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Context: Cryptosporidium spp. is a zoonotic infection, now being recognized as a significant cause of diarrhea in both immunocompetent and immunocompromised hosts. However, there still exist significant knowledge gaps in its estimated global burden, epidemiology, diagnosis and management., Evidence Acquisition: A semi-systematic search was performed across PubMed to select studies on epidemiological burden of cryptosporidium diarrhea using the following keywords- ['crytosporidiosis' OR 'cryptosporidium'] AND ['diarrhea' OR 'diarrhoea']. Articles were included if participants were 'Humans', belonged to pediatric (0-18 y) age group, and were published after 1990. The results were compiled separately for acute and persistent diarrhea., Results: Cryptosporidium spp is commonly detected in stools of both cases (acute/ persistent diarrhea) and asymptomatic controls. The prevalence is higher in children with diarrhea than non-diarrheal controls (1.7-35% vs 0.3-15%); varying widely across different studies. The positivity rate is higher in younger children (<2 years) suffering from diarrhea. The main symptoms associated with cryptosporidiosis include fever, vomiting and abdominal pain with propensity for prolonged duration of diarrhea. It predisposes to malnutrition, which is also a risk factor for cryptosporidiosis. The prevalence is higher in HIV positive patients; certain socio-demographic factors play a more important role than mere geographical distribution for infection., Conclusion: The high positivity rates during both acute and persistent diarrhea highlights the need to suspect this infection even in immunocompetent children.

Aim: Many countries have guidelines recommending the use of oral zinc in acute dehydrating diarrhoea in children aged 2 months to 5 years of age, but no guidelines exist for older children. This study tested how effective existing recommendations are in children from 5 to 12 years of age., Methods: Children hospitalised with acute dehydrating diarrhoea (n = 134) were randomised to receive 40 mg of oral zinc sulphate tablets or a placebo for 14 days. The primary outcome variable was the time taken for diarrhoea to stop. Secondary outcome variables included time taken for rehydration, duration of hospitalisation and recurrence of diarrhoea in the next 3 months., Results: The median time for resolution of diarrhoea was 60 h in both groups. The zinc group was marginally better, but not statistically significant, for resolution (hazard ratio = 0.89, 95% CI 0.63-1.24), rehydration (hazard ratio = 0.93, 95% CI 0.66-1.32) and hospitalisation (hazard ratio = 0.94, 95% CI 0.67-1.34). The risk ratio of recurrence for zinc versus placebo (95% CI) was 0.65 [0.37-1.23] [p = 0.11]., Conclusion: Daily zinc supplements (40 mg for 14 days) in children aged 5-12 years with acute dehydrating diarrhoea did not shorten the duration of diarrhoea or reduce subsequent episodes. Further adequately sized, community-based trials are needed., (©2014 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.)

Objective: The aim of the present study was to study microscopic colitis (MC) in children with special reference to its role in chronic diarrhea and changes in mucosal biopsies., Methods: A total of 100 consecutive children ages 3 to 12 years, with nonbloody diarrhea (passage of ≥3 loose stools per day) of >12 weeks' duration were screened and 26 were enrolled in the study in which no specific etiology could be found and colonoscopy did not reveal any mucosal abnormality. Colonic biopsies were evaluated for the presence of lymphocytic colitis or collagenous colitis and those with the characteristic changes were defined to have MC (group A). Colonic biopsies from patients with MC were compared with biopsies from patients with chronic diarrhea but no evidence of MC (group B). One hundred children ages 3 to 12 years with bleeding per rectum were screened and colonic biopsies from 45 patients (group C) who had colonic mucosal changes but no vascular or polyp lesion were compared with patients with MC., Results: Of the 26 patients with chronic diarrhea, MC was found in 5 (3 lymphocytic colitis and 2 collagenous colitis). Significantly higher polymorphonuclear infiltration was seen in group A as compared with group B (13.8 [5.4-20.6] vs 7.2 [0-19.6]; P = 0.03) or group C (13.8 [5.4-20.6] vs 4 [0-13.4]; P = 0.007). Intraepithelial lymphocytes (12 [4-32] vs 4 [0-24]; P = 0.008) and basement membrane thickening (3.5 [2.9-10.6] vs 2.5 [1.6-5.86]; P = 0.008) were also significantly higher in group A as compared with group C., Conclusions: MC was found to be present in children with nonbloody chronic diarrhea in children. Further multicentric studies may provide adequate data on its prevalence.

