Double blind, randomised controlled clinical trial of hypo-osmolar oral rehydration salt solution in dehydrating acute diarrhoea in severely malnourished (marasmic) children.

AIMS: To compare the clinical efficacy of hypo-osmolar oral rehydration salt (ORS) solution (224 mmol/l) and standard ORS solution (311 mmol/l) in severely malnourished (marasmic) children having less than 60% Harvard standard weight for age with dehydrating acute watery diarrhoea. METHODS: In a double blind, randomised, controlled trial, 64 children aged 6-48 months were randomly assigned standard (n = 32) or hypo-osmolar ORS (n = 32). RESULTS: Stool output (52.3 v 96.6 g/kg/day), duration of diarrhoea (41.5 v 66.4 hours), intake of ORS (111.5 v 168.9 ml/kg/day), and fluid intake (214.6 v 278.3 ml/kg/day) were significantly less in the hypo-osmolar group than in the standard ORS group. Percentage of weight gain on recovery in the hypo-osmolar group was also significantly less (4.3 v 5.4% of admission weight) than in the standard ORS group. A total of 29 (91%) children in the standard ORS group and 32 (100%) children in the hypo-osmolar group recovered within five days of initiation of therapy. Mean serum sodium and potassium concentrations on recovery were within the normal range in both groups. CONCLUSION: Our findings suggest that hypo-osmolar ORS has beneficial effects on the clinical course of dehydrating acute watery diarrhoea in severely malnourished (marasmic) children. Furthermore, children did not become hyponatraemic after receiving hypo-osmolar ORS.     

Randomised controlled trial of zinc supplementation in malnourished Bangladeshi children with acute diarrhoea

OBJECTIVE—To evaluate the impact of zinc supplementation on the clinical course, stool weight, duration of diarrhoea, changes in serum zinc, and body weight gain of children with acute diarrhoea.
DESIGN—Randomised double blind controlled trial. Children were assigned to receive zinc (20 mg elemental zinc per day) containing multivitamins or control group (zinc-free multivitamins) daily in three divided doses for two weeks.
SETTING—A diarrhoeal disease hospital in Dhaka, Bangladesh.
PATIENTS—111 children, 3 to 24 months old, below 76% median weight for age of the National Center for Health Statistics standard with acute diarrhoea. Children with severe infection and/or oedema were excluded.
MAIN OUTCOME MEASURES—Total diarrhoeal stool output, duration of diarrhoea, rate of weight gain, and changes in serum zinc levels after supplementation.
RESULTS—Stool output was 28% less and duration 14% shorter in the zinc supplemented group than placebo (p = 0.06). There were reductions in median total diarrhoeal stool output among zinc supplemented subjects who were shorter (less than 95% height for age), 239v 326 g/kg (p < 0.04), and who had a lower initial serum zinc (< 14 mmol/l), 279 v 329 g/kg (p < 0.05); a shortening of mean time to recovery occurred (4.7 v 6.2 days, p < 0.04) in those with lower serum zinc. There was an increase in mean serum zinc in the zinc supplemented group (+2.4 v −0.3 µmol/l, p < 0.001) during two weeks of supplementation, and better mean weight gain (120 v 30 g, p < 0.03) at the time of discharge from hospital.
CONCLUSIONS—Zinc supplementation is a simple, acceptable, and affordable strategy which should be considered in the management of acute diarrhoea and in prevention of growth faltering in children specially those who are malnourished.

     

Hypo-osmolar oral rehydration salts solution in dehydrating persistent diarrhoea in children: double-blind, randomized, controlled clinical trial

A double-blind, randomized, controlled trial was conducted to compare the clinical efficacy of hypo-osmolar oral rehydration salts (ORS) solution (224 mmol/L) and standard ORS solution (311 mmol/L) in children with persistent diarrhoea who were prone to develop dehydration. Initially, 95 children aged between 3 and 24 mo were included in the study for overnight observation. Of these, 70 children who passed stool more than 2 g/kg/h were finally enrolled in the study and were randomly assigned either standard ORS or hypo-osmolar ORS. After decoding the identity of ORS, it was observed that 37 children were in the standard ORS group and 33 in the hypo-osmolar ORS group. Clinical parameters and microbiological findings of stool samples were comparable in the two groups at the time of enrolment. Total stool output (2.5 ± 1.1 vs 3.2 ± 1.6 kg; p = 0.04), duration of diarrhoea (114.8 ± 38.3 vs 145.4 ± 40.0 h; p = 0.002), total intake of ORS (5.4 ± 1.6 vs 7.8 ± 1.8 l; p = 0.002) and total fluid intake (7.9 ± 2.6 vs 10.0 ± 4.1 l, p = 0.01) were significantly less in the hypo-osmolar ORS group compared to the standard ORS group. However, the percentage of weight gain on recovery in the hypo-osmolar group was less compared to that of the standard ORS group, though the difference was statistically insignificant. Thirty-five (95%) children in the standard ORS and 33 (100%) children in the hypo-osmolar group recovered within 10 d of initiation of therapy and modified dietary management. Conclusion: Our findings suggest that hypo-osmolar ORS has beneficial effects on the clinical course of dehydrating persistent diarrhoea.     

