Development of a Scale to Measure Infant Eating Behaviour Worldwide

In order to create a short, internationally valid scale to assess eating behaviour (EB) in young children at risk of undernutrition, we refined 15 phrases describing avidity or food refusal (avoidance). In study one, 149 parents matched phrases in English, Urdu, Cantonese, Indonesian or Greek to videos showing avidity and avoidance; 82-100% showed perfect agreement for the avidity phrases and 73-91% for the avoidant phrases. In study two, 575 parents in the UK, Cyprus and Indonesia (healthy) and in Kenya, Pakistan and Guatemala (healthy and undernourished) rated their 6-24 months old children using the same phrases. Internal consistency (Cronbach's α) was high for avidity (0.88) and moderate for avoidance (0.72). The best-performing 11 items were entered into a principal components analysis and the two scales loaded separately onto 2 factors with Eigen values > 1. The avidity score was positively associated with weight (r = 0.15 p = 0.001) and body mass index (BMI) Z scores (r = 0.16 p = 0.001). Both high and low avoidance were associated with lower weight and BMI Z scores. These scales are internationally valid, relate to nutritional status and can be used to inform causes and treatments of undernutrition worldwide.

Water insecurity potentially undermines dietary diversity of children aged 6-23 months: Evidence from India

Dietary diversity is a crucial pathway to child nutrition; lack of diversity may deprive children of critical macro and micronutrients. Though water along with hygiene and sanitation is a known driver of child undernutrition, a more direct role of household water in shaping dietary diversity remains unexplored. Existing literature provides a sound theoretical basis to expect that water could affect dietary diversity among young children. Here, we test the proposition that suboptimal household access to water and low regional water availability associate with lower dietary diversity among young children. Using the nationally representative 2015-2016 India Demographic and Health Survey data, we conducted a probit analysis on the sample of 69,841 children aged 6-23 months to predict the probability that a child achieves minimum standards of dietary diversity (MDD). After controlling for relevant socioeconomic and gender-related covariates, we found that children in household with suboptimal household water access were two percentage points less likely to achieve MDD, when compared with those from households with optimal water access. Children in high water availability regions had nine percentage points greater probability of achieving MDD compared with children from low water availability regions, accounting for household water access. As dietary diversity is central to nutrition, establishing the role of water access in shaping early childhood dietary diversity broadens the framework on how household material poverty shapes child malnutrition-independent of sanitation and hygiene pathways. This provides additional window for nutrition planning and intervention wherein water-based strategies can be leveraged in multiple ways.

A double-blind placebo-controlled trial of azithromycin to reduce mortality and improve growth in high-risk young children with non-bloody diarrhoea in low resource settings: the Antibiotics for Children with Diarrhoea (ABCD) trial protocol

BACKGROUND

Acute diarrhoea is a common cause of illness and death among children in low- to middle-income settings. World Health Organization guidelines for the clinical management of acute watery diarrhoea in children focus on oral rehydration, supplemental zinc and feeding advice. Routine use of antibiotics is not recommended except when diarrhoea is bloody or cholera is suspected. Young children who are undernourished or have a dehydrating diarrhoea are more susceptible to death at 90 days after onset of diarrhoea. Given the mortality risk associated with diarrhoea in children with malnutrition or dehydrating diarrhoea, expanding the use of antibiotics for this subset of children could be an important intervention to reduce diarrhoea-associated mortality and morbidity. We designed the Antibiotics for Childhood Diarrhoea (ABCD) trial to test this intervention.

METHODS

ABCD is a double-blind, randomised trial recruiting 11,500 children aged 2-23 months presenting with acute non-bloody diarrhoea who are dehydrated and/or undernourished (i.e. have a high risk for mortality). Enrolled children in Bangladesh, India, Kenya, Malawi, Mali, Pakistan and Tanzania are randomised (1:1) to oral azithromycin 10 mg/kg or placebo once daily for 3 days and followed-up for 180 days. Primary efficacy endpoints are all-cause mortality during the 180 days post-enrolment and change in linear growth 90 days post-enrolment.

DISCUSSION

Expanding the treatment of acute watery diarrhoea in high-risk children to include an antibiotic may offer an opportunity to reduce deaths. These benefits may result from direct antimicrobial effects on pathogens or other incompletely understood mechanisms including improved nutrition, alterations in immune responsiveness or improved enteric function. The expansion of indications for antibiotic use raises concerns about the emergence of antimicrobial resistance both within treated children and the communities in which they live. ABCD will monitor antimicrobial resistance. The ABCD trial has important policy implications. If the trial shows significant benefits of azithromycin use, this may provide evidence to support reconsideration of antibiotic indications in the present World Health Organization diarrhoea management guidelines. Conversely, if there is no evidence of benefit, these results will support the current avoidance of antibiotics except in dysentery or cholera, thereby avoiding inappropriate use of antibiotics and reaffirming the current guidelines.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03130114. Registered on April 26 2017.

