Sister-chromatid exchange (SCE) and cell proliferation in lymphocytes from infected and non-infected children with severe protein calorie malnutrition (PCM)

The frequency of sister-chromatid exchanges (SCE) and the rate of cell proliferation were evaluated through differential staining of sister chromatids in mitogen-stimulated cultured lymphocytes sampled from five well-nourished children, from seven severely malnourished children infected with bacterium, and from 10 severely malnourished children following treatment for infection with antimicrobial drugs 2 weeks before blood sampling. The replication indices at 48 h of culture were higher in both groups of malnourished children than in the well-nourished children, indicating either a faster response to PHA and/or a shorter cell cycle in lymphocytes of these patients. The average frequency of SCE per mitosis was also significantly higher than in the control group. The mitotic index was similar in the three groups of children. The lack of significant difference in response between the two groups of malnourished children suggests that the effects observed at the cytogenetic level are caused by severe malnutrition per se, and not by any associated infection.

Nutritional influences on linear growth: a general review

The first section of this paper reviews what is known about the roles of specific nutrients in the general linear growth faltering that occurs in developing countries. Those reviewed are energy, protein, zinc, iron, copper, iodine and vitamin A. For none of these nutrients was there clear, consistent evidence that supplementation with the nutrient benefited linear growth. Rather, interventions with each specific nutrient had a positive effect on length gain in some studies, while in others these affected only weight gain or had no effect. Reasons for these conflicting results are suggested, including the strong probability that growth is limited by multiple, simultaneous deficiencies in many populations. This point is illustrated with data from the Nutrition Collaborative Research Support Program (CRSP) and other reports. Most interventions with single nutrients have been tested on children older than the age when linear growth faltering is most rapid, that is, within a few months of birth. Possible reasons why growth stunting begins so early in life are presented, but these are mostly hypothetical because of the paucity of information on this topic.

Introduction. Causes and mechanisms of linear growth retardation (stunting)

A workshop held 6 years ago examined the epidemiology and natural history of stunting in Third World children. Although this condition is extremely common and is usually regarded as a manifestation of chronic malnutrition, in fact almost nothing is known about its causes and mechanisms in nutritional, biochemical, or metabolic terms. The objective of the present workshop is to fill these gaps and to identify, if possible, critical mechanisms by which environmental factors might affect linear growth. An example is described of a longitudinal study which attempted to examine, in more detail than has been done before, what is happening to children during the process of becoming stunted.

Effects of macrobiotic diets on linear growth in infants and children until 10 years of age

In order to study the relationship between diet and growth, we have assessed growth patterns in children 0-10 years old on macrobiotic diets. A cross-sectional anthropometric study (0-8 years old children, n = 243) indicated that deviation from the reference growth curve occurred during the weaning period. Between 2 and 4 years there was a partial catch-up for weight and arm circumference but not for height. As a next step, a mixed-longitudinal study was performed in 4-18-month-old macrobiotic infants (n = 53) and matched omnivorous controls (n = 57). For a period of 6 months, data on growth and dietary intake were collected. The data on linear growth supported the findings on growth stagnation observed cross-sectionally. Linear growth was associated with the protein content of the diet, but not with energy intake. On the basis of our findings nutritional modifications to the macrobiotic diet (addition of fat and fish) were recommended for all macrobiotic families. Six months later (two years after the first cross-sectional data collection) the anthropometric study was repeated in the same cohort (n = 194). This follow-up study revealed that children from families which, since the initial study, had increased the consumption of fatty fish, dairy products, or both, had grown in height more rapidly than the remaining children (P < 0.05). Since no indications were found for the presence of adverse social circumstances, infectious diseases or other confounding factors, our data clearly demonstrate that linear growth retardation in children on macrobiotic diets is caused by nutritional deficiencies alone.

