Genotypic characterization of rotaviruses and prevalence of serotype-specific serum antibodies in children in Kuwait.

There are no data on the serotypes of rotaviruses prevalent in Kuwait, which has a large expatriate population and hence a focal point for transmission of pathogens. The serotype information will contribute to the fund of knowledge on the world epidemiology of rotavirus serotypes and will predict the outcome of vaccination in Kuwait. Of the 75 rotavirus-positive samples from 172 children (aged <5 years) with severe diarrhoea, 69 were genotyped. The distribution of genotypes was G1 (63.8%) followed by G9 (10.2%), G2 (7.3%), G4 (7.3%) and G3 (4.4%). Among the P types, P[8] was the most common type found across all G types. By fluorescent focus neutralization test, serum antibodies to genotypes G1 (94%), G4 (68%) and G9 (46%) were found in 120 other children. These results show that G1 is the predominant serotype in Kuwait and that a vaccine that contains G1 will be most effective.

Intestinal permeability is increased in bronchial asthma.

BACKGROUND: Increased intestinal permeability has been reported in one study of adult asthmatics. AIM: To determine whether children with asthma have altered intestinal permeability. METHODS: Thirty two asthmatic children, and 32 sex and age matched controls were recruited. The dual sugar (lactulose and mannitol) test was used to evaluate intestinal permeability, and the percentage of ingested lactulose (L) and mannitol (M) in the urine, and the L:M ratio were determined. All patients were skin prick tested for common aeroallergens, and specific IgE to some food items was determined. RESULTS: The median value of L in asthmatic children (2.29, IQR 0.91-4.07) was significantly higher than that in controls (0.69, IQR 0.45-1.08), and that of M was almost similar. The ratio L:M was significantly higher in asthmatic children (0.20, IQR 0.11-0.40) than in controls (0.06, IQR 0.04-0.09). Intestinal permeability did not correlate with eczema, inhaled steroids, positive skin prick test to aeroallergens, or severity of asthma. CONCLUSIONS: Intestinal permeability is increased in children with asthma, suggesting that the whole mucosal system may be affected.

Effects on health of fluid restriction during fasting in Ramadan.

During the 9th month (Ramadan) of the Islamic calendar (Hijra) many millions of adult Muslims all over the world fast during the daylight hours. Since Hijra is a lunar calendar, Ramadan occurs at different times in the seasonal year over a 33-year cycle. Fasting during Ramadan is partial because the abstention from food, fluid, tobacco and caffeine is from sunrise to sunset. Several categories of people are exempt or can postpone the Ramadan fast. The effect on health and well being of the month-long intermittent fast and fluid restriction has been studied in various potentially vulnerable groups in addition to normal healthy individuals in many countries. The majority of the studies have found significant metabolic changes, but few health problems arising from the fast. A reduction in drug compliance was an inherent negative aspect of the fast. Common findings of the studies reviewed were increased irritability and incidences of headaches with sleep deprivation and lassitude prevalent. A small body mass loss is a frequent, but not universal, outcome of Ramadan. During the daylight hours of Ramadan fasting, practising Muslims are undoubtedly dehydrating, but it is not clear whether they are chronically hypohydrated during the month of Ramadan. No detrimental effects on health have as yet been directly attributed to negative water balance at the levels that may be produced during Ramadan.

Comparison of safety of glucose oral rehydration solution and maize oral rehydration therapy for home management of diarrhoea in Kenya.

Safety margins and variability in the composition of glucose and maize-based oral rehydration therapy (ORT) prepared by mothers in a rural district of Western Kenya, are reported here. In a 2-year longitudinal field study, packets containing glucose ORS and a home solution made with maize and table salts, were provided to the mothers of 6180 children in Kakamega District in two separate sub-locations. Experienced and trained field workers supported by community registered nurses provided training for the preparation and use of ORT during weekly visits to every household. On four occasions separated by 4-6 months, a 5 per cent random sampling was done of the home-prepared solutions actually used for the treatment of children with diarrhoea. The water used for preparing ORT was also sampled. Samples of 174 glucose-based ORT, 148 maize-salt ORT, and 201 samples of water were analysed. Only 2 per cent of the maize-based ORT were above 120 meq/1 sodium (i.e., the safe range of sodium concentration) compared to 17.8 per cent for glucose solutions (p < 0.001). Home water samples contained substantial amounts of salt, which could unpredictably affect the final composition of the ORT solutions. We conclude that maize-salt ORT had a better margin of safety than glucose-based ORS.

