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Factors Influencing Nutritional Status of Children in Bihar
The Institute for Research in Medical Statistics, New Delhi undertook a study to assess the nutritional stauts of the population residing in Bihar. Among children, nutritional deficiency was observed inspite of higher intake of energy. This indicates that the magnitude of malnutrition is not only affected by the diet but could also be influenced by the other related factors. Therefore, to examine the role of dietary and other related factors on nutritional status of children, a detailed analysis was done for the data collected in the study. This paper aims to identify the target group for the nutritional programs.
The survey covered all the 50 districts including all 704 blocks, 1418 villages, 236 urban ward, 28360 households and about 11,000 children of Bihar. For selection of villages/wards and households, an appropriate sampling methodology(1) was used. Information was collected on households characteristics, demographic profile, anthropometry, etc. Health status and measurement of height and weight were carried out for the members of these 20 households per village/town. The calorie and other nutritive intake was calculated by using table of nutritive value of Indian foods(2). Children under five years of age were categorized using Gomez classifica tion as severe, moderate, mild and normal on the basis of NCHS standard. With reference to both protein and energy intake, the households were also categorized on basis of RDA. For each of the above categories further sub-grouping was made on the basis of socio-economic conditions of the households.
Two thirds of the households had kutcha house in the state. About 38 per cent of the households in urban and 27 per cent in rural areas had a separate room as kitchen. Electricity was available in 14 per cent and piped water was available in 4 per cent of households. Flush toilet were available in 5 per cent of the households in the state. The proportion of normal children was much lower among scheduled caste as compared to others according to level of protein and calorie intake (p <0.01). Malnutrition was significantly lower (p<0.01) in children who were (i) residing in pucca house; (ii) house with electric facility as compared to those who were using kerosene oil/others as a source of light, having facility of tap water for drinking as compared to those children who used to take water from hand pump and well; and (iv) those residing in house with flush toilet facility as compared to houses with toilet facility as pit or others.
This analysis indicates that the malnutrition among children depends on both better sanitary conditions and on dietary intake. The severe and moderate level of malnutrition among children was much higher among those with poor housing and sanitary conditions even with the same level of dietary intake whereas inspite of lower dietary intake, the level of malnutrition was much lower for those living in better sanitary conditions. Thus to reduce the problem of malnutrition among children, there should be dual focus on dietary intake as well as providing safe drinking water, better sanitation and housing condition for improving their general standard of living.
Poor housing and sanitary conditions could represent indicators for identifying the target group for nutritional programs. The preference should be given for those living in kutcha houses, not having access to safe drinking water, using kerosene as source of lighting and using toilet facility as bush/fields.
This group is more vulnerable and any deficiency in diet will adversely affect the nutritional status specially of children.
1. Yadav RJ, Singh P. Nutritional status and dietary intake in tribal children of Bihar. Indian Pediatr 1999; 36: 37-42.
2. Gopalan C, Ramashastry BV, Balasubra-maniam SC. Table of food composition. In: Nutritive Value of Indian Foods. Hyderabad, National Institute of Nutrition, 1993.
Immature Gastric Teratoma in an Infant
We report a huge, exclusively exogastric immature teratoma of the stomach which had a very narrow pedicle of attachment to the posterior gastric wall and its excision was easily achieved taking only a narrow margin of serosa alongwith the tumor.
A 6-month-old sick looking boy, presented to us with gradually increasing abdominal distension that was first noticed by the parents when the child was 2 months old. There was loss of appetite and failure to thrive. The delay in presentation at the hospital was due to the child being investigated and treated by local practitoners. At admission, the child was pale and poorly nourished. A huge, firm, lobulated lump with well defined margins was found to occupy almost the whole of the left and central abdomen. The lump was partly reaching the pelvis and this portion was hard in consistency.
Plain X-ray of abdomen showed a soft tissue density in central and left abdomen with a few areas of calcifications. Ultrasonography revealed the lump to be of variable echo-genicity and free from liver and kidney. CECT of the abdomen revealed the lump to be multicystic and lobulated with a few areas of calcifications. The kidneys and the liver were normal. The clinical and radiological impression was that of a teratoma, though its area of origin could not be commented on. The serum AFP and HCG levels were within normal limits.
Fig. 1. Photograph of tumor showing the narrow attachment to the gastric wall (arrow).
On exploration, a huge lobulated multi-cystic mass measuring approximately15´18 cm was found to be arisign from the posterior wall of the greater cuvature of the stomach. The tumor was free from surrounding viscera and was attached to the serosa of the stomach with a very narrow vascular pedicle only (Fig. 1). The tumour was excised completely along with a narrow margin of serosa and superficial muscular layer of the stomach. The excised tumor weighed approximately 2 kg. The histopathological analysis of the specimen revealed it to be an immature gastric teratoma with predominance of the immature neurological elements. The patient was discharged on 7th post operative day in satisfactory condition.
At six months of follow up, the patient is asymptomatic. There is no recurrence of the tumor on the clinical or on ultrasonic examination. The AFP and HCG levels are also within normal limits.
Less than 1% of all teratomas occur in stomach. More than 90% of these have occur in the neonatal period and infancy. Exogastric growths (58-70%) are commoner than endo-gastric growths(30%)(1). In most of the cases the presenting symptoms are abdominal mass (75%) and abdominal distension (56%). Endogastric teratoma may present with vomiting, hematemesis or malena.
Most gastric teratoma are considered to be benign. However, malignant gastric tera-toma(2) and malignancy in gastric teratoma (3) has been reported recently. Only four cases of immature gastric teratoma in children are published in the English literature so far(4-6). Surprisingly, most of these case reports, including the present one, have been from India.
The histopathological grading and the long term follow up after surgical excision of these tumors is not studied in detail due to their rare occurrence. Immature teratomas, especially with higher grades of immaturity are known to have malignant potential. The recurrence of the tumour after excision of immature gastric teratoma in a neonate has been reported(6). A careful follow up of the patients by clinical evaluation, radiological imaging and tumor marker monitoring is, therefore, indicated. Histologically, as in immature teratomas at other sites, the presence of embryonal neuroepithelial structures that resemble medulloblastoma, neuroblastoma, retinoblastoma and ependymoblastoma should be considered as predictors of poor outcome. The authors recommend the institution of radiotherapy and chemotherapy in all cases with either higher grades of immaturity or with the above stated poor histological prognosticators.
Simmi K. Ratan,
Department of Pediatric Surgery,
New Delhi 110 029, India.
1. Logani KB, Tayal A, Bhan S, Choudhury M, Uma G. et al. Gastric teratoma in infants_A report of two cases. Indian J Cancer 1993; 30: 34-37.
2. Bourke CJ, Mackay AJ, Payton. Malignant gastric teratoma_A case report. Pediatr Surg Int 1997; 12: 192-193.
3. Matsukuma S, Wada R, Daibou M, Watanabe N, Kuwabara N, Abe H, et al. Adenocarci-noma arising from gastric immature tera-toma.Cancer 1995; 75: 2663-2668.
4. Ravikumar VR, Raghupathy R, Das L, Palanimuth M, Ravi N, Sakar PG, et al. Gastric teratoma in an infant. J Pediatr Surg 1986; 21: 948.
5. Sharma AK, Sarin YK, Agarwal LD. Immature gastric teratoma in a neonate. Indian Pediatr 1994; 31: 357-360.
6. Sarin YK, Agarwal LD, Jhamaria VN, Goyal RB, Sharma R, Shekhawat NS. Immature gastric teratoma. Indian J Pediatr 1997; 64: 896-901.