Infant feeding practices and child health in Bolivia.

The effects of breast-feeding and supplementation practices on recent diarrhoea occurrence and stunted growth are modelled using logistic regression techniques. Data from the Demographic and Health Survey of Bolivia, 1989, show that, among children aged 3-36 months at the date of interview, the benefits of breast-feeding to child health were most pronounced among children living in rural poverty. Reduced breast-feeding among these children increased the likelihood of diarrhoea and stunted growth. In addition, the introduction of solid foods to currently lactating infants negatively influenced child health.

PIP: This study assesses, in two models, the effects of infant feeding practices on stunted growth and diarrhea incidence among breast fed children aged 3-36 months in Bolivia. Data were obtained from the 1989 Demographic and Health Survey, which included 1143 breast-fed children. About 38% of the children were stunted. Stunting increased with age and parity. In the bivariate analysis, breast feeding increased stunting, and maternal characteristics were related. Stunting increased with maternal age and indigenous ethnicity. Stunting was associated with blue collar and agricultural households and households in the rural Altiplano and Valles regions. About 33% of the children had experienced an episode of diarrhea. Bivariate analysis revealed that only maternal education and having waste removal were related to the occurrence of diarrhea. Logistic models show that the positive effects of breast feeding were more prominent in impoverished environments. Cessation of breast feeding among infants 6 months or less and living in households with extreme rural poverty increased the risk of stunting fourfold. Children with birth intervals of 2-3 years were at 1.5 times lower risk. Children in rural areas were less likely to be stunted than children in urban areas, when socioeconomic status was controlled. Children who had diarrhea were 40% more likely to be stunted. Diarrhea decreased with maternal education. Diarrhea increased with the number of household members. Food supplementation introduced at about 6-9 months, when most infants are fed solids, increased the risk of stunting by about 75%. Introduction earlier or later had no significant impact on child growth. Only 30% of infants received solids before the age of 4 months. Personal living conditions or socioeconomic status were key explanatory factors in stunting and diarrhea.

The role of breast milk in protecting urban Peruvian children against cryptosporidiosis.

To test the hypothesis that breast milk of nursing mothers may afford children protection against cryptosporidiosis, a prospective cohort study was carried out in the young peoples' community of San Juan de Miraflores near Lima, Peru. Mothers and newborn children were sorted into cohort groups based on the mothers' breast milk antibody response to Cryptosporidium sporozoites using an antibody-capture enzyme-linked immunosorbent assay to detect parasite-specific immunoglobulin A. Children were monitored for Cryptosporidium infection using an indirect immunofluorescence assay. Of 211 mothers enrolled in the study, 39 (18.5%) had high breast milk antibody titers, 107 (50.7%) had medium titers, and 65 (30.8%) had low titers. Sixty-one episodes of Cryptosporidium infection were detected in 50 children of these mothers. Eleven (22%) had mothers in the high antibody titer group, 20 (40%) had mothers in the medium titer group, and 19 (38%) had mothers in the low titer group. The prevalence of infection within children of each group was 0.17, 0.19 and 0.38 respectively. There was no significant difference in the prevalence or duration of infection among children of the different groups. The data does not support the notion that there is protection from Cryptosporidium infection afforded children whose mothers have demonstrable breast milk antibodies against the parasite.

PIP: Researchers determined the antibody response to Cryptosporidium sporozoites in 6475 breast milk samples from 211 mothers of newborns living in the shantytown of San Juan de Miraflores on the outskirts of Lima, Peru to determine the association of breast milk with cryptosporidial infection rates, mean duration of infection, and age at 1st infection. They determined that 18.5%, 50.5% and 30.8% of the mothers had high, intermediate, and low anti-Cryptosporidium antibody titers respectively (0.6 optical density [OD], 0.3-0.6 OD, and 0.3 OD respectively). The cryptosporidial infection prevalence rate among the infants was 23.7%. the 50 infected infants experienced 61 episodes of infection. Most of the ill children were confined to the medium and low antibody groups (40% and 38% respectively). Since the study was ongoing, the researchers expected a higher prevalence rate. Infants whose mothers were in the high antibody titer group were significantly younger at 1st infection than those whose mothers were in the low antibody titer group (4.05 months vs. 7.51 months; p.01). The researchers did not anticipate this result. Infection rates were highest between February and June. They were also greatest among 4-8 month old infants which may be associated with weaning off breast milk. No significant differences in prevalence or duration existed among the infants in the various groups. Considerable antibodies to Cryptosporidium in a mother's breast milk did not necessarily protect the infants from the parasitic protozoan.

