Neonatal jaundice, aflatoxins and naphthols: report of a study in Ibadan, Nigeria

Endocrine Effect of Some Mycotoxins on Humans: A Clinical Review of the Ways to Mitigate the Action of Mycotoxins

Fungi such as Aspergillus spp. and Fusarium spp., which are commonly found in the environment, pose a serious global health problem. This study aims to present the results of epidemiological studies, including clinical cases, on the relationship between human exposure to some mycotoxins, especially zearalenone and aflatoxin, and the occurrence of reproductive disorders. In addition, examples of methods to reduce human exposure to mycotoxins are presented. In March 2023, various databases (PubMed, Google Scholar, EMBASE and Web of Science) were systematically searched using Google Chrome to identify studies evaluating the association between exposure to mycotoxins and the occurrence of complications related to impaired fertility or cancer incidence. The analysed data indicate that exposure to the evaluated mycotoxins is widespread and correlates strongly with precocious puberty, reduced fertility and increased cancer incidence in women and men worldwide. There is evidence to suggest that exposure to the Aspergillus mycotoxin aflatoxin (AF) during pregnancy can impair intrauterine foetal growth, promote neonatal jaundice and cause perinatal death and preterm birth. In contrast, exposure to the Fusarium mycotoxin zearalenone (ZEA) leads to precocious sexual development, infertility, the development of malformations and the development of breast cancer. Unfortunately, the development of methods (biological, chemical or physical) to completely eliminate exposure to mycotoxins has limited practical application. The threat to human health from mycotoxins is real and further research is needed to improve our knowledge and specific public health interventions.

Mycotoxin Exposure during the First 1000 Days of Life and Its Impact on Children’s Health: A Clinical Overview

The first 1000 days of life are very sensitive to any event that alters health programming, and they represent a window for intervention to improve population health. Pregnant women, fetuses, and infants are particularly vulnerable to exposure to food contaminated with mycotoxins. This review aimed to gather data from the literature on mycotoxins exposure during intrauterine life and early childhood, and associated health risks, as assessed through human biomonitoring and mycotoxins occurrence in foods, in different continents. Maternal internal exposure to aflatoxins is associated with fetal growth restriction, while exposure to fumonisins increases the risk of offspring’s neural tube defects. Mycotoxin contamination of breast milk is reported worldwide, but data on adverse effects of the lactational transfer of mycotoxins on infant health are lacking. Young children are exposed to mycotoxins through contaminated infant formulas and baby foods. Both external and internal exposure to aflatoxins and fumonisins in children are reported to be associated with growth impairment. In low-income settings, where other co-factors can affect growth, this association should be interpreted with caution. Further studies on human biomonitoring of mother–infant pairs and young children are needed to guide management strategies aiming to minimize mycotoxin exposure at critical developmental stages.

Health Effects of Naphthalene Exposure: A Systematic Evidence Map and Analysis of Potential Considerations for Dose-Response Evaluation

BACKGROUND

Naphthalene is a polycyclic aromatic hydrocarbon that has been associated with health effects, including cancer. As the state of the science on naphthalene toxicity continues to evolve, updated toxicity reference value(s) may be required to support human health risk assessment.

OBJECTIVES

We present a systematic evidence map of studies that could be used to derive toxicity reference value(s) for naphthalene.

METHODS

Human and animal health effect studies and physiologically based pharmacokinetic (PBPK) models were identified from a literature search based on populations, exposures, comparators, and outcomes (PECO) criteria. Human and animal studies meeting PECO criteria were refined to a smaller subset considered most informative for deriving chronic reference value(s), which are preferred for assessing risk to the general public. This subset was evaluated for risk of bias and sensitivity, and the suitability of each study for dose-response analysis was qualitatively assessed. Lowest observed adverse effect levels (LOAELs) were extracted and summarized. Other potentially relevant studies (e.g., mechanistic and toxicokinetic studies) were tracked as supplemental information but not evaluated further. Existing reference values for naphthalene are also summarized.

