Aflatoxin exposure in utero causes growth faltering in Gambian infants

BACKGROUND: Growth faltering in West African children has previously been associated with dietary exposure to aflatoxins, particularly upon weaning. However, in animal studies in utero exposure to low levels of aflatoxin also results in growth faltering. OBJECTIVE: This study investigated the effect of in utero aflatoxin exposure on infant growth in the first year of life in The Gambia. METHODS: Height and weight were measured for 138 infants at birth and at regular monthly intervals for one year. Aflatoxin-albumin (AF-alb) adduct level was measured in maternal blood during pregnancy, in cord blood and in infants at age 16 weeks. RESULTS: The geometric mean AF-alb levels were 40.4 pg/mg (range 4.8-260.8 pg/mg), 10.1 pg/mg (range 5.0-189.6 pg/mg) and 8.7 pg/mg (range 5.0-30.2 pg/mg) in maternal, cord and infant blood, respectively. AF-alb in maternal blood was a strong predictor of both weight (P = 0.012) and height (P = 0.044) gain, with lower gain in those with higher exposure. A reduction of maternal AF-alb from 110 pg/mg to 10 pg/mg would lead to a 0.8 kg increase in weight and 2 cm increase in height within the first year of life. CONCLUSIONS: This study shows a strong effect of maternal aflatoxin exposure during pregnancy on growth in the first year of life and thus extends earlier observations of an association between aflatoxin exposure during infancy and growth faltering. The findings imply value in targeting intervention strategies at early life exposures.     

早产儿追赶性生长与代谢综合征的关联性研究进展

代谢综合征(MS)又称胰岛素抵抗综合征,主要包括Ⅱ型糖尿病、肥胖、血糖调节异常、高血压和血脂异常等。早产儿追赶性生长可以弥补早产儿宫外发育迟缓的缺陷,提高其免疫功能,促进其智力运动的发育。但研究表明,追赶性生长与MS关系密切。本文主要对早产儿追赶性生长致成人期发生MS的机制、早期预测及干预进行综述。     

Giardia intestinalis is unlikely to be a major cause of the poor growth of rural Gambian infants

Parasite-specific plasma immunoglobulins have been used to indicate the presence of Giardia intestinalis infection in 60 infants living in a rural area of The Gambia. Infants were studied longitudinally between 2 and 8 mo of age. The median age for first exposure to G. intestinalis was between 3 and 4 mo, and by 8 mo all but 3 infants (95%) showed a positive titer on at least one occasion. Raised Giardia-specific IgM titers were associated with reduced weight gain in the 2 wk preceding a positive titer, but catch-up growth occurred in the following 2 wk. IgM antibody titers were also positively associated with intestinal permeability (lactulose/mannitol ratio), urinary lactose excretion, plasma concentrations of alpha1-antichymotrypsin and total IgM, IgA and IgG immunoglobulins. However, infant growth over the whole 6-mo period (i.e., between 2 and 8 mo of age) was not related to mean Giardia-specific antibody titers, nor the time of first exposure to the parasite. The data suggest that giardiasis in these very young breast-fed children occurs as a mild, acute disease, and its presence could not explain the marked, long-term growth faltering observed in many of the subjects.     

The growth of young children in a Gambian village

A detailed study of the growth and health of 215 children under 5 years in the village of Keneba (Gambia) during 1962-1963 was conducted. At the same time, outline information was collected in 3 adjacent villages--Jali, Manduar, and Kantongkunda. There were 99 live births during 1962-1963. It became obvious during the 1st year of the study that season exercised a marked effect on trends in body weight, and it became necessary to define the seasons. Data from children who died during the survey period were excluded. Of the 99 liveborn babies, 93 were measured within 3 days of birth. The data suggested that birth weights were on average lower during the wet than the dry months, but the differences between the quarter years were not statistically significantly. There was no indication that the weight gains in the 1st 6 months of small babies differed from those of large babies. The seasonal effect was slight during the early months of life but became obvious at later ages. Children born in the early part of the year gained very well until nearly the end of their 1st rainy season, when there was a short setback. Children born during the wet months grew well until the onset of the rains in the following year. Those born during the earlier part of the dry season received a marked check to growth soon after entering the wet months. Both season of birth and age dictated the average pattern of gain in weight during the 1st year of life. Until about 6 months of age, season made little difference to rates of gain in Keneba, but thereafter increments were about zero or slightly negative during the wet months with some catch up during the dry months. The Keneba babies grew much faster than American babies during the first 3 months of life, but much more slowly during the 2nd half of the 1st year. By the end of the 2nd year the average rate of growth in height had practically caught up with the American standard. The data confirmed the previous finding that, in general, the growth of children who die is not very different from that of children who survive, and that the events which precede death cause effects on body weight which are of relatively short duration.     

