Gelephu CCRH reported around 25 cases of infantile beriberi annually in the past six years

Nima | Gelephu

A study conducted by group of health officials at the paediatric department in Gelephu Central Regional Referral Hospital (CRRH) recommends providing thiamine supplements to pregnant and breastfeeding mothers in the country.

This is to ensure infants below six months, depending exclusively on breastfeeding for micronutrient requirements, receive adequate thiamine, without which they become vulnerable to infantile beriberi, a thiamine deficiency disorder (TDD).

The researchers say that children below six months are extremely vulnerable to infantile beriberi since they are already in a state of sub-clinical thiamine deficiency due to poor dietary intake of thiamine by their mothers.

“These children would initially suffer from a mild respiratory (cough, common cold, fever) or gastrointestinal disease (vomiting, diarrhoea) and rapidly deteriorate into heart failure, seizures and coma in the next few days.”

Despite the best available care, almost 80 percent of the children would succumb to the illness in about a week due to multi-organ failure without thiamine treatment that involves providing thiamine for the treatment, according to the study.

“The mortality rates for the children with infantile beriberi have dropped from approximately 80 percent to 6 percent after the paediatric department started treating these children with thiamine.”

Gelephu CRRH recorded over 50 deaths for infantile beriberi in the past six years: 10.9 deaths per 1000 live births against the national average of 23.8 per 1,000 births.

One of the research members, Doctor Dinesh Pradhan, said that the national infant mortality rate could be brought down significantly if there is a national guideline on the diagnosis and management of infantile beriberi, including nationwide supplementation of thiamine for all pregnant and breastfeeding mothers.

“Currently, the treatment for infants with infantile beriberi using thiamine is practiced at a department level – children with the symptoms are brought to health centres and paediatricians consulted late sometimes,” he said.

He added that the vitamin supplementation in the form of micronutrient powder (MNP) launched in September 2019 as part of the government’s accelerating mother and child health program (AHCP) included only infants aged six months till two years.

“The problem lies in children below six months, where most of the deaths are; that part is missing. We are proposing that all pregnant and breastfeeding mothers should get extra thiamine,” said Dr Dinesh Pradhan.

He added that the level of thiamine in mothers drops during pregnancy and breastfeeding, and thiamine is not present in the mothers’ diets because of poor dietary habits.

“Babies have only mother’s milk as a source of thiamine, maternal dietary intake should be improved. The vitamins given to pregnant mothers have very negligible amounts of thiamine,” said Dr Dinesh Pradhan.

The study recommends giving more thiamine to pregnant mothers so that by the time of delivery, both mothers and children would have adequate thiamine levels. This kind of program is practiced in Laos, Cambodia, Thailand, and Myanmar.

Supplementing thiamine in pregnant and breastfeeding mothers could potentially eliminate this disease in infants in the country, evident from the reduction in mortality in the paediatric department of Gelephu CRRH. With policy changes, it would translate to a reduction in infant mortality rate on a national level, according to the research team.

The study observed that most of the deaths in infants up to one year were because of infantile beriberi. Some were brought to the hospital late, while some die on the way from a peripheral health centre. This problem exists for the lack of the thiamine supplement program, according to the official.

The team’s plan to present the findings at the first national micronutrient conference is on hold, as the conference was postponed because of the lockdown in January this year.

Gelephu CCRH reported around 25 cases of infantile beriberi annually in the past six years. Without thiamine treatment 80 out of 100 would have died, according to Dr Dinesh Pradhan.

“But, now we know that it had a huge impact. The mortality rate was brought down to single digits from around 80 percent before 2018. Providing thiamine routinely would save lives. There are babies dying on the way to the hospital,” he said.

Over 15,000 deliveries are reported in a year, according to the annual health bulletin. It is expected to cost around Ngultrum 5 million per year for the government if nationwide thiamine supplementation program for pregnant and breastfeeding mothers begins as recommended.

How health  professionals came  to know the condition?

According to Dr Dinesh Pradhan, infantile beriberi was considered an infection called meningoencephalitis before the paediatric department of Jigme Dorji Wangchuck National Referral Hospital made a breakthrough with thiamine in August 2018, and shared their preliminary findings with paediatricians in the country.

Meningoencephalitis in infants first came into focus when pentavalent vaccine, a vaccine that contains five antigens (diphtheria, pertussis, tetanus, and hepatitis B, and Haemophilus influenza type b) was launched in the country in September 2009.”

“Bhutan was among the first countries to introduce the vaccine and it was a big public health achievement for a developing country,” the Doctor said.

Shortly after the introduction of pentavalent vaccine, a total of 8 infants died. The vaccination was suspended for six months in October 2009. The investigations concluded the vaccine as safe and the vaccine was reintroduced only in 2011 after a year of extended suspension.

“We thought it was an infection called meningoencephalitis before, which it was not. Meningoencephalitis turned out to be the wrong diagnosis. It was actually infantile beriberi,” said Dr Dinesh Pradhan.

“That is what our study shows. The poor outcome of approximately 80 percent mortality before 2018 was brought down to 5-6 percent with the simple addition of thiamine to the treatment, proving that the actual diagnosis was infantile beriberi,” said the official.

The study was recently presented at the prestigious annual conference of the Royal College of Paediatrics and Child Health (RCPCH), of the United Kingdom.

Edited by Jigme Wangchuk