The role of zinc and vitamin A in persistent diarrhea among infants and young children.
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Acute Disease↗
Biomedical subjects
N Bhandari
Publications and source records attributed to N Bhandari.
The impact of vitamin A supplementation on physical growth of children is dependent on season.
OBJECTIVE: To determine the impact of vitamin A supplementation on physical growth in young children. DESIGN: Randomized, double blind, placebo controlled trial. SETTING: Urban slum community clinic. SUBJECTS: 900 children, aged 12-59 months, attending the community clinic with diarrhea of < or = 7 d were included in the trial. INTERVENTION: Each child was given a single dose capsule containing 200,000 IU vitamin A or placebo at enrollment. MAIN OUTCOME MEASURES: Mean increments in weight and height during the 90 d period post supplementation. RESULTS: In all children, the mean increments in weight following supplementation were 0.66 kg (s.d. 0.5) and 0.64 kg (s.d. 0.6) in the vitamin A and placebo groups (P = 0.5). The mean increments in height were also similar in the two treatment groups (P = 0.5). Serum vitamin A was measured in 40 randomly selected children in each group; the proportion of subclinical deficiency (serum retinol < 20 micrograms/dl) was 62.5% in those enrolled during summer (April through July) as compared to 21.1% in those enrolled during the remaining cooler months of the year (P = 0.02). In the children supplemented with vitamin A during summer, the mean increment in weight was 140 g more than those who received placebo (95% confidence interval CI 30-250); there was also a significant reduction in the proportion of children who were wasted (< -2 weight-for-height Z-score) at end study (Odds Ratio 0.53, 95% CI 0.28-1.0, P = 0.03). There was no significant impact of vitamin A on height increments in children supplemented during summer. CONCLUSION: Vitamin A supplementation in 12-59 month old children improves weight gain in the subsequent three months only in the summer season, but not during the rest of the year.
Body Height↗
Efficacy of zinc supplementation in reducing the incidence and prevalence of acute diarrhea--a community-based, double-blind, controlled trial.
A community-based, double-blind, randomized trial was conducted in a population of low socioeconomic status in urban India to determine whether daily zinc supplementation reduces the incidence and prevalence of acute diarrhea, especially in those with zinc deficiency. Children 6-35 mo of age were randomly assigned to zinc (n = 286) and control (n = 293) groups and received a supplement daily for 6 mo. Zinc gluconate (10 mg elemental Zn) was given, with both zinc and control groups also receiving multivitamins. The primary outcome measures determined by home visits every fifth day and physician examinations were the number of acute diarrheal episodes (incidence) and total diarrheal days (prevalence). Zinc supplementation had no effect in children 6-11 mo old. In children aged > 11 mo there was significantly less diarrhea in the zinc group. In boys > 11 mo old, supplementation resulted in a 26% (95% CI: 13%, 38%) lower diarrheal incidence and a 35% (95% CI: 20%, 50%) lower prevalence. In zinc-supplemented girls > 11 mo of age, the incidence was 17% (95% CI: 2%, 30%) lower and the prevalence was 19% (95% CI: 4%, 47%) lower. Overall, zinc supplementation resulted in a 17% (95% CI: 1%, 30%) lower diarrheal incidence in children with plasma zinc concentrations < 9.18 mumol/L at enrollment and a 33% (95% CI: 6%, 52%) lower incidence in children with concentrations < 50 mumol/L. In conclusion, zinc supplementation had a significant effect on acute diarrheal morbidity in children > 11 mo old and in children with low plasma zinc concentrations.
Acute Disease↗
Breast-feeding status alters the effect of vitamin A treatment during acute diarrhea in children.
Vitamin A administration in children reduces the incidence of severe diarrhea during the subsequent few months. We therefore examined the effect of treatment with vitamin A during acute diarrhea on the episode duration and severity. In a double-blind controlled field trial, 900 children 1 to 5 y of age with acute diarrhea of < or = 7 d duration were randomly assigned to receive vitamin A (60 mg) or a placebo. Children were followed up at home every alternate day until they recovered from the diarrheal episode. In all study children, those treated with vitamin A had a significantly lower risk of persistent diarrhea [odds ratio (OR) 0.30, 95% confidence interval (CI) 0.07-0.97], but there was no effect on the mean diarrheal duration or the mean stool frequency, in the subgroup of children who were not breast-fed, the mean diarrheal duration [ratio of geometric means (GM) 0.84, 95% CI 0.72-0.97], mean number of stools passed after the intervention (ratio of GM 0.73, 95% CI 0.56-0.95), the proportion of episodes lasting > or = 14 d (P = 0.002) and the percentage of children who passed watery stools on any study day (OR 0.40, 95% CI 0.21-0.77) were significantly lower in those treated with vitamin A. We conclude that administration of vitamin A during acute diarrhea may reduce the severity of the episode and the risk of persistent diarrhea in non-breast-fed children. Similar benefit was not seen in breast-fed children.