Faecal candida and diarrhoea

BACKGROUND—Candida species are frequently isolated from stools of children with diarrhoea but are not proven enteropathogens. It is hypothesised that faecal candida causes diarrhoea.
AIMS—To determine the prevalence of faecal candida in childhood diarrhoea and the relation between faecal yeasts and diarrhoea.
METHODS—Comparison of clinical and laboratory data, including quantitative stool culture for yeasts from 107 children hospitalised with diarrhoea and 67 age matched controls without diarrhoea.
RESULTS—Yeast species, predominantly candida, were identified in the stools of 43 children (39%) with diarrhoea and 26 (36%) without diarrhoea. The concentration of candida was positively associated with recent antibiotic use (p = 0.03) and with the presence of another enteric pathogen (p < 0.005), but not with patient age, nutritional status, or duration of diarrhoea.
CONCLUSION—Candida species do not cause childhood diarrhoea in well nourished children.

     

Fish oil supplementation improves docosahexaenoic acid status of malnourished infants

AIM—To investigate whether the low docosahexaenoic acid (DHA) status of malnourished, mostly breast fed, Pakistani children can be improved by fish oil (FO) supplementation.
METHODS—Ten malnourished children (aged 8-30 months) received 500 mg FO daily for nine weeks. The supplement contained 62.8 mol% (314mg) long chain polyunsaturated fatty acids of the ω3 series (LCPUFAω3) and 22.5 mol% (112 mg) DHA. Seven FO unsupplemented children served as controls. Red blood cell (RBC) fatty acids were analysed at baseline and at the study end.
RESULTS—FO supplementation augmented mean (SD) RBC DHA from 2.27 (0.81) to 3.35 (0.76) mol%, without significantly affecting the concentrations of LCPUFAω6. Unsupplemented children showed no RBC fatty acid changes. One FO supplemented child with very low initial RBC arachidonic acid showed a remarkable increase from 4.04 to 13.84 mol%, whereas another with high RBC arachidonic acid showed a decrease from 15.64 to 10.46 mol%.
CONCLUSION—FO supplementation improves the DHA status of malnourished children. The supplement is apparently well absorbed and not exclusively used as a source of energy.

     

Children's perception of breathlessness in acute asthma

AIM—To determine whether asthmatic children who present to hospital with hypoxia perceive breathlessness less well than non-hypoxic presenters.
METHODS—A total of 27 children aged 5-16 years (mean age 10) admitted with acute asthma had recordings of oxygen saturation (SaO₂), clinical score, forced expiratory volume in one second (FEV₁), and breathlessness score (HMP) at admission and at 5, 10, 24,48, and 72 hours after admission. Those defined as hypoxic (SaO₂ <92%) at admission were compared with a non-hypoxic group.
RESULTS—Twelve children were hypoxic at admission. Compared with the non-hypoxic group they were younger (8.6 (SD 2.8) v 11.2 (2.8) y, p = 0.02), and had greater airway obstruction (FEV₁ 32.5 (10)% v 54.3 (26)%, p = 0.0073, 95% confidence interval (CI) −36.9 to −6.6) yet had a trend towards less breathlessness (median HMP 4 v 3, p = 0.062, CI −0.001 to 2.00) at admission. The hypoxic group had a smaller change in breathlessness from admission to discharge, despite a similar improvement in FEV₁, reflected in a lower ratio of change in HMP to change in FEV₁ (ΔHMP/ΔFEV₁) (median ΔHMP/ΔFEV₁ 0.021%⁻¹v 0.073%⁻¹, p = 0.0081, CI −0.075 to −0.016). Linear regression analysis showed a strong relation between ΔHMP/ΔFEV₁ and initial SaO₂ (p = 0.004, r = 0.54).
CONCLUSIONS—Asthmatic children who present to hospital hypoxic tend to perceive themselves as less breathless than non-hypoxic children. This may predispose to a future life threatening attack.

