Keith R. Sullivan

A randomized study comparing rectally administered misoprostol versus Syntometrine combined with an oxytocin infusion for the cessation of primary post partum hemorrhage

Background. Post partum hemorrhage is a major cause of maternal death, particularly in developing countries, and most cases are due to an atonic uterus. Hemorrhage can occur despite active management of the third stage of labor. Presently, misoprostol (Cytotec, Searle Pharmaceuticals) is the only thermostable uterotonic agent potentially available which would be economically beneficial for developing countries where refrigeration of drugs poses a problem. The objective of the study was to compare intra‐muscular Syntometrine (Sandoz Pharmaceuticals) (ampoule=5 iu oxytocin and 500 mcg ergometrine maleate) plus Syntocinon (Sandoz Pharmceuticals) (10 iu oxytocin diluted in 500 ml normal saline) intravenous infusion versus 800 mcg misoprostol per rectum for treatment of primary post partum hemorrhage in a developing country.

The effect of antenatal vitamin A and beta-carotene supplementation on gut integrity of infants of HIV-infected South African women.

Background Vitamin A is important for protection against diarrhea, and supplements may benefit gut function of infants of HIV-infected mothers. Methods We studied 238 infants of HIV-infected South African women participating in a randomized, double-blind, placebo-controlled trial of vitamin A during pregnancy (1.5 mg retinyl palmitate and 30 mg &bgr;-carotene daily) plus 60 mg retinyl palmitate at delivery. The placebo group received identical placebo capsules at the same times. When infants were 1, 6, and 14 weeks of age, lactulose/mannitol dual sugar intestinal permeability tests were performed. Results Maternal vitamin A supplementation did not significantly affect infant gut permeability in the group as a whole at any time. By multiple regression analysis, HIV infection of the infant by 14 weeks was significantly associated with increased gut permeability at both 6 and 14 weeks. After controlling for birth weight, gestational age, current weight, feeding mode and recent morbidity, there was a trend toward an interaction between vitamin A supplementation and HIV infection (P = 0.086) at 14 weeks. Vitamin A made no difference to gut permeability of uninfected infants (lactulose/mannitol ratio for vitamin A group: 0.11, 95% confidence interval [CI] 0.08, 0.15, n = 73 and for placebo group: 0.09, 95% CI 0.06, 0.12, n = 76), but largely prevented the increase in the ratio of HIV-infected infants (vitamin A group: 0.17, 95% CI 0.13, 0.23, n = 23; placebo group: 0.50, 95% CI 0.37, 0.68, n = 20). The effects on the lactulose/mannitol ratio were related to changes in lactulose, not mannitol, excretion. Vitamin A supplementation was associated with significantly lower lactulose excretion at 1 and 14 weeks, suggesting the major effect of vitamin A was on maintaining the integrity of gut tight junctions. Conclusions Vitamin A supplementation of HIV-infected pregnant women may prevent the deterioration in gut integrity in the subgroup of their infants who themselves become infected. Improving vitamin A status of HIV-infected infants may decrease their gastrointestinal morbidity.

A comparison of kangaroo mother care and conventional incubator care for thermal regulation of infants < 2000 g in Nigeria using continuous ambulatory temperature monitoring

Abstract Although skin-to-skin contact (or kangaroo mother care, KMC) for preterm infants is a practical alternative to incubator care, no studies have compared these methods using continuous ambulatory temperature monitoring. To compare thermal regulation in low birthweight infants (< 2000 g) managed by KMC alternating with conventional care (CC) and to determine the acceptability to mothers of KMC, an experimental study with a crossover design with observational and qualitative data collected on temperature patterns and mothers attitudes to skin-to-skin care was conducted in the neonatal wards of three hospitals in Lagos, Nigeria. Thirteen eligible infants were nursed by their mothers or surrogates in 38 4-hour sessions of KMC and the results compared with 38 sessions of incubator care. The risk of hypothermia was reduced by > 90% when nursed by KMC rather than conventional care, relative risk (RR) 0.09 (0.03–0.25). More cases of hyperthermia (> 37.5°C) occurred with KMC, and coreperiphery temperature differences were widened, but the risk of hyperthermia > 37.9°C (RR 1.3, 0.9–1.7) was not significant. Micro-ambient temperatures were higher during KMC, although the average room temperatures during both procedures did not differ significantly. Mothers felt that KMC was safe, and preferred the method to CC because it did not separate them from their infants, although some had problems adjusting to this method of care. Where equipment for thermal regulation is lacking or unreliable, KMC is a preferable method for managing stable low birthweight infants.