Acute Disease↗
Treating sick young infants in urban slum setting.
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Hospitalization↗
Century scale solar variability imprinted in the 44Ti activity in meteorites.
The measurements of gamma-activity of the 44Ti (T1/2 = 66.6 years) produced by spallation reaction of galactic cosmic rays (GCR) in Alfianello, Olivenza, Rio Negro, Dhajala and Torino meteorites, which fell in the time interval 1883 AD (Alfianello)-1988 AD (Torino), show a century scale modulation, connected to long-term solar-wind flux variations in the interplanetary space. The variation of the 44Ti activity with the time of fall of meteorites is qualitatively consistent with the Gleissberg solar cycle, but the amplitude is three-four times higher than expected (about 5%) for GCR flux modulated by solar activity, as determined solely by the sunspot number. The cosmogenic 44Ti is a suitable radioisotope for this investigation, but its activity in meteorites is very low. We performed these measurements in the underground low level counting station of Monte dei Cappuccini in Torino, by means of a big hyperpure Ge crystal (approximately 2 kg) in selective coincidence with a heavy NaI (T1) scintillation detector (approximately 28 kg). This system allows a reliable and non destructive measurement of 44Ti (44Sc) in meteorites of 200-1200 g in weight. The background is about 1 count per day in the gamma-peak at 1157 keV of 44Sc in equilibrium with its parent 44Ti. The high stability of the performance allows long-lasting runs (approximately 10(7) s) in order to attain results with a standard deviation up to about 10%.
Cosmic Radiation↗
Colonization factors of enterotoxigenic Escherichia coli isolated from children in north India.
Colonization factor antigens (CFAs) mediate attachment of enterotoxigenic Escherichia coli (ETEC) to the intestinal mucosa and induce protective immunity against ETEC diarrhea. ETEC strains (n = 111) isolated from North Indian children from 1985 to 1989 were examined for CFAs and putative colonization factors (PCFs). CFA/IV was the most common factor (26%), followed by coli surface antigen 17 (CS17) (19%), CFA/I (14%), PCFO166 (7%), and CFA/II (5%), while 24% of the isolates were negative for CFAs and PCFs. Among the strains producing heat-stable and heat-labile toxin (ST+LT+ strains), the STaI gene was strongly associated with the absence of known CFAs and PCFs, making the STaI+LT+ isolates an interesting target for the identification of previously undescribed factors. Repetitive sequence--based polymerase chain reaction revealed that the CS17+ strains, although clonally related, represented endemically circulating strains with a diversity greater than that of the CFA/I+ strains, which showed a substantial clonal clustering.
Bacterial Proteins↗
Zinc supplementation reduces the incidence of persistent diarrhea and dysentery among low socioeconomic children in India.
Persistent diarrhea (PD) and dysentery (DD) account for most diarrhea-associated deaths among children in developing countries. Zinc deficiency can cause stunting and impaired immune function, both of which are risk factors for these diarrheal illnesses. We investigated the effect of zinc supplementation on the incidence of PD and DD in a community-based, double-blind randomized trial in children 6-35 mo of age. Increase over baseline in plasma zinc concentrations in the supplemented group compared with a control group (3.61 vs. 0.009 mumol.L-1), indicated successful supplementation. The overall reductions in the zinc supplemented group of 21% in the incidence of PD (95% CI -6 to 42%) and 14% in the incidence of dysentery (95% CI -15 to 36%) were not significant. There was a significant interaction of treatment effect with baseline plasma zinc concentration and age for PD and with gender for DD. In the zinc-supplemented group compared with the control group, the incidence of PD was reduced by 73% (P < 0.05; 95% CI 34 to 91%) in children with a baseline zinc < 7.65 mumol.L-1 and by 49% (P < 0.05; 95%CI 24 to 66%) in children > 11 mo of age. Zinc supplementation resulted in a 38% (P < 0.05 95%CI 8 to 59%) reduction in the incidence of DD in boys. There was no effect on PD among children 6-11 mo old or on DD in girls. In conclusion, zinc supplementation had a significant impact on the incidence of persistent diarrhea in children > 1 y old and in children with low plasma zinc, as well as on dysentery in boys. These findings may have important implications for reducing diarrhea-related morbidity and mortality.
