Nutritional rehabilitation of malnourished children detected by Screening Tool for Assessment of Malnutrition in Pediatric: Urban versus rural settings

BACKGROUND

Malnutrition presents a major global health burden. In Egypt, it remains an important issue in children under 5 years especially in rural communities.

AIM OF THE STUDY

The aim of the study was to screen 2-5 years old children enrolled from Egyptian hospitals in rural and urban areas for the risk of malnutrition using Screening Tool for Assessment of Malnutrition in Pediatric (STAMP) and to evaluate the effectiveness of nutritional intervention programs.

SUBJECTS AND METHODS

This cross-sectional study was conducted on 90 patients recruited from two hospitals in urban and rural Cairo, Dietary history and anthropometric measurements were assessed. Patients at intermediate and severe risk of malnutrition according to STAMP were given tailored nutritional programs.

RESULTS

In the rural hospital, 4.4% of the screened children were underweight, 22.2% were marginally underweight, and 73.3% had normal weight. Regarding the urban hospital, 15.6% were marginally underweight, 84.4% had normal weight and no underweight patients. Among the rural group 35.6% were at high risk according to STAMP score results compared to 20% in the urban group. Nevertheless, the only significant differences were the more stunting and higher BMI in rural hospital patients. After nutritional intervention, high-risk category patients decreased in both groups coupled by significant improvement in the anthropometric parameters and nutrition data with no significant differences between them.

CONCLUSION

Nutritional education and prompt implementation of nutritional rehabilitation program for malnourished children detected by screening tools result in improvement in their nutritional status disregards their location whether urban or rural.

Ketogenic diet for epilepsy control and enhancement in adaptive behavior

The Ketogenic Diet (KD) is gaining attention as a management line in childhood drug resistant epilepsy (DRE). The objective of this study was to highlight KD benefits for Ain Shams University (ASU) Children's Hospital patients. This cross-sectional study included all patients at the Ketoclinic of ASU Children's Hospital since it started. Anthropometric measurements and laboratory data were recorded. Chalfont severity score and daily frequency of epileptic attacks were used to evaluate KD efficacy. Vineland test was used to demonstrate the adaptive behavior of a selected group of patients. ASU Children's Hospital Ketoclinic records included 143 patients. During KD therapy, the weight and height/length assessment showed significant increase with significant decrease in the severity of seizures and its frequency. There were no significant changes in the lipid profile of the patients. Vineland test showed significant improvement in the adaptive behavior in 65% of patients. The Ketoclinic data proves that KD is a tolerable, safe, and effective line of therapy for DRE in children without significant negative impact on their anthropometric measurements or lipid profile. Furthermore, the enhancement in adaptive behavior is a promising finding. It is prudent to recommend wider scale studies for longer duration to demonstrate additional cognitive benefits of KD in pediatric age group.

Nutritional rehabilitation of malnourished children: are nutritional supplements a must?

OBJECTIVE

Malnutrition threatens children worldwide. The objective of the current study was to highlight the role of nutritional screening, evaluate the effectiveness of nutritional intervention program, and whether nutritional supplements have surplus benefit.

PATIENTS AND METHODS

Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) was used to screen 3640 clinically stable 2-5 years old children recruited from the outpatient clinics, Children's Hospital, Ain Shams University. A total of 100 patients at high risk of malnutrition were enrolled. Full nutritional assessment was done and according to the distribution of the calories in the daily meal plan, the patients were randomly divided into two groups each comprised 50 patients. Group A received tailored nutritional dietary rehabilitation plan including dietary supplements, while Group B received only dietary advice. Anthropometric measurements, laboratory tests, as well as STAMP scoring were reassessed after the nutritional rehabilitation programs.

RESULTS

Nutritional screening revealed that 5.14% were at high risk of malnutrition. Both studied groups showed significant improvement in caloric intake and all anthropometric measurements upon nutritional rehabilitation, except for the height z scores. Patients who received nutritional supplements showed significantly better changes regarding weight, BMI, caloric intake, and hemoglobin. Regarding STAMP categories during follow up, Group A had only 6% of the patients still in the high-risk category and 76% were at low risk compared to 14% high risk and only 54% were at low risk in Group B.

