INTRODUCTION: Small intestinal bacterial overgrowth refers to the proliferation of abnormal numbers and types of microorganisms in the lumen of the proximal bowel. Bacterial overgrowth has been implicated as a possible factor in prolonging some episodes of infantile gastroenteritis. This thesis examines 2 different aspects of the duodenal flora of infants with gastroenteritis, and has therefore been divided into 2 separate studies. CARBOHYDRATE STUDY: Objective: To test the hypothesis that during a diarrhoeal episode the presence of malabsorbed carbohydrate in the duodenal lumen acts as a factor promoting bacterial proliferation. Patients and methods: Infants admitted to the rehydration ward with acute gastroenteritis were selected for study if they fulfilled various criteria in terms of age, nutritional status, previous diarrhoeal episodes and antibiotic administration. They were admitted to the research ward. Weights were measured and if they had severe diarrhoea (≥ 30g/kg) were included in the study. Twenty patients were entered into the study. On admission into the trial the first duodenal intubation was done to measure the duodenal flora quantitatively and qualitatively. Thereafter the patients were assigned on an alternate basis to one of 2 groups. One group (carbohydrate-containing group) received a soy-based infant formula containing carbohydrates (Isomil, Ross). The other group (carbohydrate-free group) received an identical milk but from which all carbohydrate had been omitted (Ross CHO-free). To these infants carbohydrate was given intravenously. Stool output was measured daily. After 3 days of the respective diets the duodenal flora was re-examined. Results: Longitudinal analysis of the duodenal flora of the carbohydrate-containing group showed a small decrease in the number of bacterial isolates and in their magnitude. The duodenal flora of the carbohydrate-free group was virtually unchanged. Comparing the duodenal bacteriology of the groups the only significant difference was that the number of isolates and the magnitude of Haemophilus was greater in the carbohydrate-free group- (p < 0.05). The diarrhoea resolved in 5 patients: 2 in the carbohydrate-containing and 3 in the carbohydrate-free group. Conclusions: The lack of difference in the response of the duodenal flora between the two groups studied suggests that the presence of carbohydrates in the lumen is not important in encouraging the growth of bacteria in that site. The possible causes for an increase in Haemophilus numbers in the carbohydrate-free group are discussed. BOWEL COCKTAIL STUDY: Objective: Small intestinal bacterial overgrowth has been proposed as a cause of progression of acute diarrhoeal episodes to persistence. The "bowel cocktail", a combination of oral gentamicin and cholestyramine, has been shown to be effective in terminating episodes of persistent diarrhoea. It has been postulated to work by eradicating small intestinal bacterial overgrowth, but its mode of action is not known. The objective of this study was to examine the changes in the duodenal flora associated with administration of the bowel cocktail in order to elucidate its possible mechanism or mechanisms of action. Patients and methods: The study group comprised 15 patients. Fourteen were infants from the carbohydrate study who had ongoing diarrhoea. The remaining infant (the "late entry") was selected from the rehydration ward. Severe diarrhoea, as defined by a stool output equal to or greater than 30g/kg/day, was a pre-requisite for entry into the study. The investigation involved 2 duodenal intubations for microbiological analysis of the duodenal fluid. After the first intubation (which was the second intubation for the 14 infants who had been in the carbohydrate study) the bowel cocktail was administered. This comprised a 3-day course of oral gentamicin and 5 days of oral cholestyramine. Forty-eight hours after the start of therapy the duodenal bacteriology was repeated. The patient management was the same as during the carbohydrate study and the feeding regimen of the infants was not altered. The study ended immediately after completion of the bowel cocktail course. Results: Administration of the bowel cocktail was associated with a decreased stool output in all patients. Bacteriological analysis of the duodenal flora after this treatment showed a statistically significant decrease in the total microbial count, the aerobic microbial fraction and the Enterobacteriaceal fraction. On analysis of the bacterial genera a significant decrease was noted in Neisseria, Haemophilus, and aerobic lactobacilli. Analysis of individual patients' duodenal fluid bacteriology in conjunction with the stool bacteriology results before administration of the bowel cocktail often provided an explanation as to the possible aetiology of the diarrhoea and its resolution by therapy. Conclusions: Small intestinal bacterial overgrowth, in the accepted sense of a luxuriant flora teeming with faecal organisms, did not appear to be a feature of the patients in this study. The total bacterial count was only slightly above the accepted upper limit of normal. Although the decrease in the number of Enterobacteriaceae could possibly be interpreted in the context of bacterial overgrowth, a study of the individual patients' duodenal flora shows that these microorganisms were more likely to be acting as specific enteric pathogens. It is concluded that small intestinal bacterial overgrowth, as currently defined, is not an important cause of persistent diarrhoea. The efficacy of the bowel cocktail is more likely to reside in its ability to eradicate specific enteric pathogens. The author ends by questioning the validity of the whole concept of small intestinal bacterial overgrowth.

