Mohammad M. Rahman

Simultaneous zinc and vitamin A supplementation in Bangladeshi children: randomised double blind controlled trial

Abstract Objective: To evaluate the effect of simultaneous zinc and vitamin A supplementation on diarrhoea and acute lower respiratory infections in children. Study design: Randomised double blind placebo controlled trial. Setting: Urban slums of Dhaka, Bangladesh. Participants and methods: 800 children aged 12-35 months were randomly assigned to one of four intervention groups: 20 mg zinc once daily for 14 days; 200 000 IU vitamin A, single dose on day 14; both zinc and vitamin A; placebo. The children were followed up once a week for six months, and morbidity information was collected. Results: The incidence and prevalence of diarrhoea were lower in the zinc and vitamin A groups than in the placebo group. Zinc and vitamin A interaction had a rate ratio (95% confidence interval) of 0.79 (0.66 to 0.94) for the prevalence of persistent diarrhoea and 0.80 (0.67 to 0.95) for dysentery. Incidence (1.62; 1.16 to 2.25) and prevalence (2.07; 1.76 to 2.44) of acute lower respiratory infection were significantly higher in the zinc group than in the placebo group. The interaction term had rate ratios of 0.75 (0.46 to 1.20) for incidence and 0.58 (0.46 to 0.73) for prevalence of acute lower respiratory infection. Conclusions: Combined zinc and vitamin A synergistically reduced the prevalence of persistent diarrhoea and dysentery. Zinc was associated with a significant increase in acute lower respiratory infection, but this adverse effect was reduced by the interaction between zinc and vitamin A. What is already known on this topic Trials of vitamin A supplementation have failed to show a beneficial effect on morbidity in children Experimental studies have shown that, in the presence of zinc deficiency, vitamin A supplementation fails to reverse vitamin A deficiency Coexistence of deficiencies of zinc and vitamin A could be a reason for the failure of vitamin A supplementation, but data in humans are limited What this paper adds Combined zinc and vitamin A supplementation is more effective in reducing persistent diarrhoea and dysentery than either vitamin A or zinc alone Zinc alone increased respiratory illnesses, but interaction between zinc and vitamin A reduced this adverse effect

High prevalence of cagA and vacA seropositivity in asymptomatic Bangladeshi children with Helicobacter pylori infection.

Aim: To evaluate the prevalence of antibodies against two major markers of virulence of Helicobacter pylori—cytotoxin‐associated gene A (cagA) and the vacuolating cytotoxin gene (vacA)—among children in a peri‐urban community of Bangladesh, and to evaluate Western blot (WB) assay for detection of H. pylori infection diagnosed by 13C urea breath test (UBT) in such children. Methods: One hundred and eighty‐two children aged 18–60 mo, of the peri‐urban community of Dhaka, were screened for H. pylori infection using UBT, and the serum samples were analysed for antibody against cagA and vacA by Western blot. Results: The overall prevalence of H. pylori infection by 13C‐urea breath test was 80%. The seroprevalence of cagA with or without vacA, vacA with and without cagA, and both cagA and vacA were 82%, 82% and 81%, respectively. Among children with a positive UBT, 95% were seropositive for both cagA and vacA, indicating that the products of these genes are frequently co‐expressed in H. pylori infection in this community. The sensitivity, specificity, positive and negative predictive value of the Western blot test for H. pylori infections, compared to UBT, were 94%, 68%, 92% and 76%, respectively.

Evaluation of an energy-dense meal liquefied with amylase of germinated wheat in children with acute watery diarrhoea: A randomized controlled clinical trial

Abstract To evaluate the role of an energy-dense diet liquefied with amylase of germinated wheat flour (ARF) in increasing the energy intake in children with acute diarrhoea and its effect on the course of diarrhoea, 95 children aged 6–23 months were randomized to receive either an ARF treated liquid porridge (test diet) or an unaltered thick porridge (control-1) or a porridge diluted with extra water (control-2). The children were rehydrated with rice-based oral rehydration solution (ORS) and intravenous acetate solution (if needed) and the study diets were offered 4 times a day for four days. In addition, they received a milk cereal mixture and breast feeding ad libitum . Intake was calculated by subtracting the left-over from the amount offered. Intake (ORS, IV, and food) and output (stool, urine, and vomiting) were summarized 8 hourly. The mean ± SD total energy intake (kJ/kg.d) from porridge in the test, control-1 and control-2 groups were 414 ± 97, 355 ± 120, and 351 ± 73 respectively (difference between mean, 95% CI: test vs control-1 = 59, 5–114 and test vs control-2 = 63, 20–106). Breastmilk intake was similar in the three groups. There was no difference in stool output, ORS intake, and duration of diarrhoea among the three groups. However, vomiting was more marked in the test and control-2 group who had increased volume intake of liquid meals compared to control-1 group. The results suggest that energy intake can be increased in children during acute diarrhoea using liquefied high energy porridge and its use did not worsen the diarrhoea.

