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OBJECTIVE: To assess the effect of an improved local ingredient-based gruel fortified or not with selected multiple micronutrients (MM) on Hb concentration of young children. DESIGN: In a nutrition centre that we opened in their villages, children received either MM supplement (containing iron, zinc, vitamin A, vitamin C and iodine) with the improved gruel (MMGG) or the improved gruel only (GG), twice daily, 6 d/week, for 6 months. We assessed baseline and endpoint Hb concentration and anthropometric indices. SETTING: Kongoussi, a rural and poor district of Burkina Faso. SUBJECTS: In a community-based trial, we randomly assigned 131 children aged 6-23 months with Hb concentrations in the range of 80-109 g/l into two groups. RESULTS: The groups did not differ significantly at baseline. Mean baseline Hb concentration was 89·2 (sd 6·5) g/l and 90·3 (sd 8·4) g/l in the GG and the MMGG, respectively (P = 0·42). It increased to 104·1 (sd 11·4) g/l in the GG (P < 0·001) and 107·6 (sd 14·7) g/l in the MMGG (P < 0·001). The between-group difference of 3·5 (95 % CI -1·0, 8·1) g/l in mean (sd) endpoint Hb concentration was not significant (P = 0·13). The endpoint anthropometric indices were not different between the groups. CONCLUSIONS: This MM supplement had no additional effect on Hb concentration. Thorough studies are needed to evaluate the actual efficacy of the gruel before its introduction into household routine.

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Nutritional status of children is a global indicator of children's well-being and, indirectly, of the community's well-being. The first objective of this work is to assess the nutritional status of children under five years-old living in a suburb of the city of Lubumbashi, DR Congo, at the end of the 1998-2003 armed conflict. The second objective aims to identify some predictors of malnutrition. A multivariate logistic regression was applied to the results of a cross-sectional survey of 1963 children from selected households. In addition to the anthropometric variables, living conditions were also used. We observed 33.5% stunted growth and 3.8% emaciation. After logistic regression, a low maternal educational level (less than 7 years), the absence of a drinking water tap available in the house or yard, male gender, and age of children ( > 11 months) were all significantly associated with increased risk of stunted growth. Moreover, decreased appetite, diarrhea and age of children ( < 12 months) were significant predictors of emaciation. Compared to the classification of the World Health Organization, our results indicate that the prevalence of stunting is high and the prevalence of emaciation is low. Interventions against malnutrition should consider the various predictors discussed in this study in order to reduce mortality and morbidity in children and contribute to their well-being.

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BACKGROUND: Food technology transfer to rural households, based on local ingredients, is a relevant and sustainable strategy to ensure better nutrition of young children. Objective. To develop an improved mush based on local ingredients and evaluate the potential for transferring its technology to rural housewives. METHODS: We developed a flour-based food using Alicom software and performed laboratory trials to evaluate its actual nutritional quality. Then we recruited housewives from each of the 27 project villages and trained them in flour production and mush preparation twice daily, 6 days a week, for 26 weeks. Mush was sampled during the training session and at weeks 4, 12, and 22 and evaluated for actual flow distance and dry matter content, which served to estimate energy density and iron and zinc contents. RESULTS: The laboratory trials reported average energy densities of 103 kcal/l00 g, iron contents of 2.6 mg/100 kcal, and zinc contents of 1.2 mg/100 kcal. The average (+/- SD) energy densities of the mush samples obtained during the training session and at weeks 4, 12, and 22 were 103.0 +/- 5.6, 103.3 +/- 5.2, 107.9 +/- 11.5, and 101.3 +/- 8.7 kcal/100 g, respectively. The average iron contents were 2.3 +/- 0.5, 2.3 +/- 0.5, 2.6 +/- 0.3, and 1.8 +/- 0.8 mg/ 100 kcal, respectively, and the average zinc contents were 1.6 +/- 0.1, 1.6 +/- 0.1, 1.7 +/- 0.1, and 1.6 +/- 0.2 mg/100 kcal. CONCLUSIONS: Developing a suitable complementary food from local ingredients and educating households in nutrition and use of local products are feasible. Such education should come with measures aimed at improving the accessibility of some ingredients to ensure feasibility and sustainability.

