New concepts on nutritional management of severe malnutrition: the role of protein

Milk products in the dietary management of childhood undernutrition - a historical review

The present narrative review outlines the use of milk products in infant and young child feeding from early history until today and illustrates how research findings and technical innovations contributed to the evolution of milk-based strategies to combat undernutrition in children below the age of 5 years. From the onset of social welfare initiatives, dairy products were provided by maternal and child health services to improve nutrition. During the last century, a number of aetiological theories on oedematous forms of undernutrition were developed and until the 1970s the dogma of protein deficiency was dominant. Thereafter, a multifactorial concept gained acceptance and protein quality was emphasised. During the last decades, research findings demonstrated that the inclusion of dairy products in the management of severe acute malnutrition is most effective. For children suffering from moderate acute malnutrition the evidence for the superiority of milk-based diets is less clear. There is an unmet need for evaluating locally produced milk-free alternatives at lower cost, especially in countries that rely on imported dairy products. New strategies for the dietary management of childhood undernutrition need to be developed on the basis of research findings, current child feeding practices, socio-cultural conditions and local resources. Exclusive and continued breast-feeding supported by community-based nutrition programmes using optimal combinations of locally available complementary foods should be compared with milk product-based interventions.

Malnutrition causing neonatal dyslipidemia

Lipid abnormalities in children have become more common in recent decades. This trend is related to the increase in overweight and obesity. The 2002 National Health and Nutrition Examination Survey reported that the percentage of risk for overweight and overweight in children aged > 6 years is 31%, higher than the previous surveys. Serum lipids tend to increase quickly up to 6 months of age and reach values very close to adult values by age 2. As suggested by the American Heart Association, serum lipid values for children and adolescents (2-19 years old) are considered abnormal when total cholesterol is >200 mg/dL, high-density lipoprotein is <35 mg/dL, low-density lipoprotein is >130 mg/dL, and triglycerides are >150 mg/dL. Dyslipidemia can be found in patients with malnutrition, a severe condition that needs prompt nutrition intervention. This report describes a case of malnutrition causing severe dyslipidemia in a newborn. Primary dyslipidemia was excluded by the presence of primary malnutrition, normal response to a postheparin lipoprotein lipase activity test, a favorable clinical course after nutrition intervention, and relatives' blood lipid levels close to normal that did not indicate familial dyslipidemia. The child was fed fat-free milk formula supplemented with medium-chain triglycerides and had adequate weight gain with a decrease in blood lipids. Subsequently the formula was changed to regular milk-based formula, and the child maintained adequate growth rate. Although blood lipids never returned to normal values for age and sex, they were lower than before treatment.

Treatment of severe malnutrition in children: experience in implementing the World Health Organization guidelines in Turbo, Colombia

OBJECTIVE

To evaluate the implementation of the World Health Organization guidelines for the treatment of children with severe acute malnutrition in a class I hospital.

PATIENTS AND METHODS

Descriptive and prospective study of 335 children under the age of 6, admitted between 2001 and 2005 for severe acute malnutrition (83%) and moderate acute malnutrition associated with illness (17%). The care of the children was provided by clinicians and medical staff trained under World Health Organization guidelines.

RESULTS

Kwashiorkor was a common result in children with severe acute malnutrition (60.8%); 58% were younger than 1 year old. Complications upon admission were diarrhea (68.4%) and anemia (51.1%), and the most common complication during hospital stay was sepsis (9%). Overall, 61.7% attained -1 standard deviation of weight for height after an average stay of 3 weeks in the hospital; 5.1% were sent to tertiary care hospitals. Overall, mortality during the 5 years was 5.7%, with sepsis the most common cause. In the first year, the mortality rate was 8.7%; it decreased to 4.0% in the last year. The mortality rate was significantly higher in children with edema. Children with moderate acute malnutrition had similar complications and mortality when compared with children with severe acute malnutrition (5.3%).

CONCLUSIONS

Once the World Health Organization guidelines were implemented, low mortality rates were achieved in children with severe acute malnutrition in class I hospitals.

The use of whey or skimmed milk powder in fortified blended foods for vulnerable groups

Fortified blended foods (FBF), especially corn soy blend, are used as food aid for millions of people worldwide, especially malnourished individuals and vulnerable groups. There are only a few studies evaluating the effect of FBF on health outcomes, and the potential negative effect of antinutrients has not been examined. Different lines of evidence suggest that dairy proteins have beneficial effects on vulnerable groups. Here we review the evidence on the effects of adding whey or skimmed milk powder to FBF used for malnourished infants and young children or people living with HIV or AIDS. Adding whey or skimmed milk powder to FBF improves the protein quality, allowing a reduction in total amount of protein, which could have potential metabolic advantages. It also allows for a reduced content of soy and cereal and thereby a reduction of potential antinutrients. It is possible that adding milk could improve weight gain, linear growth, and recovery from malnutrition, but this needs to be confirmed. Bioactive factors in whey might have beneficial effects on the immune system and muscle synthesis, but evidence from vulnerable groups is lacking. Milk proteins will improve flavor, which is important for acceptability in vulnerable groups. The most important disadvantage is a considerable increase in price. Adding 10-15% milk powder would double the price, which means that such a product should be used only in well-defined vulnerable groups with special needs. The potential beneficial effects of adding milk protein and lack of evidence in vulnerable groups call for randomized intervention studies.

Metabolic bioenergy homeostatic disruption: a cause of anorexia nervosa

We believe anorexia nervosa is the result of a disruption in bioenergy homeostasis induced by lipid dysregulation. This disruption has two major determinants: (1) a biological predisposition to primary multihormonal disharmony linked to post-pubertal growth and development; and (2) an acquired abnormal lipid-induced loop operation precipitated by inappropriate diet. We present a step-by-step model describing the cascade of disorders that culminates in anorexia nervosa: defective digestion and absorption of essential fatty acids; diversion of lipids from adipose cells into bloodstream; defective carbohydrate and lipid metabolism which modifies the blood brain barrier; neuroendocrine membrane alteration causing severe endocrine impairment; changes in the negative feedback mechanism which escalate the body's use of bioenergy; derangement of the appetite center which causes a constant sensation of satiety; replacement of the correct body image with the premorbid one that encourages poor judgement concerning food intake and self-support. The loop-like nature of this mechanism perpetuates the disease.