RESULTS

We identified 26 epidemiology studies and 16 animal studies that were considered most informative for further analysis. Eleven PBPK models were identified. The available epidemiology studies generally had significant risk of bias and/or sensitivity concerns and were mostly found to have low suitability for dose-response analysis due to the nature of the exposure measurements. The animal studies had fewer risk of bias and sensitivity concerns and were mostly found to be suitable for dose-response analysis.

CONCLUSION

Although both epidemiological and animal studies of naphthalene provide weight of evidence for hazard identification, the available animal studies appear more suitable for reference value derivation. PBPK models and mechanistic and toxicokinetic data can be applied to extrapolate these animal data to humans, considering mode of action and interspecies metabolic differences. https://doi.org/10.1289/EHP7381.

Assessment of serum aflatoxin B1 levels in neonatal jaundice with glucose-6-phosphate dehydrogenase deficiency: a preliminary study

Aflatoxin (AF) contamination of food products is still a major health issue globally. Prior studies suggest that exposure to AFs during pregnancy has harmful fetal outcomes. This preliminary study was designed to assess serum AFB₁ levels in neonatal jaundice (NNJ) secondary to glucose-6-phosphate dehydrogenase (G6PD) deficiency. Twenty-four full-term neonates with hemolytic jaundice secondary to G6PD deficiency were enrolled in the study. Erythrocyte G6PD status was assessed colorimetrically, and serum aflatoxin B₁ (AFB₁) concentrations were measured by high-performance liquid chromatography. The results revealed that AFB₁ was detected in 58% (14/24) of the studied newborns while detected in 75% (18/24) of their mothers. AFB₁ positive cases had a highly significantly lower birthweight and G6PD activity (P = 0.001, each). Birthweight (r = - 0.574, P = 0.032) and G6PD activity (r = - 0.585, P = 0.028) negatively correlated with serum AFB₁ levels while serum alanine aminotransferase activity positively correlated with serum AFB₁ levels (r = 0.536, P = 0.048). Maternal AFB₁ exposure is associated with adverse birth outcomes as verified by the low birthweight and the evident decline in the activity of G6PD enzyme with the resultant hemolytic NNJ.

Mycotoxin exposure and pregnancy

Pregnancy is not a disease condition; it is a physiological process. However, the risks prevail until this process ends. While many pregnancies and births culminate without any problems, a considerable number of them end up with undesirable pregnancy outcomes such as intrauterine growth retardation, preterm labor, and low birth weight infants. Although the causes of these negative pregnancy outcomes are not fully understood, they occur in a multifactorial ways. One of the important issues here is the foods consumed by women with pregnancy. Pregnant women should avoid consuming fast food products, alcohol, or tobacco, which are already known to be harmful to human health, as well as harmful natural products containing mycotoxins. Mycotoxins are natural toxins with a wide range of chemical structures. While people can get these toxins directly from agricultural products, they can also be exposed indirectly through products of animals fed with contaminated feed. Mycotoxins have negative impacts on human health with their carcinogenic, teratogenic, and mutagenic effects. There are some evidences that mycotoxins can lead to negative pregnancy outcomes. These possible negative effects have been determined to be lower birth weight, neonatal jaundice, fetal loss, fetal defects, preterm birth, maternal anemia, and preeclampsia. However, more evidence is needed on this topic. This review aims to investigate the adverse effects of mycotoxins during pregnancy.

Maternal Instruction About Jaundice and the Incidence of Acute Bilirubin Encephalopathy in Nigeria

OBJECTIVE

To evaluate whether teaching mothers about neonatal jaundice will decrease the incidence of acute bilirubin encephalopathy among infants admitted for jaundice.

STUDY DESIGN

This was a multicenter, before-after and cross-sectional study. Baseline incidences of encephalopathy were obtained at 4 collaborating medical centers between January 2014 and May 2015 (Phase 1). Structured jaundice instruction was then offered (May to November 2015; Phase 2) in antenatal clinics and postpartum. Descriptive statistics and logistic regression models compared 3 groups: 843 Phase 1 controls, 338 Phase 2 infants whose mothers received both antenatal and postnatal instruction (group A), and 215 Phase 2 infants whose mothers received no instruction (group B) either because the program was not offered to them or by choice.