A double-blind, placebo-controlled, glutamine-supplementation trial in growth-faltering Gambian infants

BACKGROUND: Growth faltering during infancy is a characteristic of life in developing countries. Previous studies have shown that small-intestine mucosal enteropathy, accompanied by endotoxemia and a persistent systemic inflammatory response, accounts for up to 64% of the growth faltering in Gambian infants. OBJECTIVE: The objective was to test whether glutamine, with its putative trophic effects on enterocytes, immune cells, and intestinal integrity, can accelerate the repair of the intestine, lower immunostimulation, and reduce growth faltering. DESIGN: Ninety-three infants aged 4-10 mo from the West Kiang region of The Gambia were studied in a double-blind, double-placebo, controlled trial. Glutamine (0.25 mg/kg body wt) or a placebo that contained an isonitrogenous, isoenergetic mix of nonessential amino acids was orally administered twice daily throughout the 5-mo rainy season. Anthropometric measurements were made monthly during the supplementation period and for 6 mo after supplementation. Intestinal permeability was measured monthly (by determining the ratio of lactulose to mannitol), and finger-prick blood samples were collected for the analysis of plasma proteins on 3 occasions. RESULTS: Gambian infants showed a seasonal deterioration in growth and persistently elevated acute phase protein concentrations and intestinal permeability. Oral supplementation with glutamine did not improve growth (x +/- SE: weight gain, 60 +/- 19 and 69 +/- 20 g/mo; length gain, 1.01 +/- 0.05 and 0.95 +/- 0.03 cm/mo) or intestinal permeability [lactulose:mannitol ratio: 0.29 (95% CI: 0.23, 0.35) and 0.26 (95% CI: 0.21, 0.32)] in the glutamine and placebo groups, respectively. It also had no effect on infant morbidity or on plasma concentrations of immunoglobulins or acute phase proteins. CONCLUSION: Glutamine supplementation failed to improve growth or intestinal status in malnourished Gambian infants.     

The impact of milk and weaning diet on gastrointestinal permeability in English and Gambian infants

To test the hypothesis that cow's milk formula and weaning diet may damage the gut mucosa, the gastrointestinal permeability of 77 healthy English and Gambian infants was measured from the urinary recovery of the markers lactulose and mannitol included in feeds. All infants were born at term and studied at 6, 12 and 18 weeks of age. No infant developed diarrhoea or failed to thrive. Infants fed on cow's milk formula had higher urinary lactulose: mannitol excretion ratios than breast-fed infants at 6 weeks of life (P less than 0.05). There was no significant difference in the urinary marker excretion ratios of English formula-fed and Gambian breast-fed infants at 12 weeks. An increase in urinary lactulose: mannitol excretion ratios was seen in all infants at 18 weeks. This was more probably due to increasing age than to the introduction of weaning diet. Cow's milk formula feeding was associated with greater intestinal permeability than breast feeding in infants aged 6 weeks. The introduction of weaning diet after 6 weeks did not appear to have an impact on the gastrointestinal permeability of healthy growing infants born in either England or rural Gambia.     