Onset and evolution of stunting in infants and children. Examples from the Human Nutrition Collaborative Research Support Program. Kenya and Egypt studies

The etiology of the early onset of stunting is diverse among populations of varying biological, environmental and cultural circumstances. This is exemplified within the Nutrition CRSP project, which took place in three different populations and ecological conditions. Within each study area a different mix and varying proportions of causative factors were identified. At least in Kenya, and probably in Mexico, the problem has its antecedents in prepregnancy and pregnancy. Powerful determinants of the infants' size at birth and during the first 6 months of life are maternal size upon entry into pregnancy, and weight and fat gain during pregnancy and lactation. In all three countries a low pregnancy weight gain was observed. Notably in Kenya, where the energy intake of the mother decreases progressively throughout pregnancy, not only do mothers gain only half as much as European or North American women, but they even lose weight and fat in the last month of pregnancy, and some mothers gain no weight or lose weight during the whole of pregnancy. Mothers in Kenya start lactation with relatively poor fat stores. Although their energy intake increases somewhat during lactation, preliminary estimates suggest that these increases may be insufficient to maintain their bodily integrity, to carry out their normal tasks of daily living, and to produce a sufficient amount of milk for optimal infant growth. In addition to an energy deficit, diet quality is a problem, particularly in Kenya and Mexico and less so in Egypt. Intakes of animal products and animal protein are very low. Zinc and iron intakes are not only low, but the bioavailability of these nutrients is poor because of the high phytate, fiber and tea content of the diet. Also vitamin B12 intake is extremely low, and at least mild-to-moderate iodine deficiency (IDD) is present in Kenya. The above micronutrients have been demonstrated to affect the linear growth of the Kenyan children, even after confounding factors have been controlled. The early use of supplemental feeding in Kenya is a double-edged sword. On the one hand, there is a slight increase in febrile illness and possible displacement of breast milk intake in the supplemented infants, although mothers do not decrease breast feeding frequency and duration. On the other hand, even the modest amounts of available zinc and B12 in supplemental foods appear to have a positive effect on linear growth.(ABSTRACT TRUNCATED AT 400 WORDS)

Adequacy of dietary mineral supply for human bone growth and mineralisation

The evidence on the relationship between dietary mineral supply and bone development in children has been extensively reviewed. Data from children and primates suggest that overt deficiencies of Ca, P and Zn are likely to produce rickets and growth retardation, while the effects of Mg deficiency on human bone are unknown. The manifestations of marginal deficiencies are little understood. The biological needs for Ca, P, Mg and Zn in childhood have been calculated based on mineral deposition rates, using published values for the mineral content of the human body, and on obligatory endogenous losses. As a rough guide, the estimated biological requirements for the Ca, P, Mg and Zn can be taken as 200, 100, 4 and 1 mg/d respectively. A comparison of measured daily intakes of children in developing countries with biological requirements was made. This revealed that P and Mg intakes were many times higher than estimated needs. Ca intakes at all ages were found to be close to the biological requirement for children in many Third World societies, before any allowance for possible poor absorption. Zn intakes approach estimated needs in breast-fed infants, particularly during weaning, but are 4-5 times higher in older children. Poor absorption from phytate-rich diets could affect Zn supply. Supplementation studies indicate that raising Zn intakes can increase height gains in certain vulnerable groups, such as infant and adolescent boys. In conclusion, the evidence suggests that inadequate dietary intakes of Ca and Zn may contribute to linear growth retardation in children of developing countries but more research is needed.

Intake from an energy-dense porridge liquefied by amylase of germinated wheat: a controlled trial in severely malnourished children during convalescence from diarrhoea

OBJECTIVE

To evaluate the role of an energy-dense diet liquefied with amylase-rich flour from germinated wheat (ARF) in increasing the energy intake in severely malnourished infants and young children and its acceptability to mothers.

DESIGN

A randomized controlled clinical trial with two sets of controls.

SETTING

Nutrition rehabilitation unit of a large diarrhoea treatment centre where mothers stay with their very severely malnourished children.

SUBJECTS

78 severely malnourished children aged 5-18 months just recovered from diarrhoea.

