Contamination of weaning foods and transmission of E. coli in causation of infantile diarrhea in low income group in Chandigarh.

Samples of weaning foods and other sources of contamination, such as water, mother's nails, utensils and swab samples of feeding bottle nipple, mother's teats and child's hands were collected from a total of 100 houses of Low Income Group (LIG) in Chandigarh. A high incidence of E. coli isolation (72.3%) was noticed amongst the collected samples. Seventy nine per cent of storage containers of water exhibited the presence of E. coli. Eighty per cent of the children had diarrhea even when exclusively breastfed. Sixty six per cent children were weaned within 3-6 months; the ratio increasing with increase in the educational qualification of the mother. Eighty out of the total 100 households which had a history of infantile diarrhea exhibited 80.9% E. coli isolation.

PIP: In Chandigarh, India, samples of weaning food, water, utensils, and mother's nails and swab samples from the bottle nipple, mother's teats, and infant's hands were collected from randomly selected houses where the household income was less than Rs. 2000/month. Researchers aimed to determine sources of contamination of child's weaning food and the various modes of transmission of Escherichia coli into the infant's body and these modes' roles in causing infantile diarrhea. 99% of the infants were breast fed at birth; 68% at age 1. 66% of the infants were introduced to weaning foods at age 3-6 months, 25% at age 6-12 months, and 2% at age 12-18 months. E. coli was isolated in 72.4% of all samples collected. It was isolated in 79% of containers used to store drinking water. The most common method of feeding was finger feeding (67%). E. coli was isolated from 80.9% of the households where the infants had a history of diarrhea (p .05). It was also isolated in 38.5% of households where the infants had no history of diarrhea. Only 2 of the 100 households sampled had neither history of infantile diarrhea nor E. coli isolation. E. coli was isolated from 91.5% of the mother's teats. The E. coli isolation rate for weaning food, water, mother's nails, utensils, feeding bottle, and child's hands was 56%, 79%, 79%, 66%, 71.8%, and 88.6%, respectively. 80% of infants had diarrhea even during exclusive breast feeding. 44% of mothers did not reheat weaning foods before serving those food to their baby if the foods had already been cooked. Only 10% boiled it for 5-7 minutes before feeding it to the infant. These findings show several opportunities for cross-contamination from one source to the other, indicative of poor personal hygiene. They also suggest that knowledge about hygiene and sanitation are low among low income mothers.

Enteropathogens associated with acute diarrhoeal diseases.

PIP: Five types of Escherichia coli are responsible for as much as 25% of all diarrheal diseases in developing countries. They tend to be transmitted via contaminated foods, particularly weaning foods, and water. They include enterotoxigenic, enteropathogenic, enteroadherent, enteroinvasive, and enterohemorrhagic E. coli. Shigella species are responsible for 10-15% of acute diarrheas in children less than 5 years old and the most common etiologic agents of childhood dysentery. Shigellosis is common in the warm season. An outbreak of shigella dysentery in West Bengal, India, had a high attack rate in children less than 5 years old and was resistant to many drugs. Nontyphoid Salmonella species cause watery diarrhea with nausea, cramps, and fever. Worldwide, various Salmonella strains exhibit resistance to ampicillin, chloramphenicol, and co-trimoxazole. Campylobacter jejuni produces watery diarrhea which, in 33% of cases and 1-2 days after onset, contains blood and mucus. Many normal healthy children in developing countries are carriers of C. jejuni. Vibrio cholerae O1 is endemic in parts of Africa and Asia (e.g., 5-10% of hospitalized diarrhea patients). The ElTor cholera biotype is responsible for the 7th pandemic. Other bacterial enteropathogens are Aeromonas species, Bacteroides fragilis, and Providencia alcalifaciens. Rotavirus is a major cause of sporadic and epidemic diarrhea among 6-23 month olds. Its incidence peaks in cold or dry seasons. Other viral enteropathogens are Norwalk virus, adenoviruses, astroviruses, and coronaviruses. In India, the prevalence of Entamoeba histolytica varies from 3.6% to 47.4%. It occurs equally in high and low socioeconomic classes. Giardia lamblia usually infects 1-5 year old children. Its transmission routes are food, water, and the fecal-oral route. Cryptosporidia produce acute watery diarrhea, especially in children less than 2 years old. Cryptosporidia diarrhea is common among AIDS patients. Oral rehydration therapy and proper feeding during and after diarrhea reduces deaths from diarrhea.^ieng

An outbreak of diarrhoea associated with rotavirus serotype 1 in a day care nursery in Rio de Janeiro, Brazil.