Health education through interactive radio: a child-to-child project in Bolivia.

In developing countries it is common for older children to assume much of the responsibility for care of their younger siblings. Based on this observation, the "child-to-child" approach to health education targets these older children as a means of improving child health. As the initial phase in the development of a radio health curriculum in Bolivia, a module on diarrheal disease was developed and field-tested among fourth- and fifth-grade students in Cochabamba. The module consists of 10 interactive radio lessons in which the students respond orally to drill and practice, sing songs, or write key concepts in their notebooks. Following the 25-minute radio broadcast, the teacher conducts a 20-minute session that focuses on application and practice of the new behaviors. The module includes lessons on personal hygiene, water and oral rehydration, home sanitation, and nutrition. The field evaluation revealed the need for modifications in the teachers' role and greater attention to teacher training. Students responded enthusiastically and achieved significant knowledge gains as a result of the program. Plans are underway to expand the radio health program.

Health beliefs related to diarrhea in Haitian children: building transcultural nursing knowledge.

Regardless of where they live or under what circumstances, mothers throughout the world seem to have a compelling desire to provide the best possible health care for their children (Huston, 1979). Haitian mothers living in the Dominican Republic were no exception. The health beliefs and practices of these mothers related primarily to diarrhea among their children which demonstrated a concern and resourcefulness that is commendable. The results of this study clearly indicate the importance of transcultural nurses conducting culturally relevant research as a basis to develop sound health programs in developing countries. Diarrhea was identified as the single most important threat to a child's health in these communities. That mothers did not know about the correct ingredients and/or proportions for oral rehydration solutions (Western views) was of interest. Although the Dominican government makes some commercial packets of ORS, most of the women interviewed did not have ready access to this product. This finding reflected the need for transcultural nurses to offer to teach mothers how to make ORS using the sugar, salt, and water they had available. Since the mothers' perception that diarrhea was a dangerous threat to their children's health, was verified by childhood mortality statistics in the bateys, it would seem that ORS could make a significant impact on the health status of the children. Breastfeeding also was a major health belief factor associated with the treatment of diarrhea. Even though the majority of mothers believed breast feeding should be continued if a child had diarrhea, a number believed it should be discontinued. Nurses working with CHWs will need to emphasize the importance of breastfeeding and help them to develop creative ways of communicating this information to the mothers. The second most dangerous threat to the child identified by the mothers was respiratory ailments. This suggests a new area of concentration for future research and training of CHWs. A host of new questions related to respiratory problems such as health beliefs, causative factors, course of disease, traditional treatments, mortality rate, etc. need to be investigated. When transcultural nurses plan health care programs for women and children in other cultures, it is important to recognize the concerns mothers have for their children, and their intense desire to nature and care for them. In this study, mothers willingly participated and demonstrated active interest in learning to use methods to improve the health and well being of their children. It is well documented (Lieban, 1977) that established health beliefs are not automatically discarded when new knowledge is made available, but that exploration and incorporation of new information when presented in a culturally relevant framework does occur. An understanding of local beliefs surrounding health is fundamental to the development of appropriate transcultural nursing interventions.

PIP: Interviews conducted by community health workers with 83 Haitian women working in sugar cane fields in the Dominican Republic underscored the importance of understanding local health beliefs so that culturally appropriate interventions are implemented. The respondents all had at least 1 child under 5 years of age; their average age was 29 years and they had a mean parity of 4.9. The mothers identified gastrointestinal problems, chiefly diarrhea, as the greatest threat to their child's health. 82% of the mothers had at one time had a diarrheal episode among her children and 31% reported that a child currently had diarrhea; 16% said at least 1 child had died of diarrhea. Water, food, and microbes were identified as the major cause of diarrhea. Although not routinely cited as a cause of diarrhea, the evil eye (transmitted by male of female witches) was viewed by all but 1 mother as a powerful factor in child mortality. The foods mothers claimed they would give a child with diarrhea included lemonade, soups, bananas, and other fruit juices. Both cooking oil and milk were considered harmful. Of concern was the finding that 38% of mothers would discontinue breastfeeding during a diarrhea episode. None of the mothers had heard of oral rehydration; however, most were treating diarrhea with a solution prepared by pouring boiling water over herbs and leaves. This practice suggests that these mothers can be instructed to prepare oral rehydration solutions in which all ingredients are precisely measured. Since diarrhea is a major cause of child mortality in these Haitian communities in the Dominican Republic, promotion of oral rehydration could make a significant contribution to child survival. It is essential, however, that all such interventions incorporate existing beliefs and present new information in a culturally relevant framework.