Bangladeshi rural mothers prepare safer rice oral rehydration solution.

Mothers in rural Bangladesh were trained to prepare and use either Rice-ORS (R-ORS) or Glucose-ORS (G-ORS) solutions to treat children with diarrhoea. Families were provided with either G-ORS or R-ORS of the same electrolyte composition through a depot holder. Subsequently, random samples of solutions actually used for treatment by the mothers were collected from homes by field workers. A total of 227 R-ORS and 239 G-ORS samples were analysed. The sodium concentration in about 90% of the samples had a safe range (50-120 mmol/l). Only 4% of R-ORS solutions were above 120 mmol/l in sodium concentration, while 12% of G-ORS solutions exceeded these limits (p < 0.0025). R-ORS (after acid hydrolysis) provided significantly higher glucose (257 +/- 42 mmol/l) for active but safe absorption compared to G-ORS (115 +/- 39 mmol/l). To make R-ORS liquid enough to drink requires addition of sufficient water, preventing the risk of higher sodium concentration. Unlike rice starch, glucose is a highly soluble substance. It is thus possible to prepare a drinkable solution containing dangerously high concentrations of both sodium and glucose, but this can be minimized by more intensive training of the mothers.

Risk factors for nutritional rickets among children in Kuwait.

AIM: To assess the risk factors for nutritional rickets among children in Kuwait. METHODS: One hundred and three children with rickets and 102 control children matched for age and socioethnic characteristics were recruited over a 2 year period (January 1995 to January 1997) in Al-Adan Hospital in Kuwait. Diagnosis was made on clinical, radiologic and biochemical parameters. A specially designed questionnaire was administered by one of the investigators to both mothers of patients and mothers of control subjects to assess the role of social, nutritional and other related factors in the pathogenesis of nutritional rickets. Biochemical investigations included estimation of hemoglobin, serum calcium, serum phosphorus, serum alkaline phosphatase and serum 25-hydroxy vitamin D. RESULTS: The mean birthweights of rickets patients and control subjects were 3.20 +/- 0.46 and 3.19 +/- 0.45 kg, respectively. At the time of diagnosis, bodyweights of the patients and controls were 9.36 +/- 1.50 and 10.15 +/- 2.10 kg, respectively. Heights at the time of diagnosis were 73.58 and 77.24 cm for the patients and the controls, respectively. Mean hemoglobin, serum calcium and serum phosphate were significantly lower in the patients compared with the controls. Alkaline phosphatase was higher among the patients (P < 0.0001). The mean serum 25-hydroxy vitamin D level of the patients was 26.5 nmol/L, compared with 83.5 nmol/L in the controls. The mean age of starting semisolid feeds for the patients was 8.12 months, compared with 5.7 months in the controls. The nutritional quality of semisolid feeds was adequate among 71.6% of the controls as opposed to 13.6% of the patients. CONCLUSION: Nutritional rickets is a multifactorial condition. However, several factors seem to make important contributions. Among these, lack of exposure to sunlight, prolonged breast feeding without supplementation and inadequate weaning practices are important. Maternal education is important as it can influence all of the above factors.

Efficacy of traditional rice-lentil-yogurt diet, lactose free milk protein-based formula and soy protein formula in management of secondary lactose intolerance with acute childhood diarrhoea.

Secondary lactose intolerance is often a cause of prolongation of diarrhoeal episodes. As appropriate management of lactose intolerance is elimination of lactose from diet, expansive lactose free formulae are often prescribed in acute childhood diarrhoea without establishing diagnosis of lactose intolerance. Since cheap weaning diets made from locally available cereals have been found effective in management of persistent diarrhoea, we postulated that same weaning diet made of rice lentil and yogurt (K-Y diet) could be effectively used in management of acute childhood diarrhoea associated with secondary lactose intolerance. We compared this K-Y diet with milk protein-based lactose free and soy-protein formula. Thirty children between 3-18 months of age completed dietary trial for 72 h. Of these nine children received K-Y diet (Group A), four children received milk protein-based formula (Group B) and 11 children received soy protein formula (Group C). Stool frequency was significantly reduced in children in Group A (13 +/- 6 on day 1 to 6 +/- 5 on day 3) and in Group B (13 +/- 5 on day 1 to 7 +/- 4 on day 3), but not in Group C (13 +/- 4 on day 1 to 10 +/- 8 on day 3). No significant difference was observed in intake of diet, total calories intake, and fluid intake among the three groups. It is concluded that cheap weaning diet made of locally available cereals and yogurt can be used effectively in management of secondary lactose intolerance associated with acute childhood diarrhoea.