CONCLUSIONS

Nutritional screening in pediatric outpatient facilities can lead to implementing prompt nutritional rehabilitation, which can reflect on the patients' overall health. Tailored nutritional plan can accomplish good response in terms of improvement of caloric intake, anthropometric measurements and laboratory parameters. Adding a nutritional supplement to the dietary plan during nutritional rehabilitation isn't a must but it ensures superior goal achievement.

Severity of Pediatric COVID-19: Role of Vitamin D

Objective Vitamin D has many immune benefits and because its deficiency impacts most age groups, it became a nutrient of interest in the coronavirus disease 2019 (COVID-19) era. The objective of this study was to highlight the contribution of vitamin D status to the disease severity of hospitalized pediatric patients suffering from COVID-19 infection.

Methods This was a cross-sectional study that was conducted on 42 children with documented positive polymerase chain reaction for COVID-19 infection. Detailed history taking and thorough clinical examination were done for each recruited patient. Besides the laboratory and radiological assessment done for COVID-19 patients, 25 hydroxy vitamin D levels [25(OH) D] in the serum were estimated using enzyme linked immunosorbent assay.

Results Using the cutoff level of 10 ng/mL, only 40% of the patients were below this level and 60% had their vitamin D level more than or equal to 10 ng/mL. Significantly more patients of the first group needed oxygen support (denoting more severe COVID-19 infection and lung involvement). The older the patients, the more evident was vitamin D deficiency among them, and 25(OH) D values were not correlated to weight for length nor weight categories in the studied series of patients suffering from COVID-19.

Conclusion Vitamin D deficiency affects the severity of pediatric COVID-19 infection in hospitalized patients. It is prudent to advise vitamin D level assessment in such cases and promptly manage the patients accordingly. We recommend further studies to assess the effect of vitamin D supplementation on the clinical outcome of COVID-19 in the pediatric population and other vulnerable groups.

Effect of ketogenic diet for drug-resistant epilepsy on immunological cells

BACKGROUND AND AIM OF THE WORK

Ketogenic diet (KD) is one of the treatments in drug-resistant epilepsy (DRE). The current study aimed at assessing the effect of KD-induced ketosis on different immunological cells since ketosis is reported to affect neutrophil function.

METHODOLOGY

We recruited 21 pediatric patients diagnosed with DRE assigned to start KD. Anthropometric measurements, complete blood picture with differential count, phagocytic function, lymphocyte subsets, and IgG estimation were estimated initially and after 6 months of KD.

RESULTS

There were no differences between the initial total leucocytic, neutrophil, and lymphocytic counts as well as the lymphocyte subsets, and the values after 6 months of KD. IgG values showed significant increase yet the values were still within the reference ranges. For the innate immune system, the phagocytic index was assessed and it showed a marked statistical reduction in patients after KD.

CONCLUSION

KD has no effect on neutrophil and lymphocytic counts as well as the number of adaptive and immune cells; nevertheless, it causes a reduction in phagocytic index in DRE. Accordingly, further detailed study for the full immunological profile and function is needed to ensure the safety of this therapeutic line and correlate it with the clinical history.

Is There a Benefit of Vitamin D Supplementation in Deficient Children and Adolescents Suffering from Obesity? A Meta-Analysis

