Maternal and socioeconomic factors and the risk of severe malnutrition in a child: a case-control study

OBJECTIVE

To examine the relation of maternal and socioeconomic factors with the development of severe malnutrition in young children.

DESIGN

A case-control study.

SETTING

A large diarrhoea treatment centre in a metropolitan city.

SUBJECTS

Cases were 125 severely malnourished children, aged < 36 months, having weight-for-age < 55% of the United States National Center for Health Statistics (NCHS) median values. Controls (n = 125) were recruited concurrently matching for gender, disease type (i.e. diarrhoea or dysentery) and age stratum, having weight-for-age > 60% of NCHS median values.

INTERVENTION

Mothers of the children were interviewed to record personal history and various socioeconomic variables and examined for height and weight.

RESULTS

Maternal factors such as illiteracy, mothers' employment outside, lack of breastfeeding and maternal malnutrition (as indicated by low body mass index, weight or height); and selected socioeconomic indicators such as poor family income, use of unprotected surface water or unhygienic latrine were found to be significantly associated with severe malnutrition in their children. In multivariate analysis, maternal illiteracy and lack of breastfeeding were associated with approximately fourfold increased risk of severe malnutrition in their children. A strong positive association of employment of mothers outside homes with fivefold increased risk was surprising and may reflect a complex social problem of poor urban mothers; malnourished mothers were 2.5 times more likely to have severely malnourished children.

CONCLUSION

The findings confirm the well-known association of lack of maternal education and breastfeeding with severe malnutrition of their children. Maternal malnutrition may be a useful indicator to identify at-risk families with severely malnourished children. However, its causal association, though plausible, cannot be inferred from the study.

Impact of health education on the feeding of green leafy vegetables at home to children of the urban poor mothers of Bangladesh

To evaluate the impact of health education on mothers, on the feeding of their children green leafy vegetables (GLV) at home, we studied 160 children aged 6 to 35 months and their mothers in two intervention groups and one comparison group. The mothers of the first intervention group (n = 44) were given health education including a feeding demonstration, by offering a single meal of cooked GLV to their children. The mothers in the second intervention group (n = 36) received health education only. Mothers of both the intervention groups were visited at home after eight weeks of intervention without prior notice, and for each of them an immediate neighbourhood mother having a child in the same age range was selected as a comparison mother (n = 80). During this visit, mothers were asked whether they had cooked GLV that day and fed these to their children; this was confirmed by spot-checking. Also, mothers were interviewed to elicit their perceptions about GLV. The percentages of mothers who thought that GLV are good for health were 88.7%, 86.1% and 76.2% in groups 1, 2 and comparison respectively (P = 0.06). However, the percentages of mothers who actually fed their children GLV were 57%, 64% and 26% in groups 1, 2 and comparison group respectively (P < 0.001). The influence of health education on GLV feeding persisted after controlling for the effect of maternal literacy (Mantel Haenszel chi-square = 16.99; P < 0.0001) and family income (Mantel Haenszel chi-square = 17.36; P < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Diabetes mellitus-induced enhancement of prostaglandin F2 alpha-responses is inhibited by lipoxygenase- but not cyclooxygenase-inhibitors in mesenteric veins and arteries of mouse and rat

The mechanisms responsible for diabetes mellitus-induced enhancement of prostaglandin (PG) F2 alpha response were investigated in vascular smooth muscles isolated from diabetic mice and rats. Streptozocin (150 mg/kg, i.v. bolus, 6 week-elapsed)-ddY mice and (60 mg/kg, i.v. bolus)-Wistar rats and genetically diabetic GK-rats were used. The responses to PGF2 alpha were enhanced in small blood vessels such as mesenteric arteries (diabetic rats) and veins (diabetic mice) and they were reduced in large blood vessels such as the aorta and vena cava (diabetic rats). The enhanced response to PGF2 alpha in diabetic blood vessels was significantly inhibited by nordihydroguaiaretic acid (NDGA) (0.03 mM) and phenidone (0.05 mM), lipoxygenase inhibitors, cycloheximide (1 mg/kg, i.v.), a protein synthesis inhibitor and actinomycin D (2.8 mg/kg, i.v.), a RNA polymerase inhibitor, but neither inhibited by cyclooxygenase inhibitors, a thromboxane antagonist, nor Ca2+ antagonists. The PGF2 alpha response was also enhanced with aging alone, whereas the extent of enhancement was less than that with diabetes mellitus, and not significantly blocked by NDGA. These results demonstrate that diabetes mellitus-induced imbalance in the regulation of the eicosanoid metabolic pathways (suppressed cyclooxygenase and accelerated lipoxygenase) may cause the enhancement of PGF2 alpha-induced responses in small blood vessels.