published_or_final_version / Microbiology / Doctoral / Doctor of Philosophy

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2009. / Härtill 4 uppsatser.

Thesis (M.Sc. (Nutrition))--Mahidol University, 1979.

CoordenaÃÃo de AperfeÃoamento de Pessoal de NÃvel Superior / Maternal self-efficacy in preventing childhood diarrhea is a modifiable variable, which measures the maternal confidence to adopt the necessary precautions to prevent illness in children, essential for the promotion of health. Considering that nurses should promote and support maternal self-efficacy in preventing childhood diarrhea, educational technologies have emerged in order to favor this practice. The objective was to analyze maternal self-efficacy to prevent childhood diarrhea before and after a combined educational intervention (educational video and dialogue wheel). It was a quasi-experimental study, before and after type, with single group composed by 58 mothers of children aged from zero to five years, developed in two health units belonging to the Regional Secretariat III and V, respectively. Data collection was performed from July to October 2014 in three stages: first, an interview was conducted with the mothers, individually, when it was applied Maternal Self-efficacy Scale for Prevention of Infant Diarrhea and the sociodemographic and diarrhea clinical form; the second stage corresponded to the educational group intervention with the application of educational video and the participation of women in dialogue wheel mediated by the researcher. The third stage corresponded to the telephone follow-up and the implementation of Maternal Self-efficacy Scale for Prevention of Infant Diarrhea and the reduced form of childhood diarrhea occurrence research every fortnight for two months. Data were analyzed using the Statistical Package for Social Sciences version 20.0. The study was approved by the Ethics Committee of the Federal University of CearÃ. Most participants were female from 20-29 years of age (56.9%), with partner (65.5%), with more than eight years of education (62.1%), housewives (74.5%), with monthly income of up to two minimum wages (91.4%). There was statistical significance between the sociodemographic variables health and the means of EAPDI scores in the four moments of follow-up (p <0.05): age, marital status, maternal education, occupation, per capita income, number of residents in the household , number of children and child sex. For sanitary variables: type of home, surface, garbage disposal, flies in the house, water source, origin of the water that the child drinks, treatment, soap near the tap, type of toilet, type of sewage, existence of refrigerator and presence of animal at home. There was no statistical significance relationship between the occurrence of diarrhea and self-efficacy, but it was observed the increase in self-efficacy scores and the reduction of cases of diarrhea over the follow-up times, indicating that the combined educational intervention influenced in reducing the chance of occurrence of childhood diarrhea. It is concluded that the combined educational intervention increased maternal self-efficacy in preventing childhood diarrhea and decreased the chances of occurrence childhood diarrhea in mothers of the study. The use of educational video combined with the guidelines of nurses in dialogue wheel can and should be done consistently for health education activities by health professionals, especially nurses. / A autoeficÃcia materna em prevenir a diarreia infantil à uma variÃvel modificÃvel, que mede a confianÃa materna em adotar os cuidados necessÃrios para prevenir a doenÃa na crianÃa, sendo essencial para a promoÃÃo da saÃde. Considerando que o enfermeiro deve promover e apoiar a autoeficÃcia materna na prevenÃÃo da diarreia infantil, as tecnologias educativas surgiram como favorecedoras dessa prÃtica. Objetivou-se analisar a autoeficÃcia materna para prevenir diarreia infantil antes apÃs uma intervenÃÃo educativa combinada (vÃdeo educativo e roda de conversa). Tratou-se de um estudo quase experimental, do tipo antes e depois, com grupo Ãnico composto por 58 mÃes de crianÃas com idade de zero a cinco anos, desenvolvido em duas unidades de saÃde pertencentes à Secretaria Regional III e V, respectivamente. A coleta de dados foi realizada, no perÃodo de julho a outubro de 2014, em trÃs etapas: na primeira, foi realizada uma entrevista com as mÃes, individualmente, onde se aplicou a Escala de AutoeficÃcia Materna para PrevenÃÃo da Diarreia Infantil e o formulÃrio sociodemogrÃfico e clÃnico da diarreia; a segunda etapa correspondeu à intervenÃÃo educativa grupal com a aplicaÃÃo do vÃdeo educativo e a participaÃÃo das mulheres na roda de conversa mediada pela pesquisadora. A terceira etapa correspondeu ao acompanhamento telefÃnico com a aplicaÃÃo da Escala de AutoeficÃcia Materna para PrevenÃÃo da Diarreia Infantil e o formulÃrio reduzido de investigaÃÃo da ocorrÃncia da diarreia infantil quinzenalmente por dois meses. Os dados foram analisados no Statistical Package for the Social Sciences, versÃo 20.0. O estudo foi aprovado pelo Comità de Ãtica em Pesquisa da Universidade Federal do CearÃ. Predominaram mulheres com 20 a 29 anos de idade (56,9%), com parceiro (65,5%), com mais de oito anos de estudos (62,1%), donas do lar (74,5%), com renda mensal de atà dois salÃrios mÃnimos (91,4%). Verificou-se significÃncia estatÃstica entre as variÃveis sociodemogrÃficas, sanitÃrias e as mÃdias dos escores da EAPDI nos quatro momentos de acompanhamento (p< 0,05): idade, estado civil, escolaridade materna, ocupaÃÃo, renda per capita, nÃmero de residentes no domicÃlio, nÃmero de filhos e sexo da crianÃa. Quanto Ãs variÃveis sanitÃrias: tipo de casa, tipo de piso, destino do lixo, moscas na casa, origem da Ãgua, procedÃncia da Ãgua que a crianÃa ingere, tratamento, sabÃo prÃximo das torneiras, tipo de sanitÃrio, tipo de esgoto, existÃncia de refrigerador e presenÃa de animal no domicÃlio. Observou-se, a partir do primeiro mÃs de acompanhamento, efeito positivo da intervenÃÃo combinada na ocorrÃncia da diarreia infantil e na autoeficÃcia materna, visto que houve reduÃÃo do percentil de crianÃas com diarreia e, tambÃm, elevaÃÃo na classificaÃÃo da autoeficÃcia materna de baixa para moderada e elevada. Conclui-se que a intervenÃÃo educativa combinada elevou a autoeficÃcia materna em prevenir a diarreia infantil, assim como diminuiu as chances ocorrÃncia da diarreia infantil nas mÃes do estudo. A utilizaÃÃo do vÃdeo educativo aliado Ãs orientaÃÃes dos enfermeiros em roda de conversa pode e deve ser realizada constantemente durante as atividades de educaÃÃo em saÃde pelos profissionais de saÃde, em especial o enfermeiro.