Dietary management of acute diarrhoea in children: effect of fermented and amylase-digested weaning foods on intestinal permeability.

BACKGROUND There is a strong relationship between diarrhoea, malnutrition, and intestinal integrity. To investigate the effect of different dietary-treatment on intestinal permeability during acute diarrhoea, 87 Tanzanian children aged 6-25 months were recruited to this study when admitted to hospital. METHODS Children with acute diarrhoea were rehydrated and then randomly assigned to one of three dietary treatment groups: a conventional low-energy density porridge, a high-energy density amylase digested porridge (AMD), or a high-energy density amylase digested and then fermented porridge (FAD). Lactulose/mannitol permeability tests were performed on admission, at 3 days, and at follow-up 2 and 4 weeks after discharge. The lactulose/mannitol (L/M) ratios were compared between dietary treatment groups and to a group of age-matched, healthy control subjects. RESULTS Children with diarrhoea had higher L/M ratios (geometric mean 0.85, 95% CI 0.68-1.05) compared with control subjects (0.14, 0.12-0.17) on admission. There was a significant difference in the change in L/M ratio between admission and 3 days between dietary treatment groups in favour of the FAD group (p < 0.05). CONCLUSIONS Dietary treatment and intestinal damage at admission explain 13.5% of the variation in L/M ratio, but when age at admission and age at weaning are included as covariants, 21.9% is explained. FAD porridge seems to be more effective in the treatment of intestinal permeability than AMD or conventional porridge. Urinary lactose concentrations in spot urine samples taken prior to the permeability test were also measured. There was a significant correlation with the L/M ratio (correlation coefficient = 0.62, p < 0.001).

Active management of the third stage at caesarean section: a randomised controlled trial of misoprostol versus syntocinon.

The objective of this trial was to investigate whether 500 ug oraJ misoprostol given immediately after delivery of the neonate at Caesarean section is as effective as a bolus intravenous injection of 10 iu Syntocinon in stimulating uterine contractions and thereby reducing blood loss.

A randomized controlled trial of the effect of antihelminthic treatment and micronutrient fortification on health status and school performance of rural primary school children

Summary Single interventions for helminthic infections and micronutrient deficiencies are effective, but it is not clear whether combined interventions will provide equal, additive or synergistic effects to improve childrens health. The study objective was to determine the impact of single and combined interventions on nutritional status and scholastic and cognitive performance of school children. A double-blind, randomized, placebo-controlled trial in 11 rural South African primary schools randomly allocated 579 children aged between 8 and 10 years into six study groups, half of whom received antihelminthic treatment at baseline. The de-wormed and non-de-wormed arms were further divided into three groups and given biscuits, either unfortified or fortified with vitamin A and iron or with vitamin A only, given daily for 16 weeks. The outcome measures were anthropometric, micronutrient and parasite status, and scholastic and cognitive test scores. There was a significant treatment effect of vitamin A on serum retinol (p < 0.01), and the suggestion of an additive effect between vitamin A fortification and de-worming. Fortified biscuits improved micronutrient status in rural primary school children; vitamin A with de-worming had a greater impact on micronutrient status than vitamin A fortification alone and antihelminthic treatment significantly reduced the overall prevalence of parasite infection. The burden of micronutrient deficiency (anaemia, iron and vitamin A) and stunting in this study population was low and, coupled with the restricted duration of the intervention (16 weeks), might have limited the impact of the interventions.

A health and nutritional profile of rural school children in KwaZulu-Natal, South Africa.

Summary A community-based cross-sectional study was undertaken to measure anthropometric indices, micronutrient status and prevalence of parasite infections in 579 rural South African primary school children. Eleven schools were selected randomly from a Magisterial District in southern KwaZulu-Natal (KZN). In each school, all pupils aged between 8 and 10 years were selected. The following outcome measures were obtained: anthropometric—height for age, weight for age and body mass index; micronutrient status—anaemia, serum ferritin and vitamin A; and prevalence of parasite infections—Ascaris lumbricoides, Trichuris trichiura and Schistosoma haematobium. The observed prevalences were: stunting 7.3%, underweight for age 0.7%, and obesity 3.1%; anaemia 16.5% (Hb < 12 g/dl), vitamin A deficiency 34.7% (serum retinol < 20 μg/dl) and 28.1% with reduced serum ferritin (< 12 ng/ml); Trichuris trichiura 53.9%, Ascaris lumbricoides 27.3% and Schistosoma haematobium 24.5%. We conclude that micronutrient deficiency, parasitic infestations and stunting remain significant problems among school-aged children in South Africa. Micronutrient supplementation and de-worming provide opportunities for school-based health promotion and primary health care interventions, and might produce significant health and educational benefits.