Child, Preschool↗
Efficacy of antimicrobial treatment in non-dysenteric persistent diarrhoea in a community setting.
OBJECTIVES: To determine the efficacy of antimicrobial treatment in non-dysenteric persistent diarrhoea in a community setting. METHODS: In this double-blind field trial, 156 children aged 4-36 months with persistent diarrhoea not associated with Giardia lamblia infestation seeking treatment in a community outpatient clinic, were randomized to receive a combination of nalidixic acid and metronidazole, metronidazole alone, or placebo for 7 days. RESULTS: In comparison with placebo, metronidazole treatment did not result in a significant reduction in the mean post-enrollment diarrhoeal duration and stool frequency, increase in the proportion of patients recovered by days 3, 5 and 7 of treatment, and increase in weight gain at days 7 and 14. Comparing the combination of nalidixic acid and metronidazole with metronidazole alone, 17.5% more children treated with the combination recovered by day 3 of treatment (p = 0.08) and the mean stool frequency ascertained on day 7 for the previous 24 h was 26.8% less in them (p = 0.05). The weight gains at days 7 and 14 were similar in the two groups. CONCLUSIONS: These findings indicate that metronidazole offers no therapeutic benefit in persistent diarrhoea not associated with Giardia lamblia and nalidixic acid has only a modest clinical benefit, which is not substantial enough to warrant its routine use.
Anti-Infective Agents↗
Increased diarrhoeal and respiratory morbidity in association with zinc deficiency--a preliminary report.
Plasma zinc levels, in a cohort of 116 children aged 12-59 months recently recovered from an episode of acute diarrhoea attending a community health clinic in an urban slum, were related to diarrhoeal and respiratory morbidity in the 3 month period following recovery. Children with low plasma zinc levels (< 60 micrograms dl-1) spent a significantly greater number of days with watery diarrhoea (rate ratio 1.69 (95% confidence intervals 1.03-2.78)), diarrhoea associated with fever (rate ratio 1.88 (95% confidence intervals 1.05-3.34)), and acute lower respiratory tract infections (rate ratio 2.69 (95% confidence intervals 1.64-4.38)).
Child, Preschool↗
Monteggia lesion in a child: variant of a Bado type-IV lesion. A case report.
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Accidental Falls↗
Epidemiology & management of persistent diarrhoea in children of developing countries.
Diarrhoea that begins acutely but lasts longer than two weeks is defined to be persistent. Revised estimates in developing countries including India showed that acute diarrhoea accounts for 35 per cent, dysentery 20 per cent and non-dysenteric persistent diarrhoea (PD) for 45 per cent of total diarrhoeal deaths. PD also often changes marginal malnutrition to more severe forms. Factors that increase the risk of acute diarrhoea becoming persistent have been identified in India and other developing countries. These include antecedent malnutrition, micronutrient deficiency particularly for zinc and vitamin A, transient impairment in cell mediated immunity, infection with entero aggregative Escherichia coli and cryptosporidium, sequential infection with different pathogens and lack of exclusive breast feeding during the initial four months of life particularly use of bovine milk. Several issues regarding the management of persistent diarrhoea in hospitalized children in India have been resolved. Diets providing modest amounts of milk mixed with cereals are well tolerated. In those who fail on such diets providing carbohydrate as a mixture of cereals and glucose or sucrose hasten recovery. The role of antimicrobial agents and individual micronutrients in PD is currently being investigated. A management algorithm appropriate for India and other developing countries has been developed and found to substantially reduce case fatality in hospital settings to about 2-3 per cent. Recent epidemiological and clinical research related to persistent diarrhoea is also reviewed.
Animals↗
Zinc supplementation in young children with acute diarrhea in India.
BACKGROUND: In developing countries the duration and severity of diarrheal illnesses are greatest among infants and young children with malnutrition and impaired immune status, both factors that may be associated with zinc deficiency. In children with severe zinc deficiency, diarrhea is common and responds quickly to zinc supplementation. METHODS: To evaluate the effects of daily supplementation with 20 mg of elemental zinc on the duration and severity of acute diarrhea, we conducted a double-blind, randomized, controlled trial involving 937 children, 6 to 35 months of age, in New Delhi, India. All the children also received oral rehydration therapy and vitamin supplements. RESULTS: Among the children who received zinc supplementation, there was a 23 percent reduction (95 percent confidence interval, 12 percent to 32 percent) in the risk of continued diarrhea. Estimates of the likelihood of recovery according to the day of zinc supplementation revealed a reduction of 7 percent (95 percent confidence interval, -9 percent to +22 percent) in the risk of continued diarrhea during days 1 through 3 and a reduction of 38 percent (95 percent confidence interval, 27 percent to 48 percent) after day 3. When zinc supplementation was initiated within three days of the onset of diarrhea, there was a 39 percent reduction (95 percent confidence interval, 7 percent to 61 percent) in the proportion of episodes lasting more than seven days. In the zinc-supplementation group there was a decrease of 39 percent (95 percent confidence interval, 6 percent to 70 percent) in the mean number of watery stools per day (P = 0.02) and a decrease of 21 percent (95 percent confidence interval, 10 percent to 31 percent) in the number of days with watery diarrhea. The reductions in the duration and severity of diarrhea were greater in children with stunted growth than in those with normal growth. CONCLUSION: For infants and young children with acute diarrhea, zinc supplementation results in clinically important reductions in the duration and severity of diarrhea.