Factors associated with safe preparation and home use of sugar-salt solution

The use of oral rehydration salts is frustratingly low, mostly because one must visit a health care provider to procure the packets. Mothers are advised to use sugar-salt solution (SSS) and other home-based fluids as first fluid replacement during diarrhoea. However, the use rate of SSS is also not encouraging and few mothers can prepare it correctly. We conducted an observation study on mothers who reported to the diarrhoea treatment centre of the International Centre for Diarrhoeal Disease Research, Bangladesh during September 1990 through to December 1992. At quarterly intervals, 240 mothers were recruited randomly to elicit their knowledge and ability to prepare SSS. Most (94.6%) of the mothers knew about the solution, but only 62% of them used the solution at home. The use rate was higher when mothers came to know about the solution through interpersonal communication (e.g. community health workers, doctors, friends, neighbours and relatives) and from multiple sources (72%) than when they learned about it from the media or from a single source (54%). As many as 85.4% of the mothers could prepare the solution within the safe limits of sodium concentrations (30 to 100 mmol/l). The figure rose to 95.8% after practical instruction as to how to prepare the solution. This improvement was dependent neither on the literacy level of mothers nor on their knowledge and use of the solution earlier. To increase interpersonal communication and to improve mothers' behaviour in using and correctly preparing SSS, every contact with health care providers should be utilised for organising sessions on the use and preparation of the solution.

Intake from an energy-dense porridge liquefied by amylase of germinated wheat: a controlled trial in severely malnourished children during convalescence from diarrhoea

OBJECTIVE

To evaluate the role of an energy-dense diet liquefied with amylase-rich flour from germinated wheat (ARF) in increasing the energy intake in severely malnourished infants and young children and its acceptability to mothers.

DESIGN

A randomized controlled clinical trial with two sets of controls.

SETTING

Nutrition rehabilitation unit of a large diarrhoea treatment centre where mothers stay with their very severely malnourished children.

SUBJECTS

78 severely malnourished children aged 5-18 months just recovered from diarrhoea.

INTERVENTION

Children were randomly assigned to receive either an energy-dense porridge made liquid by adding ARF (test diet) or an unaltered thick porridge of similar energy density (control 1 diet), or the porridge made liquid with addition of water to have the same viscosity as the test diet but of lower energy (control 2 diet), in four major meals a day for 5 days and intake was measured; breast-milk was measured by test weighing. Children also received an additional three milk-cereal meals a day.

RESULTS

The mean energy intake (95% CI, P value for difference between test and control) was 385 (339-431), 289 (251-327, P < 0.005), and 255 (222-289, P < 0.001) kJ/kg.d respectively. Feeding test diet was not associated with significant adverse effects e.g. on diarrhoea, vomiting, breast-milk intake, and was well accepted by mothers.

CONCLUSION

The results suggest that use of an energy-dense ARF-treated liquefied porridge increases calorie intake by very severely malnourished children during convalescence from diarrhoea, and that it does not produce any adverse effect.

Evaluation of bioassay for toxicity of ciguateric fish and associated toxins

Evaluation of the mouse toxicity assay symptom of hind leg paralysis (HLP) with mouse death by statistical analysis is presented in this study. The fishes assessed were herbivores including Ctenochaetus strigosus (kole), Ctenochaetus hawaiiensis, Acanthurus sandvicensis (manini), and Mugil cephalus (mullet); and the carnivores, Cephalopholis argus (roi) and Cheilinus rhodochrous (po'ou). The latter can also be considered an omnivore. The extracts of both herbivore and carnivore species appeared to be most toxic when HLP occurred in the mice. Ninety-three percent of the mice with HLP died, whereas when no HLP (NHLP) occurred, only 51% of the mice died. Carnivore flesh extracts (po'ou and roi) were least toxic with one death out of a total 22 mice. The unidentified toxin associated with HLP appears to differ in biological properties from that of ciguatoxin(s) in that it was not found in the flesh tissues of carnivores. Further chemical studies of this toxin(s) is being addressed presently.