Drivers of Under-Five Stunting Trend in 14 Low- and Middle-Income Countries since the Turn of the Millennium: A Multilevel Pooled Analysis of 50 Demographic and Health Surveys

BACKGROUND

Understanding the drivers contributing to the decreasing trend in stunting is paramount to meeting the World Health Assembly's global target of 40% stunting reduction by 2025.

METHODS

We pooled data from 50 Demographic and Health Surveys since 2000 in 14 countries to examine the relationships between the stunting trend and potential factors at distal, intermediate, and proximal levels. A multilevel pooled trend analysis was used to estimate the association between the change in potential drivers at a country level and stunting probability for an individual child while adjusting for time trends and child-level covariates. A four-level mixed-effects linear probability regression model was fitted, accounting for the clustering of data by sampling clusters, survey-rounds, and countries.

RESULTS

Stunting followed a decreasing trend in all countries at an average annual rate of 1.04 percentage points. Among the distal factors assessed, a decrease in the Gini coefficient, an improvement in women's decision-making, and an increase in urbanization were significantly associated with a lower probability of stunting within a country. Improvements in households' access to improved sanitation facilities and drinking water sources, and children's access to basic vaccinations were the important intermediate service-related drivers, whereas improvements in early initiation of breastfeeding and a decrease in the prevalence of low birthweight were the important proximal drivers.

CONCLUSIONS

The results reinforce the need for a combination of nutrition-sensitive and -specific interventions to tackle the problem of stunting. The identified drivers help to guide global efforts to further accelerate stunting reduction and monitor progress against chronic childhood undernutrition.

Animal Models of Undernutrition and Enteropathy as Tools for Assessment of Nutritional Intervention

: Undernutrition is a major public health problem leading to 1 in 5 of all deaths in children under 5 years. Undernutrition leads to growth stunting and/or wasting and is often associated with environmental enteric dysfunction (EED). EED mechanisms leading to growth failure include intestinal hyperpermeability, villus blunting, malabsorption and gut inflammation. As non-invasive methods for investigating gut function in undernourished children are limited, pre-clinical models are relevant to elucidating the pathophysiological processes involved in undernutrition and EED, and to identifying novel therapeutic strategies. In many published models, undernutrition was induced using protein or micronutrient deficient diets, but these experimental models were not associated with EED. Enteropathy models mainly used gastrointestinal injury triggers. These models are presented in this review. We found only a few studies investigating the combination of undernutrition and enteropathy. This highlights the need for further developments to establish an experimental model reproducing the impact of undernutrition and enteropathy on growth, intestinal hyperpermeability and inflammation, that could be suitable for preclinical evaluation of innovative therapeutic intervention.

Identifying Dietary Strategies to Improve Nutrient Adequacy among Ethiopian Infants and Young Children Using Linear Modelling

Nutrient adequacy of young children's diet and best possible strategies to improve nutrient adequacy were assessed. Data from the Ethiopian National Food Consumption Survey were analysed using Optifood (software for linear programming) to identify nutrient gaps in diets for children (6-8, 9-11 and 12-23 months), and to formulate feasible Food-Based Dietary Recommendations (FBDRs) in four regions which differ in culture and food practices. Alternative interventions including a local complementary food, micronutrient powders (MNPs), Small quantity Lipid-based Nutrient Supplement (Sq-LNS) and combinations of these were modelled in combination with the formulated FBDRs to compare their relative contributions. Risk of inadequate and excess nutrient intakes was simulated using the Estimated Average Requirement cut-point method and the full probability approach. Optimized local diets did not provide adequate zinc in all regions and age groups, iron for infants <12 months of age in all regions, and calcium, niacin, thiamine, folate, vitamin B12 and B6 in some regions and age-groups. The set of regional FBDRs, considerably different for four regions, increased nutrient adequacy but some nutrients remained sub-optimal. Combination of regional FBDRs with daily MNP supplementation for 6-12 months of age and every other day for 12-23 months of age, closed the identified nutrient gaps without leading to a substantial increase in the risk of excess intakes.

Determinants of Undernutrition among Young Children Living in Soth Nikum District, Siem Reap, Cambodia

BACKGROUND

Child undernutrition is of public concern in Cambodia. An understanding of factors influencing child nutritional status is essential to design programs that will reduce undernutrition. Using the UNICEF conceptual framework of causes of malnutrition, our research investigates the relationship between nutritional status of children aged 6⁻23 months and its immediate and underlying determinants.