Faeces from 17 children less than 1.6 years old and 15 adults more than 22 years old were collected during an outbreak of gastroenteritis in a day care nursery and screened for the presence of adenovirus and rotavirus by enzyme immunoassay (EIARA) and other viruses by electron microscopy (EM) and polyacrylamide gel electrophoresis (PAGE). Ten samples (58.8%) from children and one (6.7%) from adults were positive for rotavirus and all samples were negative for bacteria and parasites. No other viruses were observed in EM. An enzyme immunoassay test using monoclonal antibodies (MAb-EIA) to determine the subgroup(s) and the serotype(s) of rotavirus was performed and the results showed that all positive samples belong to serotype 1, subgroup II of group A rotaviruses. In PAGE test all samples had the same profile and the 10 and 11 dsRNA segments corresponded to the "long" profile of group A of rotaviruses. These results corroborated the MAb-EIA results and indicate a sole source of infection. The major symptoms observed were: vomiting (60%), fever (70%) and diarrhoea (100%). In previous years (1989 to 1991) we observed only rotavirus serotype 2 in this same day care nursery, but no outbreak was reported.

PIP: Acute gastroenteritis in children under 5 years of age is caused mainly by rotaviruses. Severe dehydration is commonly associated with this condition, which may lead to death if left untreated. Epidemiologic studies have attempted to describe the etiology of acute gastroenteritis caused by rotaviruses; however, much is still not understood. This paper describes a diarrhea outbreak in a children's day care center in Brazil that was caused by rotavirus serotype 1, subgroup II. 17 infants and 15 adults had their feces virologically analyzed. Rotavirus-positive samples were analyzed by enzyme immunoassay (EIA). Bacteriological analysis was performed after culturing. All samples were negative for both parasites and pathogenic bacteria. Rotavirus was found in 10/17 (58.8%) of the infant and in 1/15 (6.7%) of the adult fecal samples tested. The major clinical symptoms observed in rotavirus-positive children were fever (70%), vomiting (60%), and diarrhea (100%).

[Etiology of acute diarrhea in children]. / Etiologie de la diarrhée aigue de l'enfant.

PIP: 170 children aged a few days to six years underwent outpatient examinations at a maternal-child health center in Tunis for acute diarrhea between July and September 1986. Examination and analysis of stool samples led to positive identification of etiology in 59 cases, or 34.5%. 27 cases were of bacterial origin, including 4 cases of salmonella, 7 of shigella, 8 of campylobacter, and 8 of E. coli. 21 cases of rotavirus were isolated, including 2 in which campylobacter were also observed, and one each in which E. coli and giardia were observed. Giardia were observed in 10 cases and ascaris in 1 case. 78% of the children were under two years old, 16% were two to four, and 6% were four to six. Most of the patients were from socioeconomically disadvantaged social strata. There were 91 boys and 79 girls. Among the 170 children, 3 were treated for moderate dehydration as outpatients and one was hospitalized with severe dehydration. 84 children without diarrhea and aged under six months served as controls. A positive etiology was found in 7.1% of controls, including 1 of campylobacter, 4 of rotavirus, and 1 of Giardia.^ieng

Epidemiologic studies of Escherichia coli diarrheal infections in a low socioeconomic level peri-urban community in Santiago, Chile.

The incidence of diarrhea due to six categories of diarrheogenic Escherichia coli was determined in two pediatric cohorts in a low socioeconomic level community in Santiago, Chile, with access to chlorinated water. An age cross-sectional cohort of 340 children aged birth to 47 months was assembled. A newborn cohort was assembled by enrolling 10-12 newborns monthly for 12 months. Episodes of diarrhea were detected by twice weekly household visits. E. coli from stool cultures of cases and matched controls were hybridized with DNA probes specific for enterotoxigenic, enteroinvasive, enteropathogenic, enterohemorrhagic, enteroaggregative, and diffuse adherence E. coli. Overall, the incidence of diarrhea was low (2.1 episodes/infant/year). Nevertheless, a putative E. coli enteropathogen was found in a large proportion of diarrheal episodes, particularly during the summer. In both cohorts, enterotoxigenic E. coli were important pathogens. Enteropathogenic E. coli were incriminated during the first year of life in the newborn cohort, where they were found significantly more often in cases (p = 0.021) than in controls; beyond this age, isolation rates were similar. In contrast, the relative risk of isolation of diffuse adherence E. coli increased with age in the age cross-sectional cohort, where, overall, the difference in rate of isolation between cases and controls was significant (p = 0.0024). Enteroinvasive and enterohemorrhagic E. coli were isolated infrequently. Enteroaggregative E. coli were encountered equally in cases and controls. Facile transmission of E. coli enteropathogens is occurring in this community despite the availability of potable water.

