[Modular diet and parenteral support in persistent diarrhea]

Eleven infants with protracted diarrhea were treated with modular diet and short-term parenteral nutrition. Mean age at admission was 3.7 months with males predominating. Enteropathogenic E. coli, classic serotypes, were isolated from 7 patients and rotavirus from one. A child with combined, severe immunodeficiency died. Milk protein intolerance was diagnosed in another patient. Balance studies and peroral biopsies were performed. Malnutrition was more frequent and hospital stay was longer in those infants who developed nosocomial infections. Even though this treatment shortened the duration of the hospitalization, the negative nutritional impact persisted: Weight/Age (NCHS) decreased from 84% to 61%, with rapid recovery after discharge. Fecal lactic acid excretion was increased on admission to 1,296 mg x day and disaccharidase activity was decreased. The modular diet decreased both fecal volume and lactic acid excretion.

Effect of an acidified milk on diarrhoea and the carrier state in infants of low socio-economic stratum

The effect on diarrhoeal disease of an acidified, modified powdered cow's milk infant formula (Pelargon) was evaluated in 82 infants (Group I) for six months; 104 infants who received the same formula but non acidified, served as controls (Group II). Nutritional status remained satisfactory in both groups throughout the observation period. Some children rejected the taste of the acidified milk. The incidence of diarrhoea was lower in Group I (p less than 0.001). The proportion of days in which the children suffered from acute diarrhoea, and the duration of the episodes were also lower in the children given the acidified milk (p less than 0.001). The rate of detection of enteropathogens and the species identified were comparable in both groups. Carrier rates for bacterial enteropathogens fell over time in Group I while they rose in Group II (p less than 0.001). Carrier rates for enteric parasites were comparable to those expected in our setting for this age group. These results suggest that acidified milk exerts a protective effect against diarrhoeal disease.

[Retrospective evaluation of persistent diarrhea at a primary health service]

Information about persistent diarrhea is scarse despite the fact that it is a frequent cause of death in children who live in developing countries. The 36,358 pediatric consultations performed at a Primary Health Care Center in Southeastern Santiago in 1984 were retrospectively evaluated. Diarrheic syndromes represented 5.1% of consultations and corresponded to 909 episodes; of these, 6.3% were cases of persistent diarrhea (greater than 15 days). The highest frequency occurred among children under 2 years of age (60.7%). In 68.7% of cases feces were liquid and in 37.5% mucus, pus or blood was present in stools. Persistent diarrhea was more frequent among malnourished patients (p less than 0.001) who, in turn, suffered the greatest nutritional deterioration in relation to the episode of diarrhea. Intravenous fluids were required by 23.3% of patients while 27.9% were admitted to hospital. This contrasts with patients who suffer episodes which lasted less than 15 days, who were all orally hydrated and only 7.8% required hospitalization (p less than 0.01).

Faecal excretion of rotavirus and other enteropathogens in newborns of the high and low socio-economic stratum in Santiago, Chile

Faecal excretion of enteropathogens was studied in newborns in their first week of life. Rotavirus was investigated in 225 neonates, of whom 107 belonged to the low socio-economic stratum (SES) and 118 to the high SES. Half of each group were delivered by caesarean section. Rotavirus was detected in 10 infants (4.4%). Eight of them had been in the same ward and excreted the same viral electrophoretype. Enteropathogenic bacteria were isolated from 8 out of 57 (14.0%) newborns. Positive cultures were equally distributed by SES and route of delivery. Giardia lamblia was the only parasite detected, in one infant (2.6%) of the high SES. None of the children developed symptoms. Faecal excretion of enteropathogens ended spontaneously within a week in all cases. It is suggested that the lack of symptomatology and the spontaneous termination of the faecal excretion are related to immaturity of the small intestinal mucosa, that does not allow the completion of the steps that must take place during a successful infectious event.

Effect of structured dietary fiber on bioavailability of amoxicillin

The effect of structured dietary fiber on the bioavailability of amoxicillin (AMX) was evaluated. Ten healthy volunteers ingested one of two isocaloric, isonitrogenous diets providing 7.8 gm/day (diet I) and 36.2 gm/day (diet II) of structured fiber for 3 days. Then they ingested one tablet (500 mg) AMX after breakfast. The other diet was administered for an additional 3 days and the study was repeated. Plasma and urinary AMX concentrations were measured at 9 and 24 hours, respectively, by a microbiologic technique. An open one-compartment model was used for pharmacokinetic analysis. AMX was absorbed more slowly when ingested with diet I than with diet II: the absorption rate constant was 1.04 +/- 0.37 and 1.75 +/- 0.75 (P less than 0.05); lag time for absorption was 0.34 +/- 0.13 hours and 0.29 +/- 0.11 hours (P less than 0.05). The first-order rate constant and elimination half-life were similar. Bioavailability was higher with diet I: the AUC was 12.17 +/- 3.04 vs. 9.65 +/- 2.64 micrograms/ml/hr with diet II (P less than 0.05). A higher content of dietary fiber increased AMX absorption rate and decreased the amount of drug absorbed.

