Article 1: An egg a day keeps the doctor away? (Ecuador)
What’s it about?
Childhood stunting is attributed to both biological factors and environmental factors such as poverty. The World Health Assembly has set a global target to reduce childhood stunting by 40% by 2025. Previous interventions to improve growth have included fortification of food and dietary supplementation. Utilising locally available nutritious food is an important step in improving outcomes. Eggs have high nutritional value and contain high concentrations of choline, a nutrient previously found to promote growth in animal models. Â There has been no previous study investigating the use of eggs as a complementary nutrition source for infants.
Why does it matter?
The study was completed in Cotopaxi Providence, a rural indigenous population in Ecuador. This population is estimated to have a baseline prevalence of stunting of 38%. Children aged 6 to 9 months were randomised to treatment (1 egg per day for six months [n=83], and control (no intervention [n=80]). Children were excluded if they had a medical condition, severe malnutrition or egg allergy. Eggs were delivered on a weekly basis, and a log report of egg consumption, morbidities, and anthropometric measures was taken after 6 months. Egg intervention increased length-for-age z score by 0.63 (93% CI, 0.38-0.88, p<0.001), and weight-for-age z score by 0.61 (95% CI 0.45-0.77, p<0.001). There was a reduced prevalence of stunting by 47% (prevalence ratio, 0.53; 95% CI, 0.37-0.77). Children in the treatment group also had reduced intake of sugar-sweetened foods compared with control (PR, 0.71; 95% CI, 0.51-0.97 p=0.032).Â
Clinically Relevant Bottom Line:
This study found that supplementing the diet of 6—to 9-month-olds with an egg a day significantly improves linear growth and reduces stunting in a population from a developing country with a high prevalence of stunting (38%). There were no reports of allergic reactions. Care must be taken in applying this study to different contexts and cultural backgrounds.
Reviewed by: Lorraine Cheung
Article 2: Maternal influenza immunisation to improve infant outcome (Nepal)
Why does it matter?
Influenza can cause serious illness in children, especially infants younger than six months of age. Immunisations are strongly recommended for pregnant women and any child over 6 months of age. Maternal immunisation during pregnancy induces high levels of maternal antibodies that can be transferred to the foetus and prevents influenza virus infection in pregnant women and their infants during their first few months of life.
What’s it about?
This randomised controlled trial assessed the safety and efficacy of maternal influenza immunisations in mothers and infants in Nepal, where Influenza viruses circulate perennially. Between 2011 and 2013, 3693 women in 17 to 34 weeks of gestation were recruited. Maternal influenza immunisations were offered throughout the year, and 3629 infants were included in the immunisation efficacy analysis.
The study found that influenza immunisation reduced maternal febrile influenza-like illness with an overall efficacy of 19% (95% CI 1-34). Â Among infants followed from birth to six months of age, immunisation had an overall efficacy of 30% (95% CI 5-48. There was also a 42g increase in birth weight (95% CI: 8-76) among infants born to immunised mothers (with an overall decrease in low birth weight infants by 15%). There were no differences noted in the rates of small for gestational-age infants or preterm births. Both groups had a similar number of adverse events.
Clinically Relevant Bottom Line:
Maternal influenza immunisation reduced maternal influenza-like illness, influenza in infants and rates of low birth weight in Nepal. Maternal immunisation should be considered in subtropical regions where the virus is present for many months.
Reviewed by: Jessica Win See Wong
Article 3: Comparing infusion rates of fluid boluses in septic shock (India)
What’s it about?
This was a randomised controlled trial in which the researchers identified children with septic shock in a paediatric ED and ICU in a tertiary hospital in northern India and compared intravenous fluid boluses of 40-60mL/kg per hour in 20mL/kg aliquots delivered over 15-20 minutes versus over 5-10 minutes. The primary outcomes were the need for mechanical ventilation and/or impaired oxygenation. There were several other secondary objectives.
Subjects were aged 9 months to 12 years and included children with suspected infection with two or more clinical signs of decreased perfusion. They excluded children with dengue, malaria, severe anaemia, severe malnutrition, primary cardiac illness, those on non-invasive ventilation before developing shock, those who had already received fluids or inotropes, and those with contraindications to central line insertion.