Prescribing pattern in acute diarrhoea in three districts in Bangladesh

Irrational use of drugs is a serious problem in the management of diarrhoea in developing countries. Many studies have been conducted in many different countries to document the prescribing pattern in diarrhoeal diseases in the hope of promoting rational use of drugs and thereby improve patient care. In only a few of these studies have standard drug use indicators been used to quantify the extent and nature of irrational prescribing. We report here the findings of a prescribing survey in acute diarrhoea (prescriptions written by graduate doctors) in the government health facilities (GHF) and private dispensaries (PD) in the districts of Dhaka, Tangail and Serajgonj of Bangladesh. In the study a set of standard indicators concerning prescribing, patient care and drug supply developed by the International Network for Rational Use of Drugs (INRUD; and later adopted by WHO) has been employed. Twelve prescriptions given in acute diarrhoea cases in children under 5 years old were prospectively collected on a random basis from each of the 10 centres from three districts. They were analysed by the methods suggested in the INRUD manual.

Maternal and child health services: evaluating mothers' perceptions and participation

Urban mothers' perceptions and their actual practices in respect of antenatal care, postnatal care, childbirth and breast-feeding were reviewed through a predesigned questionnaire provided to all mothers (n = 114) staying for a day in the Clinical Research Centre of the International Centre for Diarrhoeal Disease Research, Bangladesh. Only 8% of mothers surveyed were pregnant and 71% had access to a maternal and child health clinic near their homes. Although 61% of the mothers replied that antenatal care is needed, 45% of all mothers actually used the service. Similarly, 79% of them felt that postnatal care is needed, yet only 26% attended the clinics. Only 6% of all mothers had their previous children delivered at a hospital or clinic. The majority (91%) were delivered at home, traditional birth attendants assisting in childbirth in most cases (74%). In spite of mass campaigning against the use of pre-lacteal foods (like honey and sugar water), these were given to 90% of the newborns. Underutilization of maternal and child health clinics was mostly due to the clinics only being open during the busy hours of family work and because of the misbehaviour of the staff. Changing clinic opening times, supervising staff properly and educating mothers will help to overcome their taboos and to motivate them to use 'institutional services'.

Trends of immunisation status of the children and women attending an urban diarrhoea hospital in Bangladesh

Since October 1988 the International Centre for Diarrhoeal Disease Research, Bangladesh has been offering immunisations to children less than 2 years old and women of reproductive age (15 to 45 years) who report for treatment at its Dhaka-based treatment centre. A survey conducted during October 1989 to June 1992 has revealed that 22.5% of these targeted children (n = 4,456) and 21.7% of the women (n = 5,266) had not received any immunisations. Only 23.2% of the children had completed an immunisation schedule, whereas 70.1% of the women had received 2 doses of tetanus toxoid. The percentage of women receiving both doses of tetanus toxoid vaccine increased significantly from 55.2% to 80.5% during the survey period (Chi Square = 9.47, p = 0.002). However, the percentage of children receiving all doses of vaccines against the six communicable diseases increased only from 15.8% to 23.4% (Chi Square = 1.13, p = 0.29) during the reporting period. Our observation shows that it is possible to cover a significant percentage of women with at least 2 doses of tetanus toxoid vaccine. However, immunisation services need to be intensified utilising all the health centres to improve immunisation coverage for the children.

Can infants and young children eat enough green leafy vegetables from a single traditional meal to meet their daily vitamin A requirements?