METHODS

Baseline data from a cluster-randomized controlled trial aiming to assess the impact of the promotion of optimal feeding practices combined or not with the provision of local foods among 360 children 6⁻23 months of age were used. Anthropometry and biochemical measurements were performed at baseline. Data on each determinant of undernutrition were collected through interviews and direct observations.

RESULTS

Our results show that the degree of satisfaction of proteins and zinc requirements as well as the access to improved water sources and sanitation were positively associated with length-for-age, while having a better health status and a higher degree of satisfaction of energy, protein, zinc, and iron requirements were associated to an improved weight-for-length. Only child health status was associated to ferritin.

CONCLUSION

Our results reiterate the importance of improving child diet and health status, but also the access to a healthy environment to ensure an optimal nutritional status.

A multicenter, randomized controlled comparison of three renutrition strategies for the management of moderate acute malnutrition among children aged from 6 to 24 months (the MALINEA project)

BACKGROUND

The aim of this open-label, randomized controlled trial conducted in four African countries (Madagascar, Niger, Central African Republic, and Senegal) is to compare three strategies of renutrition for moderate acute malnutrition (MAM) in children based on modulation of the gut microbiota with enriched flours alone, enriched flours with prebiotics or enriched flours coupled with antibiotic treatment.

METHODS

To be included, children aged between 6 months and 2 years are preselected based on mid-upper-arm circumference (MUAC) and are included based on a weight-for-height Z-score (WHZ) between - 3 and - 2 standard deviations (SD). As per current protocols, children receive renutrition treatment for 12 weeks and are assessed weekly to determine improvement. The primary endpoint is recovery, defined by a WHZ ≥ - 1.5 SD after 12 weeks of treatment. Data collected include clinical and socioeconomic characteristics, side effects, compliance and tolerance to interventions. Metagenomic analysis of gut microbiota is conducted at inclusion, 3 months, and 6 months. The cognitive development of children is evaluated in Senegal using only the Developmental Milestones Checklist II (DMC II) questionnaire at inclusion and at 3, 6, and 9 months. The data will be correlated with renutrition efficacy and metagenomic data.

DISCUSSION

This study will provide new insights for the treatment of MAM, as well as original data on the modulation of gut microbiota during the renutrition process to support (or not) the microbiota hypothesis of malnutrition.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03474276 Last update 28 May 2018.

Critical Windows for the Programming Effects of Early-Life Nutrition on Skeletal Muscle Mass

Skeletal myogenesis begins in the embryo with proliferation and differentiation of muscle progenitor cells that ultimately fuse to form multinucleated myofibers. After midgestation, muscle growth occurs through hypertrophy of these myofibers. The most rapid growth phase occurs in the perinatal period, resulting in the expansion of muscle mass from 25% of lean mass at birth to 40-45% at maturity. These 2 phases of muscle growth are regulated by distinct molecular mechanisms engaged by extracellular cues and intracellular signaling pathways and regulatory networks they activate. Nutrients influence muscle growth by both providing the necessary substrates and eliciting extracellular cues which regulate the signal transduction pathways that control the anabolic processes of the fibers. The uniquely large capacity of immature myofibers for hypertrophy is enabled by a heightened capacity and sensitivity of protein synthesis to feeding-induced changes in plasma insulin and amino acids, and the ability to expand their myonuclear population through proliferation of muscle precursor cells (satellite cells). With maturation, satellite cells become quiescent, limiting myonuclear accretion, and the capacity of the muscles for protein anabolism progressively diminishes. Therefore, the early developmental phases represent critical windows for muscle growth which, if disrupted, result in muscle mass deficits that are unlikely to be entirely recoverable.

Improved Information and Educational Messages on Outer Packaging of Micronutrient Powders Distributed in Indonesia Increase Caregiver Knowledge and Adherence to Recommended Use