PIP: Researchers conducted an age cross sectional cohort analysis of 340 0-47 month old children and newborn cohort analysis of 144 newborns to determine the diarrheogenic Escherichia coli incidence in Santa Julia, a low socioeconomic community in Santiago, Chile. Children in the age cross sectional cohort had age, sex, and sector matched controls. The newborns had sex matched controls. A public health nurse or nurse auxiliary visited the household of each subject 2 times a week to detect diarrhea episodes. Between December 1986 and February 1990, the age cross sectional cohort had 1178 episodes of diarrhea and the newborn cohort had 674 episodes. The overall diarrhea incidence was only 2.1 episodes/child/year. An E. coli enteropathogen was isolated in many of these episodes, especially during the summer (e.g. enterotoxigenic E. coli [ETEC], 2.2 cases/month in summer vs. 0.4 cases/month in winter; p = .00001). Diffuse adherence E. coli (DAEC) and enteropathogenic E. coli (EPEC) infections also peaked in the summer. ETEC contributed greatly to diarrheal episodes in both cohorts. Among newborns, EPEC was isolated significantly more often in cases than controls during the 1st 12 months of life (6.7% vs. 2.5%; p = .021). After 1 year, however, E. coli isolation rates were essentially the same. On the other hand, in the age cross sectional cohort, the relative risk of isolation of DAEC rose with age (e.g., 1.1 for 0.11 months, 1.4 for 36-47 months, and 2.1 for = or 48 months). In the same cohort, DAEC infections were much more common in cases than controls (16.6% vs. 11.9%; p = .0024). Enteroinvasive and enterohemorrhagic E. coli were the most rarely isolated E. coli types. No difference in the isolation rate of enteroaggregative E. coli existed between cases and controls. Since most households in Santa Julia have access to potable water (68%) and an indoor toilet (64%), food contamination were likely the vehicles of E. coli transmission because more than 50% of households do not have a refrigerator.

Ethnographic study on childhood diarrhoeal diseases in a rural Nigerian community.

Mothers in thirty households in a rural Nigerian community were subjected to ethnographic studies on food handling practices as they relate to diarrhoeal diseases in children. The study had a first phase of three open-ended unstructured interviews each lasting about 2 hours and a second phase of direct observations on food handling practices during preparation, administration and storage by mothers. Results indicated that as many as 20 (66.7%) of the mothers identified diarrhoea as a common cause of childhood diseases. Diarrhoea due to food contamination was recognized by as many as 18 (60.0%) respondents. Four important food handling practices relating to water treatment, handwashing before preparation and feeding, administration and storage were recognized in the first phase but the claimed practices in the first phase differed significantly from the observed practices in the second phase (p < 0.025). Many (32.1%) mothers had contaminating food handling behaviours. The low literacy level, poverty and lack of good personal hygiene among the studies population were the most likely causes of the behaviours observed.

Comparative aetiology of childhood diarrhoea in Kakamega and Kiambu Districts, Kenya.

Two hundred diarrhoea specimens collected during January to February 1988, from rural children aged 0 to 60 months in Kakamega District were examined for bacteria, parasites and rotavirus. The results were compared with a sample of 184 diarrhoea specimens matched for month of collection, taken from data collected in the same manner from children in Kiambu District. The mean ages of children in the 2 samples did not differ significantly. There were significant differences in the prevalence of specific potential pathogens isolated in the 2 areas. Notably, A. lumbricoides and rotavirus were more common in Kakamega, while G. lamblia, Entamoeba histolytica, Trichomonas hominis, Cryptosporidium sp., Hymenolepis nana and EPEC were more common in Kiambu. There was no difference with respect to prevalence of Campylobacter sp. or Blastocystis hominis. Factors which were probably important in determining aetiological differences included climate, water sources, animal contact and crowding. The differences highlight the fact that general predictions about aetiology cannot be made from isolated studies.