This was a small RCT, with only 96 children randomised. The study was terminated after about 50% enrolment after interim analysis suggested harm in the 5-10 minute group. They found that children who received fluid boluses over 5-10 minutes were at higher risk of intubation and mechanical ventilation, had higher rates of intubation due to fluid overload, and had higher percentages of fluid overload in 24 hours. There was no difference in the mortality rate.
Why does it matter?
Recognition and treatment of sepsis are crucial in acute paediatrics. Guidelines worldwide recommend treating septic shock with fluid resuscitation of up to 60mL/kg as boluses, although the 2011 FEAST trial highlighted the potential harms of fluid boluses, suggesting a cautious approach to fluid bolus administration.
This study compared infusion times instead of examining different fluid volumes or types. Unlike the FEAST study, it excluded children vulnerable to the effects of fluid overload, allowing for a more broad applicability of the results. Both groups of children received almost identical volumes of fluid as boluses; it was only the infusion times that differed.
The researchers suggested that rapid fluid bolus administration is difficult in developing countries due to a shortage of staff, fear of fluid overload, and the need for ventilation, which is not easy to achieve in resource-restricted settings.
The Bottom Line
Research is yet to identify the optimal fluid management of septic shock in developing and developed countries, so caution is prudent in the meantime.
Reviewed by: Katie Nash
Article 4: Think zinc! (India)
Why does it matter?
Coeliac disease is characterised by gluten intolerance, which leads to damage to the small bowel mucosa via an autoimmune process in genetically susceptible individuals. Partial or total villous atrophy affects the maintenance of nutrients. Zinc is implicated in the improvement of mucosal healing and faster normalisation of micronutrient status in susceptible patients. Therefore, zinc supplementation may prove to be beneficial in patients with coeliac disease.
What’s it about?
This study compares the serum zinc, iron and copper status in paediatric patients following a gluten-free diet with or without zinc supplementation. All children aged <18 years with newly diagnosed coeliac disease were randomised to either the gluten-free diet (GFD) group or the gluten-free diet + zinc supplementation (GFD+Zn) group via computer-generated random sequences. Patients were assessed with clinical history, examination and blood tests at baseline and various follow-up reviews up to 3 months. Unsurprisingly, iron, zinc and copper levels were below the normal range at baseline in all patients. The rise in haemoglobin, serum iron and ferritin levels was better in the GFD+Zn group than the GFD alone group. Otherwise, there was no significant difference in the rise of zinc, copper and weight gain in the two groups.
Clinically Relevant Bottom Line:
The study has shown that zinc supplementation significantly improves iron status but does not affect serum zinc or copper levels. The authors speculate this may be secondary to the contributory effect of zinc towards mucosal healing and improvement of intestinal absorption. Although interesting, it would have been helpful to couple these biochemical results with endoscopic findings with zinc supplementation. Nevertheless, the mainstay of treatment for coeliac disease remains the gluten-free diet, and you may think of supplementing zinc if you want a faster improvement in iron status.
Reviewed by: Jennifer Moon
Article 5: The power of playtime (Ethiopia)
Why does it matter?
The study looked at foster children aged between 3 and 59 months living with foster mothers in Jimma, a town in Ethiopia. The children were randomly assigned to intervention and control groups at a 1:1 ratio. The intervention group received home-based play stimulation once a week for six months, which focused on activities to promote developmental skills and mother-child interactions. The therapy was provided by a trained nurse, however, they also spent time teaching the foster mothers, so they could provide ongoing play therapy at home.
The assessors, who were blinded to the children’s allocations, used culturally specific and standardized developmental screening tools at baseline, 3 months and six months. The study found that intervention was beneficial for language, social-emotional and personal-social performances (statistically significant for language [P = 0.0014], personal-social [P = 0.0087] and social-emotional [P < 0.0001] performances).
Clinically Relevant Bottom Line:
The study showed positive effects on multiple domains of development in the 6 months of follow-up for children who received home-based play therapy. This approach is highly sustainable, as the foster mother’s acquired skills mean they can continue to provide play therapy and hopefully continue to have positive effects on children living in resource-limited settings.
Reviewed by: Tina Abi Abdallah
If we have missed out on something useful or you think other articles are absolutely worth sharing, please add them in the comments! We are also looking to expand the Bubble Wrap team so please contact us if you’re interested in this! That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to.
The conclusion to article 1 appears to be incorrect…
Thank you, well spotted