CoordenaÃÃo de AperfeiÃoamento de Pessoal de NÃvel Superior / Conselho Nacional de Desenvolvimento CientÃfico e TecnolÃgico / A confianÃa das mÃes em relaÃÃo à capacidade para cuidar de suas crianÃas à relevante para a promoÃÃo da saÃde das mesmas. Objetivou-se construir uma escala para mensurar a autoeficÃcia materna em prevenir a diarreia infantil, elaborar seus itens e suas dimensÃes, avaliar as propriedades psicomÃtricas de validade e de confiabilidade do instrumento. Tratou-se de um estudo metodolÃgico e de um estudo de desenvolvimento, adotando-se o polo teÃrico, empÃrico e analÃtico para a construÃÃo de escalas, propostos por Pasquali (1997). No polo teÃrico, identificou-se e se aprofundou o construto de interesse prevenÃÃo da diarreia infantil, para tanto se realizou um levantamento bibliogrÃfico, utilizando os descritores âcrianÃaâ, âprevenÃÃo e controleâ, âdiarreiaâ nas bases de dados PubMed, CINAHL, Cochrane e LILACS. A sÃntese de 82 estudos selecionados norteou a operacionalizaÃÃo da primeira versÃo da escala, com 35 itens, e a identificaÃÃo de quatro domÃnios: prÃticas alimentares, ambiente domÃstico, comportamento materno e higiene da crianÃa/infantil. Procedeu-se à anÃlise teÃrica dos 35 itens, submetendo-os à avaliaÃÃo de sete juÃzes, considerados experts na Ãrea do construto, de 30 mÃes, que realizaram a anÃlise semÃntica, e de 31 mÃes, que participaram do prÃ-teste da escala. Realizados os cÃlculos do Ãndice de Validade de ConteÃdo â IVC, e as alteraÃÃes, sugeridas pelos participantes do polo teÃrico, obteve-se o instrumento-piloto composto por 25 itens. No polo empÃrico, a amostra foi de 448 mÃes de crianÃas menores de 5 anos, cadastradas em um dos seis Centros de SaÃde da FamÃlia no qual o estudo foi executado. Efetivou-se a coleta de dados de novembro de 2009 a fevereiro de 2010. Utilizou-se, alÃm do instrumento-piloto da escala com 25 itens, um formulÃrio abordando dados sociodemogrÃficos e dados relacionados à saÃde da crianÃa. No polo analÃtico, encontram-se a validade de construto e de critÃrio, o alfa de Cronbach e o Coeficiente de CorrelaÃÃo Intraclasse â CCIC. A validade de construto, atravÃs da anÃlise fatorial, indicou a necessidade de exclusÃo do item sete e a existÃncia de dois fatores/domÃnios (higiene da famÃlia, com 15 itens, e prÃticas alimentares/gerais, com 9 itens) na Escala de AutoeficÃcia Materna para PrevenÃÃo da Diarreia Infantil â EAPDI. Na validade de construto, procedeu-se ainda a testagem de hipÃteses por comparaÃÃo dos grupos contrastados. Nessa anÃlise, observou-se a correlaÃÃo negativa entre os escores mais elevados da autoeficÃcia materna em prevenir a diarreia infantil e a ocorrÃncia anterior de diarreia na crianÃa (p=0,001), assim como a associaÃÃo entre os escores mais elevados de autoeficÃcia, com mÃes que possuem mais idade (p=0,018). A validade de critÃrio, utilizando-se a validade preditiva, revelou que nÃveis elevados de autoeficÃcia materna configuram-se em fator protetor para diarreia infantil, de acordo com a especificidade e Valor Preditivo Negativo. O alfa de Cronbach da EAPDI foi de 0,84, indicando alta consistÃncia interna. O CCIC, na anÃlise da estabilidade teste-reteste, foi de 0,45, demonstrando a capacidade de aplicaÃÃo da EAPDI mesmo com o passar do tempo. Concluiu-se neste estudo que a escala à confiÃvel, vÃlida e capaz de avaliar a autoeficÃcia materna para a prevenÃÃo da diarreia infantil. / Motherâs confidence in their ability to provide good care to their children has proven to be relevant when it comes to maternal health promotion. This dissertation aims to construct a scale in order to measure maternal self-efficacy for preventing infantile diarrhea, by creating its items and dimensions, as well as evaluating the instrumentâs psychometric aspects (validity and reliability). The following is both a research on methodology and development, having the model proposed by Pasquali on scale elaboration (1997) as our theoretical landmark. In the pre-empirical part, we carefully examined infantile diarrhea prevention as our construct of interest. The bibliographical survey searched for the keywords âchildrenâ, âprevention and controlâ, âdiarrheaâ on the PubMed, CINAHL, Cochrane and LILACS database. The first version of the scale was led by the synthesis of 82 selected papers. It had 35 items and also presented four domains: alimentary habits, domestic environment, mother behavior and child hygiene. The 35 items were evaluated by 30 mothers (who performed the semantic analysis), by 31 other mothers who participated in the scale pre-test and also by seven experts in the construct field. After calculating the Content Validity Index (CVI) and making the proper alterations suggested by the mentioned participators, the pilot test was elaborated, containing itself 25 items. In the empirical part of this paper, the selected sample was formed by 448 mothers of less than 5 years old children. Those women were all registered on one of the six Family Health Centers in which the research took place. Data collection was performed from November of 2009 to February of 2010. A questionnaire on socio-demographic elements and child health aspects was used along with the pilot test. The analytical work involved the construct validity, the criterion validity, Cronbachâs alpha and Intraclass Correlation Coeficient (ICC). Construct validity, through the factor analysis, has indicated the need for exclusion of the item seven and has also shown the existence of two factors/domains (family hygiene, formed by 15 items; and alimentary/general habits, with 9 items) in the Maternal Self-Efficacy for Infantile Diarrhea Prevention Scale (MSIDPS). Regarding the construct validity, hypotheses were tested by contrasting groups comparison. A negative correlation has been observed between the higher maternal self-efficacy for infantile diarrhea prevention scores and the previous occurrence of diarrhea in the child (p=0,001).The higher self-efficacy scores were also associated with older mothers (p=0,018). By using predictive validity, the criterion validity has shown that higher levels of maternal self-efficacy turned out to be a protective factor against infantile diarrhea, according to specificity and to Negative Predictive Value. Cronbachâs alpha of the MSIDPS was 0,84, which indicates high internal consistency. ICC, after test-retest stability analysis, was 0,45, showing the scaleâs applicability throughout time. This dissertation has come to the conclusion that the scale is reliable, valid and capable of evaluating maternal self-efficacy for infantile diarrhea prevention.