PIP: A total of 200 loose or watery specimens of diarrhea collected during January and February 1988 from rural children aged 0 to 60 months (mean age of 17.9 months) in Kakamega District, Kenya, were examined for bacteria, parasites, and rotavirus. The results were compared with data from a sample of 184 diarrhea specimens collected during January and February 1986, in the same manner from children with a mean age of 19.7 months in Kaimbu District. Complete investigations were accomplished in 140 of 184 specimens in the Kiambu sample. The most common organism in the Kakamega sample was A. lumbricoides (31%) compared with Escherichia coli (EPEC, 26.4%) and G. lamblia and (26.1%) in the Kiambu sample. There was no Cryptosporidium or Hymenolepis nana isolated in the Kakamega sample, while their frequencies were 2.7% and 3.8%, respectively, in the Kiambu sample. A. lumbricoides and rotavirus were significantly more common in the Kakamega sample, while all the protozoa, including G. lamblia, Entamoeba histolytica, and Trichomonas hominis, were more commonly isolated in the Kiambu ample. The Kiambu sample involved significantly more persistent diarrheas: more than 8 days (18.8%) than the Kakamega sample (3.5%) (p 0.001). A total of 44/140 (31.4%) of diarrheas were negative for potential pathogens in the Kiambu sample compared with 67/200 (33.5%) in the Kakamega sample. Mixed infections were common in both samples in which pathogens were isolated, with 53/133 (39.8%) in Kakamega being mixed, compared with 51/96 (53.1%) in Kiambu. One specimen in Kakamega had 5 potential pathogens (rotavirus, EPEC, C. lamblia, A. lumbricoides, B. hominis), while 1 specimen in Kiambu harbored 7 (EPEC, Shigella, Campylobacter, E. histolytica, T. hominis, G. lamblia, B. hominis). The community etiology of childhood diarrhea appears to be influenced by many factors which encourage direct fecal-oral transmission including climate, water sources, animal contact, and crowding.

Persistent diarrhea in children: epidemiology, risk factors, pathophysiology, nutritional impact, and management.

PIP: A review of data on the morbidity and mortality caused by persistent diarrhea (more than 14 days' duration) was undertaken from studies in several geographic areas, including Bangladesh, Brazil, Ethiopia, India, Indonesia, and Peru, over the last 3 decades. An estimated 3-5 billion diarrheal illnesses and 5-10 million diarrhea-related deaths occur annually among 3 billion people in Africa, Asia, and Latin America. Mostly the 338 million to 1 billion episodes and 4.6 million deaths annually. A study from India showed that the incidence of persistent diarrhea was greater in the age group 0-11 months (31 episodes/100 child-years) than at age 12-23 months (9 episodes/100 child years) or 24-35 months (6 episodes/100 child-year). Similar results were obtained in periurban Peru, periurban northeastern Brazil, and rural guatemala. Diarrhea is believed to precipitate and exacerbate malnutrition while malnutrition predisposes to diarrhea. 2 studies in both Bangladesh and Peru indicate that the risk of developing diarrhea inversely parallels delayed-type hypersensitivity reactions to standard skin-test antigens. In a cohort of 175 children under 5 years of age over a 28-month period in an urban slum in northeastern Brazil the children had an average of 11 episodes/year and spent 82 days/year with diarrhea. The leading potential pathogens seen with persistent diarrhea in some areas are enteroaggregative E. coli and Cryptosporidium. Other pathogens include Shigella, Salmonella, enteropathogenic (LA (local)) E. coli, and variably Giardia lamblia. Recent nutritional management promotes breast feeding, dietary supplementation with vitamin A, zinc, iron, folate, and vitamin B 12, and improved oral rehydration solutions with glucose polymers (such as rice starch) and possibly neutral amino acids (such as alanine or glycine) and glutamine.^ieng

The role of home environment in infant diarrhea in rural Egypt.