Background and Aim: The World Health Organization recommends oral zinc (tablets or syrups) as adjunct therapy with oral rehydration solution (ORS) for acute childhood diarrhea. Mixing zinc with ORS can be an attractive approach for simultaneous provision of these 2 effective interventions. This double-masked randomized controlled trial evaluated the efficacy of ORS containing 40  mg/L elemental zinc per liter (zinc-ORS) in reducing stool weight and duration of diarrhea., Patients and Methods: Five hundred northern Indian children ages 1 to 35 months with diarrhea <7 days' duration were randomized to zinc-ORS or ORS. The primary outcomes were total stool output and time to recovery., Results: The median total stool output was 2.12 g · kg⁻¹ · h⁻¹ (interquartile range [IQR] 0.9-3.76) in the zinc-ORS group compared with 1.78 g · kg⁻¹ · h⁻¹ (IQR 0.83-3.45) in the ORS group. The time to recovery was also similar in the 2 groups (hazard ratio 1.06 [95% confidence interval 0.88-1.27]). In subjects who received zinc-ORS, the median (IQR) zinc intakes were 27 (16-46) mg on day 1, 15 (6-27) mg on day 2, and negligible thereafter., Conclusions: The World Health Organization-recommended daily dose of zinc for diarrhea was not achieved in most children beyond the first day of treatment. This is the likely explanation for the lack of improvement in outcomes from zinc-ORS when compared with ORS alone. Our findings do not support a change from using zinc syrup or dispersible tablets for treatment of acute diarrhea in children.

Despite gains in controlling mortality relating to diarrhoeal disease, the burden of disease remains unacceptably high. To refocus health research to target disease-burden reduction as the goal of research in child health, the Child Health and Nutrition Research Initiative developed a systematic strategy to rank health research options. This priority-setting exercise included listing of 46 competitive research options in diarrhoeal disease and their critical and quantitative appraisal by 10 experts based on five criteria for research that reflect the ability of the research to be translated into interventions and achieved disease-burden reduction. These criteria included the answerability of the research questions; the efficacy and effectiveness of the intervention resulting from the research; the maximal potential for disease-burden reduction of the interventions derived from the research; the affordability, deliverability, and sustainability of the intervention supported by the research; and the overall effect of the research-derived intervention on equity. Experts scored each research option independently to delineate the best investments for diarrhoeal disease control in the developing world to reduce the burden of disease by 2015. Priority scores obtained for health policy and systems research obtained eight of the top 10 rankings in overall scores, indicating that current investments in health research are significantly different from those estimated to be the most effective in reducing the global burden of diarrhoeal disease by 2015.

Background: Rotavirus (RV) is the commonest cause of severe gastroenteritis in young children worldwide. However the natural immune mechanisms controlling and preventing rotavirus disease in humans are not fully understood., Objective: To examine cellular immune responses to whole rotavirus (vaccine strain, 116E) and non-structural protein-4 (116E-NSP4) in children during natural rotavirus-infection., Study Design: Gamma-interferon (IFN-gamma) responses were evaluated by enzyme-linked immunospot assay in peripheral blood mononuclear cells from children with RV (n=26) or non-RV (n=10) gastroenteritis and from RV-exposed adults (n=10). Additionally, IL-4 responses were assessed in 5 of the 10 adults and 6 of 26 RV-infected children., Results: IFN-gamma secreting cells specific to whole RV were detected in 68% of RV-positive children and to NSP4 in 43% of these children between 4 and 30 days of illness onset. IFN-gamma responses were transient and were found higher in RV-exposed adults than in children (P<0.05). Within the RV-positive group, IFN-gamma responses in children with prior RV-exposure were higher than children without prior exposure (P<0.05). The response to whole RV and NSP4 were positively correlated (P<0.01, r(s)=0.66)., Conclusions: Significant IFN-gamma responses to rotavirus candidate vaccine strain 116E were detected in children during natural RV-infection and in RV-exposed adults. Significant IFN-gamma responses to NSP4 were also observed in these study groups.

Background: Rotaviral antigen and RNA have recently been identified in the serum of patients with rotaviral gastroenteritis, but the roles they play in disease remains undetermined., Methods: Rotaviral antigen and RNA were quantified by enzyme-linked immunosorbant assay and by quantitative reverse-transcription polymerase chain reaction in stool and serum specimens from children with rotaviral diarrhea (n=102), children with nonrotaviral diarrhea (n=40), and nondiarrheal control children (n=30)., Results: Rotaviral antigenemia was detected in 64%, 3%, and 0% of the children with rotaviral diarrhea, the children with nonrotaviral diarrhea, and the nondiarrheal control children, respectively. The level of rotaviral antigen in serum was approximately 2x10(2) -fold lower than that in stool, and a moderate correlation was observed between the 2 levels. Rotaviral RNA was detected in 93% of the antigen-positive serum specimens. The median number of RNA copies in serum was approximately 1 x 10(5) -fold lower than that in stool, and no correlation was observed between the 2 levels. Serum levels of both antigen and RNA were inversely associated with baseline titers of rotaviral serum immunoglobulin G (P<.01). Antigenemia was also associated with G1 serotype., Conclusions: Rotaviral antigenemia and viremia were common in children with rotaviral diarrhea, but antigen and RNA levels in serum were substantially lower than those in stool. Antigenemia was associated with infection with G1 strains and with low baseline titers of rotaviral serum antibody.

