Knowledge, Attitudes, and Practices of Exclusive Breastfeeding at Dhulikhel Hospital, Nepal

Abstract

Background: Frontoethmoidal encephalomeningocele (FEEM) is a neural tube defect (NTD) characterized by a persistent foramen cecum and herniation of cranial contents through an anterior skull defect. The mycotoxin fumonisin, a contaminant of maize, has been implicated in the pathogenesis of FEEM as it disrupts sphingolipid metabolism and decreases folate bioavailability. Studies have demonstrated that exposure to fumonisin in experimental animals induces FEEM. A high prevalence of FEEM has been observed at the rural Casa Colibri Clinic (CCC) in Nuevo Eden, Guatemala. Fumonisin exposure in women of childbearing age is a suspected contributory risk factor due to the high consumption of maize. Methods: This investigation involved a review of the FEEM cases that have presented to the CCC, as well as a toxicological analysis of fumonisin exposure in women of childbearing age residing in villages surrounding the CCC. To determine the exposure level and accumulation of fumonisin breakdown products, urine and finger-stick blood samples were collected and analyzed using high performance liquid chromatography. Findings: Eight cases of FEEM (3 males: 5 females) were evaluated. The average age at presentation was 6.3 years. Three sub-types of frontoethmoidal encephalocele were observed as follows: 5 nasoethmoidal; 1 nasofrontal; and 2 naso-orbital. Fumonisin exposure was quantified in 104 women from two FEEM villages and four non-FEEM villages. Analysis of the exposure data demonstrated an average fumonisin intake of 6.33 mg/kg (range ¼ 0.0 mg/kg e 118.81 mg/kg) (World Health Organization provisional maximum tolerable daily intake (PMTDI) is 2.0 mg/kg). When comparing FEEM and non-FEEM villages significant differences in mean fumonisin exposure were revealed, with a mean fumonisin exposure of 14.62 mg/kg in FEEM villages (95% confidence interval ¼ 5.63 mg/kg e 23.61 mg/kg), and 3.12 mg/kg in non-FEEM villages (95% confidence interval ¼ 1.79 mg/kg e 4.5 mg/kg) (p-value ¼ 0.015). Interpretation: Fumonisin exposure levels in villages with known cases of FEEM were significantly higher than those of non-FEEM villages. Of the villages sampled, four of six had mean fumonisin exposure levels that exceeded the WHO PMTDI. Due to the startling number of cases of FEEM in this rural region, exposure to fumonisin has been implicated as a contributory risk factor.