Folic acid in the treatment of acute watery diarrhoea in children : a double-blind, randomized, controlled trial

One‐hundred and six male children aged 6‐23 months with a history of acute watery diarrhoea of less than 72 h duration were randomized to receive either folic acid in a dose of 5 mg at 8‐h intervals or placebo for 5 d. There were 54 children in the folic acid group and 52 in the placebo group. The admission characteristics were comparable between the two groups. No significant differences were observed in the intake of oral rehydration solution or stool output between the groups. The mean ± SD of total stool output (g kg−1) was 532 ± 476 vs 479 ± 354 and the duration (h) of diarrhoea was 108 ± 68 vs 103 ± 53 in the folic acid vs placebo group, respectively. The findings, therefore, should have a positive influence on preventing the inappropriate use of folic acid in acute diarrhoea.

Subclinical vitamin A deficiency in young infants from Bangladesh

Abstract In Bangladesh, the high prevalence of clinically evident vitamin A deficiency in children under 5 years has been well documented, however, little is known about the vitamin A status of children under 1 year. The relative dose response (RDR) test was carried out in 85 healthy infants (5.9±2.3 months) coming to the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) or Dhaka Shishu Hospital for routine immunization and whose parents agreed to participate in the study. Mean serum retinol [R] was 0.66±0.3 μmol/l and mean RDR value was 29.8±22.1. Fifty-six (56%) percent of the infants had serum [R] values under 0.70 μmol/l and 18% under 0.35 μmol/l. Sixty-four percent (64%) of the infants had abnormal RDR values (≥20) indicating low liver reserves of vitamin A. These results indicate that there is a high prevalence of subclinical vitamin A deficiency in Bangladeshi infants. RDR values showed a negative correlation with weight-forage. The percentage of infants with serum retinol concentration

Distribution of cause of death in rural Bangladesh during 2003–2010: evidence from two rural areas within Matlab Health and Demographic Surveillance site

Objective This study used the InterVA-4 computerised model to assign probable cause of death (CoD) to verbal autopsies (VAs) generated from two rural areas, with a difference in health service provision, within the Matlab Health and Demographic Surveillance site (HDSS). This study aimed to compare CoD by gender, as well as discussing possible factors which could influence differences in the distribution of CoD between the two areas. Design Data for this study came from the Matlab the HDSS maintained by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) since 1966. In late 1977, icddr,b divided HDSS and implemented a high-quality maternal, newborn and child health and family planning (MNCH-FP) services project in one half, called the icddr,b service area (SA), in addition to the usual public and private MNCH-FP services that serve the other half, called the government SA. HDSS field workers registered 12,144 deaths during 2003-2010, and trained interviewers obtained VA for 98.9% of them. The probabilistic model InterVA-4 probabilistic model (version 4.02) was used to derive probable CoD from VA symptoms. Cause-specific mortality rates and fractions were compared across gender and areas. Appropriate statistical tests were applied for significance testing. Results Mortality rates due to neonatal causes and communicable diseases (CDs) were lower in the icddr,b SA than in the government SA, where mortality rates due to non-communicable diseases (NCDs) were lower. Cause-specific mortality fractions (CSMFs) due to CDs (23.2% versus 18.8%) and neonatal causes (7.4% versus 6%) were higher in the government SA, whereas CSMFs due to NCDs were higher (58.2% versus 50.7%) in the icddr,b SA. The rank-order of CSMFs by age group showed marked variations, the largest category being acute respiratory infection/pneumonia in infancy, injury in 1-4 and 5-14 years, neoplasms in 15-49 and 50-64 years, and stroke in 65+ years. Conclusions Automated InterVA-4 coding of VA to determine probable CoD revealed the difference in the structure of CoD between areas with prominence of NCDs in both areas. Such information can help local planning of health services for prevention and management of disease burden.Objective This study used the InterVA-4 computerised model to assign probable cause of death (CoD) to verbal autopsies (VAs) generated from two rural areas, with a difference in health service provision, within the Matlab Health and Demographic Surveillance site (HDSS). This study aimed to compare CoD by gender, as well as discussing possible factors which could influence differences in the distribution of CoD between the two areas. Design Data for this study came from the Matlab the HDSS maintained by the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b) since 1966. In late 1977, icddr,b divided HDSS and implemented a high-quality maternal, newborn and child health and family planning (MNCH-FP) services project in one half, called the icddr,b service area (SA), in addition to the usual public and private MNCH-FP services that serve the other half, called the government SA. HDSS field workers registered 12,144 deaths during 2003–2010, and trained interviewers obtained VA for 98.9% of them. The probabilistic model InterVA-4 probabilistic model (version 4.02) was used to derive probable CoD from VA symptoms. Cause-specific mortality rates and fractions were compared across gender and areas. Appropriate statistical tests were applied for significance testing. Results Mortality rates due to neonatal causes and communicable diseases (CDs) were lower in the icddr,b SA than in the government SA, where mortality rates due to non-communicable diseases (NCDs) were lower. Cause-specific mortality fractions (CSMFs) due to CDs (23.2% versus 18.8%) and neonatal causes (7.4% versus 6%) were higher in the government SA, whereas CSMFs due to NCDs were higher (58.2% versus 50.7%) in the icddr,b SA. The rank-order of CSMFs by age group showed marked variations, the largest category being acute respiratory infection/pneumonia in infancy, injury in 1–4 and 5–14 years, neoplasms in 15–49 and 50–64 years, and stroke in 65+ years. Conclusions Automated InterVA-4 coding of VA to determine probable CoD revealed the difference in the structure of CoD between areas with prominence of NCDs in both areas. Such information can help local planning of health services for prevention and management of disease burden.

