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Brief Reports Indian Pediatrics 2002; 39:1021-1026 |
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Effect of Deworming on Nutritional Status of Ascaris Infested Slum Children of Dhaka, Bangladesh |
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Ascariasis associated with childhood undernutrition has been observed in many parts of the world especially in tropical and subtropical countries and is reported to be one of the important contributory factors towards childhood undernutrition(1-5). Gupta et al(6) observed no gastrointestinal protein loss among mildly worm infested children, while Hall(7) reported that role of intestinal parasites on growth of children depends on several factors like parasitic burden and duration of infection, other associated infections, existing nutritional status, inadequate sanitation and poor personal hygiene. He further added that the catch up growth of deworming children also depends on their growth deficit, an adequate diet after treatment, a sufficient period for catch up growth to occur, and freedom from disease(7). Intestinal parasitism, particularly with Ascaris lumbricoides, and all degrees of undernutrition are widely prevalent in the urban slums of Bangladesh(8,9). A cross sectional study conducted on under five children in urban dispensaries of Dhaka showed a high (73%) prevalence of helminthiasis among the children and the study also reported that undernutrition was higher among infested (90.6%) than among non-infested children (32.3%)(10). Hall et al.(11) reported that in urban slums of Bangladesh, more than 40% children aged 1 to 12 years were moderately to heavily infested (defined as ³15 worms) with Ascaris lumbricoides. The purpose of this study was to determine if deworming has any positive effect on the nutritional status of Ascaris infested children living in urban slums of Dhaka, Bangladesh. Subjects and Methods The study was carried out in Mirpur slum, a suburb of Dhaka, Bangladesh consisting of 900 households. The families live in a single small room (area 8-8 sqm) which is inadequately ventilated with earthern floor and thatched roof. The dwellings are dirty, crowded and have inadequate sanitation. Most of the households use tap water for drinking, cooking and washing practices. Personal hygiene is poor. Most people have no formal education and live on weaving, providing casual labor, engaging in petty business or by pulling rickshaw. Table I- Baseline Characteristics of the Study Children
Among 97 pre-surveyed households, 298 children aged 2 to 12 years were identified and of them 234 (78.5%) had roundworm infestation. Total 85 children divided into 2 groups (42 in the treatment group and 43 in the control) were enrolled in the study (One child (the younger one) aged 2 to 12 years was selected per household and 12 households refused to participate in the study). Sample size requirement was calculated by using data from the study conducted by Stephenson et al.(3) in Kenya, as no such study was found to be conducted in Bangladesh. On the assumption that the deworming group will gain 50% more weight than the control after 16 weeks observation, using a power of 0.80, an alpha value of 0.05 and suggested formula(12), 40 children were required in each group. Additional children were included to adjust dropouts. Informed written and verbal consent was taken from the parents prior to enrollment. Before enrollment a fresh stool sample was collected from the subjects in a plastic container and was examined microscopically by direct film method for the presence of ova in a private laboratory in Dhaka. The Ascaris infested subjects were divided into two groups and a double bind randomization procedure was followed using a random table to assign a treatment group receiving Pyrantel pamoate syrup (Combantrin; Pfizer, Bangladesh) given as a single dose of 11 mg/kg body weight or the control group receiving placebo syrup. The syrups were identical in appearance and flavor and were packaged in identical containers. Randomized patient numbers were labeled on the bottles to maintain the double blind design. At baseline, 42 children received anthelmintics and another 43 children received placebo. Anthropometric measurements were carried out at baseline and after 16 weeks of intervention by the same investigators using the same instruments. Body weight was measured using a scale to nearest 100 gm and height was measured with a locally constructed board to nearest 1 mm. Nutritional status was determined as percentage of median of the NCHS standard(13). At the end of intervention 2 children from each group dropped out because of either they left the place or had become sick. Children in the placebo group were treated with anthelmintics before winding up the study. The study was approved by both the ethical (research) and review committee of Bangladesh National Nutrition Council. Statistical analysis After checking the forms for errors the data were entered into a computer database using programs written in Fox-Pro (version win-3.1). The analysis