INTERVENTION

Children were randomly assigned to receive either an energy-dense porridge made liquid by adding ARF (test diet) or an unaltered thick porridge of similar energy density (control 1 diet), or the porridge made liquid with addition of water to have the same viscosity as the test diet but of lower energy (control 2 diet), in four major meals a day for 5 days and intake was measured; breast-milk was measured by test weighing. Children also received an additional three milk-cereal meals a day.

RESULTS

The mean energy intake (95% CI, P value for difference between test and control) was 385 (339-431), 289 (251-327, P < 0.005), and 255 (222-289, P < 0.001) kJ/kg.d respectively. Feeding test diet was not associated with significant adverse effects e.g. on diarrhoea, vomiting, breast-milk intake, and was well accepted by mothers.

CONCLUSION

The results suggest that use of an energy-dense ARF-treated liquefied porridge increases calorie intake by very severely malnourished children during convalescence from diarrhoea, and that it does not produce any adverse effect.

A longitudinal study of dental caries in the primary teeth of children who suffered from infant malnutrition

A prospective, four-year longitudinal study of 209 Peruvian children was conducted to evaluate the effect of a single malnutrition episode occurring at infancy (i.e., < 1 year of age) on dental caries in the primary teeth. Children were recruited into the study at age 6-11 months after they had suffered from a malnutrition episode and were thus classified by anthropometry as either: (1) Normal; (2) Wasted (low weight for height); (3) Stunted (low height for age); or (4) Stunted and Wasted (S and W). Eruption of the primary teeth was significantly delayed in all malnourished children; however, the effect of stunting--that is, retarded linear growth--was more pronounced and lasted longer than that of wasting or acute malnutrition (i.e., 2.5 vs. 1.5 years, respectively). By age 4 years, children from group 4 (S and W) showed a significantly higher caries experience in the primary teeth than did those in any of the other three groups. In summary, this longitudinal study has confirmed previous studies in animals and indirect epidemiological evidence which had suggested a cause-effect relationship between early malnutrition and increased dental caries.

[Early severe malnutrition and psychomotor development. Effects of a rehabilitation program]

This study evaluates the psychomotor development of 228 undernourished infants submitted to an integral rehabilitation program in Nutritional Recovery Centers. At admission these children present a moderate retardation of their developmental quotient: mean 0.59 +/- 0.17, improving significantly to mean 0.79 +/- 0.4 (p < 0.001) after an average period of 178.2 +/- 63.9 days of intervention. As regards areas of development, rehabilitation only demonstrates a significant change in coordination and language, not so in the social and motor areas. Those children presenting the most severe developmental delays are also those who obtain the greater benefits from this integral rehabilitation program.

Fetal nutrition and cardiovascular disease in adult life

Babies who are small at birth or during infancy have increased rates of cardiovascular disease and non-insulin-dependent diabetes as adults. Some of these babies have low birthweights, some are small in relation to the size of their placentas, some are thin at birth, and some are short at birth and fail to gain weight in infancy. This paper shows how fetal undernutrition at different stages of gestation can be linked to these patterns of early growth. The fetuses' adaptations to undernutrition are associated with changes in the concentrations of fetal and placental hormones. Persisting changes in the levels of hormone secretion, and in the sensitivity of tissues to them, may link fetal undernutrition with abnormal structure, function, and disease in adult life.

Non-organic failure to thrive: growth failure secondary to feeding-skills disorder

In this article the authors propose that non-organic failure to thrive (FTT) is a growth failure secondary to feeding-skills disorder, and that this disorder is neurophysiological in origin. The symptoms of feeding-skills disorder were suggestive of an oral sensorimotor impairment which is usually present from birth or early life, but tends to go unrecognized. Data from 38 infants with non-organic and 22 infants with organic FTT demonstrated that early clinical symptoms of feeding impairment, and observed maternal and infant feeding behaviours and interactions, were similar for both groups, suggesting a need to redefine the term 'non-organic'.

The Kingston Project. III. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: morbidity and growth

In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65% of the sample were found to have additional illnesses at enrollment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic, treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group.

[Oral rice-based rehydration solution (SRO), alternative of SRO of WHO in acute diarrhea in malnourished patients]

BACKGROUND

Although malnutrition is frequently associated with diarrhea, most oral rehydration solutions have been tested in well-nourished children. The study tests efficacy of rice, a traditional treatment for diarrhea in Madagascar.