RESULTS

Acute bilirubin encephalopathy occurred in 147 of 843 (17%) Phase 1 and 85 of 659 (13%) Phase 2 admissions, which included 63 of 215 (29%) group B and 5 of 338 (1.5%) group A infants. OR for having acute bilirubin encephalopathy, comparing group A and group B infants adjusted for confounding risk factors, was 0.12 (95% CI 0.03-0.60). Delayed care-seeking (defined as an admission total bilirubin ≥18 mg/dL at age ≥48 hours) was the strongest single predictor of acute bilirubin encephalopathy (OR 11.4; 6.6-19.5). Instruction decreased delay from 49% to 17%. Other major risk factors were home births (OR 2.67; 1.69-4.22) and hemolytic disease (hematocrit ≤35% plus bilirubin ≥20 mg/dL) (OR 3.03; 1.77-5.18). The greater rate of acute bilirubin encephalopathy with home vs hospital birth disappeared if mothers received jaundice instruction.

CONCLUSIONS

Providing information about jaundice to mothers was associated with a reduction in the incidence of bilirubin encephalopathy per hospital admission.

Maternal mycotoxin exposure and adverse pregnancy outcomes: a systematic review

Mycotoxin exposure from food occurs globally but is more common in hot humid environments, especially in low-income settings, and might affect pregnancy outcomes. This study aimed to synthesize the evidence from epidemiological studies on the relationship between maternal or fetal exposure to different mycotoxins and the occurrence of adverse pregnancy outcomes. Multiple databases were systematically searched up to December 2018 to identify studies that assessed the association between mycotoxin exposure in pregnant women or fetuses and at least one pregnancy outcome. Studies were appraised and results were synthesized using standard methods for conducting systematic reviews. This review identified and included 17 relevant studies. There is some evidence to suggest that exposure to various Aspergillus mycotoxins (e.g., aflatoxin) during pregnancy may impair intrauterine fetal growth and promote neonatal jaundice. Findings were inconclusive concerning the influence of aflatoxin exposure on perinatal death and preterm birth. Only two studies assessed effects of maternal exposure to Fusarium mycotoxins (e.g., fumonisin) on adverse pregnancy outcomes. These studies found that maternal fumonisin exposure may be associated with hypertensive emergencies in pregnancy and with neural tube defects. Studies using grain farming and weather conditions as a proxy measure for mycotoxin exposure found that such exposure was associated with an increased risk of preterm birth and late-term miscarriage. In conclusion, there is already some evidence to suggest that exposure to mycotoxins during pregnancy may have detrimental effects on pregnancy outcomes. However, given the limited number of studies, especially on effects of Fusarium mycotoxins, more studies are needed for a more comprehensive understanding of the effects of different mycotoxins on maternal and fetal health and to guide public health policies and interventions.

Dietary mycotoxins exposure and child growth, immune system, morbidity, and mortality: a systematic literature review

The aim of this study was to systematically review associations between dietary mycotoxins exposure and child growth and morbidity of children aged 5 years or younger. Peer-reviewed literature was searched in MEDLINE, EMBASE, COCHRANE, CINAHL, Web of Science, and PsycINFO. Experimental and observational studies were considered. The exposures were dietary mycotoxins during pregnancy, lactation and childhood, and mycotoxins concentrations in the diet, breast milk, urine, and blood. From a total of 4869 references, 86 full-text papers were extracted of which 50 were included in this review. The methodological quality and risk of bias were evaluated and quality of the collective evidence was assessed using GRADE. Uncertainty remains whether mycotoxins exposure affects child growth, immunity and mortality and the overall quality of the evidence is very low. Overall however, we cannot rule out a possible association between dietary mycotoxins, in particular, AF and FUM and child malnutrition. Our analyses were limited by the reporting quality, difference in findings, heterogeneity of outcomes, mycotoxins detection methods, and the observational nature of most studies. Robust study designs with adequate sample size, use of validated biomarkers of exposure and assessment of co-occurrence of mycotoxins and their synergistic effects are required to provide the further evidence regarding a potential effect of dietary mycotoxins exposure on child growth and immunity.