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The present study was undertaken to determine the actual amounts of mush consumed and energy iron and zinc intakes of, and to investigate the attendance rate among, children aged 6-23 months due to an improved mush intervention. A cohort of 208 children from 27 villages was followed up for 6 months. Twice a day, 6 days/week, each mother took her child to the nutrition centre we had opened in her village to receive the mush and fed it to her child. Amounts consumed were 15, 21 and 33 g/kg body weight/meal for children aged 6-8, 9-11 and 12-23 months respectively. The average (standard deviation) attendance rate was 68.0% (25.6%). The median (range) daily intakes from the mush were 213 (25-373) kcal, 5.3 (0.6-9.3) mg, and 2.3 (0.3-4.1) mg for energy, iron and zinc, respectively. This flour and mush production should enter the routines of individual households, supported by a large-scale programme of nutrition education.

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The study's aim was to evaluate the impact of an in-service training course and supervision of physicians and nurses in terms of quality of care on intra-hospital mortality. The study included 2 cohorts of children. Cohort 1 included 414 children from 0 to 15-years-old who were followed in the paediatric wards of the provincial hospital of Goma (HPG) between April 1, 2003 and March 31, 2004. Cohort 2 included 996 children from 0 to 15-years-old where were treated and followed in the same service between January 1, 2005 and December 31, 2005. General and specific mortalities occurring before and after an intervention were compared, as were the ratios of the observed deaths to the predicted deaths through the application of the Goma1 model to cohort 2. Overall mortality decreased by 15,9% (before the intervention) to 4,6% (after the intervention), translating to a total reduction of 71,1%. The ratios between the observed deaths and the predicted deaths were lower than 1, globally and when stratified. The risk of death in the cohort 1 (before the intervention) is 6,8 times higher than in cohort 2 (after the intervention). This shows an improvement of child survival after the intervention.

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OBJECTIVE: To assess the effect of supplementation with iron or multiple micronutrients (MM) on the prevalence of anaemia in a malaria-endemic area. METHODS: A community-based randomized double-blind trial was conducted in rural Burkina Faso, including children aged 6-23 months with haemoglobin (Hb) concentrations of 70-109 g/l who were randomized into an iron group (Fe, n = 96), an iron and zinc group (IZ, n = 100) or an MM group (MM, n = 100), 5 days/week for 6 months. All children were provided with insecticide-treated bednets; those who had a Plasmodium falciparum (PF) positive-smear at baseline and/or at each monthly checking received antimalarial therapy. RESULTS: The mean (SD) endpoint Hb concentration was higher in the MM group [113.2 (13.6) g/l] than in the IZ group [106.3 (15.6) g/l] and the Fe group [107.1 (12.9) g/l] (P = 0.001). Children in the MM group were more likely to recover from anaemia than those in the Fe group [prevalence rate ratios, PRR (95% confidence interval, CI) = 1.62 (1.22-2.15), P < 0.001]. The IZ group did not differ from the Fe group [PRR (95% CI) = 0.94 (0.65-1.35), P = 0.72]. None of the interactions on the effect of supplementation of baseline age (0.13), or baseline height-for-age z-score (P = 0.33), or incident PF parasitemia (P = 0.99), was significant. CONCLUSION: In this malaria-endemic area, in combination with malaria management, the MM supplement was more efficacious than the Fe supplement and the IZ supplement for reducing anaemia. Further investigation into limiting factors and amounts of micronutrients that would be more efficacious for reducing anaemia is recommended.

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The aim of this study is to describe the quality of care provided to children hospitalized in the provincial hospital of Goma (HPG) and to identify the risk factors in the management of care, especially those which can contribute to a poor or inaccurate prognosis, and to uncover and show any inadequacies in care management. The data were collected with the use of a structured questionnaire updated by Nolan in 2001. The study allowed us to look at the initial assessment of incoming patients and to describe the quality of triage, emergency care, diagnosis, inpatient care, staff knowledge and practices, hospitals support services and any factors related to these that may lead to negative outcomes. The level of the severity of the illness and a late diagnosis were risk factors identified for mortality. The quality of care provided to the children during the day was high and good; however, night time care was insufficient. It was noted that nurses were found to lack adequate knowledge.