Twenty-four-hour energy expenditure and basal metabolic rate measured in a whole-body indirect calorimeter in Gambian men

By use of a respiration chamber, 24-hour energy expenditure (EE), diet-induced thermogenesis (DIT), and basal and sleeping EE were measured in 20 young rural Gambian men during the "hungry" season (weight, 60.8 +/- 1.4 kg) and in a group of 16 European men matched for body composition (weight, 66.9 +/- 1.9 kg). The 24-h EE was lower in Gambian than in European men (2047 +/- 46 vs 2635 +/- 74 kcal/d, p less than 0.001, respectively). Basal EE and sleeping EE were also lower in Gambian than in European men (1.05 +/- 0.02 vs 1.25 +/- 0.02 kcal/min and 1.0 +/- 0.02 vs 1.18 +/- 0.02 kcal/min, p less than 0.01, respectively). DIT was blunted in Gambian compared with European men (6.3 +/- 0.6% vs 12.1 +/- 0.5%, p less than 0.001 respectively). The net efficiency of walking was greater in Gambian than in European men (23.2 +/- 0.3% vs 20.1 +/- 0.4%, p less than 0.001, respectively). A low basal and sleeping EE, a reduced DIT, and a high work efficiency are important energy-sparing mechanisms in Gambian men, which allow them to cope with a marginal level of dietary intake during the hungry season.     

The Gambian National Impregnated Bednet Programme: Evaluation of the 1994 cost recovery trial

Following the success of a controlled trial of insecticide-impregnated bednets in reducing mortality in children. The Gambia started a National Impregnated Bednet Programme (NIBP) in 1992. The objectives of this programme were to introduce impregnated bednets into all primary health care (PHC) villages and to establish a system of cost recovery over a three-year period. During the initial phase of the programme, when insecticide was given out free, a high uptake was achieved. However, after small user charges were introduced in 1993, coverage dropped to a low level. In 1994, different systems of insecticide distribution and permethrin formulations were tried in an attempt to improve coverage. A nationwide cross-sectional survey carried out during the 1994 rainy season measured coverage by distribution channel, as well as the knowledge, attitudes and practices of health workers and villagers during the intervention. Overall, only 16% of bednets were impregnated in 1994, compared to 80% when the insecticide was offered free of charge in previous years. Lack of money was the major reason given by villagers for not impregnating their bednets in 1994. Use of impregnated bednets was higher in areas where the sale of permethrin emulsion by village health workers was supplemented by the sale of insecticide in individual packages through shops. In villages where insecticide was distributed free to women with small children through governmental mother and child health (MCH) services, higher levels of coverage were achieved among women and young children than in villages where other distribution systems were used. We conclude that the sale of insecticide through the private sector may increase bednet impregnation rates in African communities, and that the free distribution of insecticide through MCH services may be an effective way of targeting young children, the group most at risk of malaria.     

Screening for metabolic disorders among high risk infants and children.

In a screening program in Cincinnati urine specimens from over 20,000 infants and children were tested for inherited metabolic disorders involving amino acids, carbohydrates, phenolic acids, organic acids, keto acids, mucopolysaccharides, and imidazoles. The subjects were selected on the basis of symptoms such as vomiting, diarrhea, acidosis, seizures, failure to thrive, delayed development, mental retardation, and others. The tests were based primarily on paper chromatographic techniques. Patients with 21 different metabolic disorders were found. The patterns of abnormal excretion of amino acids and other metabolites are often useful in making a diagnosis.     

Factors influencing sleeping metabolic rate in infants

Seven West African infants were studied prospectively from birth to 1 year to investigate factors affecting sleeping metabolic rate (SMR), particularly acute infection. There was no rise in SMR associated with acute infection, after adjustment for the effects of changes in body weight and body temperature. In the case of two illnesses, malaria and 'fever', there were falls in adjusted SMR. It is suggested that these falls can be accounted for by the effects of altered energy intake. Other effects on SMR were in close agreement with previous work.     

Parenteral amino acid and metabolic acidosis in premature infants

BACKGROUND: Aggressive parenteral nutrition (PN) including amino acids is recommended for low-birth-weight infants to prevent energy and protein deficit. Their impact on acid-base homeostasis has not been examined. METHODS: We investigated the impact of dose and duration of parenteral amino acids, with cysteine, on acid-base parameters in 122 low-birth-weight infants. Premature infants 24 hours), or 3 g/kg/d for a short (5 hour), extended (24 hour), or prolonged (3-5 days) duration were included in the study. Data were obtained at age 0-3 days (n = 43) or, when clinically stable, age 3-5 days (n = 49). Data from 30 infants, matched for birth weight and gestational age, receiving PN during the first 5 days after birth were also obtained. Acidosis was defined as pH <7.25. RESULTS: Acidosis was evident in all infants between 2 and 5 days after birth. Infants with large patent ductus arteriosus (PDA) exhibited significantly (p < .05) lower pH early, had higher blood urea nitrogen levels (26 +/- 9 vs 18 + 8 mg/dL; p < .05), and had greater weight loss ( approximately 17% of birth weight) when compared with infants without PDA. Gestational age, weight loss, and patent ductus arteriosus accounted for 65% of variance in acidosis. CONCLUSIONS: Low-birth-weight infants develop metabolic acidosis between 2 and 5 days after birth, irrespective of dose and duration of parenteral amino acid administration. Careful management of parenteral fluids and comorbidities may lower the incidence of acidosis and promote protein accretion.     