To evaluate the feasibility of providing adequate vitamin A precursors to meet the daily need from a meal oftraditionally cooked green leafy vegetables and boiled rice and to understand mothers' perceptions and acceptance of leafy vegetables for infants and young children, 118 children aged 6 months to 3 years and their mothers were studied. The mothers were interviewed regarding their acceptance and perceptions about giving leafy vegetables to their young children. Their children were served a measured amount of rice and cooked leafy vegetables and mothers were asked to feed the child within about half an hour. Median intakes of leafy vegetables in children aged 6-11 months, 12-17 months and 18-35 months were 41 g, 71 g and 129 g respectively (in terms of raw green leaf). Approximately 40 g green leaf provides the recommended daily allowance for vitamin A precursors. 77% of the under-1-year-old children were breast-fed. The breast-fed children had a lower intake of vegetables than the completely weaned children. 87% of the children were found to like vegetables, 89% of the mothers liked to give vegetables to their children and 74% of the mothers answered that vegetables were good for health. Only two mothers (1.5%) refused to feed their children the leafy vegetables. The results show that leafy vegetables are acceptable to most of the mothers, and that children can eat enough leafy vegetables to meet a day's need of vitamin A precursors. Feasibility of feeding children enough green leafy vegetables at home on a regular basis needs further study.

Evaluation of preventive health services for hospitalised children under a child health programme

In the hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh, the Child Health Programme (CHP) has been offering preventive health care services to about 60,000 patients per year. The patient populations are mostly children who stay with their mothers or other relatives. In this programme, health education, immunisation and nutrition rehabilitation services are offered. Health education is offered as group discussion and face-to-face interaction between the educator and the mother. Immunisation is offered daily from 0700h to 1900h to all children and women attending the hospital. Nutrition rehabilitation services, both inpatient and outpatient, are offered to severely undernourished children. These preventive services are implemented by health workers and health assistants. All attendants and adult patients participate in health education sessions. More than 80% of unimmunized children and 50% of unimmunized women receive immunisation. The experience of the CHP shows that it is possible to offer different preventive health care services to all attendants and patients attending a busy hospital.

Why do some families become defaulters in a hospital based nutrition rehabilitation follow-up programme?

Since 1989, a nutrition rehabilitation follow-up (NFU) service is being offered in the Dhaka hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh. Parents bring their children for treatment of diarrhoea and those with additional diagnosis of moderate to severe protein energy malnutrition (PEM) are referred to NFU. Families with severely undernourished children are encouraged to attend NFU. Some of them do not come back to NFU after the first or subsequent visits and are considered as 'defaulters'. This paper focuses on the reasons why some families become defaulters. Thirty-two defaulter families were matched with an equal number of non-defaulter families for age and gender of the child and follow-up visit number. All families were interviewed. Children from both groups had similar nutritional, socio-economic status and parental education level. The main reason stated by defaulter mothers for not coming to NFU was 'follow-up was not needed since the child was okay'. The main reason for coming to NFU stated by non-defaulter mothers was for 'the child's improvement', indicating that parental perception of the child's nutritional status differ in the two groups. A greater proportion (75%) of defaulter mothers as compared to non-defaulter mothers (41%) came to NFU accompanied by another adult. It was not possible to identify potential defaulters. Thus all families accepting NFU must be given equal attention. The poor nutritional status of the child and associated risks must be explained to the mother and other family members. The benefits of NFU to the child and family must be stressed.(ABSTRACT TRUNCATED AT 250 WORDS)

Solubilization, purification, and characterization of a truncated form of rat hepatic squalene synthetase

Rat hepatic microsomal squalene synthetase (EC 2.5.1.21) was induced 25-fold by feeding rats with diet containing the hydroxymethylglutaryl-coenzyme A reductase inhibitor, fluvastatin, and cholestyramine, a bile acid sequestrant. A soluble squalene synthetase protein with an estimated mass of 32-35 kDa, as determined by gel filtration chromatography on Sephacryl S-200 column, was solubilized out of the microsomes by controlled proteolysis with trypsin. Approximately 25% of the activity was recovered in a soluble form. The enzyme was purified to homogeneity utilizing a series of column chromatography purification steps on DEAE-cellulose, hydroxylapatite, and phenyl-Sepharose sequentially. The purified enzyme showed a single band on sodium dodecyl sulfate-polyacrylamide gel electrophoresis. Initial kinetic analysis indicated an S0.5 values for trans-farnesyl diphosphate of 1.0 microM and for NADPH of 40 microM. The Vmax with respect to trans-farnesyl diphosphate was calculated at 1.2 mumol/min/mg. NADH also serves as substrate for the reaction with S0.5 value of 800 microM. Western blot analysis utilizing rabbit antisera raised against the purified, trypsin-truncated enzyme showed a single band for the isolated solubilized enzyme at 32-33 kDa and a band for the intact microsomal enzyme at about 45-47 kDa.