A field trial of wheat-based oral rehydration solution among Afghan refugee children.

A total of 326 Afghan children aged between 6 months and 5 years with uncomplicated nondysenteric diarrhea for the previous 24 h to 5 days were treated at home by their mothers with either wheat-salt solution (WSS) or World Health Organization recommended glucose-oral rehydration salts (G-ORS). For 7 consecutive days the children were examined in the household and the mothers interviewed to assess the progress, feeding practices, and perception of treatment efficacy. Children treated with WSS recovered significantly earlier; the mean duration on treatment was 4.0 days (SD 1.7 days) on WSS compared to 6.4 days (SD 1.7 days) on G-ORS. By the second day of treatment, significantly more mothers using WSS (56%) reported that their children had formed stools versus 11% of their G-ORS counterparts; the mean stool frequency after 2 days was also significantly reduced; 3 stools day-1 (SD 2.1) on WSS versus 5 (SD 2.9) on G-ORS. The cereal-based solution was not confused with normal food and led to better feeding patterns. By day 2, 74% of the mothers using WSS had resumed their normal feeding frequencies as opposed to 33% of G-ORS mothers. On recovery the WSS group had gained significantly more weight; the WSS group gained 169 g (SD 142 g) while the G-ORS group lost 150 g (SD 174g). This study suggests by subjective and objective measures that WSS could be considered as an effective home fluid for the first-line treatment of diarrhea.

Therapy of multidrug-resistant typhoid fever with oral cefixime vs. intravenous ceftriaxone.

We randomly allocated 80 children with suspected multidrug-resistant tyhpoid fever to therapy with either cefixime or ceftriaxone. Of these, an alternative diagnosis was subsequently made in 10 children and another 10 were excluded because cultures were negative. In 9 cases the typhoidal organisms isolated were susceptible to first-line drugs. In all, 50 children were randomly allocated to receive therapy with either intravenous ceftriaxone (65 mg/kg/day once daily, Group A, n = 25) or oral cefixime (10 mg/kg/day divided every 12 hours, Group B, n = 25) for 14 days. The two groups were comparable in their clinical characteristics, duration and severity of illness at the time of admission. The time to defervescence was comparable in both groups (8.3 +/- 3.7 vs. 8.0 +/- 4.1 days, P = not significant). An equal number (3 in each group) failed to respond and underwent a change in therapy. Three children in Group A and one in Group B relapsed. No adverse effects were seen in either group during the course of therapy. Our data suggest that oral cefixime can be used as effectively as parenterally administered ceftriaxone for management of typhoid fever in children.

Is rice based oral rehydration therapy effective in young infants?

Rice based oral rehydration therapy (ORT) solutions have been shown to be superior to glucose oral rehydration salts (World Health Organisation (WHO) ORS) in reducing stool volume and duration of diarrhoea in children and adults. Rice based ORT has been used only sparingly in young infants, however, because of theoretical concerns about digestibility. A randomised controlled trial of rice based ORT (50 g rice and electrolytes identical to WHO ORS) and WHO ORS was carried out in 52 male infants less than 6 months old with moderately severe acute diarrhoea to evaluate efficacy and digestibility. Nineteen (70%) of 27 children who received rice based ORT and 18 (72%) of 25 children who received WHO ORS were treated successfully. The mean (SD) diarrhoeal stool output for the first 24 hours of treatment was significantly lower in the infants receiving the rice based ORT than in those receiving WHO ORS (101.0 (60.5) v 137.1 (74.6) g/kg). The stool output was also significantly less in the rice based ORT group in the second 24 hours. Infants in the rice based ORT group drank significantly less rehydration solution than infants in the WHO ORS group (mean (SD) 165.4 (77.4) v 217.9 (86.1) during the first 24 hours of treatment. There was no difference in the duration of diarrhoea between the groups. The volume of breast and formula feeding was similar in the two groups. No difference was seen in the frequency of finding reducing substances or acid pH in the stools of either group of children. The results suggest that rice based ORT is as effective as WHO ORS in infants with moderately severe diarrhoea and that rice based ORT is as well tolerated as WHO ORS in infants.