Chronic environmental enteropathy in a temperate climate

Forty-three apparently healthy young adult male volunteers underwent an evaluation of their nutritional status, blood chemistry and faecal excretion of enteropathogens, which did not reveal current malnutrition or illnesses. Ten of them were further studied for small intestinal histology, culture of aerobic and anaerobic bacteria in the duodenal juice, disaccharidase activities, glucose absorption and faecal excretion of fat and nitrogen. The study revealed mild morphological changes associated with the appearance of anaerobic bacteria in the upper intestine, decreased glucose transport and increased faecal losses of nitrogen. Although all these changes were rather mild, they may be significant for people whose diet is of borderline nutritional quality.

Acute diarrhoea and asymptomatic infection in Chilean preschoolers of low and high socio-economic strata

Preschoolers who belonged to the high (Group I, n = 112) or the low (Group II, n = 90) socio-economic stratum were followed prospectively for six months. Mean monthly incidence of diarrhoea was 3 and 7 episodes per 100 children for Group I and Group II respectively (p less than 0.001). Episodes were shorter and affected a smaller proportion of children in Group I (p less than 0.002 and p less than 0.05), respectively). Bacterial enteropathogens were recovered in 12.6% and 13.5% of the episodes in Group I and Group II and parasites in 15.4% and 62.8%, respectively. Rotavirus was detected once in each group. Asymptomatic carrier rates for enteropathogenic bacteria were 12.0% in Group I and 7.2% in Group II. The corresponding figures for parasites were 28.2% and 62.8% (p less than 0.001). Nutritional status was normal in all children. These results suggest that socio-economic stratum plays an important role in the characteristics of diarrhoeal illness in the groups which conform the population of the less developed countries. Acute diarrhoea is less frequent in preschoolers living in Santiago than in other developing areas. Rates of asymptomatic infection are high.

Enteropathogens associated with acute diarrhea in hospitalized infants

Thirty-five infants of low socioeconomic status who were living in urban Santiago were hospitalized for acute diarrhea were prospectively evaluated for the presence of enteropathogens associated with the episode. Some degree of malnutrition was evident in 20 infants (57.1%); 15 of these (75%) were under 6 months of age. Mean duration of the hospital stay was 11.8 days for well-nourished patients and 15.7 days for the malnourished patients. One or more enteropathogens were found in 60% of the cases studied: in 17 cases (48.6%) these were bacteria and in four cases (11.4%) it was rotavirus. Parasites were not detected. In three patients, two different pathogens were demonstrated. Among the bacteria, 12 isolates (34.3%) were enteropathogenic E. coli (EPEC) and two (5.7%) were Shigella. Campylobacter jejuni was also isolated from two different cases (5.7%) and Salmonella from one case (2.9%). The recovery of pathogens was independent of the nutritional status. Mean age of detection of EPEC was 3.2 months among well-nourished infants and 6.2 months among the malnourished (p less than 0.001). Half of the EPEC strains isolated were multiresistant to antibiotics. One of these strains transferred some of its resistance in vitro to E. coli K12. Ampicillin and kanamycin were the antibiotics to which EPEC showed the greatest resistance. The other bacterial pathogens were mostly sensitive to antibiotics. Campylobacter jejuni, together with Shigella, was the second most frequent pathogen isolated during episodes of diarrhea. Campylobacter should be included in the routine study of diarrheal episodes in our setting.

