Effective health education in rural Gambia.

We aimed to measure the impact of a structured health education programme on the incidence of infectious disease in young children of a rural Gambian village. In a prospective intervention study, mothers of children under 3 years living in a rural West African village without running water (population 1600) were divided into two groups by site of residence. Group 1 (n = 70) received a fortnightly education talk on hand-washing and skin hygiene, and group 2 (n = 84) on family planning. The incidence of infectious skin and diarrhoeal, eye, and respiratory diseases were recorded at the clinics attended by all children. The mean incidence of skin infections in the children of mothers of group 1 (1.07) was significantly lower (p < 0.05) than that of group 2 (1.59) during the rainy season. Between 1981 and 1994 the incidence of skin, diarrhoeal, and eye disease showed a statistically significant (p < 0.0001) decline following the implementation of the health education programme. There was no statistical significance in the trend for respiratory disease, the incidence of which would not be expected to be affected by hygiene education. Focused health education had a sustained beneficial effect on the health of young children living in conditions where infectious diseases and poor hygiene are common.

Giardia intestinalis is unlikely to be a major cause of the poor growth of rural Gambian infants.

Parasite-specific plasma immunoglobulins have been used to indicate the presence of Giardia intestinalis infection in 60 infants living in a rural area of The Gambia. Infants were studied longitudinally between 2 and 8 mo of age. The median age for first exposure to G. intestinalis was between 3 and 4 mo, and by 8 mo all but 3 infants (95%) showed a positive titer on at least one occasion. Raised Giardia-specific IgM titers were associated with reduced weight gain in the 2 wk preceding a positive titer, but catch-up growth occurred in the following 2 wk. IgM antibody titers were also positively associated with intestinal permeability (lactulose/mannitol ratio), urinary lactose excretion, plasma concentrations of alpha1-antichymotrypsin and total IgM, IgA and IgG immunoglobulins. However, infant growth over the whole 6-mo period (i.e., between 2 and 8 mo of age) was not related to mean Giardia-specific antibody titers, nor the time of first exposure to the parasite. The data suggest that giardiasis in these very young breast-fed children occurs as a mild, acute disease, and its presence could not explain the marked, long-term growth faltering observed in many of the subjects.

Prognostic factors in severely malnourished hospitalized Nigerian children. Anthropometric and biochemical factors.

To determine the clinical factors that are of prognostic importance in protein-energy malnutrition (PEM), 150 patients admitted into the paediatric wards at the University College Hospital, Ibadan, Nigeria, were studied. Detailed clinical history, anthropometry and biochemical investigations were done immediately on admission. Case fatality rate decreased with age: 75% and 33% in those aged 12 months and below, and 30 to 36 months, respectively. The mortality in marasmus, kwashiorkor and marasmic-kwashiorkor were 35%, 47% and 60%, respectively. Hepatomegaly on admission had no significant impact on prognosis, but mortality increased with increasing hepatomegaly. Growth failure on admission, as measured by weight-for-age, weight-for-height and mid-upper-arm circumference were significantly associated with poor prognosis (p < 0.01, p < 0.01 and p < 0.001, respectively). Hypokalaemia and hyponatraemia were each separately associated with poor prognosis. When both electrolytes were low, more patients died (81%) than when both were normal (24%) (p < 0.001). Similarly, hypoproteinaemia and hypoalbuminaemia were associated with poor prognosis singly and in combination. When both serum proteins and albumin were low, the mortality was 32%, and there were no deaths when both were normal. The outcome in severe PEM is still poor. Good clinical precision in identifying clinical and biochemical prognostic factors, early intervention and good subsequent management are important in reducing mortality in PEM.

Is cow's milk suitable for the dietary supplementation of rural Gambian children? 1. Prevalence of lactose maldigestion.

To define the age-related prevalence of lactose maldigestion (LM), 218 children aged 13-72 months from a rural Gambian village were studied using a lactose breath hydrogen test. There was a significant rise in LM from 21% to 76% between the 2nd and 3rd-5th years of life (p < 0.001). Only eight children had diarrhoea within 2 weeks before the test. Diarrhoea and abdominal discomfort followed in only seven children (3%). There was no difference in mean time of introduction of supplementary diet or cessation of breastfeeding between children aged 12-36 months with lactose digestion and LM. There was a greater proportion of children with normal lactose digestion than with LM in those still receiving breast milk (85% vs 15%), and a greater proportion of LM in the fully weaned group (63% vs 37%) (p < 0.001). There was no relation between weight-for-age or weight-for-height and the ability to digest lactose. The ability to digest lactose is lost in the majority of children during the 2nd year, coincident with the cessation of breastfeeding, but is not a major factor associated with growth failure thereafter.