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OBJECTIVES: To find a simple mortality prediction model based on nutritional and infection indicators for the assessment of the care of children admitted to hospital in central Africa. METHOD: Cohort study of 414 children admitted at Goma Hospital between 1.4.2003 and 31.3.2004. We conducted univariate analysis and logistic regression, computed adjusted odds ratios and constructed a prognostic score from the coefficients of logistic regression. The performance of logistic model and score were evaluated by the calculation of areas under the ROC curves. RESULTS: The intrahospital mortality rate reached 15.9%. In univariate analysis, age, WAZ, arm circumference, neurological status (Blantyre coma score), stiff neck, subcostal indrawning, and infection were significantly associated with mortality. Logistic regression model analysis and adjusted odds ratios (AOR) confirmed higher risks of death for young (AOR 3.4 (1.4-8.8) and underweight children (WAZ -2->-3 and WAZ < or = -3, AOR 3.2 (1.4-7.6) and AOR 4.4 (1.7-11.2)), for children with arm circumference under 115 mm (AOR 3.4 (1.5-7.3)), impaired consciousness (AOR 9.6 (3.1-29.9)) and bloodstream infections (AOR 6.6 (2.1-21.1)). The area under the ROC curve of the prognostic model is 0.83 (0.78-0.88), that of the prognostic score, 0.80 (0.75-0.86). CONCLUSION: This study provides a simple mortality prediction model for hospitalised children in central Africa, based on age, weight for age or arm circumference, neurological status (Blantyre coma score), and infection. This model and scoring system can be used to evaluate programs set up to reduce intrahospital mortality in this region.

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BACKGROUND: In-hospital mortality from lower respiratory tract infections (LTRI) is unacceptably high in developing countries where LTRI are still a leading cause of death. OBJECTIVE: To identify new approaches to reduce in-hospital mortality of LRTI through the improvement of its management. METHODS: The prospectively collected database of children admitted during an 11-year period with LRTI in a pediatric rural hospital in Central Africa was reviewed to determine the predictors of death and to evaluate the impact on mortality of 4 different protocols for the management of malnutrition. RESULTS: During the study period, 859 children were admitted with a nonmeasles severe LRTI. In the 3-year period during which blood cultures were obtained, 29.0% of the children with LRTI were bacteremic, and multiresistant Enterobacteriaceae were recovered in 81.4% of positive blood cultures. Independent predictors of death in children without edema were age <24 months, dehydration and hepatomegaly with adjusted odds ratios (numbers in parentheses, 95% confidence interval) of 3.47 (1.70-7.08), 4.24 (2.11-8.50) and 2.90 (1.43-5.85), respectively. In those with edema, a significantly increased risk of death was noted for girls [4.31 (1.71-10.90)], in children with z-score of weight to height < or = -3 [5.45 (1.67-17.79)] and when the serum albumin was <16 g/l [2.58 (1.01-6.58)]. The improvement in the management of malnutrition was followed by a reduction of LRTI-related mortality in children with edema from 32.4 to 8.9% (P < 0.001). In children without edema, the LRTI-related mortality decreased from approximately 12% to 3.5% when their diet was supplemented with micronutrients. CONCLUSION: This study indicates that the improvement of the management of underlying nutritional deficiencies is crucial for the reduction of the high in-hospital case fatality rate associated with severe nonmeasles LRTI. The empiric antibiotic regimen should be modified to cover for multiresistant Enterobacteriaceae.