was done using SPSS (version win-9.0) statistical software and anthropometric calculations were done using ANTHRO (version DOS-1.01) software. Group means were compared using Student’s and paired t-tests. The Chi-square test was used to test differences in proportions. A multiple linear regression model was performed to identify the relationship between weight gain and other important biological factors. Differences were considered to be statistically significant at the 5% level. Results Children in the two groups were matched by age, sex, weight and height (Table I). Children who completed the study (n = 81) did not differ from those who dropped out (n = 4) with respect to any of the baseline characteristics and therefore they were excluded from the analysis. On the other hand, the distribution of children in both groups according to age and sex were inadequate for meaningful interpretation and therefore, the results are not presented by age and sex distribution. Table II presents the post intervention anthopometric changes between the two groups. The change of weight gain was significantly higher of children given anthelmintics than those of children given placebo (0.92 kg vs. 0.54 kg.). The mean change of weight gains of both deworming and placebo groups was significant. Although the mean change in the increment of height did not differ significantly between the two groups, the significant height increment was observed in children of both deworming and placebo groups. The mean changes of weight for age (W/A, % of median) differed significantly between deworming and placebo groups (0.8% vs. –0.1%). The mean change of weight for age in deworming group increased while in placebo group decreased significantly. The changes of weight for height (W/H, % of median) and height for age (H/A, % of median) were comparable between the two groups. The mean changes of weight for height increased significantly while the change of height for age decreased significantly of both groups after intervention. A multiple linear regression model was done to determine the relationship between the weight gain and, baseline age, weight, sex and intervention group. The regression explained 45% of the outcome variable. After controlling for sex, deworming and height correlated positively while age and weight correlated negatively with weight change (Table III). Table II__ Changes in the Anthropometric Measurements between Deworming (DW: N = 40) and Placebo (PL: n = 41) Groups Before (baseline) and After Intervention (endline)
Discussion The finding of our study, which demonstrates the positive role of deworming on weight gain of children, is in agreement with others(2,3,14). Our study results demonstrate that the Ascaris infested children given antihelmintics are likely to gain 410 g more weight over a 16 weeks period than those of children given placebo (Table-III). Gupta(15) showed that ascariasis contributes significantly to malnutrition in communities where both coexist. Ascariasis leads to childhood undernutrition by mechanical and irritant action, decreasing intestinal absorption, competition for host’s nutrition and alterations in the intraluminal conditions of the small bowel(16). The effect on height or H/A increment of deworming children did not differ significantly compared with the nondeworming ones within the 16 weeks of intervention. The fact might be explained thus (a) 16 weeks follow up may not be sufficient in showing the height discrimination and (b) intestinal absorption decreased to affect host’s height particularly among heavily infested subjects. We however did not examine the worm burden among the study subjects. Gupta(15) conducted a matched pair case control study on 200 Indian children. The study showed that the children without history of passing roundworms in the preceding 1 year or no roundworm ova in stool had more percentage height for age. Table III- Multiple Linear Regression Analysis to Identify the Factors Associated with the Post Intervention Weight Change Among the Children
Dependent variable = Weight change; R2 = 0.45, P < 0.001 Children of our study were mostly malnourished (Table II). Ascaris infested malnourished children can lead to marked nutritional impairment when a high parasite load is associated with low protein intake(5). Therefore, it is important that the worm load to be identified at first of malnourished Ascaris infested children before finding out the relationship with absorption and nutritional status of those subjects. Contributors: NRS assisted in implementation of the study and data collection; analyzed and interpreted the data; and drafted the manuscript. KSA conceptualized, designed and implemented the study, besides revising the manuscript. KBB assisted in analysis and interpretation of data. MAM revised and finally approved the manuscript. NRS shall act as gurantor for the study. Funding: This study was conducted by a research grant from the World Bank and was funded by the Bangladesh National Nutrition Council. Competing interests: None stated.
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