Energetic cost of physical activity in cystic fibrosis children during Pseudomonas aeruginosa pulmonary exacerbation

Chronic pulmonary infection by Pseudomonas aeruginosa is observed in 50% of patients with cystic fibrosis and requires the use of recurrent intravenous therapy. A decrease of resting energy expenditure (REE) and an increase of physical activity (PA) after intravenous anti-P. aeruginosa therapy (IVAT) is observed while total energy expenditure (TEE) does not change. A decrease in the energetic cost of physical activity (ECPA) could be hypothesized but has never been studied. Our aim was to assess the evolution of ECPA after home IVAT in both standardized condition at hospital and in free-living condition twice before and after IVAT. Sixteen CF patients (nine boys, seven girls) chronically colonized by P. aeruginosa with a mean age of 12.1+/-2.3 years (range 7.1-14.6) were studied before and after IVAT. Each patient passed throughout a visit in hospital: weight, height and fat-free mass were measured. Then, energy expenditure (EE) measured by indirect calorimetry and heart rate (HR) were simultaneously recorded at different levels of PA: REE, and at different intensity of physical activities on a cycloergometer using an incremental increase of the power brake force. Physical activity energy expenditure (PAEE) was computed in laboratory condition using PAEE=EE-BEE (basal energy expenditure). Linear regression between PAEE and power brake force was fitted for each patient before and after IVAT. ECPA in standardized conditions was compared at different range of power brake force using area under the curve (AUC). After coming back at home, 24 h TEE using the heart rate monitoring technique and PA by triaxial accelerometry were simultaneously measured in free-living condition for 24 h during a school day. ECPA in free-living conditions was compared by the ratio PAEE:PA where PAEE=DEE-REE (DEE=daily energy expenditure). After IVAT, median AUC between 60 and 90 W in standardized condition decreased significantly by -15.4% (median 14.9, range 8.8-30.3 vs. median 12.6, range 8.5-17.6; P<0.05, Wilcoxon rank test) while the decrease for lower range of power work load did not reach significance. Spearman correlation was significant between variations of forced expiratory volume in 1 s and variation of AUC at 30-60 W before and after IVAT in standardized condition. In free-living conditions, ratio PAEE/PA did not vary significantly (median 3.4, range 1.6-6.4 vs. median 2.8, range 1.4-4.8; NS). Our data demonstrate a decrease of ECPA after IVAT in standardized conditions for moderate level of PA (60-90 W), but not in free-living conditions. The decrease of ECPA was probably due to a decrease in the energetic cost of breathing after IVAT, that is particularly relevant to promote PA in CF patients.     

Prostitutes and their clients: a Gambian survey.

The social backgrounds and working behaviour of 248 prostitutes in urban and rural areas of The Gambia were investigated. Prostitutes were found to be highly mobile, moving frequently between a number of working locations in The Gambia and neighbouring Senegal, from which most of them originated. The educational level of prostitutes and the standard of living of their natal families were above average. Prostitutes worked on average four days a week and had between two and three clients a night. Condoms were used in up to 80% of contacts. 795 clients of prostitutes were interviewed and found to be on average of low educational and occupational status. Half were non-Gambian and most were currently travelling or living away from home.     

Regulatory intensity and hospital cost growth

This article parameterizes and examines the regulatory intensity of New York's all-payer rate setting system. The model, using hospital level data, compares the effects of specific features of rate-setting designed to promote cost containment. Two indicators measuring regulatory intensity were examined; the extent of hospital-specific disallowances, and how frequently the base year was adjusted (the degree of prospectivity). The results indicate that both the degree of prospectivity and the extent of disallowances importantly affect cost growth. Hospitals, when constrained, primarily achieved cost savings through reductions in non-medical personnel.     

