SKIN RASHES IN CHILDREN AND PALM KERNEL OIL

SKIN RASHES IN CHILDREN AND PALM KERNEL OIL (Manyanga)
AT BAMENDA, CAMEROON, July – August 2007

ABSTRACT
An operational research was carried out in July and August 2007 in Bamenda involving 251children attending Infant Welfare Clinics (IWC) in two health facilities in order to elucidate the relationship between the skin rashes in children and menyanga (palm kernel oil). The magnitude of use of menyanga was 81.3%. The prevalence rate of skin rashes at IWC was 71.31%. The statistical relationship between the skin rashes in children and menyanga was very significant: (83.8%) of the 204 of children who rub menyanga had skin rashes and (95.5%) of the 179 children with rashes rubbed manyanga. Candida albicans was identified by culture on Sabouraud dextrose agar of specimens from skin rashes; samples of menyanga from the factory, the vendor at the market, and the mothers; Candida albicans was positive in both black and white menyanga. This research has shown that Candida albicans effectively grows in palm kernel oil. This research has thus established that there is a causal relationship between skin rashes in children and menyanga. The skin rashes observed on children at infant welfare clinic (IWC) are caused by Candida albicans present in the menyanga that mothers rub on their children. It is therefore imperative that an intensive health education should be given to the population to dissipate their ignorance and to stop the use of menyanga. Stopping the rubbing of menyanga (palm kernel oil) on children is guaranteeing the right of children to better health care and better health status.


INTRODUCTION
In Bamenda, of recent, mothers are using menyanga (palm kernel oil) as rubbing oil for their children to prevent and treat skin rashes (jeti-jeti). There are two types of menyanga: white menyanga obtained by compressing palm kernels in factories; and black menyanga obtained traditionally by frying the palm kernels in a pot until the oil is extracted. They are all crude palm kernel oil.

The uses of menyanga as conceived by the community are: apply on the body of the child to prevent and treat skin rashes (jeti-jeti), rub and give the child to eat to treat high fever and convulsion; eat to treat abdominal pain; it is a good and cheap rubbing oil that smoothens the body of the child; it is used to make bread sandwich, to prepare traditional medicine concussions and to oil the head hair.

Ugbogu et al (2006) demonstrated that, in vitro, palm kernel oil samples showed noticeable inhibitory effect on Staphylococcus aureus and Streptococcus sp. while no significant inhibitory effect was observed on Candida albicans…… and concluded that palm kernel oil can be used as an ointment for the body to minimize infections by microorganisms and this may justify its usage amongst the populace in some parts of Nigeria.

Ekwenye et al (2005) concluded that the traditionally extracted palm kernel oil , Mmanyanga, a black viscous non-drying liquid, derived from mixed varieties of Elaeis guineens (Jacquin) showed minimal antimicrobial activity against Escherichia coli compared to Pseudomonas aeruginosa, Staphylococcus aureus, Candida albicans and Asperigillus niger with no sign of inhibition.

In a previous experience, the author observed that the bottle of menyanga of one of his patients had a whitish grey layer on top of the menyanga, which was suggestive of the presence of fungi. The skin rashes responded to an antifungal treatment while stopping the menyanga.

In the daily consultations at St Mary Soledad Health Centre, it was noticed that there was an increasing number of children aged up to eighteen months consulting for skin rashes despite widespread rubbing of menyanga on the bodies of children. The rashes in these children responded to antifungal treatment while withholding the menyanga.

The hypothesis that there is a relationship between the skin rashes in children and menyanga was consequently made.

A research was thus carried out in children, attending Infant Welfare Clinics (IWC) at St Mary Soledad Health Centre Alakuma – Mankon and the Sub Divisional Medical Centre (SDMC) Nkwen in Bamenda in July and August 2007, in order to elucidate this hypothesis.

The goal of the research was to improve the health status of children at IWC and in the community; and to initiate a reflection on the amelioration of the quality of palm kernel oil (menyanga) as rubbing oil for children if the hypothesis of a causal relationship between skin rashes in children and menyanga was established.