In 1982 and 1983, a descriptive environmental survey was conducted in 317 households with newborn infants in rural Bilbeis, Egypt. The incidence of infant diarrhea in these households was ascertained by twice-weekly home visits for a 1-year period (1981-1982). Using univariate and multivariate analyses, the authors identified household factors that were statistically associated with infant diarrhea incidence, including number of children in the house under 4 years of age; number of persons per household; incidence of diarrhea in other family members; having a dirt (vs. concrete) dining room floor; having multiple living areas in the house; having a house or roof in need of repair; using well water rather than tap water for cooking or bathin; the absence of a sewer for waste bathwater; food being left out at room temperature between meals; and having many rodents in the house. Two practices involving interaction with the environment appeared to be protective: butchering of cattle by the family for home consumption, and protection of the infant from flies by a veil during napping. The combined household variables explained 25% of the variance in the total incidence of diarrhea. Categories of variables that accounted for most of the total variance explained by environmental factors are, in decreasing order: house structure (28%); water usage (24%); toilet and bathing area (12%); animal management (11%); food preparation area (10%); hygiene (8%); and wastewater management (6%). This approach may be useful in identifying environmental characteristics whose change would reduce diarrheal illness among infants.

[Prevalence of protozoans in children with acute diarrheal disease]. / Prevalencia de protozoos en ninos con enfermedad diarreica aguda.

PIP: A cross-sectional study was conducted in June-September 1991 in the oral rehydration unit of a children's hospital in Santo Domingo to determine the prevalence of enteric protozoa as a cause of diarrhea. The 100 randomly selected children were aged 3-35 months and had light to moderate dehydration and diarrhea of less than 15 days' duration. The relationship between the presence of protozoans and various risk factors was assessed following the model of a case control study, with children having protozoa infections considered cases and those with diarrhea but not protozoa infections considered controls. 79 of the children were under 1 year old. 36% were malnourished. 60% of the children's families had inadequate garbage disposal facilities, 23% lived in crowded conditions (defined as more than 3 persons per room), 10% drank nonpotable water, 7% lacked piped water, and 2% had no toilet facilities. 66% of the children were found to be positive for protozoa, with 26% positive for Giardia lamblia, 19% for Entamoeba histolytica, 17% for Cryptosporidium, 2% for Dientamoeba fragilis, and 2% for Isospora belli. 6 cases of mixed infection were observed. A significant relationship was found between infection and garbage disposal in the open air and between infection and ingestion of nonpotable water. The high prevalence of protozoa infection is consistent with recent clinical observations. Public health measures should be taken to improve sanitation and personal hygiene.^ieng

An outbreak of Cryptosporidium diarrhea in a pediatric hospital.

PIP: Physicians investigated a nosocomial diarrhea outbreak among 11 2 year old undernourished children in the nutrition service of the pediatric teaching hospital, Hospital Infantile, in Mexico City, Mexico in April 1988. Health practitioners took at least 2 stool samples from each ill child to be analyzed for Cryptosporidium oocysts. The attack rate stood st 82%. The hospital admitted a malnourished child with chronic diarrhea and pneumonia on March 22. Laboratory tests revealed that he had many Cryptosporidium oocysts and was positive for HIV. Hospital staff did not isolate him. He died on May 9 of Escherichia coli and Candida septicemia. The outbreak ended 1 week later. Laboratory tests detected Cryptosporidium oocysts in 9 cases all of whom were 3-13 months old. Further the symptoms (mean duration 14 days, fever [mean peak 38.6 degrees Celsius, and vomiting] matched those of other reported Cryptosporidium diarrhea outbreaks. The epidemic curve suggested a common source of the outbreak. Since the infants received intravenous feedings or sterilized formula, food and water could not have been the source. The physicians believed the AIDS case was that source. Direct person to person transmission was probably not responsible since each infant had his/her own separate crib. Even though the physicians could not conclusively identify the vehicle of transmission, it was most likely the hands of hospitals staff either directly by touching the infants or by contaminating the nasogastric tubes. After the outbreak, the physicians observed that only 30% of medical personnel indeed washed their hands before caring for an infant. 4 previous studies on nosocomial Cryptosporidium diarrhea outbreaks also reported the source case as immunodeficient, but these studies only included adults.^ieng

Bacterial indicators of risk of diarrhoeal disease from drinking-water in the Philippines.