Value of a chicken-based formula for refeeding of children with protracted diarrhea and malnutrition in a developing country.

Two hospital-made, lactose-free, hypoosmolar formulas were compared for therapy for 61 children aged 10-28 months who had severe malnutrition and protracted diarrhea. The formulas were isocaloric and contained dextrin-maltose, carrots, sunflower oil, minerals, and vitamins. One had chicken meat as the protein source and the other had hydrolyzed lactalbumin (LAD). Initially the formulas were given as a continuous enteral feeding by nasogastric tube and pump. Six patients died from metabolic and infectious complications: four failed to equilibrate and changed diet. The remaining 51 were divided into two groups; group A, chicken formula (n = 26), and group B, LAD formula (n = 25). The mean duration of diarrhea was similar in both groups; number of days with liquid stools = 6.0 +/- 4.1 in group A, 5.5 +/- 2.8 in group B; number of days with greater than 4 stools/day = 3.5 +/- 3.4 in group A, 4.1 +/- 2.1 in group B. The time until beginning nutritional recovery was 13.2 +/- 12.0 days in group A and 13.3 +/- 7.8 days in group B. Intercurrent infections were significantly more frequent in patients receiving chicken formula (12 of 30 patients) than in those receiving LAD formula (4 of 27 patients) (p less than 0.05). We conclude that chicken formula is an efficient substitute to expensive semielemental formulas for continuous enteral feeding of protracted diarrhea in severely malnourished children.

[Control of diarrheal diseases in Mexico and Latin America]. / El control de las enfermedades diarreicas en México y Latinoamérica.

Oral rehydration therapy (ORT), has been considered the major advance in the treatment of the diarrheal diseases, and has been the single most important factor in the decrease of mortality and decreased morbidity in childhood diarrheal. ORT, is not limited to the administration of oral rehydration solution; it also includes feeding techniques and community education and participation. In order to promote ORT, national programs have been developed and promoted in educational centers in strategic areas of the Latin America countries, where medical and paramedical staff attend. In México there have been two national surveys to evaluate the ORT program. This policy has allowed for participating countries to reduce the cost of treatment of diarrheal disease.

PIP: Gastrointestinal infections are the most frequent causes of illness and death in children under 5 in most Latin America countries and in other developing countries. The simple and effective techniques now available to prevent death from diarrhea offer promise therefore of lowering overall pediatric mortality rates. Oral rehydration therapy is the single most effective treatment for control of diarrheal disease in children because most diarrhea deaths are directly related to dehydration. The discovery during the 1960s that intestinal absorption of glucose, sodium, and salt by the small intestine continued during diarrheal episodes gave scientific support to oral rehydration therapy. The World Health Organization estimates that up to 67% of diarrheal deaths can be prevented with oral rehydration therapy. Oral rehydration therapy can help prevent harmful treatments such as fasting and requires no laboratory controls. By the late 1980s, diarrheal control programs were in effect in over 90 countries, including all of Latin America except Chile. 20% of children with diarrhea receive modern treatment, thus avoiding an estimated 600,000 deaths annually. The World Health Organization formula for oral rehydration has been proven effective and safe for treatment of dehydration caused by diarrhea at any patient age. Early experience with oral rehydration therapy in Mexico and elsewhere demonstrated that it resulted in shorter episodes of diarrhea with fewer effects on nutritional status. The reduced need for hospitalization is another significant benefit or oral rehydration therapy. An estimated 60% of the population of Latin America has access or oral rehydration therapy. In late 1985 the rate of use was estimated at 20% for Latin America as whole but only 9% in Mexico. Research in Mexico indicated that the product name and packaging of oral rehydration packets were unattractive and intimidating to mothers. The new packaging has pictures of a healthy baby and the tree of life, a statement of indications for use (avoid dehydration due to diarrhea), and logos of institutions in Mexico's health sector. The package also provides simple instructions for preparation and use. In 1986-87 greater emphasis was placed on clinical training in use of oral rehydration therapy, communication, and increasing access. Selected personnel from each of the 32 Mexican states and territories received training in oral rehydration therapy in a hospital in Mexico City and returned to act as multipliers in their home states. Over 1700 health professionals were trained in 6 priority states. In 1986, efforts were initiated to promote use of oral rehydration therapy directly in the home. A 2nd survey showed that by 1987 the rate of use of oral rehydration therapy in Mexico had increased from 9 to 24%, but that some harmful practices persisted.