Objectives: In developed countries, small bowel histology in coeliac disease is a spectrum, ranging from normal with increased intraepithelial lymphocytes to the classic flat mucosa. In developing countries, mild to moderate enteropathies in children with chronic diarrhea and growth failure are assumed to be caused by tropical sprue, persistent infections, or malnutrition with bacterial overgrowth. We report the prevalence and histology of coeliac disease in children with chronic diarrhea at a tertiary referral hospital in North India., Methods: Two hundred fifty-nine children with symptoms indicating coeliac disease attended the All India Institute of Medical Sciences. Histology was graded after a modified Marsh classification. Serum immunoglobulin A anti-endomysial antibodies (AEA) were assayed using indirect immunofluorescence. Subjects with abnormal histology and positive AEA were put on a gluten free diet (GFD). Coeliac disease was diagnosed on small intestinal biopsy changes and a clinical response to a GFD., Results: Severe enteropathies were present in 63 (24%) subjects, and 58 (92%) responded to a GFD. Sixty-six (25%) had moderate histologic changes, 61 responding to a GFD. AEA was positive in 56 of 63 patients with severe and 65 of 66 with moderate enteropathies. Fifty-seven children had mild enteropathies, and 19 of 20 with positive AEA responded clinically to a GFD., Conclusions: Coeliac disease is more common than previously believed. It presents a variable histology, and diagnoses may be missed or delayed if based only on severe enteropathies. Serology is a useful adjunct to diagnosis, and diagnostic criteria need to be developed appropriately for coeliac disease in developing countries despite limited facilities.

Objectives: The authors evaluated the effect of zinc treatment as an adjunct to oral rehydration therapy on stool output and diarrheal duration in children with acute noncholera diarrhea with dehydration., Methods: This double-blind, randomized, controlled trial was conducted at two urban hospitals in New Delhi. A total of 287 dehydrated male patients, ages 3 to 36 months, with diarrhea for 12 months) and weight for height (65%-80% or >80% National Centre for Health Statistics median). Participants in the zinc group received 15 mg (12 months) elemental zinc daily in three divided doses for 14 days. The main outcome measures were stool output and diarrheal duration., Results: Zinc treatment reduced total stool output (ratio of geometric means, 0.69; 95% confidence interval [CI]: 0.48, 0.99) and stool output per day of diarrhea (ratio of geometric means, 0.76; 95% CI: 0.59, 0.98). The risk of continued diarrhea was lower (relative hazards, 0.76; 95% CI: 0.59, 0.97) and the proportion of diarrheal episodes lasting >or= 5 days (odds ratio, 0.49; 95% CI: 0.25, 0.97) or >or= 7 days was less (odds ratio, 0.09; 95% CI: 0.01, 0.73) in the zinc group., Conclusions: This study demonstrates a beneficial effect of zinc administered during acute diarrhea on stool output, diarrheal duration, and proportion of episodes lasting more than 7 days. The effects are large enough to merit routine use of zinc during acute diarrhea in developing countries.

While celiac disease is estimated to affect about 1% of the world's population, it is thought to be uncommon not only in India but in Asia also. There is a lack of studies on the prevalence of celiac disease from Asian nations. The aim of the present study was to estimate the prevalence of celiac disease in the community. In a cross sectional study, we estimated the prevalence of celiac disease in urban and rural populations in the National Capital Region, Delhi, India. A structured questionnaire was administered, by door-to-door visits, to all participants to collect socio-demographic data and to screen for features of celiac disease, namely chronic or recurrent diarrhea and, anemia. In children, additional features, namely short stature (linear height below 5th percentile for age) and failure to thrive/gain weight were also used. All respondents who were screen positive (any one of above) and 10% of screen negative individuals were called for serological testing, which is anti-tissue transglutaminase antibody. All serologically positive respondents were invited to undergo further evaluation including endoscopic biopsy. Celiac disease was diagnosed on the basis of a positive serology, the presence of villous atrophy and/or response to gluten free diet. Among 12 573 contacted, 10 488 (83.4%) (50.6% male) agreed to participate. Based on screening, 5622 (53.6%) participants were screen positive. Of all those screen positive, 2167 (38.5%) agreed for serological testing; additionally 712 (14%) negatives were also tested. The overall sero-prevalence of celiac disease was 1.44% (95% confidence interval [CI] 1.22 1.69) and the overall prevalence of celiac disease was 1.04% (95% CI 0.85 1.25). The prevalence of celiac disease in this north Indian community is 1 in 96. Celiac disease is more common than is recognized in India. [ABSTRACT FROM AUTHOR]