     

Differentiation of osmotic and secretory diarrhoea by stool carbohydrate and osmolar gap measurements

Clinical features and laboratory tests that determine carbohydrate in faeces were evaluated to determine which was best able to distinguish between osmotic and secretory diarrhoea in infants and children. For this purpose 80 boys aged 3 to 24 months, with acute watery diarrhoea, were studied prospectively. The faecal osmolar gap (FOG) was calculated as: serum osmolarity − [2 × (faecal sodium + potassium concentration)]. Fifty eight patients were classified as having predominantly osmotic diarrhoea (FOG >100 mosmol/l), and 22 as having predominantly secretory diarrhoea (FOG ⩽100 mosmol/l). The two groups were comparable in their clinical features on admission, in the results of blood and urine tests, and in the evolution of their diarrhoeal illness. Evidence of steatorrhoea (by positive Sudan III test) and of acid faecal pH on admission were significantly more frequent in patients with osmotic diarrhoea. Mean (SD) faecal osmolarity was not significantly different between the two groups (319 (80) mosmol/l in secretory diarrhoea v 361 (123) mosmol/l in osmotic diarrhoea). Tests for reducing substances in faeces such as Benedict''s test—with and without hydrolysis—and glucose strip, all showed a positive and significant association with osmotic diarrhoea (p <0.05, <0.025, <0.05, respectively). The presence of excess reducing substances (Benedict''s test with hydrolysis >++) on admission was the most sensitive and specific test with the best predictive value for differentiating between the two types of watery diarrhoea.

     

Randomised trial of different rates of feeding in acute diarrhoea

OBJECTIVE—To compare the effect of different feeding frequencies on the speed of recovery from diarrhoea.
METHODS—A randomised, non-blinded trial provided 0.452 MJ/kg/day as either 6 or 12 feeds of cows'' milk each day to 262 hospitalised male infants aged 3-12 months with acute diarrhoea. Stool frequency, stool weight, body weight, and diarrhoea complications were monitored until recovery or for 14days.
RESULTS—A proportional hazards regression model controlling for age, diarrhoea aetiology, and severity of dehydration on admission revealed that the frequently fed group had a significantly shorter duration of diarrhoea (hazards ratio, 1.29; 95% confidence interval, 1.002 to 1.653). Frequently fed infants had a significantly greater weight gain and significantly lower faecal frequency and faecal weight.
CONCLUSIONS—Breast feeding remains the preferred method of feeding infants with acute diarrhoea, but feeding cows'' milk to adequately nourished infants with acute diarrhoea is safe and is more rapidly effective if provided in frequent feeds with low energy loads.
     

Validation of an asthma symptom diary for interventional studies

OBJECTIVE—The Pediatric Asthma Diary was developed and validated to assess efficacy of interventions in children with asthma.
DESIGN, PATIENTS, AND SETTING—Diary validation was performed in a three week, prospective study of 106 children aged 6-14 years with asthma. Children were classified at baseline as either stable (requiring no additional asthma treatment) or new onset/worse (requiring either addition of or increase in anti-inflammatory treatment).
RESULTS—A daytime symptom scale and "day without asthma" were defined from diary questions. Both measures demonstrated significant validity and responsiveness to anti-inflammatory treatment. The stable group experienced a higher percentage of days without asthma during week 1 compared with the new onset/worse group (39.6% v 11.6%, respectively). The new onset/worse patients experienced significant improvement in days without asthma (24.5%) compared with stable patients (6.4%).
CONCLUSIONS—The Pediatric Asthma Diary daytime symptom scale and day without asthma are acceptable measures for use in asthma intervention studies of children aged 6-14 years.

     

Evaluation of oral hypo-osmolar glucose-based and rice-based oral rehydration solutions in the treatment of cholera in children

In a randomized controlled clinical trial, the efficacy of a low-sodium low-glucose oral rehydration solution (ORS) and a low-sodium rice-based ORS was compared with standard WHO glucose ORS in the treatment of severe cholera in children aged 2-10y. In total, 120 children were evaluated for the study, of whom 58 patients were positive for Vibrio cholerae and were included in the study. Of these 58 cases, 19 received rice-based hypo-osmolar ORS, 20 received WHO-ORS and 19 received glucose-based hypo-osmolar ORS. The clinical characteristics (age, preadmission duration of diarrhoea, frequency of stool before admission, incidence of vomiting, body weight and volume of initial fluid requirement) were comparable in the three treatment groups. All patients received tetracycline in a dose of 50 mg/kg/d of body weight in 4 divided doses for 3 d. CONCLUSIONS: Patients who received rice-based hypo-osmolar ORS had subsequently reduced (p < 0.05) stool output, ORS consumption and diarrhoea duration than the patients who received either WHO-ORS or glucose-based hypo-osmolar ORS.     