This systematic review/meta-analysis aims to highlight the effect of vitamin D supplementation in deficient children suffering from obesity. Published clinical studies on vitamin D supplementation in obese children and adolescents with vitamin D deficiency were identified through a comprehensive MEDLINE/PubMed search (from July 1966 to November 2017). Outcomes intended after vitamin D supplementation were improvements in vitamin D status, BMI alterations and appetite changes. The inclusion criteria were children aged 2 to 18 years of both sexes in clinical trials that specified the oral and/or intramuscular dose of vitamin D supplementation. Ten studies were retrieved, but only 6 were relevant. First, supplemented obese children and adolescents were compared to non-obese controls; thereafter, supplemented obese children and adolescents were compared to matching obese peers given placebo. Pooled risks from the 2 studies that evaluated the number of obese and non-obese children and adolescents who improved upon vitamin D supplementation revealed that obesity poses a risk for not benefiting from the vitamin D supplementation regardless of the dose and the duration of supplementation. Pooled results from the 6 retrieved studies that compared supplemented obese children and adolescents to matching non-obese or obese peers given placebo revealed significantly lower vitamin D levels in obese participants than in non-obese peers. Vitamin D levels are significantly lower in obese children and adolescents with obesity, posing a risk for not benefiting from vitamin D supplementation regardless of the dose and duration of supplementation.

Effect of COVID-19 Lockdown on Young Egyptian Soccer Players

The present study was designed to highlight the physical and psychological health hazards that a young Egyptian soccer team faced during the first COVID-19 wave lockdown. The study included 37 young Egyptian male soccer players. History taking and anthropometric measurements were taken. Two questionnaires were filled covering the athletes’` sleep habits and quality of life (QoL). Finally, the mothers were asked to fill in a questionnaire concerned with depression, anxiety, and stress. More than 50% of the enrolled athletes gained weight during the lockdown especially those without compliance to home exercises. The mothers’ anxiety score correlated positively with the increased body mass index (BMI) of the athletes. The athletes mean QoL Score worsened significantly and significant negative correlation was found between the increased BMI and the change of QoL. The increased BMI was significantly reported among the athletes who didn’t do home exercises and had a negative correlation with their QoL change throughout the lockdown. The mothers’ anxiety had a possible reflection on their youngsters’ weight gain. These findings highlight the need for weight control when outdoors physical activity is restricted during pandemics with better compliance to home exercising schedules and less screen time.

Serum 25-hydroxyvitamin D status and wheezing in pre-school children, Kuwait

Background

There has been growing recognition of the critical extra-skeletal roles for vitamin D including lung disease.

Aims

This study was performed to explore the possible role of vitamin D on wheezing occurrence among Kuwaiti preschool children.

Methods

Out of 244 children from Al-Adan Hospital, Kuwait, 151 cases were enrolled as wheezers while the rest served as controls. The wheezers were subdivided into episodic wheezers (EW) and multiple trigger wheezers (MTW). Detailed history of the wheezing attacks, previous hospitalizations, and intensive care admission were recorded as well as their serum 25-hydroxyvitamin D [25(OH)D] levels.

Results

Serum 25(OH)D was significantly lower in the wheezing group, and its decrease was a risk factor for wheezing. Moreover, serum 25(OH)D was not significantly different between EW and MTW; nevertheless, its low level could be linked to MTW.

Conclusions

Vitamin D deficiency increases the risk of wheezing among preschoolers in Kuwait. A possible link between low serum 25(OH)D and MTW could highlight a specific role for vitamin D in relation to atopy. Prevention and prompt management of vitamin D deficiency should be considered among infants and children with wheezing.

Imaging In Acute Bronchiolitis: Evaluation of The Current Practice In a Kuwaiti Governmental Hospital and Its Possible Impact on Hospitalization Period

BACKGROUND AND OBJECTIVES

Guidelines for acute bronchiolitis recommend primarily supportive care, but unnecessary treatment measures remain well documented. This study was designed to assess the Al-Adan Hospital pediatricians` attitude towards imaging of inpatients with bronchiolitis aiming to evaluate its utilization and possible impact on patients` management and length of hospital stay.

SUBJECTS AND METHODS

This study included 194 cases of acute bronchiolitis admitted to Al-Adan Hospital. Number of X-Rays done following admission and reasons stated in the files were recorded. Bronchiolitis severity was estimated from the data obtained.