The objective of this study was to examine the influence of improved information and educational messages on outer packaging of a micronutrient powder (MNP), locally known as “Taburia”, on knowledge and adherence to recommended use. A community-based cluster randomized controlled trial was conducted among 1149 caregivers and their children aged 6⁻36 months. Caregiver⁻child dyads were randomized by their villages to receive 30 sachets of Taburia with the: (i) original outer packaging; (ii) improved outer packaging; or (iii) improved outer packaging combined with cooking demonstrations. Adherence to Taburia use was assessed through caregiver interviews and observation of unused sachets during home visits; “high” adherence was defined as consuming 13⁻17 sachets in the previous month. Data collection included surveys and focus groups discussions. The majority of caregivers (>80%) preferred the improved packaging because it was more attractive and contained more comprehensive information. Caregivers who received the improved packaging had better knowledge regarding the recommended use of Taburia (p < 0.001) and higher adherence with the prescribed use of Taburia (43% with “high” adherence) (p < 0.001) than those who received the original packaging (29% with “high” adherence). Caregivers who participated in cooking demonstrations generally had better knowledge regarding the benefits of Taburia and recommended use, but this did not lead to higher adherence to recommended use. “Underconsumption” of Taburia (≤7 sachets) was much less prevalent than “overconsumption” (≥23 sachets), and original packaging users were more likely to consume Taburia daily instead of every two days as recommended. We conclude that the design of the outer packaging and comprehensiveness of information provided are important influencers of recommended MNP use by caregivers.

The "ComPAS Trial" combined treatment model for acute malnutrition: study protocol for the economic evaluation

BACKGROUND

Acute malnutrition is currently divided into severe (SAM) and moderate (MAM) based on level of wasting. SAM and MAM currently have separate treatment protocols and products, managed by separate international agencies. For SAM, the dose of treatment is allocated by the child's weight. A combined and simplified protocol for SAM and MAM, with a standardised dose of ready-to-use therapeutic food (RUTF), is being trialled for non-inferior recovery rates and may be more cost-effective than the current standard protocols for treating SAM and MAM.

METHOD

This is the protocol for the economic evaluation of the ComPAS trial, a cluster-randomised controlled, non-inferiority trial that compares a novel combined protocol for treating uncomplicated acute malnutrition compared to the current standard protocol in South Sudan and Kenya. We will calculate the total economic costs of both protocols from a societal perspective, using accounting data, interviews and survey questionnaires. The incremental cost of implementing the combined protocol will be estimated, and all costs and outcomes will be presented as a cost-consequence analysis. Incremental cost-effectiveness ratio will be calculated for primary and secondary outcome, if statistically significant.

DISCUSSION

We hypothesise that implementing the combined protocol will be cost-effective due to streamlined logistics at clinic level, reduced length of treatment, especially for MAM, and reduced dosages of RUTF. The findings of this economic evaluation will be important for policymakers, especially given the hypothesised non-inferiority of the main health outcomes. The publication of this protocol aims to improve rigour of conduct and transparency of data collection and analysis. It is also intended to promote inclusion of economic evaluation in other nutrition intervention studies, especially for MAM, and improve comparability with other studies.

TRIAL REGISTRATION

ISRCTN 30393230 , date: 16/03/2017.

Micronutrient adequacy is poor, but not associated with stunting between 12-24 months of age: A cohort study findings from a slum area of Bangladesh

The prevalence of stunting among children below 5 years of age is higher in the slum-dwelling population of Bangladesh compared to that in both urban and rural areas. Studies have reported that several factors such as inadequate nutrition, low socio-economic status, poor hygiene and sanitation and lack of maternal education are the substantial predictors of childhood stunting. Almost all these factors are universally present in the slum-dwelling population of Bangladesh. However, few studies have prospectively examined such determinants of stunting among slum populations. In this paper, we reveal the findings of a cohort study with an aim to explore the status of micronutrient adequacy among such vulnerable children and establish its association with stunting along with other determinants. Two-hundred-sixty-five children were enrolled and followed since birth until 24 months of age. We collected anthropometric, morbidity and dietary intake data monthly. We used the 24-hour multiple-pass recall approach to collect dietary intake data from the age of 9 months onward. Micronutrient adequacy of the diet was determined by the mean adequacy ratio (MAR) which was constructed from the average intake of 9 vitamins and 4 minerals considered for the analysis. We used generalized estimating equation (GEE) regression models to establish the determinants of stunting between 12–24 months of age in our study population. The prevalence of low-birth-weight (LBW) was about 28.7% and approximately half of the children were stunted by the age of 24 months. The average micronutrient intake was considerably lower than the recommended dietary allowance and the MAR was only 0.48 at 24 months of age compared to the optimum value of 1. However, the MAR was not associated with stunting between 12–24 months of age. Rather, LBW was the significant determinant (AOR = 3.03, 95% CI: 1.69–5.44) after adjusting for other factors such as age (AOR = 2.12, 95% CI: 1.45–3.11 at 24 months and AOR = 1.97, 95% CI: 1.49–2.59 at 18 months, ref: 12 months) and sex (AOR = 1.98, 95% CI: 1.17–3.33, ref: female). Improving the nutritional quality of complementary food in terms of adequacy of micronutrients is imperative for optimum growth but may not be adequate to mitigate under-nutrition in this setting. Further research should focus on identifying multiple strategies that can work synergistically to diminish the burden of stunting in resource-poor settings.