Nutrient absorption and weight gain in persistent diarrhea: comparison of a traditional rice-lentil/yogurt/milk diet with soy formula.

We prospectively studied clinical outcome and nutrition absorption in male children (6-36 months of age) with persistent diarrhea (PD) and severe protein-energy malnutrition (mean z score for age, -4.2 +/- 0.8). Fifty-one children were randomly allocated to receive a combination of khitchri, a rice-lentil mixture, yogurt, and half-strength buffalo milk (group A; n = 26) or full-strength soy formula (group B; n = 25) for 14 days. The initial caloric intake (p < 0.02) and mean weight gain (p < 0.02) were greater in the group B patients. The mean stool volume and frequency were comparable between the two groups. Seven children in group A were considered clinical failures by criteria of weight loss and PD, compared to three in group B. The coefficients of absorption (COA) for protein were similar between the two groups, but group B patients had higher values of COA for energy and fat (p < 0.05) in the second week of nutritional rehabilitation. The majority (63%) of the children improved on the khichri-yogurt-milk diet but the nutritional outcome was not as good as with the soy formula. These data indicate that a traditional diet can be successfully used in the dietary management of PD and severe malnutrition but that a more optimal composition, yielding a higher success rate, should be sought.

Is anemia an accurate predictor of vitamin A status in Pakistani children?

Serum retinol and hemoglobin levels were determined in 532 children aged 6-60 months living in urban slums of Karachi, Pakistan. Overall 67% (358 of 532) of children had hemoglobin levels of less than 11 g/dl, the World Health Organization definition of anemia for this age group. Estimations for red blood cell indices (hematocrit, mean corpuscular volume, mean corpuscular hemoglobin, mean corpuscular hemoglobin concentration, and red blood cell count) were done on a sample of 391 children to classify anemia morphologically. A similar percentage (69.8% [273 of 391 children]) of anemia was found in this group. The anemia was predominantly microcytic and hypochromic. Normocytic normochromic anemia was present in only 16.5%. Serum retinol levels were significantly correlated with hemoglobin (P < 0.002), hematocrit (P < 0.01), and red blood cell (P < 0.001) levels. However, anemia was found to be a poor predictor (positive predictive value [PPV] = 2.5%) for the presence of vitamin A deficiency (retinol < 10 micrograms/dl). The PPV increased to 54% if 20 micrograms/dl, which is an indicator of marginal vitamin A status, was used as the cutoff point. The sensitivity of the hemoglobin test was found to be 75% in correctly identifying vitamin A deficiency when retinol levels of 10 micrograms/dl and 20 micrograms/dl were both used as the cutoff points for deficiency. The specificity for the hemoglobin test varied from 33% to 40% when levels of 10 micrograms/dl and 20 micrograms/dl were used as the cutoff points for vitamin A deficiency.(ABSTRACT TRUNCATED AT 250 WORDS)

Malabsorption of nutrients in children with diarrhoea due to unknown aetiologies.

Intake and coefficient of absorption of nutrients were measured in 72 children during acute diarrhoea and 2 weeks after recovery. No diarrhoeal pathogens could be identified in 18 (25%) children (group I). Aetiology of diarrhoea was identified in rest of the 54 children (group II). Absorption of calorie, fat and carbohydrate during the recovery stage were similar in all 72 children. In group I, absorption of nutrients improved from acute stage to recovery stage as follows: fat from 62 to 85%, calories from 68 to 86% and carbohydrate from 81 to 91%. Absorption of nitrogen during the acute stage was significantly lower (P < 0.01) in group I (mean +/- SD: 2% +/- 56) than in group II (mean +/- SD: 49% +/- 28). The anion gap in the stool of group I children (32) was similar to those with shigellae (37) and rotavirus (38). This could partially be explained by the possible loss of anionic proteins, fatty acids and/or lactic acids in the diarrhoeal stool. Results suggest that the diarrhoea due to unknown aetiology is possibly of the invasive type. Further investigation is necessary to define the mechanism of nitrogen loss in acute diarrhoea of unknown aetiology.