RESULTS

Chest X-Rays were ordered in 52.1% of our inpatients with acute bronchiolitis. In nearly half of those cases, the reason for X-Ray request is a clinical severity factor, namely desaturations and apneas, and in rest of the cases, no specific reason for ordering X-Rays was documented. Significantly more patients who had two or more X-Rays were prescribed antibiotics and had statistically longer hospital stay. The number of X-Rays performed during admission was not a significant contributor to the need for PICU care, however, it was a significant factor affecting the length of hospital stay.

CONCLUSION

The implementation of acute bronchiolitis guidelines regarding imaging in admitted cases with acute bronchiolitis is highly recommended in Al-Adan hospital. Clear documentation for the reasons behind ordering X-Rays is needed for those cases. A decrease in the X-Ray utilization and subsequent unnecessary antibiotic use can help in decreasing the costs and hazards of hospitalization for patients with acute bronchiolitis.

Pattern of beverage intake and milk and dairy products sufficiency among high-school students in Kuwait

High consumption of soft drinks has been associated with lower intakes of milk and calcium-rich foods and higher body mass index (BMI). This study aimed to explore the pattern of beverage intake among Kuwaiti high-school students. A questionnaire on knowledge, attitudes and practices concerning beverages and milk and dairy products intake was completed by 190 Kuwaiti students aged 16-18 years and BMI was calculated for 181 of them. Intake of sweetened carbonated beverages and to a lesser extent packaged fruit juices affected the sufficiency of milk and dairy products intake among the sample of high-school students in Kuwait. Although BMI was not related to milk and dairy insufficiency, more of the overweight and obese students displayed incorrect practices. Nutritional education of high-school students on the importance of milk and dairy products as well as the hazards of excess sweetened carbonated beverages and packaged juice is recommended to prevent the obesity epidemic prevailing in Kuwait.

Breastfeeding practice in Kuwait: determinants of success and reasons for failure

To explore the possible determinants of duration of breastfeeding in Kuwait, 234 mothers completed a questionnaire concerning the feeding of their youngest infant. The questionnaire addressed the factors that contributed to their willingness to continue breastfeeding and enquired about the factors leading to their decision to end it. Only 26.5% of the mothers had continued breastfeeding for 6 months or more. Separate family housing, higher maternal age, late initiation of breastfeeding, being employed without the feasibility to breastfeed at work, breastfeeding information given after rather than before birth, and maternal and infant sickness were all significant contributors influencing early cessation. Father's support was a significant factor that encouraged the practice. In conclusion, preventive strategies are recommended for boosting breastfeeding, with special emphasis on the factors linked to early cessation, aiming at full implementation of the WHO global public health recommendations for successful breastfeeding in Kuwait.

Modified Atkins diet vs classic ketogenic formula in intractable epilepsy

OBJECTIVES

The study was designed to evaluate the efficacy, safety, and tolerability of the ketogenic diet (KD) whether classic 4:1 formula or the modified Atkins diet (MAD) in intractable childhood epilepsy.

PATIENTS AND METHODS

Anthropometric measurements and serum lipid profile were measured upon enrollment and after 3 and 6 months in 40 patients with symptomatic intractable epilepsy. Fifteen were given MAD diet, ten were kept on classic 4:1 ketogenic liquid formula, and the rest were allowed to eat as desired.

RESULTS

The liquid ketogenic formula group showed significantly higher body mass index compared with those who did not receive KD after 6 months. The lipid profile of KD patients was within normal limits for age and sex during the study period. The rate of change of frequency and severity of seizures showed best improvement in ketogenic liquid formula patients followed by the MAD group than the patients on anti-epileptic medications alone.

CONCLUSION

The KD whether classic 4:1 or MAD is a tolerable, safe, and effective adjuvant therapy for intractable symptomatic childhood epilepsy with limited adverse effects on the growth parameters and accepted changes in the lipid profile. The liquid ketogenic formula patients showed better growth pattern and significantly more seizure control.