Inadequate measures of water quality have been used in many studies of the health effects associated with water supplies in developing countries. The present 1-year epidemiological-microbiological study evaluated four bacterial indicators of tropical drinking-water quality (faecal coliforms, Escherichia coli, enterococci and faecal streptococci) and their relationship to the prevalence of diarrhoeal disease in a population of 690 under-2-year-olds in Cebu, Philippines. E. coli and enterococci were better predictors than faecal coliforms of the risk of waterborne diarrhoeal disease. Methods to enumerate E. coli and enterococci were less subject to interference from the thermotolerant, non-faecal organisms that are indigenous to tropical waters. Little difference was observed between the illness rates of children drinking good quality water (less than 1 E. coli per 100 ml) and those drinking moderately contaminated water (2-100 E. coli per 100 ml). Children drinking water with greater than 1000 E. coli per 100 ml had significantly higher rates of diarrhoeal disease than those drinking less contaminated water. This threshold effect suggests that in developing countries where the quality of drinking-water is good or moderate other transmission routes of diarrhoeal disease may be more important; however, grossly contaminated water is a major source of exposure to faecal contamination and diarrhoeal pathogens.

PIP: Data on 690 to 0-20 month old infants who lived in metropolitan Cebu, the Philippines and microbiological data were used to examine the association between bacteria levels in drinking water and the prevalence of diarrhea in order to evaluate 4 bacterial indicators of tropical drinking water quality. Escherichia coli and enterococci were found to be better predictors of diarrhea risk than fecal coliforms and maybe fecal streptococci. Diarrhea prevalence for children who consumed good quality water (1 E. coli/100 ml-WHO standard) was roughly equivalent to that of children who consumed medium quality water (2-100 E. coli/100 ml). In fact, water containing up to 1000 E. coli/100 ml did not increase the risk of diarrhea. Grossly contaminated water (1000 E. coli/100 ml) had a significantly higher rate of diarrhea that good and moderate water (15% vs. 9%; p=.002), however. The threshold effect of indicator risk could account for these findings. This effect occurred for the other 3 bacterial indicators as well. When controlling the density of the indicator organisms, the type of water source did not significantly affect the risk of diarrhea. But, when controlling for the type of water source, density was a significant predictor of risk. Apparently the pathogens infected the children via other transmission routes. In fact, significant determinants of diarrhea for 0-12 month old urban infants included poor water quality, poor excreta disposal practices, poor food hygiene, and crowding. Breastfeeding had a strong protective effect against diarrhea. It is concluded that low cost improvements to very contaminated water supplies and concurrent improvements in sanitation and hygiene are more cost effective than providing high quality water without improvements in sanitation and hygiene.

Knowledge and practices among rural mothers in Haryana about childhood diarrhea.

Knowledge and practices of 108 rural mothers about childhood diarrhea, were determined by using pretested semi-structured interview schedules. The common causes of diarrhea reported were eruption of teeth (67.59%), eating of mud (51.85%), worm infestation (47.22%), change of climate (35.18%), poor personal hygiene (34.25%) and changes in diet (25.92%). Majority (83.33%) of mothers practiced food restriction during diarrhea. Seventy seven percent consulted their mother-in-laws in the first instance for treatment of diarrhea. The home remedies tried by mothers were, isabgol husk with curd (30.55%), ghee with tea (28.70%) water boiled with mint leaves (25.92%), local ghutti (22.22%) and unripe mango juice (16.66%). Majority of mothers (83.33%) believed that oral rehydration therapy alone, cannot treat diarrhea.

PIP: Knowledge and practice of 108 rural mothers concerning childhood diarrhea were determined by using pretested semistructured interview schedules. The common causes of diarrhea reported were eruption of teeth (67.59%), eating of mud (51.85%), worm infestation (47.22%), change of climate (35.18%), poor personal hygiene (34.25%), and changes in diet (25.96%). The majority of mothers (83.33%) practiced food restriction during diarrhea. 77% consulted their mothers-in-law initially concerning diarrhea treatment. The home remedies tried by mothers were: isabgol husk with curd (30.55%), ghee with tea (28.70%), water boiled with mint leaves (25.92%), local ghutti (22.22%), and unripe mango juice (16.66%). The majority also believed that oral rehydration therapy alone cannot cure diarrhea.

A prospective study of persistent diarrhea among children in an urban Brazilian slum. Patterns of occurrence and etiologic agents.