Immunogenicity of experimental live attenuated Japanese encephalitis vaccine viruses and comparison with wild-type strains using monoclonal and polyclonal antibodies

A total of 105 hybridomas secreting anti-Japanese encephalitis (JE) virus monoclonal antibodies (mAbs) were generated from six fusions against four strains of JE virus: wild-type strains SA14 and G8924 and live attenuated vaccines SA14-5-3 and SA14-14-2 (PDK-9). Most of the mAbs (87%) elicited haemagglutination inhibition activity while only a minority (24%) elicited neutralization. None of the mAbs prepared against SA14-5-3, parent of SA14-14-2, elicited neutralization while the only mAbs prepared against SA14-14-2 that elicited neutralization recognized flavivirus cross-reactive epitopes. In comparison, mAbs raised against wild-type strains showed that a spectrum of epitopes with different specificities, including JE type-specific epitopes, elicited neutralizing activity. Two mAbs, prepared against SA14-5-3 virus, were found to be vaccine-specific and five, prepared against strains SA14 and G8924, were wild-type-specific.

Can mothers safely prepare labon-gur salt-sugar solution after demonstration in a diarrhoeal hospital?

Home-based salt-sugar solution (SSS) prepared with labon (locally produced sea salt) and gur (unrefined brown sugar) has been recommended as a cheap, locally available and a simple tool to prevent and treat diarrhoeal dehydration. Preparation of labon-gur SSS is demonstrated to the patients and the attendants at ICDDR, Bangladesh. To evaluate performances, 150 mothers were asked to measure labon and gur by finger pinch and first method and 100 mothers measured half a seer of water to prepare labon-gur SSS, shortly after the demonstration sessions. 4.0% of the samples exceeded the upper safety limit while 1.3% exceeded the upper danger limit for salt and 98.7% samples of gur were within safe and effective range. Mothers' performances were not different with regard to their educational status and prior practice at home. 80% knew about the solution before coming to the hospital and 45% had utilized this knowledge. Our study suggests that demonstration of home-based SSS in a diarrhoeal hospital may positively affect health education and that health personnel should actively participate in increasing health awareness.

Assessing homogeneity and association in male and female infant mortality in Bangladesh

"This paper reveals some interesting characteristics regarding the nature of sex differential in neonatal, post neonatal and infant mortality [in Bangladesh]. The association between sex of an infant and mortality appears to be highly significant for neonatal and post-neonatal stages but these associations are not very heterogeneous over time.... The association appears to be nonsignificant for infant mortality but the association in male and female infant mortality is found to be heterogeneous over time." Data cover the period 1966-1981.

Stimulation of cholesterol and lipid synthesis by insulin in familial hypercholesterolemic fibroblasts

Cultured skin fibroblasts from two patients with homozygous familial hypercholesterolemia and three normal subjects were preincubated for 24 hours in medium containing 10% delipidated serum with insulin concentrations of 0.4, 4, or 40 ng/mL. [14C]acetate incorporation into total lipids, cholesterol, and phospholipids was significantly increased in familial hypercholesterolemic cells at insulin concentrations of 0.4 and 4 ng/mL, which had no effect in normal cells. When the data were normalized as percent stimulation over control for individual experiments, [14C]acetate incorporation into cholesterol was comparable at 40 ng/mL in both cell types. Similar results were obtained in cells preincubated in serum free artificial medium. Coordinate increases in the activity of 3-hydroxy-3-methylglutaryl CoA reductase in response to insulin were not found. These studies show that familial hypercholesterolemic cells have an altered lipogenic response to low concentrations of insulin.

A preliminary study on the ecology of the capped langur

There are little published data on the ecology of the capped langur (Presbytis pileatus), so a study of this species was undertaken at Madhupur National Park, Bangladesh, from December 1977 to July 1978. The langurs spend 32% of their 709-min day feeding, 49% in sitting and resting, and 19% moving, playing and grooming. Feeding occurs in the early morning and late afternoon, and there is a peak of resting in the middle of the day. Leaves form the major part of the diet (61%), with flowers, fruits, and seeds next in importance (30%). On average, groups move about 450 m each day.