Patterns of acute bilirubin encephalopathy in Nigeria: a multicenter pre-intervention study

BACKGROUND

Acute bilirubin encephalopathy (ABE) is an important cause of neonatal morbidity in Nigeria, accounting for 5-14% of neonatal deaths. Most newborns with severe ABE have irreversible damage before receiving treatment emphasizing the need for timely pre-admission monitoring and referral. There is limited evidence that educational interventions targeting mothers and health care providers will reduce delayed care.

OBJECTIVE

To provide baseline data on the incidence of ABE and associated pre-admission risk factors in five centers of Nigeria in order to evaluate the effect of subsequent educational interventions on outcome.

STUDY DESIGN

The incidence of ABE among newborns treated for hyperbilirubinemia was documented prospectively. Bivariate analysis and multivariate logistic regression were used to evaluate risk factors for acute bilirubin encephalopathy and reasons for regional differences in its occurrence.

RESULTS

Of 1040 infants, 159 treated for hyperbilirubinemia (15.3%) had mild to severe bilirubin encephalopathy (including 35 deaths), but the incidence ranged from 7 to 22% between centers. Logistic regression identified four common predictors: total serum bilirubin (odds ratio 1.007 per mg/dl rise), out-of-hospital births (OR 2.6), non-alloimmune hemolytic anemia (OR 2.8), and delayed care seeking (OR 4.3).

CONCLUSION

The high occurrence of bilirubin encephalopathy in Nigeria is due in large part to a delay in seeking care. A planned intervention strategy will target conditions leading to severe hyperbilirubinemia and delay.

Medical genetics and genomic medicine in Nigeria

Medical genetics and genomic medicine in Nigeria.

Markers of oxidative stress in umbilical cord blood from G6PD deficient African newborns

Glucose-6-phosphate dehydrogenase (G6PD) deficiency is an X-linked disorder that affects as many as 400 million people worldwide, making it the most common enzymatic defect. Subjects with G6PD deficiency are more likely to develop neonatal hyperbilirubinemia potentially leading to kernicterus and are at increased risk for acute hemolytic anemia when exposed to pro-oxidant compounds such as anti-malarial drugs. We collected umbilical cord blood from 300 males born in Uganda to assess for novel markers of systemic oxidative stress. We determined that 10.7% of the samples collected were G6PD A- deficient (G202A/A376G) and when these were compared with unaffected controls, there was significantly higher 8-hydroxy-2'-deoxyguanosine (8-OHdG) concentration, elevated ferritin, increased leukocyte count and higher small molecule antioxidant capacity. These data suggest increased baseline oxidative stress and an elevated antioxidant response in umbilical cord blood of patients with G6PD deficiency.

Risk factors for severe neonatal hyperbilirubinemia in low and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Available evidence suggests that low- and middle-income countries (LMICs) bear the greatest burden of severe neonatal hyperbilirubinemia characterized by disproportionately high rates of morbidity, mortality and neurodevelopmental disorders compared to high-income countries. We set out to identify the risk factors that contribute to the burden of severe hyperbilirubinemia in the most developmentally disadvantaged LMICs to highlight areas for action and further research.

METHODS

We systematically searched PubMed, Scopus, Ovid EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), WHO Library Database (WHOLIS), African Index Medicus (AIM), African Journals Online (AJOL), LILACS, and IndMed for reports published between January 1990 and June 2014. We included only studies that controlled for the effects of confounding variables in determining maternal and infant risk factors for severe hyperbilirubinemia. We conducted meta-analysis of the eligible studies and computed the summary risk estimates with random effects models.

RESULTS

A total of 13 studies with 1,951 subjects and 32,208 controls from India, Nigeria, Pakistan, Nepal and Egypt were identified and analyzed. The pooled data showed that primiparity (OR, 1.59; 95% CI:1.26-2.00), delivery outside public hospitals (OR, 6.42; 95% CI:1.76-23.36), ABO incompatibility (OR, 4.01; 95% CI:2.44-6.61), Rhesus hemolytic disease (OR, 20.63; 95% CI:3.95-107.65), G6PD deficiency (OR, 8.01; 95% CI:2.09-30.69), UGT1A1 polymorphisms (OR, 4.92; 95% CI:1.30-18.62), low gestational age (OR, 1.71; 95% CI:1.40-2.11), underweight/weight loss (OR, 6.26; 95% CI:1.23-31.86), sepsis (OR, 9.15; 95% CI:2.78-30.10) and high transcutaneous/total serum bilirubin levels (OR, 1.46; 95% CI:1.10-1.92) placed infants at increased risk of severe hyperbilirubinemia or bilirubin induced neurologic dysfunctions. Low social class was not associated with an increased risk of severe hyperbilirubinemia.