Role of amylase‐treated, energy‐dense liquid diet in the nutritional management of acute shigellosis in children: a controlled clinical trial

To evaluate if an energy‐dense porridge liquefied by amylase‐rich flour (ARF) from germinated wheat increased the calorie intake in children with acute shigellosis, we studied 66 children, aged 6‐35 months, in a randomized, controlled clinical trial. Children were randomized to receive either an energy‐dense porridge liquefied with ARF (group 1), a thick unaltered porridge (group 2) or a porridge diluted with water (group 3) to a similar viscosity as that in group 1. MeanSD calorie intakes (kJ/kg/ day) from the porridges were 280 113, 167100 and 15180 in groups 1, 2 and 3, respectively (p = 0.006, ANOVA). Total energy intakes (meanSD) from the study diet and other food sources were 469151, 377121 and 351look J/kg/day, respectively (p= 0.006, ANOVA). Intake of breast milk was similar in all groups. Using multiple regression analysis the effect of ARF‐treated energy‐dense porridge in increasing the calorie intake persisted after adjusting for a number of confounders, such as age of the child, isolation of Shigella dysenteriae type 1 and fever. The results of this study suggest that ARF‐treated porridge increases energy intake in infants and young children during acute shigellosis. This feeding approach may be useful in preventing malnutrition following dysentery due to shigellosis.Amylase, energy‐dense, energy intake, liquefied, shigellosis

What’s the need?

The study reported by Moet et al found benefit at two years after rifampicin, but did not find any significant difference between rifampicin chemoprophylaxis and placebo treatment in the third and fourth years after rifampicin treatment.1 Mycobacterium leprae multiplies very slowly, and the incubation period of leprosy is about five years but can be up to 20 years (www.who.int/mediacentre/factsheets/fs101/en/index.html). Whether …

Absorption of macronutrients and nitrogen balance in children with dysentery fed an amylase-treated energy-dense porridge

The aim of this study was to determine the absorption of macronutrients and energy from an energy‐dense diet liquefied with amylase from germinated wheat (ARF) in children suffering from acute dysentery. Thirty‐male children aged 6–35 months presenting with acute dysentery were randomly assigned to receive either an ARF‐treated porridge or a standard porridge liquefied with water to make its consistency similar to the ARF porridge. After 24‐h stabilization a 72‐h metabolic balance was performed. Sixteen children received an ARF‐treated porridge and 14 received a standard porridge liquefied with water. The mean ± SD coefficients of absorption (%) of carbohydrate, fat. protein and energy (ARF porridge vs regular porridge) were 81.4 ± 11 vs 86.9 ± 7. 86.1 ± 10 vs 82.8 ± 15, 57.3 ± 12 vs 48.4 ± 24 and 81.4 ± 9 vs 83.1 ± 8, respectively. The stool loss of carbohydrate, protein, fat and energy was similar in the two groups. The net absorption of energy was substantially greater in the ARF‐fed than regular porridge‐fed children (by 28%, p= 0.01). The nitrogen balance was 6.9 ± 3.4mgkg‐1 d‐1 in the ARF porridge group and 1.1 ± 6.7mgkg‐1 d‐1 in the regular porridge group (p= 0.01). These results show that, despite being hyperosmolar, an amylase‐treated liquefied energy‐dense porridge is absorbed as well as a regular porridge by malnourished children with severe dysentery. Consequently, its use substantially increased the absorption of a net amount of macronutrients and resulted in a better nitrogen balance. These results further support this innovative approach of feeding sick children in developing countries.