Twelve year outcomes following bacterial meningitis: further evidence for persisting effects

AIM—To determine whether intellectual and cognitive impairments observed seven years following early childhood bacterial meningitis persist into adolescence.
METHODS—Blinded neuropsychological, auditory, and behaviour assessments were conducted in 109 (69%) subjects from an original cohort of 158 children, seven and 12 years after their meningitis, and in 96controls.
RESULTS—Meningitis subjects remained at greater risk than controls for any disability (odds ratio OR 4.7, confidence interval 2.2to 9.6). Those with acute neurological complications had more sequelae than children with uncomplicated meningitis or controls (47% v 30% v 11.5% respectively; p < 0.001). Differences in intellectual, academic, and high level cognitive function between subjects and controls were maintained at the seven and 12 year assessments. In contrast, lower order skills improved, while behaviour scores deteriorated significantly (p = 0.033).
CONCLUSIONS—Many of the deficits identified at the seven year follow up persist 12 years after an episode of bacterial meningitis.
     

Risk assessment of renal cortical scarring with urinary tract infection by clinical features and ultrasonography

AIMS—To address some of the issues in the ongoing debate over the optimal diagnostic imaging following childhood urinary tract infection (UTI), by determining the risk of missing renal cortical scarring which would be detected on a technetium-99m dimercaptosuccinic acid (DMSA) gold standard if ultrasound alone were used, factoring for clinical features (upper or lower tract), UTI recurrence, and age group (infants, preschool, or school age).
METHODS—Details of UTI clinical features and recurrence were recorded for 990 children with a proven UTI, and their DMSA and ultrasound results were compared for each kidney.
RESULTS—The risks of missing DMSA scarring varied between 0.4% (school age children with solitary lower tract UTI) and 11.1% (infants with recurrent upper tract UTI).
CONCLUSIONS—UTI clinical features are important in assessing the need for DMSA imaging. Current UK imaging guidelines are endorsed, although preschool children with solitary lower tract UTI remain a controversial group and more attention needs to focused on children with recurrent UTI.

     

Alanine- and glucose-based hypo-osmolar oral rehydration solution in infants with persistent diarrhoea: a controlled trial

To evaluate the efficacy of a hypo-osmolar and a standard (World Health Organization) oral rehydration salt (ORS) solution in persistent diarrhoea, a randomized controlled clinical trial was conducted in 55 children. After a 1-day observation period the children were assigned to one of three solutions: standard ORS (WHO-ORS) (osmolality 311 mosmol/1), hypo-osmolar ORS containing L-alanine and glucose (osmolality 255 mosmol/1) and iv polyelectrolyte solutions (osmolality 293 mosmol/1) for ongoing replacement of stool loss for the next 4 days. Excellent acceptability of ORS (101-160 ml/kg body weight/day) by the children was observed. There were no significant differences in the total intake of solutions and food, and frequency of stools among the groups Stool outputs were significantly less in infants receiving hypo-osmolar ORS than in those receiving WHO-ORS for 0-24h (p = 0.04), 0-48h (p = 0.01), 0-72h (p = 0.04) and 0-96h (p = 0.03). The results indicate a sufficient scope of ORS practice in persistent diarrhoea. Furthermore, we found that a hypo-osmolar ORS containing L-alanine and glucose is as efficacious as an iv solution and more effective than WHO-ORS for replacement of ongoing stool loss in persistent diarrhoea. Alanine-glucose ORS, hypo-osmolar solution, oral rehydration solution, persistent diarrhoea     

Hypo-osmolar sucrose oral rehydration solutions in acute diarrhoea: a pilot study

Based on studies showing improved absorption of hypo-osmolar oral rehydration solutions (ORS) with reduced glucose and sodium concentration, a hypo-osmolar ORS with sucrose replacing glucose (sodium 60, potassium 15, chloride 60, citrate 5, sucrose 58mmoll^?1, calculated osmolality 198mOsmkg^?1) was compared with mildly hyperosmolar glucose ORS (WHO) in 46 children aged 6–30 months with acute diarrhoea and dehydration. In the hypo-osmolar sucrose ORS group (n = 18) faecal output was less by 30% during the initial 24 and 48 h compared with controls, suggesting better absorption. Sucrose may be a suitable alternative to glucose in an absorption-efficient hypo-osmolar ORS.     