Persistent diarrhea is a major health problem among children in developing areas of the world. Since few community-based studies have addressed the epidemiology or etiology of this condition, we undertook prospective diarrheal surveillance among a cohort of 175 children less than 5 years of age over a 28-month period in an urban slum in northeastern Brazil. Very high diarrhea illness burdens were found. The children in this cohort had an average of 11 episodes per year and spent 82 days per year with diarrhea. A total of 65% of children had at least one episode of persistent diarrhea (greater than or equal to 14 days duration). These episodes accounted for 50% of all days of diarrhea and 11% of all episodes. The occurrence of at least one episode of persistent diarrhea identified all children who spent at least 15% percent of days with diarrhea. Among children with and without diarrhea, rotavirus was the agent isolated most frequently, followed by Giardia lamblia and enterotoxigenic coliforms. The agents isolated from children with acute and persistent diarrhea were similar, which suggests that other factors must be operative in the development of persistent diarrhea.

Protection of breast-fed infants against Campylobacter diarrhea by antibodies in human milk.

To investigate the role of breast-feeding in preventing diarrhea caused by Campylobacter jejuni, we followed 98 Mexican children prospectively for 2 years beginning at their birth. Attack rates of diarrhea in children less than 6 months of age who were not fed human milk were 2.3 times greater than those in children of the same age who were fed human milk. Breast-fed children remained free of diarrhea for a longer time than non-breast-fed children (p less than 0.0005). The diarrhea attack rate caused by C. jejuni for non-breast-fed infants was significantly greater (p less than 0.005) than that in the breast-fed group. Secretory IgA milk antibody titers against glycine acid-extractable antigen of C. jejuni were high in colostrum, decreased during the first month of breast-feeding, and generally persisted throughout lactation. Human milk consumed by children in whom Campylobacter diarrhea developed did not contain secretory IgA antibodies to the glycine acid-extractable common antigen of Campylobacter. This study shows an association between Campylobacter antibodies in human milk and prevention of diarrhea caused by Campylobacter.

Factors influencing the duration of acute diarrheal disease in infancy.

The majority of episodes of acute infectious diarrhea in infancy are of relatively short duration. Prolongation of the diarrhea presents problems in management, deterioration of the infant's nutritional status, and an increased mortality. As part of a prospective study of the etiology of acute infectious diarrhea, some factors associated with the probability (more or less) of having self-limiting disease have been identified. The well-nourished infant over 6 months of age is more likely to have self-limiting disease, whereas this outcome is least likely in the very young infant under 3 months of age, particularly if underweight for age. With the exception of Shigella, bacterial enteropathogens (Campylobacter fetus jejuni, Salmonella B, and certain enteropathogenic Escherichia coli types) were also associated with a decreased likelihood of self-limiting disease. Rotavirus infection was associated with self-limiting disease except in the infant under 3 months of age, where the probability of self-limiting disease was decreased.

Effect of carbohydrate composition of semi-elemental diets on the nutritional recovery of children with chronic diarrhea.

46 of 74 children with chronic diarrhea of unknown etiology between the ages of 44-627 days were studies. They were assigned, by single randomization, to 3 dietary treatments: a) cow's milk, b) a sucrose- free (SED-S), and c) a sucrose containiNG semi-element diet (SED+S), for 15 days. The authors registered the daily increase of body weight, daily amount of ingested kcal, and the increase of body weight/1000 kcal. The number of days with diarrhea before hospitalization, the age and weight of each child before treatment were recorded and analyzed as covariates. Maltase, sucrase, and lactase activity values were compared before treatment, but were not different among the 3 groups. A significant increase of body weight/1000 kcal ingested was observed in children fed the SED-S diet compared to that observed in children on cow's milk (P=.013 in ANCOVA; P+.053 in RANCOVA), and those fed SED+S (P=.009 in Ancova; p.001 in RANCOVA). The covariates did not have any apparent effect on these results. Only 7 of 24 children receiving cow's milk completed the assigned diet. The carbohydrate composition of the semi-elemental diets proved to be fundamental in the nutritional recovery of these patients.

Intestinal permeability assessed with polyethylene glycols in children with diarrhea due to rotavirus and common bacterial pathogens in a developing community.