PIP: During the dry season in the rural village of Keneba, The Gambia, health workers conducted the lactose breath hydrogen test on 218 children, 13-72 months old, following an overnight fast and ingestion of an aqueous factors solution (2 gm/kg body weight). They also took anthropometric measurements and a 2-week clinical history to determine the age-related prevalence of lactose maldigestion (LM) and to link it to diet, growth, and clinical signs and symptoms of lactose intolerance. Overall LM prevalence stood at 68% . 3-5 year old children were significantly more likely to have LM than 2-year-olds (76% vs. 21%; p .001), coinciding with weaning. Lactose digesters and lactose maldigesters began supplementary feeds and were completely weaned at essentially the same age. Yet, a greater proportion of lactose digesters still consumed breast milk (85% vs. 15%), while a greater proportion of lactose maldigesters were completely weaned (63% vs. 37%) (p .001). LM did not affect weight-for-age or weight-for-height, suggesting that LM does not contribute to childhood growth failure. 8 children suffered from diarrhea during the 2 weeks before the test. 7 children had clinical signs of lactose intolerance (flatus, diarrhea, and/or abdominal cramps). These results led the researchers to recommend that cow's milk should only be given to completely weaned children as a means to supplement carbohydrate, protein, and calcium in areas with high rates of protein energy malnutrition.

Is cow's milk suitable for the dietary supplementation of rural Gambian children? 2. Patterns of cow's milk intake.

Cow's milk has been advocated as a source of supplementary diet for children in many parts of the developing world. The frequency and forms of cow's milk intake and the factors regulating its availability and consumption by 507 children aged up to 6 years in three Gambian villages were measured. Nineteen per cent of mothers did not give cow's milk to their children. Of 413 children taking cow's milk, 41% consumed it only once a week, 32% two to four times a week, 19% once a day and 8% more than once a day. Eighty per cent of children took both fresh and sour milk. Forty-one per cent of infants up to 1 year old received cow's milk at some time. There was a decrease with age in the proportion of children taking fresh milk and a rise with age in the proportion taking sour milk alone (p < 0.001) and both forms of milk. Only 2% of children were reported to have an adverse reaction to fresh cow's milk. The main factors affecting intake were the availability of money and milk. The consumption of cow's milk in early life is common and free of adverse effects. When it is available, it should be used to supplement the diet of the weaned child.

PIP: In The Gambia, field assistants interviewed 349 mothers of 507 children no older than 6 years old in Kantonkunda, Manduar, and Keneba, in the West Kiang district, to determine the frequency and forms of milk intake and to identify factors which control milk availability and ingestion. 413 children consumed cow's milk. The remaining children consume the milk of goats and sheep. 41% of the 413 children ingested cow's milk once a week, 32% 2-4 times a week, 19% once a day, and 8% more than once a day. More than 30% of children who were at least 1 year old drank cow's milk at least once a week. 80% of all children drank both fresh and sour milk. 13% only drank fresh milk. 5% drank only sour milk. Just 2% were ever given pasteurized milk. Children 1-year-old were more likely to ingest fresh milk than older children (e.g. 50% vs. 18% for 1-2 year olds, the next largest fresh milk consuming group). Sour milk consumption increased with age, while fresh milk consumption decreased with age (p .001), suggesting that increased sour milk consumption was a way to reduce the symptoms of milk tolerance. Just 2% of children suffered from an allergic reaction to fresh milk. The cost of cow's milk limited its widespread use as a food for children. Knowledge of the significance of milk did not increase milk intake, but availability did. Specifically, a higher proportion of families who owned their own cow gave their children milk once a day than did those who did not have a cow and those who did not have money (36% vs 15 and 10%, respectively). These findings led the researchers to recommend cow's milk consumption only for completely weaned children. It should be boiled or soured and served and drunk from clean containers.

Nutrient intakes of children in a rural Nigerian community.

The nutrient intakes of 30 children in a rural Nigerian community were assessed by measuring their food intakes for four consecutive days by direct weighing method. The contents of the following six nutrients were calculated: energy, protein, calcium, iron, riboflavin, and vitamin C. The mean (SD) daily energy intakes for the various ages groups were: 1-5 years 801 (317) kcal; 6-10 years 1123 (214) kcal; and 11-15 years 903 (134) kcal, while the mean (SD) daily protein intakes for the same group of children were 21 (11) g; 35 (10) g, and 27 (7) g. These figures show a wide departure from the FAO/WHO/UNU reference values and a worsening of the nutritional status of rural Nigerian children.