Diarrhoeal disease is a major cause of infant mortality in this and other developing countries. The assessment of the degree of dehydration in these children is often based on subjective findings alone. These have been shown to be inaccurate as an assessment of the degree of dehydration. Whole-body impedance (WBI) is a method of measuring total body water which is used to assess body composition. This WBI technology, which operates at a single frequency, has been applied to the assessment of dehydration in children with diarrhoeal disease. The normal range of WBI was determined on a group of normally hydrated children and was found to have a mean of 746 Ω, a standard deviation of 85 Ω and 95 % confidence interval for the mean from 720 Ω to 772 Ω. WBI did not depend on age, mass, height or sex. The WBI of a group of children dehydrated from infantile gastroenteritis was measured both before and after rehydration. The dehydrated group had a mean WBI on admission of 1089 Ω and a standard deviation of 149 Ω with a 95 % confidence interval for the mean from 950 Ω to 1109 Ω. This value was significantly greater than that of the normal group. The WBI of the dehydrated group after rehydration was not significantly different from the normal group. In addition a variable frequency bioimpedance analyser was designed and tested. It was found to have an error of less than 1 % over the frequency range 1 to 100 kHz. The device was evaluated on 11 normal and dehydrated children. Four dehydrated children were tested before and after rehydration and this data was compared to a standard electrical model for WBI. It was found that the model could represent the measured data over this frequency range. The extracellular resistive element of the model was mainly responsible for the changes seen during rehydration, suggesting that dehydration in gastroenteritis is mainly due to fluid loss from the ECF compartment.