Intestinal permeability was assessed with different-sized polyethylene glycols (PEG 400 and PEG 1,000) in small children with acute diarrhea. All children with acute diarrhea absorbed and excreted less PEG of all molecular sizes into the urine when compared with healthy control children (p less than 0.001). Children with acute rotavirus infection excreted significantly less PEG of all sizes than children with Shigella, Salmonella, and enteropathogenic Escherichia coli (EPEC) infection (p less than 0.001-0.01), suggesting a more severe mucosal lesion caused by rotavirus. In patients with severe malnutrition there was also a significant decrease in absorption of PEGs observed. In addition, malnourished patients with rotavirus diarrhea showed a pronounced decrease of PEGs in comparison with well-nourished patients. The ratio between the recovery of a large PEG molecule, 1,074 Da, and a small molecule, 370 Da, was utilized to assess the absorption of large molecules in relation to that of smaller ones. On applying this ratio, it was noted that the intestine in children with Shigella and EPEC infection was relatively more permeable to larger molecules than in healthy controls, while in rotavirus and Salmonella infection it was less permeable to larger molecules. In this study significant differences in the permeability characteristics were observed, suggesting etiology-specific effects on the mucosal barrier.

Upper small intestinal microflora in diarrhea and malnutrition in Nigerian children.

The upper small intestinal microflora was determined quantitatively and qualitatively in a group of well-nourished diarrhea-free Nigerian children and compared with those of well-nourished children with acute diarrhea and malnourished children with or without diarrhea. Intestinal aspirate was collected by intubation after a 6-h fast. Well-nourished children without diarrhea had flora consisting predominantly of gram-positive cocci. Total bacterial counts were less than 10(5) organisms/ml; 18.2% of aspirates were sterile. In contrast, malnourished children with or withour diarrhea had a wider microbial spectrum including Enterobacteriaceae, Bacteroides, and Candida. Total bacterial counts were between 10(3) and 10(9) organisms/ml; none were sterile. In both well-nourished and malnourished groups, no significant quantitative bacteriologic differences were found between patients who had diarrhea and those who did not. Candida and Pseudomonas were found more frequently in malnourished patients with diarrhea. In such diarrheal patients, Pseudomonas, Klebsiella, and enteropathogenic Escherichia coli grew as pure isolates in intestinal aspirates and could be detected concomitantly in their stools. These results establish the upper small intestinal flora of well-nourished diarrhea-free Nigerian children, confirm bacterial overgrowth as a feature of malnourished children with or without diarrhea, and suggest that Candida, Pseudomonas, and Klebsiella may account partly for the diarrhea seen in malnourished children.

Microbial etiology of acute gastroenteritis in hospitalized children in Kuwait.

During a period of 15 months 621 hospitalized children with acute gastroenteritis and 152 control children were investigated for etiologic agents of the disease. Putative enteropathogens were identified in 86% of the patients and 10% of the controls. Common viral agents associated with gastroenteritis among children included rotaviruses (45%) and enteric adenoviruses (4%). Bacterial pathogens infecting children were Salmonella serotypes (24%), enterotoxigenic Escherichia coli (9%), Campylobacter jejuni (7%), enteropathogenic E. coli (7%), Shigella (4%) and enterotoxigenic Aeromonas sp. (1%). The highest incidence of infections was observed in the 3- to 25-month age group. Mixed infections were observed in 12% of the patients. Viral gastroenteritis was clinically mild and of short duration. Upper respiratory tract infections, vomiting and watery stools were common features. In contrast bacterial gastroenteritis was more severe; stools were frequently bloody and abdominal pain, cramps, shock, convulsions and milk intolerance were predominant clinical features. Comparative analysis revealed differential features of bacterial and viral gastroenteritis which should help clinicians to make a tentative diagnosis and to start treatment early.

PIP: During a 15-month period, 621 hospitalized children with acute gastroenteritis and 152 control children were investigated for etiologic agents of the disease. Putative enteropathogens were identified in 86% of the patients and 10% of the controls. Common viral agents associated with gastroenteritis among children included rotaviruses (45%) and enteric adenoviruses (4%). Bacterial pathogens infecting children were Salmonella serotypes (24%), enterotoxigenic Escherichia coli (9%), Campylobacter jejuni (7%), enteropathogenic E. coli (7%), Shigella (4%), and enterotoxigenic Aeromonas sp. (1%). The highest incidence of infections was observed in the 3-25 month age group. Mixed infections were observed in 12% of the patients. Viral gastroenteritis was clinically mild and of short duration. Upper respiratory tract infections, vomiting, and watery stools were common features. In contrast, bacterial gastroenteritis was more severe; stools were frequently bloody and abdominal pain, cramps, shock, convulsions, and milk intolerance were predominant clinical features. Comparative analysis revealed differential features of bacterial and viral gastroenteritis which should help clinicians to make a tentative diagnosis and to start treatment early.