The rising tide of overweight among Kuwaiti children: study from Al-Adan Hospital, Kuwait

OBJECTIVE

This study was designed to screen patients who sought medical services in the Pediatric Outpatient Department, Al-Adan Hospital, Kuwait for overweight.

SUBJECTS AND METHODS

Body mass index (BMI) was used to screen 361 children (≤10 years old) for risk of overweight and overweight (BMI between 85th and 94th, and ≥95th percentile, respectively). Overweight children were fully examined and abdominal ultrasound was done for each of them.

RESULTS

Of the 361 children, 52 (14.41%) and 77 (21.33%) were at risk of overweight and overweight, respectively. There was a slight male predominance for overweight (40 males, 51.95%, compared to 37 females, 48.05%) and within the overweight category; 28 males (70%) and 26 females (70.27%) were above 6 years of age. In overweight children over 6 years, 4 (7.41%) had hepatomegaly with fatty changes and 3 (5.56%) had blood pressure above the 95th percentile for age and sex.

CONCLUSION

Childhood overweight at Al-Adan Hospital was high and increased with age. Hence childhood screening for overweight is recommended at an early age because it is an important risk factor of chronic diseases.

Neuro-developmental outcome and brain-derived neurotrophic factor level in relation to feeding practice in early infancy

This study was designed to assess brain-derived neurotrophic factor (BDNF) as a possible candidate for enhanced cognition in breastfed infants. The study was conducted on 42 infants, 4-6 months old, who were classified according to their feeding pattern into breastfed group, formula-fed group and mixed-feeding group. Each infant was subjected to history taking, clinical examination, estimation of the level of BDNF by Enzyme-Linked Immunosorbent Assay (ELISA) technique and assessment by Bayley scale of infant development-second edition (BSID-II). The current study revealed that breastfed group had higher BSID-II scores followed by mixed-fed group then formula-fed one, yet these results reached statistical significance only in total behaviour rating scale (TBRS) and Motor Quality Percentile rank values. Additionally, breastfed infants had significantly higher values of BDNF when compared to those receiving formula milk. Negative correlations between BDNF and both weight for age and weight for length scores were detected. Furthermore, significant positive correlation was detected between BDNF and TBRS. Regression analysis studies revealed that breastfeeding is the most determinant factor for BDNF, TBRS and Motor Quality Percentile rank values. Serum BDNF levels are significantly higher in breastfed infants and shows positive correlations with the results of BSID-II. Given that simultaneous increase in brain BDNF occurs due to onsite production, transport from the periphery or both, it is prudent to hypothesize that BDNF could be one of the factors responsible for the enhanced cognition detected in breastfed infants.

Effect of honey on 50% complement hemolytic activity in infants with protein energy malnutrition: a randomized controlled pilot study

Protein energy malnutrition (PEM) is associated with a significant impairment of cell-mediated immunity and complement system, which may be responsible for the high incidence of infections among these patients. This study was designed to examine the effect of honey, as a natural substance, on the 50% complement hemolytic activity (CH50) in patients with PEM. Thirty patients with PEM and 20 healthy infants serving as controls participated in this study. The patients were randomized to receive either honey (group 1) or placebo (group 2), in addition to conventional nutritional rehabilitation therapy. Measurements of weight, midarm circumference, skin fold thickness, serum albumin, and CH50 were done for all patients before and after 2 weeks of rehabilitation. Before nutritional rehabilitation, the CH50 was significantly lower in the PEM groups compared with the control. However, after rehabilitation, the CH50 increased significantly in both PEM groups, compared with the pre-interventional state and with the controls. Moreover, the rise of CH50 was significantly more in the honey group compared with the placebo. On the other hand, the improvement in the anthropometric measures and serum albumin did not differ significantly between the honey and placebo groups after rehabilitation. Thus honey supplementation in patients with PEM increased the level of CH50. Whether this would have an effect on the frequency and severity of infections in patients with PEM needs further studies.