PATIENTS AND METHODS

150 severely malnourished children, aged 6 months to 3 years, took part in this randomized trial. All the children were given oral rehydration solution, (100 ml/kg) in the first 6 hours. The first group (68 children) was given a solution containing glucose, (20 g/l). The second group (82 children) was given a solution containing rice powder (50 g/l). Treatment was then continued according to WHO recommendations, including feeding after rehydration (mixture of milk, oil and sugar).

RESULTS

The age, weight, height, duration of diarrhea before admission, degree of dehydration and pathogens in stools of the two groups were comparable on admission. Only 2 patients were withdrawn from the trial. The percentage of death was the same in both groups: 16% of those given glucose and 15% of those given rice-based rehydration solution. The weight gains were similar in both groups; the duration of diarrhea was 89 +/- 6 hours in the glucose-fed groups and 68 +/- 4 hours for those given the rice-based rehydration solution (p < 0.02).

CONCLUSIONS

Both glucose and rice-based rehydration solutions are equally effective for rehydrating severely malnourished children with acute diarrhea. The rice-based rehydration solution also reduces the duration of diarrhea.

[Radiologic changes of the hand and wrist in young children with hypotrophy and perinatal encephalopathy]

Disordered growth of the bones by length was found in infants with chronic disorders of nutrition and perinatal encephalopathy. Roentgenogrammetry helped make a more objective assessment of bone changes as against visual methods. The authors distinguish the x-ray characteristics most typical of such patients.

Initiation of food supplements and stopping of breast-feeding as determinants of weanling shigellosis

The association between the period elapsed since weaning and the risk of shigellosis was assessed between 1 November 1987 and 30 November 1989 for a cohort of 1085 Bangladeshi children aged < 3 years. The children were followed for 1 month after exposure to Shigella spp. in their residential neighbourhoods, and the 268 who developed microbiologically confirmed (n = 118) or clinically presumptive (n = 150) shigellosis were compared with the 817 control children who did not develop either syndrome. No increase in risk was noted among breast-fed infants who received food supplements within the previous 3 months compared with those who had received supplements for longer (adjusted odds ratio (OR) = 1.2; 95% confidence interval (CI) = 0.4-3.0). However, compared with breast-fed children, non-breast-fed children had an increased risk (adjusted OR = 2.0; 95% CI = 1.3-2.9; P < 0.001), which was largely attributable to a substantially increased risk in the 3 months after stopping breast-feeding (adjusted OR = 6.6; 95% CI = 2.9-14.6; P < 0.001). The early post-cessation risk was equivalent for confirmed and presumptive shigellosis, but was particularly pronounced among the severely malnourished (adjusted OR = 10.2; 95% CI = 3.1-33.3; P < 0.001). This complex temporal pattern of risk highlights the need for precise definitions of weaning to facilitate identification of children at high risk for invasive diarrhoeal syndromes.

Clinical aspects of acute vs persistent diarrhea in Ho Chi Minh City, Vietnam

A retrospective clinical study of acute and persistent diarrhea in children younger than three years of age was conducted for 12 months (October 1989 to September 1990) in a Pediatric Hospital in Ho Chi Minh City, South Vietnam. Most of the 3833 episodes of diarrhea identified were of short duration, with 77.7% lasting only 1-7 days. Only 5.3% of episodes lasted more than 14 days. Episodes of longer duration were associated with young age (0-5 months). Bloody stool was present in more than 40% of persistent episodes. Severe malnutrition was associated with persistent episodes that lasted 14-21 days (33%) or more than 22 days (59%). It is important that all patients with diarrhea have appropriate dietary management in addition to fluid therapy, and that future analysis examines etiologic factors to determine the optimal treatment of bloody diarrhea.