Upscaling Participatory Action and Videos for Agriculture and Nutrition (UPAVAN) trial comparing three variants of a nutrition-sensitive agricultural extension intervention to improve maternal and child nutritional outcomes in rural Odisha, India: study protocol for a cluster randomised controlled trial

BACKGROUND

Maternal and child undernutrition have adverse consequences for pregnancy outcomes and child morbidity and mortality, and they are associated with low educational attainment, economic productivity as an adult, and human wellbeing. 'Nutrition-sensitive' agriculture programs could tackle the underlying causes of undernutrition.

METHODS/DESIGN

This study is a four-arm cluster randomised controlled trial in Odisha, India. Interventions are as follows: (1) an agricultural extension platform of women's groups viewing and discussing videos on nutrition-sensitive agriculture (NSA) practices, and follow-up visits to women at home to encourage the adoption of new practices shown in the videos; (2) women's groups viewing and discussing videos on NSA and nutrition-specific practices, with follow-up visits; and (3) women's groups viewing and discussing videos on NSA and nutrition-specific practices combined with a cycle of Participatory Learning and Action meetings, with follow-up visits. All arms, including the control, receive basic nutrition training from government community frontline workers. Primary outcomes, assessed at baseline and 32 months after the start of the interventions, are (1) percentage of children aged 6-23 months consuming ≥ 4 out of 7 food groups per day and (2) mean body mass index (BMI) (kg/m2) of non-pregnant, non-postpartum (gave birth > 42 days ago) mothers or female primary caregivers of children aged 0-23 months. Secondary outcomes are percentage of mothers consuming ≥ 5 out of 10 food groups per day and percentage of children's weight-for-height z-score < -2 standard deviations (SD). The unit of randomisation is a cluster, defined as one or more villages with a combined minimum population of 800 residents. There are 37 clusters per arm, and outcomes will be assessed in an average of 32 eligible households per cluster. For randomisation, clusters are stratified by distance to nearest town (< 10 km or ≥ 10 km), and low (< 30%), medium (30-70%), or high (> 70%) proportion of Scheduled Tribe or Scheduled Caste (disadvantaged) households. A process evaluation will assess the quality of implementation and mechanisms behind the intervention effects. A cost-consequence analysis will compare incremental costs and outcomes of the interventions.

DISCUSSION

This trial will contribute evidence on the impacts of NSA extension through participatory, low-cost, video-based approaches on maternal and child nutrition and on whether integration with nutrition-specific goals and enhanced participatory approaches can increase these impacts.

TRIAL REGISTRATION

ISRCTN , ISRCTN65922679 . Registered on 21 December 2016.

Assessment of Micronutrient Status in Critically Ill Children: Challenges and Opportunities

Micronutrients refer to a group of organic vitamins and inorganic trace elements that serve many functions in metabolism. Assessment of micronutrient status in critically ill children is challenging due to many complicating factors, such as evolving metabolic demands, immature organ function, and varying methods of feeding that affect nutritional dietary intake. Determination of micronutrient status, especially in children, usually relies on a combination of biomarkers, with only a few having been established as a gold standard. Almost all micronutrients display a decrease in their serum levels in critically ill children, resulting in an increased risk of deficiency in this setting. While vitamin D deficiency is a well-known phenomenon in critical illness and can predict a higher need for intensive care, serum concentrations of many trace elements such as iron, zinc, and selenium decrease as a result of tissue redistribution in response to systemic inflammation. Despite a decrease in their levels, supplementation of micronutrients during times of severe illness has not demonstrated clear benefits in either survival advantage or reduction of adverse outcomes. For many micronutrients, the lack of large and randomized studies remains a major hindrance to critically evaluating their status and clinical significance.

Feasibility and effectiveness of the baby friendly community initiative in rural Kenya: study protocol for a randomized controlled trial

BACKGROUND

Interventions promoting optimal infant and young child nutrition could prevent a fifth of under-5 deaths in countries with high mortality. Poor infant and young child feeding practices are widely documented in Kenya, with potential detrimental effects on child growth, health and survival. Effective strategies to improve these practices are needed. This study aims to pilot implementation of the Baby Friendly Community Initiative (BFCI), a global initiative aimed at promoting optimal infant and young child feeding practices, to determine its feasibility and effectiveness with regards to infant feeding practices, nutrition and health outcomes in a rural setting in Kenya.