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UNLABELLED: This report is the first of 2 papers that analyse data routinely collected in the maternity ward of Rutshuru (democratic Republic of Congo). The present work describes the evolution of caesarean section, maternal deaths and the associated risk factors. MATERIAL AND METHODOLOGY: Between 1980 and 1998, data on 13,042 deliveries were collected. Characteristics, mortality, morbidity of mothers and new-borns and obstetrical interventions were recorded. The statistical analyses applied included khi2, t-test, simple linear and multiple logistic regression. RESULTS: Fifteen percent had a caesarean section and 1.9% of women died. When referred to the expected births during the period, these numbers led to a ratio of 150 maternal deaths for 100,000 expected births and a ratio of caesarean section of 1.2%. At admission, 35% of the women presented at least one of the four risk factors used for reference. The proportion of women with at least one of the 4 risk factors went up from 26.1% to 39.5%. The proportion of caesarean sections went up from 1.9% to 34.1%. The proportion of maternal deaths remained constant except in 1988, 1994, 1995 and 1997. Three of the four reference factors, the Baudeloque diameter, parity and height were associated with caesarean section. Age only was associated with maternal death. Education and marital status were both associated with caesarean section and maternal death. CONCLUSION: This analysis shows high levels of maternal mortality and caesarean section. The authors recommend to analyse on a larger scale the value of the reference factors used in antenatal services and to standardise indications for the different obstetrical interventions.

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UNLABELLED: This second paper aims at deriving useful information allowing to improve the strategy applied for maternal health care. MATERIAL AND METHODOLOGY: Between 1980 and 1998, data on 13,042 deliveries were collected. Characteristics, mortality, morbidity of mothers and new-born and obstetrical interventions were recorded. The present work describes the evolution of low birth weight (LBW), new-born deaths, and associated risk factors. The statistical analyses applied included khi2, t-test, and multiple logistic regression. RESULTS: Eighteen percent of new-born weights below 2.5 kg and 7.9% died. The proportion of low birth weights remains globally constant. Low proportions of new-born deaths were observed in 1981, 1982, 1988 and 1998. At admission, 35% of the women presented at least one of the four risks defined by the factors used for reference; this proportion went up from 26.1 to 39.2%. The four reference factors were associated with low birth weight. Baudelocque diameter and age were not associated with new-born death. Education and BMI were associated with an increased risk of new-born death. Marital status was not associated with any of the two outcomes. CONCLUSION: This analysis shows small variation of LBWs and perinatal deaths. It confirms the association between these two outcomes and most of the risk factors studied. The efficacy of the strategies implemented for improving perinatal health is questioned. The authors recommend that they be reassessed.

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OBJECTIVE: To determine the prevalence of enteroaggregative Escherichia coli (EAggEC) in African diarrheal children in Lwiro, Congo, to characterize EAggEC isolates by possible genotypic and phenotypic markers, and to evaluate the EAggEC probe pCVD432 in identifying EAggEC. METHODS: The Hep-2 cell adhesion assay and colony-blot hybridization assays were carried out for the identification of EAggEC. O:H serotyping, biotyping, antibiogram and plasmid-profile analysis were done. To detect the E. coli LT and ST, ELISA tests were used and, for VT, a vero cell assay was used. RESULTS: EAggEC strains were isolated from 56 out of 115 diarrheal children (48.7%): the organism was present alone and presumed to cause diarrhea in 22 (19.1%) cases. The rest of the cases were associated with two or more diarrheagenic E. coli strains. EAggEC strains were isolated from 25% of total diarrheal children (first day of isolation) and 8.86% of age-matched healthy individuals (p<0.03). This isolation rate was significantly higher than the one found for other diarrheagenic E. coli strains. In parallel, we evaluated the sensitivity and specificity of EAggEC probe pCVD432, and found that it had 56% sensitivity with 100% specificity compared with the Hep-2 cell test. EAggEC isolates were characterized by serotyping, biotyping, antibiotic resistance pattern, plasmid profiling and toxin production analysis. They did not produce any one of these classical toxins and nor did they relate to any particular serotypes. Plasmid analysis of the 79 EAggEC isolates (n=315) showed seven different profiles. Ten resistance patterns were identified and 34 strains were sensitive to all drugs. There was no association between plasmid profiles and antibiotic resistance patterns. All 16 classical E. coli biotypes were found in this small EAggEC population. CONCLUSIONS: EAggEC has been emerging as a cause of childhood diarrhea in African children in Congo. From the accumulated data it was found that there is a great heterogeneity in EAggEC populations.

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