia with respiratory-heart failure. Among the cases of marasmus there were no differences in mean weight gain between children with sugar intolerance and others despite a longer duration of diarrhoea in the first group. Furthermore, the experimental protocol has never been compromised because of worsening diarrhoea or weight loss. These results indicate that a formula based on fermented milk together with oral rehydration can be used to treat malnourished children with acute diarrhoea and sugar intolerance.

Management of malnourished children with acute diarrhoea and sugar intolerance.

A protocol of nutritional rehabilitation using fermented milk, vegetable oil, and castor sugar has been tested on 54 Senegalese children age 6-36 months admitted with acute diarrhoea and malnutrition. At time of admission, 39 per cent of children were dehydrated and 26 per cent had sugar intolerance. In the course of treatment three absconded and one died from acute pneumonia with respiratory and heart failure. Among those with marasmus there were no differences in mean weight gains between children with sugar intolerance and others, despite a longer duration of diarrhoea in the first group. Furthermore, the treatment protocol has never been compromised because of worsening diarrhoea or weight loss. These results indicate that a formula based on fermented milk together with oral rehydration can be used to treat malnourished children with acute diarrhoea and sugar intolerance.

Congenital selective malabsorption of glucose and galactose.

We review here the case histories and results of in vivo and in vitro tests for eight children with congenital selective glucose and galactose malabsorption (GGM) whom our laboratory has followed up since 1971. Clinically, GGM was manifested by intractable, acidic, sugar-containing diarrhea that started during the neonatal period. Diarrhea only abated when glucose and galactose were removed from the diet. The disease was notable for the absence of other symptoms, although mellituria was a common finding. Defective sugar transport was permanent, but sugar tolerance appeared to increase with age. In vitro, intracellular mucosal glucose concentration (C) was significantly below control level in GGM intestinal tissue for concentrations (M) of 10 and 0.1 mM glucose in the medium. C/M for galactose also decreased, while the C/M ratios for alanine and xylose were within the control range. Glucose influxes across the luminal membrane, net glucose transepithelial fluxes, and electrical parameters were all consistent with defective sodium and glucose cotransport at the brush border membrane of jejunal epithelial cells. However, the present results are also consistent with a small residual active transport system observed only at low glucose concentration in the medium. Further observations are needed to establish the role of glucose transport systems in absorption of other monosaccharides, the relationship between kidney and intestinal sodium-glucose cotransport systems, and their genetic control.

Oral rehydration and nutritional rehabilitation of severely malnourished children.

PIP: This report of results obtained at the Center for Nutritional Rehabilitation and Oral Rehydration in Senegal suggests that simple techniques can be extremely effective in the treatment of diarrhea and severe malnutrition. The Center operates as a day hospital, with children and their mothers attending each day from 8 AM until 6 PM. The oral rehydration solution used has a rice flour base (30 gm) and includes 3.5 gm of sodium chloride, 2.5 gm of sodium bicarbonate, and 1.5 gm of potassium chloride. Breastfeeding is never interrupted, and nutritional rehabilitation is often begun before dehydration is completely corrected. The renutrition solution used is composed of curdled milk, oil, and sugar mixed together to form a paste that keeps for about 2 weeks. Mothers meet with the health auxiliary each day for nutrition and health education sessions. Of the 233 children completing treatment at the Center over a 9-month period, 214 had marasmus and 19 had kwashiorkor or kwashiorkor-marasmus. The average weight gain was 11.6 gm/kg/day in the former group (average duration of stay 17.3 days) and 8.0 gm/kg/day in the latter group (average duration of stay 27.0 days). The greater weight gain among children with marasmus than those with kwashiorkor reflects the edemas in the latter group. Overall, the success rate was 84% among children with a weight/age ratio under 55%. The average weight gain 1 month after discharge was 1 lg. The cost of this protocol was US25 cents/child/day. The simplicity of the infrastructure required should encorage the development of similar centers in peripheral and underserved areas.^ieng

[Infantile diarrhea in Senegal: epidemiologic survey in a suburb of Dakar]. / La diarrhée infantile au sénégal: enquête épidémiologique dans un faubourg de Dakar.

Before the launching of a national program against diarrhoea in Senegal it was interesting to survey the exact impact of this disease on the under 5 children and the way the mothers and the community are dealing with it. We investigated a very crowded suburb of Dakar where we found that diarrhoea was the first cause of death among under five children. This investigation showed us that Oral Rehydration Therapy (ORT) is widely known by the approximately 1000 mothers interviewed, thanks to the gambian and senegalese broadcasts . However, only 1% of the mothers consider it as a useful and efficient treatment of diarrhoea. Expansive and inefficient medical treatments as well as traditional therapy are systematically preferred to ORT. We analyzed the reasons of that failure and we proposed a new strategy to generalize the use of ORT.

[Intestinal malabsorption of glucose and galactose. Study of a family]. / La malabsorption intestinale du glucose et du galactose. Etude d'une famille.

A girl with congenital glucose-galactose malabsorption and her two parents were studied. Hydrogen breath tests performed on the child during glucose and galactose tolerance tests (0.5 g/kg) were positive (increase in expired pH concentration of 21 p.p.m. and 32.5 p.p.m. from the basal level respectively). This was negative for fructose (2 g/kg). In vitro intestinal transport studies showed: 1) a selective decrease in active glucose accumulation (intracellular concentration 0.34 mM in 0.1 mM glucose bathing solution - controls: 1.58 +/- 0.56 (means +/- SD), and 12.1 mM in 10 mM bathing solution - controls: 38.4 +/- 12.4). 2) absence of net glucose absorption during in vitro Ussing chamber measurements with a marked decrease in mucosal membrane glucose permeability. For the parents, the hydrogen breath test was negative after glucose and galactose ingestion (2 g/kg) and intestinal transport was normal (father; intracellular concentration 1.32 mM and mother 2.04 for 0.1 mM bathing glucose concentration). The marked decrease in brush border permeability explains the absence of net glucose absorption in the child. The parents who are presumed to be heterozygotes did not exhibit any detectable transport defect.