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.

Cryptosporidium as a cause of gastro-enteritis in Sudanese children.

Stool samples from 83 Sudanese children with gastro-enteritis were examined using a safranin-methylene blue stain. Five children (6.1%) were excreting cryptosporidium oocysts but no other potential enteropathogens. The clinical features of anorexia, vomiting and pyrexia and the profuse green watery offensive stool were similar to those reported previously. All of the children were dehydrated. None of 37 children studied who did not have gastro-enteritis was excreting oocysts.

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.

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.

Aflatoxins and kwashiorkor. Epidemiology and clinical studies in Sudanese children and findings in autopsy liver samples from Nigeria and South Africa.

The aetiology and pathogenesis of kwashiorkor remains obscure. Clinical and epidemiological studies are in progress in Sudan to determine whether aflatoxins play a role in the pathogenesis of kwashiorkor. Local foods are screened for their aflatoxin content and children with kwashiorkor and age and sex matched children with marasmus and with normal nutrition are being investigated for aflatoxins in their blood and urine. Autopsy liver samples of children with kwashiorkor and other nutritional disorders in Nigeria and South Africa have been examined for their aflatoxin content. Aflatoxins are detected using two dimensional thin layer chromatography and high performance liquid chromatography. Results to date on over 350 children studied show that aflatoxins occur more frequently and at higher concentrations in the sera of children with kwashiorkor than in children with marasmus or in normal children. Urinary excretion of aflatoxins in kwashiorkor appears to be less than in other groups. In the autopsy liver samples, aflatoxins have been detected in all kwashiorkor livers but not in livers from marasmic children. These findings seem to implicate aflatoxins in the pathogenesis of kwashiorkor. If this is confirmed it would have very wide implications for the management and prevention of kwashiorkor.

Aflatoxins and kwashiorkor: a study in Sudanese children.

Blood and urine samples from 252 Sudanese children were investigated for their aflatoxin content by high-performance liquid chromatography. The children comprised 44 with kwashiorkor, 32 with marasmic kwashiorkor, 70 with marasmus, and 106 age-matched, normally nourished controls. Aflatoxins were detected more often and at higher concentrations in sera from children with kwashiorkor than in the other malnourished and control groups. Aflatoxicol, a metabolite of aflatoxins B1 and B2, was detected in the sera of children with kwashiorkor and marasmic kwashiorkor but not in the controls and only once in a marasmic child. The difference between children with kwashiorkor or marasmic kwashiorkor and those in the control or marasmus groups was significant. Urinary aflatoxin was most often detected in children with kwashiorkor but their mean concentration was lower than in the other groups. Aflatoxicol was not detected in urine in any group. These findings suggest either that the children with kwashiorkor have a greater exposure to aflatoxins or that their ability to transport and excrete aflatoxins is impaired by the metabolic derangements associated with kwashiorkor. The presence of aflatoxicol in the sera of children with kwashiorkor but not in the others suggests a difference in metabolism between the two groups. Further studies are needed, and measurement of aflatoxins in the food eaten by these children is already underway.

Complications of diphtheria seen during the 1978 outbreak in Khartoum.

Twenty-nine cases of complicated diphtheria infection occurring during an epidemic in Khartoum are reviewed. The organism was a Corynebacterium diphtheriae subsp. gravis with an unusual property of fermenting sucrose. Eighteen patients were detected during prospective follow-up, where as 11 presented initially with a complication. Complications were mostly seen among pre-school children (65.5%). A routine immunization course had been completed in only two of the patients. Neurological complications were the commonest, lasting for more than two weeks, and five of the six deaths were due to cardiovascular complications.

PIP: The clinical presentation and outcome in 29 children admitted to 2 Khartoum, Sudan, hospitals with complications of diphtheria are described. The patients ranged from 10 months to 11 years, and 66% were in the 2-5-year age group. The organism implicated was Corynebacterium diphtheriae subspecies gravis with an unusual property of fermenting sucrose. Only 2 of the 29 children had received immunizations against diphtheria. The most common complications were neurological. Palatal palsy was present in 21 children (72%) and 8 patients (28%) developed weakness of neck extensors. Bronchopneumonia was seen in 13 children (45%), while cardiovascular complications occurred in 6 children (21%). There were 6 deaths in this group, for a case fatality rate of 21%. 5 of these deaths were attributable to cardiovascular complications and the other followed tracheostomy. Analysis of the number of days from the onset of pharyngeal symptoms to the appearance of complications followed a set pattern. Cardiovascular symptoms were the 1st to appear, followed by palatal palsy, peripheral weakness or paralysis, pharyngeal paralysis, weakness of neck flexors, and 6th and 7th nerve palsies. Although 4 doses of DPT vaccine are not an absolute guarantee diphtheria will not occur, there are significant differences between vaccinated and unvaccinated children in the relative incidence, morbidity, and mortality from the disease. This suggests a justification for mass immunization programs in regions such as the Sudan where diphtheria is common.

Coeliac disease in Sudanese children.

Coeliac disease has not hitherto been documented in Sudanese children. This report describes seven Sudanese children with coeliac disease of whom two are siblings. They all had evidence of impaired intestinal absorption, severe histological changes of their jejunal mucosa with clinical and histological improvement on gluten free/sorgham free diet. Subsequently one patient had a clinical relapse when gluten was reintroduced; four had positive gluten challenge using serial one hour blood xylose estimation. They all belonged to the upper socioeconomic group of the society in the north of the Sudan.