Acute diarrhoeal disease in children under 7 years of age in a peri-urban slum of Santiago, Chile

A group of 168 families who lived in a peri-urban slum in Santiago were surveyed for 9 months. All of them had a child under 7 years of age. Medical activities and data collection were carried out at a Field Station and by means of twice-weekly visits to each home, at which time cases of diarrhoea were recorded and investigated. Faecal samples for bacteriological, parasitological and rotavirus studies were obtained during each episode. The characteristics of clinical course, hygienic practices in the family, and monthly anthropometric measurements of infants and toddlers were also recorded. The mean monthly incidence of diarrhoea was 7.1 episodes per 100 children. Of the episodes, 44.2% were associated with pathogenic bacteria, 14.4% with rotavirus, 38.4% with parasites and in 27.9% no enteropathogens were identified. It was found that adequate hygienic habits were not associated with a decreased risk of developing diarrhoea and that about 60% of children did not have diarrhoea throughout the study period. The nutritional status was adequate in most cases: weight-for-age was below the 5th percentile in 11.5% of subjects and the height-for-age was normal in all. No moderate or severe cases of malnutrition were detected.

Enteropathogen carriage by healthy individuals living in an area with poor sanitation

Faecal carriage of bacterial enteropathogens (enteropathogenic Escherichia coli (EPEC), shigellae and salmonellae) was studied in 265 individuals: 65 infants 3-6 months of age (50 bottle-fed and 15 breast-fed), 100 school-age children 8-10 years of age and 100 adults 21-50 years of age. All were apparently healthy, did not have gastrointestinal symptoms, had not received antibiotics in the preceding fortnight and were not malnourished. Enteropathogens were isolated from the faeces of 24 individuals (9.1%). Cultures were positive for enteropathogens in 20% of the infants (both breast- and bottle-fed), 8% of school-age children and 3% of the adults. EPEC was the most frequent isolate. Twelve different serotypes were detected. The highest recoveries were E. coli 026:K60 and 044 . K74. Shigella was detected only in school-age children (2%) and salmonella only in adults (1%). Campylobacter jejuni and Yersinia enterocolitica were studied only in the school-age children: there was one isolate of each of them. Most enteropathogens isolated were susceptible to the majority of the antibiotics tested. Only four E. coli strains, isolated from bottle-fed infants, could be considered multi-resistant. Two of the strains wer E. coli 044:K74 and 020a020c:K61. The remainder were E. coli 0111:K58 and wee capable of transferring some of their antibiotic resistance traits to a recipient strain.

Characteristics and analysis of electropherotypes of human rotavirus isolated in Chile

Electropherotypes of human rotavirus from stool samples of hospitalized and ambulatory infants with acute diarrhea were analysed. Thirty-two different electropherotypes were observed in 142 cases in which the viral genome RNA was characterized. The seasonal distribution of the electropherotypes, from 1979 to 1981, showed that the same electropherotypes were detected throughout the period of study while others were found only occasionally. Electropherotypes were also analyzed depending on whether the patient from whom they had been obtained required hospitalization or was treated at home. The analysis shows that the electropherotypes were equally distributed in both groups of patients.

Fine structure of the small intestinal mucosa in infantile marasmic malnutrition

The jejunal mucosa was studied in infantile marasmic malnutrition in the early phase after treatment was begun and before the onset of significant weight gain. In 7 infants light microscopy before recovery showed that the mucosa was normal or mildly abnormal in 4, and moderately abnormal in 3 cases. The electron microscope disclosed abnormalities of the brush border, large autophagosomes and residual bodies, and the deposition of collagen, filaments, and a dense, finely granular material below the basal lamella. Three of the infants were studied again during recovery. Although the histology remained unchanged, electron microscopy revealed improvement of the brush border, disappearance of the autophagosomes, and smaller and fewer residual bodies. The dense material below the basal lamella was absent whereas the fibrillar components remained. It is postulated that the fine structural lesions observed may be due to the derangements in cell metabolism caused by the severe, prolonged restriction of protein and caloric intake.

Specificity of ultrastructural changes of small intestinal epithelium in early childhood

Electron microscopical features of the small intestinal mucosa in 30 consecutive biopsies from 14 newly diagnosed coeliac patients, and 16 patients with chronic intermittent diarrhoea due to different causes, were studied. An attempt to define specific changes in each condition was made. An abnormal brush border, increased number of free ribosomes, rich rough endoplasmic reticulum, poorly developed smooth endoplasmic reticulum, large Golgi complexes, and thickened basal lamina were the most frequent findings in the coeliac biopsies. These changes suggest abnormal cellular metabolism, but as they were also observed in children with a variety of clinical conditions, they could not be specifically related to coeliac disease. These observations suggest that in small children different causes leading to different degrees of abnormal small intestinal mucosa, as observed with the light microscope, produce nonspecific changes of the cellular ultrastructure, which cannot be related to the degree of abnormality observed at the light microscope level.