The objectives of the research were to determine the magnitude of the use of menyanga in children attending IWC; determine the prevalence of skin rashes in the children; identify the germ in the skin rash; identify the germ in menyanga collected from mothers, the market, and the factory; and establish the relationship between skin rashes and menyanga.


METHOD
The case definition of skin rash was any skin eruption or change of colour from the normal skin.
A questionnaire was used to collect data from mothers during the IWC; their children were examined and pictures of some of the severe cases rashes taken. The pictures of cases of rashes in children were taken only for research purpose and in order to highlight the gravity of the lesions; the identification of the children was masked. Menyanga was collected from some mothers. Vendors of menyanga at the markets were visited and samples of menyanga bought. Some menyanga factories were visited and samples of menyanga purchased.

In the laboratory of St Mary Soledad Health Centre, specimens from skin rashes and samples of menyanga from mothers, vendors at the market, and factory were seeded on Sabouraud dextrose agar in medium plates and incubated at 37°C for 48 hours. Both black and white menyanga were cultured. The identity of C. albicans was confirmed using the germ tube test (Monica Cheesbrough). Cases of skin rashes were treated with anti fungal creams while stopping the use of menyanga. Epi Info was used to analyse the data collected (CDC).


RESULTS
The number of children studied was 251 from 18 July 2007 to 02 August 2007 distributed according to age groups as follows: less than 1 month - 5 (1.99%), 1 - 9 months - 211 (84.06%), and 10 - 18 months - 35 (13.94%).

Children from all health areas in Bamenda town were represented. The magnitude of the use of menyanga in children attending IWC was 81.3% of 251 children. The types menyanga used were black 10 (4.9%), white 180 (88.2%), white and black 14 (6.9%); 47 (18.70%) of the children did not use menyanga.

Rubbing of menyanga by age group was distributed thus less 1 month - 1 (20%) out of 5 children, 1 - 9 month - 173 (82%) out of 211 children of the age group, and 10 - 18 month - 30 (85.7%) out of 36 children.

The prevalence rate of skin rashes at IWC was 71.31%. The skin rashes were mostly located on the genitals 89.94%, buttocks 61.50%, face 27.93%, and neck 23.46%; with the genitals being 96.9% amongst the menyanga users. The prevalence rates according to age groups were less than 1 month - 0.00%, 1-9 month - 162 (76.78%), 10-18 month - 17 (48.57%).
The statistical relationship between skin rashes in children and rubbing of menyanga was significant (chi2 = 80, at p<.05); 83.8% of the 204 of children who rub menyanga have skin rashes and 95.5% of the 179 children with rashes rub manyanga. None of the children investigated had fever. Candida albicans was identified from skin rashes; the menyanga from the factory, the vendor at the market, and the mothers; Candida albicans was positive in both black and white menyanga.

DISCUSSION
The utilisation rate of menyanga (crude palm kernel oil) of 81% of the 251 children attending the IWC is very high; this may be attributed to the intense advertisement in favour of menyanga as the appropriate rubbing oil for children. The use of menyanga may be a nationwide phenomenon, or even worldwide phenomenon in palm kernel oil producing areas.

The prevalence rate of skin rashes of 71% in children attending IWC is a cause for concern because a comprehensive health care should be offered to these children. The mothers and even health workers ignore all rashes occurring on the body of the children on whom menyanga is being applied because of the ill-conceived notion that menyanga is treating the rashes.

Statistical analysis of the data of this research shows that there is a significant relationship between skin rashes and the use of menyanga (Chi square > 80.1 at p<0.05); 83.8% of children who rub menyanga have skin rashes; and 95.5% of children with rashes rub manyanga. The prevalence rate of skin rashes in children attributable to menyanga may be much higher in the community.

The most affected areas are the genitals (89.9%) and the buttocks (61.5%) corresponding with the declarations of most mothers that they apply the menyanga on the genitals and buttocks to prevent rashes (jeti-jeti).