CONCLUSIONS

Infants at risk of severe hyperbilirubinemia in LMICs are associated with maternal and neonatal factors that can be effectively addressed by available interventions to curtail the disease burden prevailing in the affected countries.

Aflatoxin B1 albumin adducts in plasma and aflatoxin M1 in urine are associated with plasma concentrations of vitamins A and E

BACKGROUND

Although aflatoxin exposure has been associated with micronutrient deficiency in animals, there are few investigations on the effects of aflatoxin exposure on micronutrient metabolism in humans.

OBJECTIVE

To examine the relationship between aflatoxin B1 (AFB1) albumin adducts (AF-ALB) in plasma and the aflatoxin M1 (AFM1) metabolite in urine and plasma concentrations of retinol (vitamin A) and alpha-tocopherol (vitamin E) in Ghanaians.

METHODS

A cross-sectional study of 147 adult participants was conducted. Blood and urine samples were tested for aflatoxin and vitamins A and E levels.

RESULTS

Multivariable analysis showed that participants with high AF-ALB (>or=0.80 pmol/mg albumin) had increased odds of having vitamin A deficiency compared to those with lower AF-ALB [Odds Ratio (OR)=2.61; CI=1.03-6.58; p=0.04]. Participants with high AF-ALB also showed increased odds of having vitamin E deficiency but this was not statistically significant (OR=2.4; CI=0.96-6.05; p=0.06). Conversely, those with higher AFM1 values had a statistically nonsignificant reduced odds of having vitamin A deficiency (OR=0.31; CI=0.09-1.02; p=0.05) and a statistically significant reduced odds of having vitamin E deficiency (OR=0.31; CI=0.10-0.97; p=0.04). Participants with high AF-ALB or high AFM1 (>or=437.95 pg/dL creatinine) were almost 6 times more likely to be hepatitis B virus surface antigen (HBsAg)-positive (OR=5.88; CI=1.71-20.14; p=0.005) and (OR=5.84; CI=1.15-29.54; p=0.03) respectively.

CONCLUSIONS

These data indicate that aflatoxin may modify plasma micronutrient status. Thus, preventing aflatoxin exposure may reduce vitamin A and E deficiencies.

Association between birth outcomes and aflatoxin B1 biomarker blood levels in pregnant women in Kumasi, Ghana

OBJECTIVE

To investigate the association between birth outcomes and blood levels of aflatoxin B(1) (AFB1)-lysine adduct in pregnant women in Kumasi, Ghana.

METHOD

A cross-sectional study of 785 pregnant women attending antenatal clinic was conducted. Aflatoxin B(1) (AFB(1))-lysine adduct levels were determined by high performance liquid chromatography (HPLC) on blood taken after delivery. The birth outcomes considered were small for gestation age, low birthweight, preterm delivery and stillbirth. Participants were divided into quartiles based on the distribution of aflatoxin B(1)-lysine adducts in pg/mg albumin ('low': <or=2.67, 'moderate': >2.67 to <or=4.97, 'high': >4.97 to <or=11.34, 'very high': >11.34). Statistical analysis involved models that included socio-demographic variables and other potential confounders.

RESULTS

The average AFB(1)-lysine adduct level in maternal serum was 10.9 +/- 19.00 pg/mg albumin (range = 0.44-268.73 pg/mg). After adjusting for socio-demographic variables and potential confounding factors, participants in the highest AFB(1)-lysine quartile with 'very high' AFB(1)-lysine level (>11.34 pg/mg) were more likely to have low birthweight babies (OR, 2.09; 95% CI, 1.19-3.68), and showed a trend of increasing risk for low birthweight (P(trend) = 0.007) compared to participants in the lowest quartile.