Comparison of efficacy of a glucose/glycine/glycylglycine electrolyte solution versus the standard WHO/ORS in diarrheic dehydrated children.

It was hypothesized that a mixture of glucose and amino acids enhances sodium and water absorption and therefore diminishes the volume of oral rehydration solution, stool output, and duration of diarrhea. To investigate this hypothesis, the efficacies of two oral rehydration solutions (ORS) were compared, one containing (mmol/L): Na+ 90, K+ 20, Cl- 80, citrate 10, glucose 67, glycine 53, and glycylglycine 30, yielding an osmolality of 350 mosmol/kg H2O, and the other, the standard ORS recommended by the World Health Organization, containing the same electrolyte concentrations and only glucose 110 mmol/L, yielding 310 mosmol/kg H2O. The study group comprised 31 infants and small children for group A (receiving solution A, the glucose/glycine/glycylglycine-based ORS) and 31 patients for group B (receiving solution B, the standard WHO/ORS). There were no significant differences between the groups in age, fluid loss, or dehydration, or between the groups with respect to clinical outcome, mean time to achieve rehydration, mean percent body weight gain, and serum electrolyte composition. The only statistically significant difference was the mean time between admission and the last diarrheic stool. The glycylglycine/glycine/glucose electrolyte solution was found to be suitable for rehydration, but not to have an advantage over the standard WHO/ORS.

PIP: A study was carried out on 62 male infant children, aged 3-24 months in San Jose, Puerto Rico. The purpose of the study was to discover if a mixture of glucose and amino acids enhances sodium and water absorption, thereby diminishing the volume of oral rehydration solution, stool output and duration of diarrhea. To investigate this hypothesis, the efficacies of two oral rehydration solutions (ORT) were compared: the ORT recommended by WHO (mmol/L) Na + 90, K + 20, C1- 80 Citrate 10, Glucose 110, yielding an osmolality of 310 (mosmol/kg H20) and one containing (mmol/L): Na+ 90, K+ 20, C1-80, Citrate 10, Glucose 67, Glycine 53, Glycylglycine 30, and yielding an osmolality of 350 (mosmol/kg H2)). Results are as follows: the infants were divided into two groups - A and B - with each consisting of 31 males per group; group A received the glycine based solution while group B received the WHO/ORS. There was no significant difference in: the mean age of the patients, mean time and mean number of vomiting, duration of diarrhea, number of stool motions, and duration of fever before admission between the two groups. The glycylglycine/glycine/ glucose electrolyte solution was found to be suitable for rehydration, but is not superior to the standard WHO/ORS. The glycine solution resulted in shortening the duration of diarrheal illness, but failed to decrease the ingested amount of ORS as well as the stool output volume.

Osmolalities of bottle- and breast-milk fed to poor urban Brazilian infants.

Feeding practices related to osmotic strength of bottle-milk and breast-milk were studied in 133 families with infants less than 1 year of age in a poor urban settlement in Brasilia, Brazil. Osmolality [mean (SEM)] of breast-milk [318.8 (4.46) mOsm/kg water] was significantly less than that of bottle-milk [568.7 (29.9) mOsm/kg water]. The wide range of osmotic strength (253.7-1,380.0 mOsm/kg water) found in bottle-milk was partly due to the predominant use (82%) of powdered cow's milk among non-breastfeeders and its improper reconstitution. Diarrhoea and feeding management are also discussed.