Incidence of abnormal haemoglobin traits among Gambian children.

The electrophoretic mobility of haemoglobin from 343 Gambian children between the ages of two months and ten years has been investigated. The incidence of Hb-S and Hb-C traits is described and compared with earlier reports on the distribution of these traits in The Gambia. One child was identified as having the rare haemoglobin, Hb-A + N.     

Net calcium absorption in premature infants: results of 103 metabolic balance studies.

Net calcium absorption was evaluated in 103 low-birth-weight preterm infants by a 72-h balance technique. At birth the infants had a mean (+/- SE) gestational age of 30.9 +/- 0.2 wk and weighed 1.43 +/- 0.03 kg. When tested 3 wk later, their net calcium absorption averaged 58 +/- 1% with an intake of 80 +/- 2 mg Ca.kg body wt-1.d-1. Of the 103 infants, 58 had been fed low-birth-weight formulas supplemented with vitamin D. The remainder received banked human milk, of whom 34 were supplemented with vitamin D and calcium; 11 infants received no supplementation. Calcium absorption in the four subgroups did not differ significantly, with neither vitamin D supplementation nor supplementation with vitamin D and calcium affecting percent absorption significantly. Net calcium absorption was a linear function of intake (40-130 mg Ca.kg body wt-1.d-1) with a zero intercept. Because vitamin D supplementation did not increase net calcium absorption, it is concluded that in preterm low-birth-weight infants calcium absorption proceeds by a nonsaturable route, with the transcellular, vitamin D-regulated mechanism not yet expressed.     

Effects of dietary supplementation on work performance in Gambian laborers.

The effect of food supplementation on productivity of Gambian subsistence farmers was studied during a natural food shortage induced by the annual hungry season. Sixteen men in two groups matched for weight, height, hemoglobin, and physical-work capacity followed a crossover protocol with 6-wk supplementation and control periods. Productivity was assessed over the final 3 wk of each period by quantifying piece-rate-paid road building. Supplementation comprised an ad libitum supply of highly palatable energy-dense food provided three times daily. Outcome variables were total loads transported, loads per working hour, time per load, total energy expenditure assessed by doubly labeled water and heart-rate monitoring, postwork activity, and anthropometry. Body weight decreased during control periods, indicating a real energy deficit, and increased during supplementation in both groups. Supplementation had no significant impact on productivity variables. Energy-deficient men can maintain maximal productivity over short periods if sufficiently motivated but at the expense of body weight.     

Human milk intake and growth faltering of rural Mesoamerindian infants.

To determine whether growth faltering during early infancy was attributable to inadequate intake of human milk, the nutrient intakes and growth of 30 Otomi infants from Capulhuac, Mexico, were studied at 4 or 6 mo of age. Growth was monitored monthly from 1 through 6 mo of age. The 2H dose-to-the-mother method was used to measure human milk intake. Energy, protein, lactose, and fat concentrations in milk were analyzed by standard techniques. Mean (+/- SD) human milk intakes were 885 +/- 145 and 869 +/- 150 g/d at 4 and 6 mo, respectively. Protein and lactose concentrations in milk were normal but fat and consequently energy concentrations were abnormally low. Energy intakes averaged 81 +/- 14 kcal.kg-1.d-1 at 4 mo and 72 +/- 14 kcal.kg-1.d-1 at 6 mo. Growth faltering by 6 mo was evidenced by the significant decline in growth velocities and National Center for Health Statistics Z scores. Weight gain at 6 mo was 8.1 +/- 3.5 g/d and length gain was 1.0 +/- 0.34 cm/mo. Weight-for-age and length-for-age Z scores were -0.81 +/- 0.94 and -1.51 +/- 0.83, respectively. Growth velocities were not significantly correlated with nutrient intakes. Growth faltering among the Otomi infants despite energy intakes comparable to those of breast-fed infants in more protected environments may have resulted from an increase in the need for nutrients or from a growth-limiting nutrient, other than energy, in their diet.