Persistent diarrhoea: factors affecting absorption and clinical prognosis during management with a rice-based diet

Twenty-six persistent diarrhoea patients aged 4 to 18 months were treated with a diet prepared with rice powder, soya oil, glucose, egg white and water. Absorption of macronutrients was estimated in a 72 h balance study and clinical response was examined during one week of dietary treatment. Nutrient absorption was compared with that of 25 healthy age-matched controls treated with the same diet. Twenty-one patients (81%) recovered from diarrhoea within seven days. Absorption of nutrients was significantly reduced among the persistent diarrhoea patients. More malnourished patients had a significantly reduced absorption of nutrients except carbohydrate and an increased severity and longer duration of diarrhoea. Total gut transit time had significant association with nutrient absorption in the persistent diarrhoea patients. The period of recovery negatively correlated with coefficient of absorption and positively with initial stool weight. Failure to recover was associated with severity of diarrhoea and systemic infection. The study indicates that nutrient absorption is significantly reduced in patients with persistent diarrhoea and nutritional status, and that initial purging rate and intestinal hurry are significantly related to the prognosis and nutrient absorption.

Host factors and acute lower respiratory infections in pre-school children

The relationship between certain host-related variables and the short-term outcome of hospitalization for severe acute lower respiratory infections was studied prospectively in a cohort of 103 pre-school Nigerian children. The respective mean ages of those with bronchiolitis and croup were 3.2 months and 18.9 months while the corresponding M:F ratios were 2.5:1 and 1:1. It was highly significant that all the eight children that died were malnourished (P less than 0.01). Furthermore, malnourished subjects with pleural effusion, in whom bacteraemia was common, stayed longest in hospital while subjects with bronchiolitis and croup, in whom malnutrition was distinctly uncommon, had the shortest duration of admission. Multiple microbial identifications and bacteraemia were common in malnourished subjects with ALRI. Mortality was significantly higher in older children (P less than 0.05), but sex, immunization/breast-feeding status and co-existing measles or pertussis, were individually neither related to the admission outcome nor the duration. It is concluded that malnutrition is a strong predictor of ALRI-related death in the pre-school child. The significance of bacteraemia and multiple microbial identifications in malnourished children, and the ARI-control implications of the study are discussed.

The influence of nutrition on neonatal respiratory muscle function

Advances in neonatal intensive care have resulted in increasing survival of very small babies, who often require prolonged periods of mechanical ventilation. These babies have limited nutritional reserves, and are difficult to feed by either parenteral or enteral routes. This review article discusses the interaction between undernutrition and respiratory muscle function in the critically ill preterm baby.

Evaluation of urinary tract infection in malnourished black children

Urinary tract infection (UTI) is a well recognized complication in malnourished children. The need to investigate these patients for underlying renal pathology has not been clearly defined. Seventy-five children with malnutrition were evaluated for UTI by culture of urine obtained suprapubically prior to antibiotic therapy. All patients with UTI were investigated with renal ultrasonography, intravenous pyelography (IVP) and voiding cystourethrography (VCU). Haemoglobin, white cell count, serum urea, creatinine and electrolytes were determined in all the children. The mean age of the children was 15.5 months (range 3-60 months). UTI was diagnosed in 26 (34.7%), of whom 21 (81%) were boys. The overall prevalence of UTI in those with kwashiorkor/marasmic kwashiorkor was 42%. Escherichia coli was the organism most commonly cultured (84.6%). Renal sonography, IVP and VCU were normal in all infected cases and vesicoureteric reflux was not detected in any. This study confirms the high prevalence of UTI in malnourished children. As no anatomical abnormalities were demonstrated in the patients with UTI, imaging of the renal tract other than real sonography does not appear to be indicated in the malnourished child in a first episode of UTI with normal renal function.

Hypokalaemic paralysis in malnourished children

Six malnourished children presenting with acute flaccid paralysis caused by hypokalaemia are described. Their ages ranged from 6 to 36 months. The extent of paralysis varied from neck flop to quadriparesis. Two cases had respiratory paralysis requiring ventilatory support for 48-72 hours. All were successfully treated with potassium supplementation. Hypokalaemia should be considered in the differential diagnosis of acute flaccid paralysis in malnourished children.