Effect of honey on gastric emptying of infants with protein energy malnutrition

BACKGROUND

Patients with protein-energy malnutrition (PEM) have delayed gastric emptying time (GET) which may affect nutritional rehabilitation. This study was designed to examine the effect of honey on GET during nutritional rehabilitation of PEM patients.

PATIENTS AND METHODS

Thirty patients were enrolled and randomly assigned to one of two equal groups. One group received conventional nutritional rehabilitation therapy and the other received honey in addition. They were compared with 20 age- and sex-matched controls. History taking, clinical examination and laboratory tests were performed for enrolled cases and GET was assessed using abdominal ultrasonography. These parameters were performed before and 2 weeks after nutritional rehabilitation.

RESULTS

The GET was significantly delayed in the PEM groups compared with the controls. Further significant delay occurred in the honey supplemented group after nutritional rehabilitation, while the un-supplemented group showed significant shortening of GET. The improvement of anthropometric measurements and laboratory parameters was equally noticed in the two PEM groups upon nutritional rehabilitation but their rate of change was distinctly higher, although non-significant, in the group supplemented with honey.

CONCLUSION

Honey supplementation increased GET in PEM patients with positive effect on the improvement in the anthropometric measurements and serum albumin which makes us wonder that this delay in GET might be primarily a compensatory phenomenon and it was augmented by the use of honey. Larger scale studies with longer term follow up are recommended to further clear this point and assess any changes in the absorptive indices in honey supplemented PEM patients.

CD95 expression in white blood cells of malnourished infants during hospitalization and catch-up growth

Malnutrition continues to be a major health burden in developing countries. Flow cytometric estimation of the apoptotic marker CD95 in peripheral neutrophils, lymphocytes and monocytes was done for 18 infants with non-oedematous protein energy malnutrition (PEM) and 12 oedematous ones, on hospital admission and after supervised nutritional rehabilitation, and compared with 12 matched controls. CD95 counts in the 3 types of white blood cells were significantly higher in PEM infants and showed improvement after nutritional rehabilitation yet not reaching the control values. Enhanced apoptosis in the leukocytes of peripheral blood of PEM patients may be a marker of increased infection and immune disturbances. This derangement reverses upon proper nutritional rehabilitation.

T-lymphocyte subsets and thymic size in malnourished infants in Egypt: a hospital-based study

Thymus size was assessed ultrasonographically and correlated to the percentage of CD4 and CD8 T-lymphocytes in peripheral blood in 32 infants with protein-energy malnutrition (PEM) and compared with 14 healthy control infants. The study revealed thymus atrophy in patients with PEM, especially the oedematous type, accompanied by changes in the peripheral lymphocyte subsets. These changes were reversible after nutritional rehabilitation. However, they may affect the immune status of PEM patients and may require a longer duration of nutrition rehabilitation than required for recovery of anthropometric measures. We recommend proper assessment of the immune functions of PEM patients during nutritional rehabilitation until full recovery.

Sleep-wake cycle disturbances in protein-energy malnutrition: effect of nutritional rehabilitation

A standard sleep questionnaire was given to the parents of 26 infants with protein-energy malnutrition who underwent polysomnographic evaluation. These investigations were repeated approximately 2 months after enrolment in a nutritional rehabilitation programme based on World Health Organization guidelines. Anthropometric values and serum serotonin levels were also measured. After nutritional rehabilitation there was a significantly higher percentage of non-rapid eye movement (REM) sleep; 2nd REM time, and latency times for sleep and REM sleep increased. Percentages of REM sleep and serum serotonin levels decreased significantly. Protein-energy malnutrition seems to affect the sleep-wake cycle; disturbed serotonin levels may be among the factors responsible.

Structural and functional affection of the heart in protein energy malnutrition patients on admission and after nutritional recovery

BACKGROUND AND OBJECTIVES

The pathogenesis of different malnutrition diseases was suggested to affect the heart. This study was designed to detect cardiac affection in protein energy malnutrition (PEM) patients, whether clinically or by electrocardiogram (ECG) and echocardiogram, and to assess the value of the cardiac marker troponin I in patients at risk of myocardial injury with special emphasis on the effect of nutritional rehabilitation.