PIP: The osmotic strength of breast and bottle milk fed to poor infants in developing countries is of critical significance given the newborn's inability to eliminate a high solute urine. Milk preparations with high osmotic activity have been associated in infants with necrotizing enterocolitis, disturbances in gastric and intestinal motility, and possible effects on gastric emptying and nutrient absorption. As part of a larger study of feeding practices and infant nutritional status in Brazil's squatter village of Paranoa, the osmotic strength of bottle milk and breast milk was studied in 133 families with infants under 1 year of age. Overall, the mean osmolality of breast milk (318.8 mOsm/kg water, range 265-475) was significantly lower than that of bottle milk (568.7 m)sm/kg water, range 253.7-1380). No trend was observed for either type of feed according to the length of lactation or the age of the infant. The wider range of osmotic strength in bottle milk was partly attributable to the predominant use (82%) of powdered cow's milk and its improper reconstitution (i.e., a tendency to overconcentrate during reconstitution). 37% of the infants in this study experienced an episode of diarrhea in the 15 days preceding the interview, with no significant difference in incidence between breastfed and bottlefed infants. Given this high incidence of infantile diarrhea, as well as the high temperature and dryness of the Brazilian climate, health authorities are urged to give greater attention to the potential contribution of solute load in the prevention of dehydration.

Breast milk anti-Escherichia coli heat-labile toxin IgA antibodies protect against toxin-induced infantile diarrhea.

A prospective study to assess whether milk IgA antibodies against Escherichia coli heat labile-toxin protect breast-fed children against labile toxin-induced gastroenteritis was carried out among infants of a marginal urban area in Guatemala. One hundred and thirty children were kept under surveillance for diarrhea by periodic home visits. Stool specimens were collected from each child routinely every 2-3 weeks and during diarrheal episodes, to study the excretion of labile toxin-producing Escherichia coli. Milk samples from the children's mothers were obtained concomitantly with the fecal specimens of the infants to be analyzed for anti-labile toxin antibodies. Twenty infections by heat-labile toxin-producing Escherichia coli as a sole agent were documented among breast-fed infants. Nine of these infections resulted in gastroenteritis, while the remaining 11 were asymptomatic. At the time of infection children who became sick were ingesting breast milk with significantly (p = 0.028) lower titers of antilabile toxin IgA than those who remained healthy. Only one of the 8 infected children receiving breast milk with high titers (greater than or equal to 256) of anti labile toxin IgA developed diarrhea, compared to 8 of the 12 subjects being fed milk with low titers (less than or equal to 64) (p = 0.025). This is the first report documenting protection by IgA antibodies in milk against labile toxin-induced gastroenteritis in infected breast-fed infants.

Effect of continued oral feeding on clinical and nutritional outcomes of acute diarrhea in children.

One hundred twenty-eight nonmalnourished male patients between 3 and 36 months of age were randomly assigned to receive one of four lactose-free dietary treatments to determine the effect of dietary therapy on the severity and nutritional outcome of diarrheal illness. Group 1 received a formula diet composed of casein, sucrose, dextrin with maltose (Dextri-Maltose), and vegetable oil to provide 110 kcal/kg body weight/d (CSO-110). Group 2 received CSO to provide 55 kcal/kg/d (CSO-55) for 2 days and then CSO-110. Group 3 received only oral glucose-electrolyte solution (GES) for 2 days, CSO-55 for the next 2 days, and then CSO-110. Group 4 received the same diets as Group 3 except that only intravenous GES was used for the first 2 days. The GES maintenance solutions provided 24 to 30 kcal/kg/d. Therapeutic success rates were similar among dietary groups, ranging from 90% to 97%. Fecal excretion was initially lower in group 4 (P less than 0.05) but was similar initially among groups treated orally and among all four groups beginning on day 3. Net apparent absorption of nitrogen, fat, carbohydrate, and total energy; retention of nitrogen; and increments in body weight, arm circumference, and skin-fold thickness were positively related to the amounts of dietary energy consumed. Thus continued oral feeding with the CSO diets during the early phase of therapy yielded improved nutritional results.

Protection against severe rotavirus diarrhoea by rhesus rotavirus vaccine in Venezuelan infants.