Acute Disease↗
Feeding advice for children with acute diarrhoea.
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Acute Disease↗
Patterns of use of oral rehydration therapy in an urban slum community.
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Child↗
Impact of massive dose of vitamin A given to preschool children with acute diarrhoea on subsequent respiratory and diarrhoeal morbidity.
OBJECTIVE: To assess the impact of vitamin A supplementation on morbidity from acute respiratory tract infections and diarrhoea. DESIGN: Double blind randomised placebo controlled field trial. SETTING: An urban slum area in New Delhi, India. SUBJECTS: 900 children aged 12-60 months attending a local health facility for acute diarrhoea of less than seven days' duration randomly allocated to receive vitamin A 200,000 IU or placebo. MAIN OUTCOME MEASURES: Incidence and prevalence of acute lower respiratory tract infections and diarrhoea during the 90 days after termination of the enrolment diarrhoeal episode measured by twice weekly household surveillance. RESULTS: The incidence (relative risk 1.07; 95% confidence interval 0.92 to 1.26) and average number of days spent with acute lower respiratory tract infections were similar in the vitamin A supplementation and placebo groups. Among children aged 23 months or less there was a significant reduction in the incidence of measles (relative risk 0.06; 95% confidence interval 0.01 to 0.48). The incidence of diarrhoea was also similar (relative risk 0.95; 0.86 to 1.05) in the two groups. There was a 36% reduction in the mean daily prevalence of diarrhoea associated with fever in the vitamin A supplemented children older than 23 months. CONCLUSIONS: Results were consistent with a lack of impact on acute lower respiratory tract related mortality after vitamin A supplementation noted in other trials and a possible reduction in the severity of diarrhoea.
Acute Disease↗
Cosmogenic 44Ti in meteorites and century scale solar modulation.
The galactic cosmic ray (GCR) flux is modulated by solar activity: 11 and 22 year cycles are well established. Meteorites offer the possibility of studying longer cycles in the interplanetary space, due to GCR nuclear interactions. 44Ti cosmogenic isotope produced in meteorites is suitable for detecting a century scale modulation. So far reliable measurements of 44Ti in the samples are scarce, the radioisotope concentration being very low. A gamma-ray sensitive spectrometer has been set up in the underground laboratory of Monte dei Cappuccini. The system consists of a 2 kg HPGe detector inside a 28 kg NaI well. The system has a background of approximately 1 count/day (in coincidence mode) in the 44Ti region. We present here the results obtained on the Rio Negro meteorite, which fell in the year 1934.
Cosmic Radiation↗
Type of milk feeding during acute diarrhoea and the risk of persistent diarrhoea: a case control study.
The role of feeding breast milk, unmodified bovine milk or adapted infant formula during acute diarrhoea in protecting against or causing persistence of the episodes was investigated in a population-based case control study in an urban area of north India. After adjustment for confounding variables, exclusive breast-feeding was associated with an odds ratio of 0.06 (95% CI 0.002-2.1), a 16.5 times lower odds in favour of developing persistence of an episode. Infants fed unmodified bovine milk in addition to breast milk had an odds of 2.5 times (95% CI 1.0-9.9) in favour of developing persistence of acute diarrhoea (p = 0.04). In infants receiving unmodified bovine milk and no breast milk, this odds ratio was 11.1 (95% CI 1.0-228.8) (p = 0.05). This study indicates that promoting exclusive breastfeeding may reduce the persistence of diarrhoea over and above its effect in decreasing the incidence of acute diarrhoea. In urban areas of the developing countries where working mothers often use milk supplementation beyond the age of three months, our findings suggest that use of adapted spray dried formula may be safer than unmodified bovine milk with respect to the risk of developing persistent diarrhoea.
Acute Disease↗