METHODS

The study, employing a cluster-randomized trial design, will be conducted in rural Kenya. A total of 12 clusters, constituting community units within the government's Community Health Strategy, will be randomized, with half allocated to the intervention and the other half to the control arm. A total of 812 pregnant women and their respective children will be recruited into the study. The mother-child pairs will be followed up until the child is 6 months old. Recruitment will last approximately 1 year from January 2015, and the study will run for 3 years, from 2014 to 2016. The intervention will involve regular counseling and support of mothers by trained community health workers and health professionals on maternal, infant and young child nutrition. Regular assessment of knowledge, attitudes and practices on maternal, infant and young child nutrition will be done, coupled with assessment of nutritional status of the mother-child pairs and morbidity for the children. Statistical methods will include analysis of covariance, multinomial logistic regression and multilevel modeling. The study is funded by the NIH and USAID through the Program for Enhanced Research (PEER) Health.

DISCUSSION

Findings from the study outlined in this protocol will inform potential feasibility and effectiveness of a community-based intervention aimed at promoting optimal breastfeeding and other infant feeding practices. The intervention, if proved feasible and effective, will inform policy and practice in Kenya and similar settings, particularly regarding implementation of the baby friendly community initiative.

TRIAL REGISTRATION

ISRCTN03467700 ; Date of Registration: 24 September 2014.

Audiometric thresholds and auditory processing in children with early malnutrition: a retrospective cohort study

CONTEXT AND OBJECTIVE

Malnutrition is one of the causes of changes in cell metabolism. The inner ear has few energy reserves and high metabolism. The aim of this study was to analyze whether malnutrition at an early age is related to impairment of auditory processing abilities and hearing abnormalities.

DESIGN AND SETTING

Retrospective cohort study conducted in a tertiary public hospital.

METHODS

45 children participated, divided as follows: G1, children diagnosed with malnutrition in their first two years of life; G2, children without history of malnutrition but with learning difficulties; G3, children without history of malnutrition and without learning difficulties. Tympanometry, pure-tone audiometry and the Staggered Spondaic Word (SSW) test (auditory processing) were performed. Statistical inferences were made using the Kruskal-Wallis test (α = 5%) and the test of equality of proportions between two samples (α = 1.7%).

RESULTS

None of the 45 children participating in this study presented hearing deficiencies. However, at six of the eight frequencies analyzed, the children in G1 presented hearing thresholds lower than those of the other groups. In the auditory processing evaluation test, it was observed that 100% of the children in G1 presented abnormal auditory processing and that G1 and G2 had similar proportions of abnormalities (P-values: G1/G2 = 0.1; G1/G3 > 0.001; G2/G3 = 0.008).

CONCLUSIONS

Malnutrition at an early age caused lowering of the hearing levels, although this impairment could not be considered to be a hearing deficiency. Every child in this group presented abnormalities in auditory processing abilities.

[Effects of perinatal nutrition on developmental outcomes]

The multifactorial nature of perinatal growth is now well established. The perinatal environment modulates each infant's genetic potential. Antenatal nutrition is dependent on maternal nutrition and is also subject to environmental factors such as tobacco smoke, which can significantly impact infant development. Current neonatal nutritional guidelines, aimed primarily at ensuring good nutrient tolerance, may no longer be optimal. Indeed, they can lead to malnutrition and growth retardation, and attempts to "catch up" through increased protein and calorie intake may have unwanted effects. Current data point to critical time windows during which nutritional optimization might improve infant development. New approches could help to prevent adult diseases of developmental origin.

Effects of neonatal programming on hypothalamic mechanisms controlling energy balance

The prevalence of overweight and obesity in most developed countries has markedly increased during the last decades. In addition to genetic, hormonal, and metabolic influences, environmental factors like fetal and neonatal nutrition play key roles in the development of obesity. Interestingly, overweight during critical developmental periods of fetal and/or neonatal life has been demonstrated to increase the risk of obesity throughout juvenile life into adulthood. In spite of this evidence, the specific mechanisms underlying this fetal/neonatal programming are not perfectly understood. However, it is clear that circulating hormones such as insulin and leptin play a critical role in the development and programming of hypothalamic circuits regulating energy balance. Here, we review what is currently known about the impact of perinatal malnutrition on the mechanisms regulating body weight homeostasis. Understanding these molecular mechanisms may provide new targets for the treatment of obesity.