Intravenous pamidronate in juvenile osteoporosis

AIMS—To investigate the use of the aminobisphosphonate, disodium pamidronate, in children with vertebral osteoporosis.
METHODS—Five children (aged 10-15 years) with vertebral osteoporosis who developed compression fractures in the thoracic and/or lumbar spine as a consequence of five different conditions, received treatment with intravenous disodium pamidronate in doses ranging from 0.5 to 12 mg/kg/y.
RESULTS—Each child had rapid pain relief following the first treatment, followed by large increments in lumbar spine bone density over one year; the change in bone density standard deviation score ranged from 0.5 to 2.5 with percentage increments of 26% to 54%.
CONCLUSION—Intravenous pamidronate appears to be a useful therapeutic option in childhood osteoporosis, but its use in children must still be regarded as experimental and therefore closely monitored.

     

Growth hormone treatment in young children with Down's syndrome: effects on growth and psychomotor development

BACKGROUND—Learning disability and short stature are cardinal signs of Down''s syndrome. Insulin-like growth factor I (IGF-I), regulated by growth hormone (GH) from about 6 months of age, may be involved in brain development.
AIMS—To study long term effects of GH on linear growth and psychomotor development in young children with Down''s syndrome.
Study design—Fifteen children with Down''s syndrome were treated with GH for three years from the age of 6 to 9 months (mean, 7.4). Linear growth, psychomotor development, skeletal maturation, serum concentrations of IGF-I and its binding proteins (BPs), and cerebrospinal fluid (CSF) concentrations of IGF-II were studied.
RESULTS—The mean height of the study group increased from −1.8 to −0.8 SDS (Swedish standard) during treatment, whereas that of a Down''s syndrome control group fell from −1.7 to −2.2 SDS. Growth velocity declined after treatment stopped. Head growth did not accelerate during treatment. No significant difference in mental or gross motor development was found. The low concentrations of serum IGF-I and IGFBP-3 became normal during GH treatment.
CONCLUSIONS—GH treatment results in normal growth velocity in Down''s syndrome but does not affect head circumference or mental or gross motor development. Growth velocity declines after treatment stops.

     

Impact of zinc supplementation in malnourished children with acute watery diarrhoea

A double-blind, randomized, controlled clinical trial was conducted on 80 malnourished children with acute dehydrating diarrhoea to evaluate the efficacy of oral supplementation of zinc as an adjunct therapy to oral rehydration solution (ORS). After decoding it was observed that 44 children received zinc sulphate (177 mg/kg/day in three divided doses equivalent to 40 mg elemental zinc) in a syrup form and 36 children received only syrup placebo. Clinical parameters and microbiological findings of stool samples were comparable in the two groups at the time of enrollment. All the children (100 per cent) in the zinc supplemented group and 32 (89 per cent) children in the placebo group recovered within 5 days of hospitalization (p = 0.04). The zinc supplemented group had a significantly shorter duration of diarrhoea (70.4 +/- 10.0 vs. 103.4 +/- 17.1 h; p = 0.0001), passed less liquid stool (1.5 +/- 0.7 vs. 2.4 +/- 0.7kg; p=0.0001), consumed less oral rehydration solution (2.5 +/- 1.0 vs. 3.6 +/- 0.8 litre; p = 0.0001) and other liquids (867.0 +/- 466.1 vs. 1354.7 +/- 675.6 ml; p = 0.0001) as compared to the placebo group. Our findings suggest that zinc supplementation as an adjunct therapy to ORS has beneficial effects on the clinical course of dehydrating acute diarrhoea.     

Reliability of percentage ideal weight for height

AIMS—To assess the reliability of percentage ideal weight for height (%WFH) as a measure in children.
METHODS—Forty two dietitians calculated %WFH of six children. Eleven of the 42 repeated the calculations.
RESULTS—Interexaminer estimates varied by 16.5 to 40 percentage points (mean 27.8). Intraexaminer variability was also large.
CONCLUSIONS—%WFH is an unreliable measure of nutritional status.