PATIENTS AND METHODS

The present study was carried out on 30 PEM infants (16 nonedematous - 14 edematous) and 10 apparently healthy age and sex-matched infants acting as the control group. All studied infants were subjected to full history taking laying stress on dietetic history, thorough clinical and anthropometric measurements. Echocardiography and ECG were also performed. Laboratory investigations were performed including complete blood count, CRP, total proteins, albumin, liver and kidney functions as well as estimation of troponin-I in blood by immulite. Following initial evaluation, all malnourished infants were subjected to nutritional rehabilitation program for approximately 8 weeks, after which the patients were re-evaluated using the same preinterventional parameters.

RESULTS

The results of the present study demonstrated that electrical properties of myocardium assessed by ECG showed significant decrease of R wave and QTc interval in patients compared to controls with significant improvement after nutritional rehabilitation. Echocardigraphic changes showed that cardiac mass index was significantly lower in both groups of malnourished cases compared to the controls with significant increase after nutritional rehabilitation. The study showed that the parameters of left ventricular (LV) systolic function which are the ejection fraction, fractional shortening and velocity of circumferential fiber shortening were not significantly reduced in patients compared to the controls. The diastolic function also showed no significant difference in the E wave/A wave (e/a) ratio between patients and controls. However, the systolic time interval showed significantly higher LV pre-ejection index in patients in comparison to controls. Edematous and nonedematous cases did not show any significant differences in ECG and echocardigraphic data before or after nutritional rehabilitation. The hearts of two severely affected patients uniquely demonstrated marked decrease of LV end diastolic diameter (LEVDd) together with the detection of troponin-I in their sera.

CONCLUSION

We can conclude that malnutrition, regardless of its type, has a definite effect on cardiac volume, muscle mass, as well as the electrical properties of the myocardium. The systolic functions of the heart are affected more than the diastolic functions and this affection becomes manifest only in severe cases and may constitute a bad prognostic parameter thus necessitating more intense management and strict follow-up of such cases.

Pancreatic size in protein energy malnutrition: a predictor of nutritional recovery

BACKGROUND

Pancreatic exocrine dysfunction has been frequently recorded in protein energy malnutrition (PEM) because the pancreas requires optimal nutrition for enzyme synthesis. This pancreatic enzyme insufficiency may play a role in the continuation of PEM.

OBJECTIVE

This study was designed to assess the pancreatic head size and exocrine pancreatic functions, namely serum amylase and lipase, in PEM and its subtypes and correlate any defect present with the various clinical and laboratory data of the PEM patients with special emphasis on the effect of nutritional rehabilitation.

PATIENTS AND METHODS

A total of 33 cases of PEM; 15 marasmus, 10 kwashiorkor (KWO) and eight marasmic kwashiorkor (MKWO) were recruited from Ain Shams University children's hospital, together with 12 matched controls. The mean age of patients was 11.87 +/- 7.8 months and that of the controls was 14.83 +/- 7.7 months. Detailed history taking and thorough clinical examination with special emphasis on anthropometric measurements were taken for each studied infant as well as laboratory investigations which included; complete blood count, liver and kidney functions and serum amylase and lipase. Ultrasonographic assessment of pancreatic head size was performed for the cases and controls. Nutritional rehabilitation program was carried out for 3-6 months followed by reassessment of the cases.

RESULTS

The pancreatic head size values were significantly lower in all subtypes of PEM (1.52 +/- 0.6, 2.73 +/- 0.12 and 3.00 +/- 0.54 cm(3) in the marasmus, KWO and MKWO respectively) compared to the controls (5.13 +/- 2.33 cm(3)). The serum amylase and lipase were also significantly lower in all subgroups of PEM when compared to the controls with significant improvement following nutritional rehabilitation coupled by a significant increase in pancreatic head size too. No significant differences were recorded when we compared the subgroups together except for a significant higher rate of change in serum amylase in edematous patients compared to nonedematous ones. The length of nutritional rehabilitation period, age of the patient, weight and serum albumin were the most determinant factors for pancreatic head size as evident from the multiple regression analysis study.