Efficacy of in-service nutrition training for mid-level providers to improve feeding practices among HIV-positive children in Tanga, Tanzania: study protocol for a cluster randomized controlled trial

BACKGROUND

Feeding practices and child undernutrition can be improved when trained health workers provide proper nutrition counseling to caregivers. However, this important management component is difficult to achieve in countries where trained health workers are limited; Tanzania is no exception. In rural and semi-urban areas, mid-level providers (MLPs) are left to manage diseases such as HIV/AIDS.Training health workers in nutrition has been shown to be an effective intervention among HIV-negative children elsewhere, but no studies have been conducted among HIV-positive children. Furthermore, in Tanzania and other countries with MLPs, no evidence currently exists demonstrating an improvement in nutrition among children who receive health services given by MLPs. This study thus aims to examine the efficacy of nutrition training of MLPs on feeding practices and the nutrition status of HIV-positive children in Tanga, Tanzania.

METHODS/DESIGN

We will conduct a cluster randomized controlled trial in care and treatment centers (CTCs) in Tanga, Tanzania. The CTCs will be the unit of randomization. We will select 16 CTCs out of 32 for this study, of which we will randomly assign 8 to the intervention arm and 8 to the control arm by coin flipping. From the selected CTCs we will attempt to recruit a total of 800 HIV-positive children aged 6 months to 14 years, half of whom will be receiving care and/or treatment in the CTCs of the intervention arm, and the other half of whom will be receiving care and/or treatment in the CTCs of the control arm (400 children in each condition).We will provide nutrition training to MLPs of the CTCs selected for the intervention arm. In this intervention, we will use the World Health Organization guidelines on nutrition training of health workers for HIV-positive children aged 6 months to 14 years. The trained MLPs will then provide tailored nutrition counseling to caregivers of children being treated at the 8 CTCs of the intervention arm. We will measure nutrition status and child feeding practices monthly for a total of six months.

CONCLUSIONS

Results of this trial will help expanding undernutrition interventions among HIV-positive children in Tanzania and other countries.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN65346364.

Standardised parenteral nutrition

Parenteral nutrition (PN) has become an integral part of clinical management of very low birth weight premature neonates. Traditionally different components of PN are prescribed individually considering requirements of an individual neonate (IPN). More recently, standardised PN formulations (SPN) for preterm neonates have been assessed and may have advantages including better provision of nutrients, less prescription and administration errors, decreased risk of infection, and cost savings. The recent introduction of triple-chamber bag that provides total nutrient admixture for neonates may have additional advantage of decreased risk of contamination and ease of administration.

[Dietary factors and their relation to appetite in children under two years with mild malnutrition]

Malnutrition is conditioned by a series of factors, among them the dietary factors, which include appetite, eating behaviors and habits. In order to assess these factors, the following objective was pursued: describe the dietary factors and their relation to appetite in children under two years of age with mild malnutrition. A correlational study was conducted. The sample consisted of all children under two years of age (n = 168) diagnosed with primary (mild) malnutrition, who attended consultation at the Centro de Atención Nutricional Infantil Antímano, CANIA, during the period 2000-2008. The results showed intake of energy and macronutrients was lower than the individual requirement; iron intake < 85% of the requirement, in accordance with the Recommended Dietary Allowances (RDA) in over 50% of the sample; weekly consumption of vegetables (57%) and miscellaneous (66%) was inadequate; inadequate intake of formula and whole milk in more than 60%; 9% were exclusively breastfed during the first six months; 64% lacked a regular eating place; in child-caregiver interaction during mealtimes, more than half of the children showed rebellious behavior and caregivers were permissive. Protein adequacy, vegetable and whole milk consumption frequency, preparation type, identification of refusals and preferences, place and duration of meals, and child-caregiver interaction at mealtimes were significantly associated with appetite; if we consider this last one as a guide and we try to modify inadequate eating behaviors and habits, we will generate an impact over the child appetite that could improve the food consumption and prevent malnutrition.

Retinol-binding protein 4 in young men with low versus normal birth weight: physiological response to short-term overfeeding