Vitamin A status of children in the urban slums of Karachi, Pakistan, assessed by clinical, dietary, and biochemical methods.

We assessed the vitamin A status of 532 children with an age range of 6-60 months who were living in slum areas of Karachi, Pakistan, using three methodologies: clinical eye examination, dietary vitamin A intake, and serum retinol level. No definite clinical signs of xerophthalmia were observed in any of these children. The mean +/- SD vitamin A intake estimated from a food frequency questionnaire for the group with inadequate (low and deficient) serum retinol levels (< 20 micrograms/dl) was 362 +/- 332 retinol equivalents (RE) compared with 431 +/- 332) RE in the group with adequate serum levels (P < 0.005). Deficient serum retinol levels (< 10 micrograms/dl) were present in 12 children (2%); two of these had a healed corneal scar. Low serum retinol levels (10-19 micrograms/dl) were present in 46%, while 51% children had adequate levels (> or = 20 micrograms/dl). The mean +/- SD serum retinol level for the inadequate (< 20 micrograms/dl) and adequate groups were 15.3 +/- 2.8 and 26.6 +/- 6.7 micrograms/dl, respectively. These results suggest that a significant number of children in these communities have low vitamin A levels and thus may constitute an at risk group. These results also suggest that the dietary intake method may be a simple and inexpensive screening tool for assessment of vitamin A status in communities.

Role of cereal-based oral rehydration therapy in persistent diarrhoea in children.

A total of 2000 children aged under five and 12,500 diarrhoea episodes were studied prospectively for assessing the efficacies of R-ORS and G-ORS and for comparing them with that of a comparison area using drugs for treatment. Efficacy was evaluated in terms of ORS use rate, consumption of ORS per episode, duration of diarrhoea and rate of recovery. The data were analysed to compare the rate of persistent diarrhoea in the three areas. Mean ORS consumption was 946 +/- 576 and 1236 +/- 766 ml per episode of watery diarrhoea in the R-ORS and G-ORS areas respectively. The mean durations of watery diarrhoea were 3.3 +/- 2.1, 5.4 +/- 3.5 and 8.8 +/- 5.5 days in the R-ORS, G-ORS and comparison area, respectively. The median durations for dysentery were 7, 9 and 12 days in the three areas respectively. The incidences of persistent diarrhoea following water diarrhoea were 0.4, 3 and 12% in the R-ORS, G-ORS and comparison area respectively, and, following dysenteric episodes, 8, 18 and 40%. The results of the study suggest that R-ORS can hasten recovery from both watery diarrhoea and dysenteries, thus reducing the incidence of persistent diarrhoea.

Nutritional management of persistent diarrhea: factors predicting clinical outcome.

In a prospective study we randomized 102 male children (age 6-36 months) with persistent diarrhea to receive a traditional rice-lentil (Khitchri) diet and yogurt (K-Y) or a soy formula (alone for seven days and then in combination with K-Y for seven days). Of 73 children satisfying the study criteria, 66 were successfully treated and there were 7 treatment failures. There was poor concordance between parental accounts of severity of diarrhea or vomiting and that observed after admission. Significant risk factors associated with treatment failure included younger age (p < 0.005) and vomiting at presentation (p < 0.02). The greatest number of risk factors associated with delayed recovery (> 10 days) were identified during an initial evaluation period (the first 8 h after admission). These included greater severity of watery diarrhoea (p < 0.01) and increased ORS intake (p < 0.02). Our data suggest that an initial evaluation period, including objective observations, may identify children with persistent diarrhea who are at greatest need of hospitalization.

Prevalence of iron deficiency anaemia in children of the urban slums of Karachi.

