Endocrines in protein-energy malnutrition

Oro-facial gangrene (noma/cancrum oris): pathogenetic mechanisms

Cancrum oris (Noma) is a devastating infectious disease which destroys the soft and hard tissues of the oral and para-oral structures. The dehumanizing oro-facial gangrenous lesion affects predominantly children ages 2 to 16 years, particularly in sub-Saharan Africa, where the estimated frequency in some communities varies from 1 to 7 cases per 1000 population. The risk factors are poverty, malnutrition, poor oral hygiene, residential proximity to livestock in unsanitary environments, and infectious diseases, particularly measles and those due to the herpesviridae. Infections and malnutrition impair the immune system, and this is the common denominator for the occurrence of noma. Acute necrotizing gingivitis (ANG) and oral herpetic ulcers are considered the antecedent lesions, and ongoing studies suggest that the rapid progression of these precursor lesions to noma requires infection by a consortium of micro-organisms, with Fusobacterium necrophorum (Fn) and Prevotella intermedia (Pi) as the suspected key players. Additional to production of a growth-stimulating factor for Pi, Fn displays a classic endotoxin, a dermonecrotic toxin, a cytoplasmic toxin, and a hemolysin. Without appropriate treatment, the mortality rate from noma is 70-90%. Survivors suffer the two-fold afflictions of oro-facial mutilation and functional impairment, which require a time-consuming, financially prohibitive surgical reconstruction.

Noma (cancrum oris): questions and answers

Noma (cancrum oris) is an infectious disease which destroys the oro-facial tissues and other neighboring structures in its fulminating course. It affects predominantly children aged 2-16 years in sub-Saharan Africa where the estimated frequency in some communities may vary from one to seven cases per 1000 children. The key risk factors are poverty, malnutrition, poor oral hygiene, deplorable environmental sanitation, close residential proximity to livestock, and infectious diseases, particularly measles. Malnutrition acts synergistically with endemic infections in promoting an immunodeficient state, and noma results from the interaction of general and local factors with a weakened immune system as the common denominator. Acute necrotizing gingivitis (ANG) is considered the antecedent lesion. Current studies suggest that evolution of ANG to noma requires infection by a consortium of microorganisms with Fusobacterium necrophorum and Prevotella intermedia as the suspected key players. Without appropriate treatment, mortality rate is 70-90%. Survivors suffer the two-fold affliction of oro-facial disfigurement and functional impairment. Reconstructive surgery of the resulting deformity is time-consuming and financially prohibitive for the victims who are poor.

Protein energy malnutrition and the nervous system

Protein-energy malnutrition (PEM), a natural ramification of poverty, continues to be a perennial source of concern to a large segment of the world population. The developing nervous system of a child is specially vulnerable to deprivations in nurture. Peripheral nerve and muscle derangements are clinically evident by weakness, hypotonia and hyporeflexia in accordance with severity and duration of PEM. Motor and sensory nerve conduction studies exhibit significant abnormalities and often furnish useful and ominous correlation with grades of PEM. The human sural nerve histology in cases of severe PEM is characterized by persistence of small myelinated fibres, striking failure of internodal elongation and significant segmental demyelination. Young rhesus monkeys are ideal experimental PEM models and they show myopathic EMG changes amenable to rehabilitation. Muscle pathology comprises obliteration of cross-striations, streaming of Z bands, increased interfibrillary spaces, mitochondriomegaly and small-for-age fibres. Radioisotope assays reveal anomalous incorporation into various nerve and muscle constituents. Central nervous system, specially the neuropsychological functions are affected in a lasting manner. Learning deficits, behavioural problems and manual indexterity are most obtrusive features.

Nutritional resilience in a hostile environment: positive deviance in child nutrition

The term "positive deviance" applies to the study of children who demonstrate above-average growth in impoverished environments. Favorable values on known malnutrition correlates and attentive child care characterize positive deviants. Best-growing children do not necessarily mirror the malnourished; for example, best- and worst-nourished infants may both get more breast-milk substitutes than middle growers. Positive deviants receive more high-quality foods, physical interaction, affection and praise, and verbal and environmental stimulation. Factors that influence child growth through care quality also predict cognitive development, health, and social adjustment. They include: the type of society; parental education, mental health, initiative, and work burden; family and community structure; and the value of children to parents. Feeding practices related to growth include: permitting the child to control the length of feeding, encouraging eating while avoiding a power struggle, actively spoon- or hand-feeding, not displacing appetite by giving frequent sweets, and timely introduction of appropriate foods.

The effect of level of nutrition on the development of resistance to Haemonchus contortus in sheep

Merino wether weaners, 5-months old at the start of the experiment and fed lucerne-based pellets at 600 g per head per day, developed resistance to Haemonchus contortus given as a continuous or "trickle" infection at the rate of 500 larvae 3 times per week over a period of 17 weeks. By contrast, the development of resistance was impaired in weaners fed pellets at 400 g per head per day. Low food intake and protein-energy deprivation, therefore, have a major effect in impairing the development and expression of host-protective immunity against haemonchosis. The point at which low food intake causes outbreaks of haemonchosis in sheep at pasture is critical in determining procedures for prevention and control of the disease.