Correspondence withdrew from the Gaza Strip, Israel still has a large number of pumping wells that surround the northern and eastern boundaries of the Gaza Strip. These wells trap the lateral flow of groundwater that is supposed to naturally enter the Gaza coastal aquifer. Without these wells, more fresh water would be available for Palestinians in the Gaza coastal aquifer and less seawater intrusion would take place. According to a 2009 World Bank report,2 the Israeli on-going closure of the Gaza Strip hinders the normal water operations—eg, by preventing the ability to drill new wells. These wells would be drilled in areas of the coastal aquifer that are not affected by seawater intrusion. Moreover, much of the water of Wadi Gaza (that crosses the Gaza Strip) is fully used by Israel and does not reach the Gaza Strip. According to the Oslo II interim agreement (Article 40) signed between the Palestinians and Israelis in September, 1995, Israel has to provide 5 million cubic metres of water to the Gaza Strip annually, but this has never been implemented. All these factors lead to a higher reliance on the Gaza coastal aquifer to cover water demand and thus result in a higher pumping stress. The gap in water consumption between Palestinians and Israelis that we mentioned was also documented by the Israeli Information Center for Human Rights in the Occupied Territories.3 In our opinion, it is not possible to appreciate the water situation in the Gaza Strip without understanding the political aspects. These aspects are not “gratuitous political innuendo”, but facts. We declare that we have no competing interests. *Reem Sarsak, Mohammad N Almasri [email protected] Environmental Health Department, UN Relief and Works Agency for Palestine Refugees in the Near East, Nablus, West Bank, occupied Palestinian territory (RS); and College of Engineering, An-Najah National University, Nablus, West Bank, occupied Palestinian territory (MNA) 1208 1 2 3 Sarsak R, Almasri MN. Seawater intrusion into the coastal aquifer in the Gaza Strip: a computer study. Lancet 2013; 382: S32. World Bank. West Bank and Gaza—Assessment of restrictions on Palestinian water sector development. Report No. 47657-GZ. http:// siteresources.worldbank.org/ INTWESTBANKGAZA/Resources/ WaterRestrictionsReportJuly2009.pdf (accessed March 17, 2014). B’Tselem. Water crisis. Discriminatory water supply. http://www.btselem.org/water/ consumption_gap (accessed March 17, 2014). allows limited amounts (0·2 g/kg) to be absorbed in young infants, and the saturability of the sublingual glucose carriers prevents the use of high doses.2,3 Rebound hypoglycaemia can be prevented by repeated sublingual administration.2,3 Future studies should evaluate the feasibility and dosage for sublingual dextrose gel or sugar in neonates. We declare that we have no competing interests. Sublingual sugar for infant hypoglycaemia *Hubert Barennes, Merlin L Willcox, Bertrand Graz, Eric Pussard We congratulate Deborah Harris and colleagues (Dec 21, p 2077)1 for demonstrating the efficacy and safety of dextrose gel as a non-invasive treatment for neonatal hypoglycaemia in at-risk babies. Dextrose gel reduces the admission rate to intensive care units, the need for intravenous dextrose infusion, and formula feeding.1 There is a crucial need for such treatments in resource-poor settings where hypoglycaemia is common and underdiagnosed.1 However, cost (US$2 per baby) and availability of dextrose gel formulation might be limitations. In Mali and Burkina Faso, we assessed use of sugar powder to correct hypoglycaemia in children, administered by the sublingual route,2,3 which is rich in carrier-mediated transport systems for glucose.4 We showed that sublingual absorption was faster than the oral route.2,3 An increase of 2 mmol/L in blood glucose concentration was achieved in 10 min, and 64% of children had a blood glucose concentration of more than 3·3 mmol/L after 20 min.3 We question the use of carboxymethylcellulose as a placebo, as it has been suspected to slow down glucose absorption and could explain failure in the placebo group.5 Finally, we agree with Harris and colleagues that the administration of low doses of sugar prevents rebound hypoglycaemia. The sublingual surface Agence Nationale de recherche sur le VIH et hépatite, Institut Pasteur, Phnom Penh, Cambodia (HB); Department of Primary Health Care, University of Oxford, Oxford, UK (MLW); University of Lausanne, Lausanne, Switzerland (BG); and Génétique Moléculaire, Pharmacogénétique et Hormonologie CHU Bicêtre, Kremlin Bicêtre, Paris, France (EP) [email protected] 1 2 3 4 5 Harris DL, Weston PJ, Signal M, Chase JG, Harding JE. Dextrose gel for neonatal hypoglycaemia (the Sugar Babies Study): a randomised, double-blind, placebocontrolled trial. Lancet 2013; 382: 2077–83. Barennes H, Valea I, Nagot N, Van de Perre P, Pussard E. Sublingual sugar administration as an alternative to intravenous dextrose administration to correct hypoglycemia among children in the tropics. Pediatrics 2005; 116: e648–53. Graz B, Dicko M, Willcox ML, et al. Sublingual sugar for hypoglycaemia in children with severe malaria: a pilot clinical study. Malar J 2008; 7: 242. Oyama Y, Yamano H, Ohkuma A, Ogawara K, Higaki K, Kimura T. Carrier-mediated transport systems for glucose in mucosal cells of the human oral cavity. J Pharm Sci 1999; 88: 830–34. Ou S, Kwok K, Li Y, Fu L. In vitro study of possible role of dietary fiber in lowering postprandial serum glucose. J Agric Food Chem 2001; 49: 1026–29. Authors’ reply We thank Hubert Barennes and colleagues for their interest in our study 1 of 40% dextrose gel administered via the buccal mucosa for treatment of neonatal hypoglycaemia, and note their work2,3 on administration of sublingual sugar in hypoglycaemic children. We would expect dextrose—the physiological D-isomer of glucose—to be absorbed more rapidly than the dissacharide sucrose, which must be split into its component glucose and fructose before changes in blood glucose can www.thelancet.com Vol 383 April 5, 2014
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