A preliminary baseline survey was conducted to estimate the prevalence of anaemia in a group of 391 children aged 6-60 months, randomly selected from three urban slums of Karachi. Haemoglobin and the red cell indices including haematocrit, MCV, MCH, MCHC, RBC and red cell distribution width (RDW) were estimated for each of the selected children. Ferritin estimation was done on 354 (91%) children to assess the iron storage status. According to WHO criteria, the accepted cut-off point for anaemia screening in children is set at 11 gm/dl, 70 fl and 20 pg for haemoglobin, MCV and MCH respectively. Following these criteria, 118 (30%) children were classified as normals (Hg = greater than 11 gm/dl) and 273 (70%) as anaemic (Hg = less than 11 gm/dl). Of the 354 ferritin estimations, 225 (64%) children had ferritin levels lower than normal (less than 11 ng/ml) and 128 (36%) had ferritin levels within normal limit (11-120 ng/ml). From this group, a total of 61% (214/354) children were classified as microcytic hypochromic (MIH) and 11% (39/354) of which had normal ferritin levels suggesting the presence of thalassemia minor trait. The overall results obtained indicate that iron deficiency anaemia is highly prevalent among these children.

Effects of food with two oral rehydration therapies: a randomised controlled clinical trial.

To evaluate the impact of food on the efficacy of oral rehydration solution (ORS), a randomised, controlled clinical trial was conducted in 182 adults with cholera. After initial rehydration with an intravenous polyelectrolyte solution for four hours, the patients were randomised to receive one of four rehydration therapies: glucose based ORS and no food for the first 24 hours (group A), glucose based ORS plus food from the beginning of treatment (group B), rice based ORS with no food for the first 24 hours (group C), and rice based ORS plus food from start of therapy (group D). Tetracycline was given after 72 hours to all patients. No significant differences in ORS intake, stool output, and duration of diarrhoea were noted between groups A and B and between groups C and D. A substantial and significant reduction in stool output was, however, shown in the groups who received rice based ORS irrespective of feeding. These results show that food does not potentiate the efficacy of either glucose based or rice based ORS in adults with cholera. Rice based ORS compared with glucose ORS substantially reduces purging in cholera patients.

Gastric emptying of liquid in children suffering from acute rotaviral gastroenteritis.

Nausea and vomiting commonly occur in children suffering from rotaviral diarrhoea. Gastric emptying was studied in 10 children (age six to 12 months) suffering from acute diarrhoea caused by rotavirus using a dye dilution double sampling technique. The test meal was 5% dextrose in water and this test was repeated 12 weeks after recovery. The median (range) of the percentages of the liquid meal remaining in the stomach at 5, 10, 20, 40, and 60 minutes after instillation of the meal were 82 (79-90), 70 (61-86), 51 (38-76), 26 (14-53), and 13 (2-35) respectively in the acute stage, whereas after the recovery period the values were 76 (70-79), 58 (49-63), 33 (24-40), 11 (2-26), and 3 (0-7). The differences were statistically significant. The half time of gastric emptying (t1/2) was 19.5 (14-30) minutes in acute stage, and 13.1 (10-15) minutes during follow up (p less than 0.01). Rotaviral gastroenteritis is accompanied by abnormal gastric motor function, as manifested by delayed emptying of a liquid meal.

Dietary management of persistent diarrhea: comparison of a traditional rice-lentil based diet with soy formula.

Recent studies have indicated that enteral diets can play an important role in the treatment of persistent diarrhea. Khitchri, a local weaning food in Pakistan, is composed of rice and lentils, which have previously been shown to be well tolerated in many children with acute diarrhea. The effectiveness of a khitchri and yogurt (KY) diet, which is inexpensive and widely available in Pakistan, was studied. One hundred two weaned boys (6 to 36 months old) with persistent diarrhea were randomly assigned to receive either soy formula (group A) or the KY diet (group B) for 14 days. Group A also received the KY diet in addition to formula for days 8 through 14. Twenty-nine children did not complete the study because of severe infection (13) or their family's decision to leave the study early (9 in group A and 7 in group B). Sixty-six children successfully completed the study protocol; there were five clinical failures in group A and two in group B. On a comparable caloric intake, there was a significantly lower stool volume (group B: 38 +/- 16 [mean +/- SD] vs group A: 64 +/- 75 g/kg per day, P less than .05) and frequency (B: 4.4 +/- 2.0 vs. A: 6.6 +/- 4.2 stools per day, P less than .005) in children fed KY during the first week of therapy. Group B children also had a significantly greater weight gain than children in group A during the first week (B: 468 +/- 373 g/wk vs A: 68 +/- 286 g/wk, P less than .005).(ABSTRACT TRUNCATED AT 250 WORDS)