The germ identified from skin rashes; samples of menyanga from the factory, the market, and the mothers, was Candida albicans. This research has shown that Candida albicans effectively grows in palm kernel oil. The quantity of Candida albicans in the menyanga seems to be proportional to the longevity of the menyanga.
Ugbogu et el observed no significant inhibitory effect on Candida albicans by different palm kernel oil samples; consequently Candida albicans can grow in palm kernel oil.

The skin rashes observed in this research is a fungal dermatitis due to the Candida albicans in menyanga, presenting clinically as: brown, red, or intensely red and shiny patches of various sizes on the body of the child; sometimes ulceration of lesions occur especially at the genitals.

Despite the popular and widespread use of palm kernel oil as rubbing oil for children and the fact that palm kernel oil does not inhibited the growth of Candida albicans, such a clinical based research on ‘skin rashes in children and palm kernel oil’, may not have yet been done to assess the clinical consequence of palm kernel oil on the skin of children.

It also follows that studies may not have yet been done to determine the presence of Candida albicans in the menyanga (palm kernel oil) that mothers are rubbing on their children although the people of Eastern region of Nigeria have been using palm kernel oil as skin ointment since prehistoric times (Ugbogu et al 2006), and despite the evidence that palm kernel oil does not inhibit the growth of Candida albicans (Ekwenye et al 2005; Ugbogu et al 2006)
Although palm kernel oil and coconut oil have the same amount of lauric acid 48% of weight that is antibacterial and antiviral, the contents of fatty acids specific for the killing of Candida albicans in palm kernel oil are Caprylic acid (C8) 4.2% and Capric acid (C10) 3.7% body weight; while in coconut oil, Caprylic acid (C8) is 7.3% and Capric acid (C10) 6.6%, (Pantzaris et al; Eric Armstrong; Mary G. Enig et al 1999).
The quantity of capric acid, specific against Candida albicans, in palm kernel oil (menyanga) may not be adequate enough to inhibit in vivo the growth of Candida albicans, although Gudmundur Bergsson et el, showed that in vitro both capric and lauric acids are active in killing C. albicans and may therefore be useful for treatment of infections caused by that pathogen or others that infect the skin and mucosa.
Eric Armstrong states that coconut oil also contains caprylic acid (8%) which kills fungus (for example, athlete's foot fungus) and yeast (Candida, as well as vaginal yeast). Zdeňka Řiháková, et al, (2002) showed that monoacylglycerols made from coconut oil have antifungal activity.
It was realised during this research that the population expressed the need for a natural vegetable oil to rub on their children; the most appropriate oil would be the coconut oil that simultaneously has antibacterial, antiviral, antifungal and antiprotozoal properties (Ian Blair Hamilton el al, Mary G. Enig et al, Eric Armstrong).
In view of the fact that coconut is grown in Cameroon, the production of coconut oil will go a long way to improve the health of children in particular and the wellbeing of the population in alleviating poverty.
The level of contamination of palm kernel oil (menyanga) by Candida albicans is still to be determined but since Candida albicans grew in all the samples of palm kernel oil from factory, market, and mothers, it may be that as fungi the spores of Candida albicans are floating in the environment.
Palm kernel oil should be reserved for its traditional use for the manufacturing of soaps, soap powders, detergents and high-tech confectionery and cosmetic industries, until the quality of menyanga is ameliorated and approved to be used as rubbing oil.
In the course of this research the following observations were made:

• Many cases of umbilical hernia were observed in children rubbing menyanga; the Candida albicans in menyanga infects the umbilicus and prevent its proper healing, thus contributing to occurrence of the umbilical hernia.


• Laboratory results show high quantity of yeast cells in the stool of children who rub menyanga.


• Menyanga is promoted as good rubbing oil for children during some infant welfare clinics.


• The napkin dressing of the baby is most often very thick and air tide: after a thick coat of menyanga or vaseline (petroleum jelly), follow a thick cotton napkin, an impermeable plastic napkin, another plastic layer of pants, the dress of the baby, and a pullover. This dressing produces high temperature in the genital area and buttocks of the child creating the appropriate moist and warm conditions for the growth of Candida albicans.