A qualitative study was conducted to explore and describe the knowledge and perceptions of parents and caregivers on the causes of diarrhoea among children under five years living in the rural areas of the Eastern Cape Province, South Africa. The aim was to assist in correcting the negative perceptions of the causes of under five child diarrhoea through improved educational interventions. Data were collected through individual, semi-structured and face-to-face interviews from seven participants who were parents and caregivers of under-five children presenting with diarrhoea or admitted for the management of diarrhoea at a specific hospital and thematic analysis was done. The findings revealed that the participants had inadequate knowledge and lacked understanding of diarrhoea and its causes. Participants could not mention all the causes and risk factors associated with diarrhoea. Noteworthy is that the participants’ perceived diarrhoea as a serious condition. The study recommends that the implementation of policies regarding public education and health promotion programmes be targeted at educating parents and caregivers / Health Studies / M.A. (Public Health)

published_or_final_version / Microbiology / Doctoral / Doctor of Philosophy

A qualitative study was conducted to explore and describe the knowledge and perceptions of parents and caregivers on the causes of diarrhoea among children under five years living in the rural areas of the Eastern Cape Province, South Africa. The aim was to assist in correcting the negative perceptions of the causes of under five child diarrhoea through improved educational interventions. Data were collected through individual, semi-structured and face-to-face interviews from seven participants who were parents and caregivers of under-five children presenting with diarrhoea or admitted for the management of diarrhoea at a specific hospital and thematic analysis was done. The findings revealed that the participants had inadequate knowledge and lacked understanding of diarrhoea and its causes. Participants could not mention all the causes and risk factors associated with diarrhoea. Noteworthy is that the participants’ perceived diarrhoea as a serious condition. The study recommends that the implementation of policies regarding public education and health promotion programmes be targeted at educating parents and caregivers / Health Studies / M.A. (Public Health)