CONCLUSION

This study adds to the growing body of evidence that aflatoxins may increase the risk of adverse birth outcomes. The findings have implications for targeted nutritional education of pregnant women in areas with high levels of aflatoxin contamination of foods.

Mycotoxins and child health: the need for health risk assessment

The occurrences of mycotoxins as food contaminants in different localities particularly in developing countries and the inevitable exposure of populations and children to these toxins with probable adverse outcomes need be scientifically and systematically assessed. Health risk assessment developed in the 1980s is separate from risk management, both with risk communication form the risk analysis framework adopted by the World Health Organization. The process contributes increasingly to policy development, public health decision making, the establishment of mycotoxin regulations and research planning. However, the exercise of the risk assessment structured approach is not simple and is faced up to lack of data, capable infrastructure facilities and need for trained personnel and resources. Furthermore, adopted methodologies need be developed focusing on child characteristics and health concerns.

Associated factors in modulating aflatoxin B1-albumin adduct level in three Chinese populations

To elucidate the potential factors modulating exposure to aflatoxin B1 (AFB1) in three Chinese populations, an epidemiologic study was conducted in Fusui County and Nanning City of Guangxi Province and Chengdu City of Sichuan Province. The incidence rates of hepatocelluar carcinoma (HCC) for males in these three regions were 92-97 per 100,000, 32-47 per 100,000, and 21 per 100,000, respectively. Eighty-nine residents from Fusui, 196 residents from Nanning, and 118 residents from Chengdu were screened for AFB1-albumin adduct (AAA) levels and hepatitis virus (HBV, HCV, HDV, HEV, and HGV) infections, as well as liver biochemistry (alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], y-glutamyl transpeptidase [GGT], 5'-nucleotidase, globulin [GLO], direct bilirubin, indirect bilirubin, and bile acid levels). At least one marker of hepatitis virus (HV) infection was present in 47.2% (42/89) of subjects from Fusui, while in Nanning and Chengdu the values were 15.8% (31/196) and 22.0% (26/118), respectively. In contrast to females, a higher level of AAA was observed in males; the difference was statistically significant in both the Nanning (P = 0.023) and the Chengdu (P = 0.026) subjects. In the Chengdu group, there was a significantly higher level of AAA in cases with HV infection (P = 0.041). There was a close association between AAA level and BMI in the adults without HV infection (r = 0.148, P = 0.044). Also, AAA was closely associated with DBIL and GGT in non-HV-infected minors (P < 0.05), closely associated with ALB, GLO, and GGT in HV-infected minors (P < 0.05), and closely associated with IBIL, GLO, TBA, and AST in non-HV-infected adults (P < 0.01). The co-effect of HV infection and AFB1 exposure may be responsible for the high risk of HCC in the Fusui region, whereas age, gender, BMI, and HV infection may modify individual aflatoxin levels. The relationship between AAA level and liver biochemistry indicates injury induced by aflatoxin to both hepatic parenchyma and biliary tract. But the associations vary with age and HV infection status.

Morbidity in neonates of mothers who have ingested aflatoxins

This study was undertaken to assess whether aflatoxin M(1) concentrations in newborn infants correlated with those of their mothers and to determine whether the presence of aflatoxin M(1) in cord blood was associated with an increase in morbidity in the newborn. There was a strong correlation (r =0.797, p <0.0001) between mothers' and cord blood levels of aflatoxin. There was also a strong negative correlation between aflatoxin levels and birthweight (r =-0.565, p <0.001) but there was no association between aflatoxin M(1) concentration in maternal or cord blood and rates of jaundice or infection.