The efficacy of the rhesus rotavirus vaccine candidate MMU-18006 was evaluated in a longitudinal double-blind field trial in Caracas, Venezuela. 247 infants aged 1-10 months were studied and followed for up to 1 year (201 completed the 1-year surveillance): 123 received a dose of 10(4) plaque-forming units of the vaccine orally and 124 received placebo. 21 episodes of rotavirus diarrhoea were detected, 16 in the controls and 5 in the vaccines: vaccine efficacy against any rotavirus diarrhoea was thus 68%. In the 1-5-month-old group the vaccine efficacy was 93%; only 1 episode of rotavirus diarrhoea was detected in 68 vaccinees and 15 such illnesses were observed in 65 controls (p less than 0.0001). For the entire study group vaccine efficacy was 100% against the most severe rotavirus diarrhoeal episodes.

Interventions for the control of diarrhoeal diseases among young children: promotion of personal and domestic hygiene.

PIP: The effects of improving personal and domestic hygiene on diarrhea morbidity are reviewed using data from studies in hospitals, day care centers, and communities. There is evidence that low educational attainment and certain religious customs predispose to diarrhea, presumably because of behavioral factors. The specific hygiene related behavior that has een most studied is handwashing. Hospital studies suggest that enteric infections can spread via contaminated hands and that hands can be decontaminated by washing with soap and water. 3 studies from Bangladesh, US, and Guatemala on the impact of hygiene education programs on diarrhea are reviewed in detail. Reductions in diarrhea incidence rates of between 14-48% were documented in these studies. Little is known of the impact of hygiene education programs on diarrheas of specific etiology or of their impact on diarrhea mortality. Information is lacking on the optimal design of such programs, on costs, and on their dependence on preexisting levels of sanitary facilities. The available evidence suggests that hygiene education programs may be a cost effective intervention for diarrhea morbidity reduction. Research is necessary to fill the current gaps in understanding and to clarfiy the operational aspects of these programs. (author's modified)^ieng

Interventions for the control of diarrhoeal diseases among young children: promotion of breast-feeding.

PIP: The feeding literature on the relative risks of diarrhea morbidity to infants on different modes suffers from several methodological problems. 35 studies from 14 countries were reviewed; 83% found that exclusive breastfeeding was protective compared to partial breastfeeding, 88% that exclusive breastfeeding was protective compared to no breastfeeding, and 76% that partial breastfeeding was protective compared to no breastfeeding. When infants receiving no breastmilk are contrasted with infants on exclusive or partial breastfeeding, the median relative risks are 3.0 for those ages 0-2 months, 2.4 for those 3-5 months, and 1.3-1.5 for those 6-11 months. Above 1 year of age, no protective effort of breastfeeding on diarrhea morbidity was evident. When infants receiving no breastmilk are contrasted with those exclusively breastfed, median relative risks are 3.5-4.9 in the 1st 6 months of life. The literature does not suggest that the relative risks of diarrhea morbidity for bottlefed infants are higher in poor families than in those wealthier. The protective efforts of breastfeeding do not appear to continue after breastfeeding cessation. There is evidence of considerably increased diarrhea severity among bottlefed infants. There is a limited, and mostly pre-1950, literature on the relative risks of diarrhea mortality to infants on different feeding modes. 9 studies from 5 countries were reviewed most of which showed that breastfeeding protects substantially against death from diarrhea. When infants receiving no breastmilk are contrasted with those on exclusive breastfeeding, the median relative risk of death from diarrhea during the 1st 6 months of life is 25. When partially and exclusively breastfed infants are contrasted, the median relative risk of death from diarrhea is 8.6. Breastfeeding can be promoted by changes in hospital routine and by giving information and support to mothers. A review of 21 studies from 8 countries shows that, by such promotion, the most likely reductions in the prevalence of nonbreastfed infants are 40% among infants ages 0-2 months, 30% among those 3-5 months, and 10% among those between 6 months-1 year. Theoretical calculations based on these data show that such promotion can reduce diarrhea morbidity rates by 8-20% and diarrhea mortality rates by 24-27% in the 1st 6 months of life. For children ages 0-59 months, diarrhea morbidity rates would be reduced by 1-4% and mortality rates by 8-9%. A recent study in Costa Rica has documented a substantial impact of breastfeeding promotion on neonatal diarrhea morbidity and mortality, and on diarrhea morbidity in infants 0-5 months. The Costa Rican data show good agreement with the theoretical computations presented in this paper. Several important aspects of breastfeeding and diarrhea remain to be clarified by research. However, the need for this research should not delay action to promote breastfeeding and to monitor its effect upon feeding practice and diarrhea. (author's modified)^ieng