Use of the retinol­binding protein : transthyretin ratio for assessment of vitamin A status during the acute­phase response

The ratio plasma retinol-binding protein (RBP):transthyretin (TTR) has been proposed as a means to improve the assessment of vitamin A status of individuals with concurrent infection or inflammation. We have measured RBP and TTR in stored sera from South African children who had accidentally ingested kerosene. Samples were collected from these children in hospital when suffering acute inflammation and respiratory distress, and from them and neighbourhood control children 3 months later. Vitamin A status was defined by modified relative dose response (MRDR) tests of liver retinol stores at 3 months and by serum retinol concentration both when children were ill and when they were well. Illness was defined as either being in hospital or, at follow-up, as having a raised plasma alpha 1-acid glycoprotein (AGP) level. The RBP:TTR value was significantly decreased by both illness and low liver retinol stores. When the effects on RBP:TTR of illness and vitamin A stores were considered together for the 3-month follow-up samples, only vitamin A status significantly decreased the value. We calculated sensitivity and specificity of the RBP:TTR ratio against established measures of vitamin A status using a cut-off value of 0.3 for RBP:TTR and standard cut-off values for MRDR (0.06) and plasma retinol (0.7 mumol/l). Compared with MRDR, RBP:TTR had sensitivities of 76% and 43% and specificities of 22% and 81% to detect vitamin A deficiency in hospitalized and well children respectively. Compared with plasma retinol, sensitivities were 88% and 44% and specificities were 55% and 64% in hospitalized and well children respectively. Only for the case of clinically well children with biochemical evidence of subclinical inflammation did sensitivity (62% and 100% against MRDR and plasma retinol respectively) and specificity (100% and 60% against MRDR and retinol) approach useful levels for an assessment tool. Overall, although a trend supporting the theory behind the use of the RBP:TTR for assessment of vitamin A status in infection was observed in the current study, the ratio did not provide adequate sensitivity and specificity to be a useful assessment tool.

Changing patterns of under- and over-nutrition in South African children-future risks of non-communicable diseases.

Abstract Under- and over-nutrition in children in KwaZulu-Natal, South Africa was investigated comparing data collected from primary school children in a rural district (643 children aged 8–11 years in 1994) with secondary data from the National Schools Study (16,179 children, 4–11 years in 1994), the Vitamin A Consultative Group Study (408 children, 2–5 years in 1994) and the Income Dynamics Study (1,593 children, 2–11 years in 1998). Stunting and wasting (WHO/NCHS guidelines) and overweight and obesity (International Obesity Task Force guidelines) were retrospectively analysed from these studies and compared in the children aged 4–5 and 8–11 years. There was moderate stunting in 10–25%, wasting in 1–6%, 5–24% were overweight and 1–10% obese. Girls in the National Schools Study (p<0.005) and in the primary datasets (p=0.02) had a significantly higher prevalence of overweight than boys; girls (1.4%) were also more obese than boys (0.9%) in the Schools Study (p=0.002), and the boys significantly more stunted (p<0.005) and wasted (p<0.005). An increasing prevalence of overweight and obesity was seen in both the 4–5- and 8–11-year age-groups. The finding that moderate stunting co-exists with overweight and obesity suggests that patterns of under- and over-nutrition in South African children are changing and might indicate the early stages of a complex nutritional transition. Action is required to prevent the future risk of non-communicable diseases.

Improved energy intakes using amylase-digested weaning foods in Tanzanian children with acute diarrhea.

Summary Amylase from germinating cereal grains enables the preparation of porridge with a higher energy density than conventional weaning foods. This food can be combined with fermentation, which inhibits pathogen growth. These food technologies are inexpensive, can be implemented at the household level, and are therefore particularly appropriate for use in developing countries. In a controlled clinical trial, 75 children aged 6–25 months admitted to hospital with acute diarrhea were rehydrated and then randomly allocated to three corn porridge dietary groups: conventional, amylase-digested (AMD), and fermented and amylase-digested (FAD). The study diets were given ad libitum five times daily, and all intakes except breast milk were weighed. Mean daily energy intakes over 4 days in the conventional AMD, and FAD groups, respectively, were 32.4 (95% CI 28.7–36.6), 46.0 (CI 39.6–53.4), and 37.3 (CI 31.8–43.9) kcal/kg/day. The energy intake in the AMD group was 42% higher than the conventional group (p = 0.003). There were no significant differences between the groups for duration of diarrhea, frequency of stooling, or vomiting. Starch digestion using amylase from germination is an effective way of improving energy intake in children with acute diarrhea.