CONCLUSION

The potentially correctable exocrine pancreatic insufficiency in cases of PEM should be carefully thought of when planning the nutritional rehabilitation program for such patients as it could be responsible for the serious continued morbidity issues that they face. We thus recommend that estimation of pancreatic head size and exocrine function should be included in the evaluation of PEM patients and they could also be used as a prognostic parameter.

SPONSORSHIP

The patients enrolled were among those admitted and managed freely in the children's Hospital Faculty of Medicine Ain Shams University, including the use of the ultrasound apparatus, while the kits have been purchased by authors who contributed in financing the study.

Ultrasonographic gastric emptying in protein energy malnutrition: effect of type of meal and nutritional recovery

OBJECTIVE AND DESIGN

The earlier reports of disturbed gastric motility in protein energy malnutrition (PEM) point out to its possible contribution in the difficulties faced during nutritional rehabilitation. This study was thus designed to assess the ultrasonographic gastric emptying time (GET) using 20 ml/kg body weight of both liquid and semisolid meals, in 27 patients suffering from PEM as well as in 15 healthy matching infants to delineate any defect present, its degree in different types of PEM and the effect of nutritional rehabilitation.

PATIENTS

The patients were recruited from the in-patient department of Children's Hospital, Ain Shams University, Cairo, Egypt. They were divided into three groups: 10 marasmic infants, 10 marasmic kwashiorkor (marasmic KWO) and seven kwashiorkor (KWO) cases. Ultrasonographic GET assessment was carried out within 72 h of admission and 30+/-7 days after nutritional rehabilitation.

RESULTS

The gastric half-emptying time T(1/2) of both liquid and semisolid meals was markedly prolonged in patients with marasmus and marasmic KWO. It was more delayed for the semisolid than the liquid meals. This delay was reversible after nutritional rehabilitation of the patients, indicating that it was secondary to the malnourished status. On the other hand, T(1/2) of both liquid and semisolid meals showed no statistically significant delay in the KWO group and nutritional rehabilitation added no further to the results.

CONCLUSION

PEM, especially marasmus and marasmic KWO, causes a delay in GET, which is reversible on nutritional recovery. This must be considered during nutritional rehabilitation of such patients to decrease the duration of their hospitalization and thus decrease the morbidity in PEM.

Nutritional stunting in Egypt: which nutrient is responsible?

We looked at the relationship between linear growth retardation and deficiencies of certain nutrients in Egyptian children. A group of 107 stunted children aged between 10 and 18 years were subjected to history-taking, physical examination and laboratory investigations. Selected cases were referred to radiology for assessment of bone age. Thirty-nine children were enrolled as controls. Serum haemoglobin, alpha-tocopherol, retinol and magnesium levels were significantly decreased in stunted children compared with the controls. Serum zinc levels were also lower in the stunted group but not significantly so. We conclude that several nutrient deficiencies occur simultaneously in stunted children and all of them may be responsible for stunting.

Impact of nutritional rehabilitation on enzymatic antioxidant levels in protein energy malnutrition

To assess the role of enzymatic antioxidants in the pathogenesis of protein energy malnutrition (PEM) and the effect of nutritional rehabilitation, we studied 30 infants with PEM (mean age 10.63 +/- 4.39 months: 10 marasmic; 8 with kwashiorkor; 12 with marasmic kwashiorkor) and 15 controls. All underwent clinical examination and laboratory investigations, including superoxide dismutase (SOD) and glutathione peroxidase (GPx) estimation before and after nutrition rehabilitation. SOD and GPx were significantly lower in all malnourished infants compared to controls, and significantly increased after nutritional rehabilitation. These significant correlations suggest that antioxidants could be introduced during PEM nutritional rehabilitation to decrease morbidity and mortality.