Benefits and challenges of newborn hearing screening for developing countries

The late detection of permanent congenital and early-onset hearing loss (PCEHL) often has severe effects on linguistic, speech, cognitive and educational development in affected children. Since newborn hearing screening (NHS) allows most PCEHL to be detected early enough for optimal intervention, the prospects of its introduction in the developing world are reviewed in this paper. It is observed that a simple generalisation on the feasibility of NHS for the developing countries seems inappropriate in view of the diversities in the health and socio-economic status of these countries and the recent favourable reports of universal newborn hearing screening from the region. NHS empowers parents to make timely choices that will allow their hearing impaired children to be given a good start in life and be fully integrated into the wider community. It also compels attention towards the development of essential hearing healthcare services, besides the specific documented benefits. Existing child-healthcare structures such as the expanded programme on immunisation (EPI), baby friendly hospital initiatives (BFHI) and integrated management of childhood illness (IMCI) provide opportunities for the introduction of some form of NHS in many of these countries where routine or systematic childhood hearing screening does not exist. Limited funding, manpower shortages, inadequate support services, low public awareness and the uncertainty regarding the commitment from healthcare practitioners may present some challenges but these are not insurmountable. Pilot studies are necessary in each country to provide empirical data that will guide healthcare providers who wish to introduce such a programme at any level of healthcare delivery.

Serum bilirubin levels in 1-month-old, healthy, term infants from southern Turkey

This study investigated bilirubin levels in 282 1-month-old, healthy, term infants from the Adana region in southern Turkey. Total bilirubin was > 5 mg/dl in 20.2% of the infants and > 10 mg/dl in 6% of the group. Thyroid function and levels of alanine aminotransferase, aspartate aminotransferase and glucose-6-phosphate dehydrogenase were determined in babies with bilirubin levels > 5 mg/dl. The results were normal in all but one case, an infant with a bilirubin level of > 10 mg/dl and glucose-6-phosphate dehydrogenase deficiency. The results indicate that in this population a 5-mg/dl cut-off level for further investigation would mean that 20% of all infants would require further evaluation. This is not cost-effective. Based on our findings, we suggest that the cut-off level for investigating prolonged jaundice in term, 1-month-old, healthy infants in the Turkish population should be > 5 mg/dl.

Fetal exposure to aflatoxins in the United Arab Emirates

This is a prospective study in which aflatoxin levels were measured in umbilical cord blood from 201 women delivered consecutively in Tawam and Al Ain hospitals in order to determine whether the fetuses had been significantly exposed to the toxin. Aflatoxin B1, M1 and M2 were measured using high performance liquid chromatography. Aflatoxins were detected in 110 (54.7%) samples, 27 of which were positive for B1, 106 for M1 and 31 for M2. There was a significant negative correlation (p < 0.001) between birthweight and levels of aflatoxin. The high rate of detection of aflatoxins confirms that a significant number of infants in the UAE are exposed to these toxins which reflects maternal ingestion of aflatoxin-containing food. The presence of aflatoxin resulted in lower birthweights.

Of sick turkeys, kwashiorkor, malaria, perinatal mortality, heroin addicts and food poisoning: research on the influence of aflatoxins on child health in the tropics

Similarities between the geographical and climatic prevalences of kwashiorkor and of exposure to dietary aflatoxins, and between the biochemical, metabolic and immunological derangements in kwashiorkor and those in animals exposed to aflatoxins, prompted investigation of the associations between kwashiorkor and aflatoxins. Studies in Africa in the 1980s indicated a role for these toxins in the pathogenesis of the disease. Paediatric cases of kwashiorkor are less prone to severe Plasmodium falciparum malaria than normal children. In mice infected with P. berghei, aflatoxin exposure inhibits parasite growth and ameliorates morbidity. Aflatoxins occur in < or = 40% of samples of breast milk from tropical Africa, usually as low concentrations of the relatively non-toxic derivatives of aflatoxin B1 (AFB1) but sometimes as high concentrations of the very toxic AFB1. This could explain kwashiorkor in breast-fed babies. Aflatoxin exposure occurs in > or = 30% of pregnancies in tropical Africa and the toxins are often in cord blood, sometimes at extremely high concentrations. Aflatoxins are now incriminated in neonatal jaundice and there is circumstantial evidence that they cause perinatal death and reduced birthweight. Aflatoxin-induced immunosuppresion may explain the aggressive behaviour of HIV infection in Africa. There are similarities between observations on HIV cases in Africa and those on heroin addicts in Europe, where 'street' heroin is frequently contaminated with aflatoxin. Aflatoxins were found in 20% of random urine samples from heroin addicts in the U.K. and the Netherlands. Aflatoxins have also been incriminated in episodes of food poisoning which have been associated with serious morbidity and mortality, particularly among young children.