• During IWC and even routine consultation not much attention is attached to the examination of the genitals and buttocks, hidden under thick and tight napkins.


• Vaseline (petroleum jelly) is applied as a coat on the genitals and buttocks of the children so that urine should run off the skin easily; this may lead to vaseline burning and desquamation of the skin.


• Most mothers declare they rub babies less than one month with olive oil; some use pork fat.


• The use of menyanga is usually promoted at home by friends and grand mothers.

All the good qualities attached to menyanga by the community are not valid. Menyanga does not prevent or treat skin rashes (jeti-jeti), does not treat high fever and convulsion, does not treat belly bite (abdominal pain) in children, and will produce more dandruff on the scalp; on the contrary menyanga causes or aggravates all the important roles falsely attributed to it by the population because it is an oil and it contains fungi - Candida albicans.

It is therefore imperative that an intensive health education should be given to the population to dissipate their ignorance on menyanga; and to stop the use of menyanga.

CONCLUSIONS
This research has proven that there is a causal relationship between skin rashes in children and palm kernel oil (menyanga). The skin rashes observed in children at infant welfare clinic (IWC) are caused by Candida albicans present in the menyanga that mothers rub on their children; mothers should therefore stop rubbing children with menyanga.

The results of this operational research and the pictures of skin rashes presented in this report will facilitate social mobilisation for behaviour change to stop the use of manyanga since it can only be achieved by providing facts to the population.

During IWC and routine consultations of children their napkins should be taken off; their genitals and buttocks examined, and any rashes observed should be treated appropriately.

Health authorities should develop a national guide for the napkin dressing of children and a policy on oils for the rubbing of children, including the management of the umbilicus of the baby; health personnel should consequently be trained to implement them.

Following the meticulous review of literature on natural oils in the course of this operational research, I will recommend the coconut oil as natural oil for the rubbing of children because it is at the same time antibacterial, antiviral, antifungal and antiprotozoal.

For the moment mothers should use the pure odourless petroleum jelly in order to avoid allergy from other sophisticated oils. The mother should apply the oil lightly on the child as she would apply on her own body in order not to block the sweat ducts that have a respiratory function for the skin; the dressing of the child should be weather appropriate and loose fitting, so that the baby does not get overheated.

The author hopes that the results of this research will enhance actions towards the amelioration of the quality of the crude menyanga, involving all partners- producers of palm kernel oil, health providers, and parents.

The health facility is the health mirror of the community and should therefore work towards the improvement of the health status of the population in that community; it is within this context that, this research was carried out to solve the health problem of skin rashes in children due to the rubbing of Candida albicans infested menyanga on children, observed at St Mary Health Centre. Health facilities should from their patients have a telescopic view on their communities in order to carry out preventive activities on diseases diagnosed at the health facility such as this operational research on ‘skin rashes in children and menyanga’.

Stopping the rubbing of menyanga (palm kernel oil) on children is guaranteeing the right of children to better health care and to better health status.

The results of this research will serve as baseline data for the evaluation of the progress in the improvement of health status of children in the domain of skin rashes attributed to menyanga and other oils.

This operational research was carried out with the personal resources of the author, and laboratory support from St Mary Soledad Health Centre.

Please acknowledge the utilisation of the results of this research; the author is available for supportive contributions to the development of policy and guides on napkin dressing of children.

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Acknowledgements
I sincerely thank Mother Purification, the Matron of St Mary Soledad Health Centre, for her encouragement, laboratory facilities offered for the research, and the production of social mobilisation posters.

I thank Sister Margarita and the IWC team; the laboratory team: Fofie Zeshung Laura, Foyah Nicoline Bih and Ndze Henry; Dr Nji Christopher of St Mary Soledad Health Centre; Dr Princely Shouasha and his IWC team of the Sub Divisional Medical Centre Nkwen; all the nursing staff of St Mary Soledad for the operational implementation of the fight against the use of menyanga.

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