Retinol-binding protein 4 (RBP4) is a plasma protein which is elevated in obesity and type 2 diabetes. We aimed to investigate whether RBP4 represents a mechanism underlying the associations between low birth weight (LBW), high-fat diet, and insulin resistance. Forty-six young, lean men with low (n = 20) or normal (n = 26) birth weight underwent a 5-day high-fat high-calorie (HFHC) dietary intervention. In vivo glucose metabolism was assessed by euglycemic-hyperinsulinemic clamp, glucose tracer and intravenous glucose tolerance test techniques. Body composition was measured by a dual-energy x-ray absorptiometry scan, and plasma RBP4 by an enzyme-linked immunosorbent assay. RBP4 was not associated with birth weight, but with BMI (β = 0.9 µg/ml (0.08; 1.8) (95% confidence interval), P = 0.03) and plasma levels of low-density lipoprotein cholesterol (β = 5.3 µg/ml (1.9; 8.7), P = 0.03) and triglycerides (β = 15.4 µg/ml (9.5; 21.3), P < 0.001). Under baseline diet conditions, RBP4 was associated with decreased disposition index (D(i)) (β = -2.4% (-4.5%; -0.2%), P = 0.04) and increased basal hepatic glucose production rate (HGP) (β = 0.02 mg kg(-1) min(-1) (0.002; 0.04), P = 0.03), but not associated with peripheral glucose disposal rate or hepatic insulin resistance index. RBP4 levels were not influenced by overfeeding or related to peripheral and hepatic insulin resistance provoked by the dietary intervention. In conclusion, plasma RBP4 in young men associates with components of the metabolic syndrome, but is not determined by birth weight and seems not to be involved in short-term high-fat diet-induced insulin resistance.

Effects of prenatal and early life malnutrition: evidence from the Greek famine

This paper examines the long run education and labor market effects from early-life exposure to the Greek 1941-1942 famine. Given the short duration of the famine, we can separately identify the famine effects for cohorts exposed in utero, during infancy and at 1 year of age. We find that adverse outcomes due to the famine are largest for infants. Further, in our regression analysis we exploit the fact that the famine was more severe in urban than in rural areas. Consistent with our prediction, we find that urban-born cohorts show larger negative impacts on educational outcomes than rural-born cohorts.

Content validation of the infant malnutrition and feeding checklist for congenital heart disease: a tool to identify risk of malnutrition and feeding difficulties in infants with congenital heart disease

Infants with congenital heart disease (CHD) have a high prevalence of feeding difficulties and malnutrition. Early intervention decreases morbidity and long-term developmental deficits. The purpose of this study was to develop and establish the content validity of a screening checklist to identify infants with CHD at risk of feeding difficulties or inadequate nutritional intake for timely referral to a feeding specialist or dietitian. The Delphi method was used, and expert participants reached consensus on 24 risk indicators. This study is the first step in establishing the validity and reliability of a screening tool for early intervention of feeding difficulties and inadequate nutritional intake in infants with CHD.

QT-interval dispersion in malnourished children

BACKGROUND

Little is known about the electrocardiographic (ECG) QT interval and its variability in malnourished children.

HYPOTHESIS

The study of the QT interval and its dispersion in malnourished children was undertaken to determine whether the QT interval and its variability are increased in these children.

METHODS

In 40 children (20 malnourished and 20 controls) aged 12.2 +/- 14.4 months (23 male) a conventional ECG was performed for computing heart rate, heart rate variability, corrected QT interval, and QT-interval dispersion. A blood sample was obtained for measuring hemoglobin, hematocrit, plasma protein, and plasma electrolytic concentrations.

RESULTS

Corrected heart rate, heart rate variability, and QT Interval were similar in both groups. When compared with the control group, the malnourished children had greater corrected QT-interval dispersion, and that dispersion was more accentuated in the precordial leads. They also had repolarization abnormalities (flattened or inverted T waves and U waves). Hemoglobin, hematocrit, plasma protein, and plasma electrolytic concentrations were lower in the malnourished children. However, the ECG findings showed no statistically significant relationship with either the blood parameters, the severity or type of malnutrition, and the size or the weight of the children.

CONCLUSIONS

QT-interval dispersion is increased in malnourished children and the dispersion is more accentuated in the precordial leads.

Perinatal malnutrition programs sustained alterations in nitric oxide released by activated macrophages in response to fluoxetine in adult rats

OBJECTIVE

Nutritional restriction during lactation has long-term consequences on the functioning of neuroimmune systems. Receptors and transporter serotonin (5-HT) are present in macrophages and may influence their role. This study evaluated nitric oxide release by alveolar macrophages (AMs) in adult control rats and rats malnourished during lactation in response to different fluoxetine (FLX) concentrations and 5-HT(1A) and 5-HT(1B) agonists at different times.

METHODS

Male Wistar rats were distributed into two groups according to maternal diet during lactation: a control group of 12 rats whose dams had received a 23% protein diet and a malnourished group of 12 rats whose dams had received an 8% protein diet. After weaning, all rats received a 23% protein diet. On the 90th day after birth, nitric oxide (NO) release kinetics was measured in supernatants of AMs cultured with FLX. The NO release following the adjunction of serotoninergic agonists was also quantified.

RESULTS

The malnourished rats weighed less at weaning (control rats = 15.3 +/- 0.4 g, malnourished rats = 11.8 +/- 0.4 g); this difference persisted until 90 days of life (control rats = 355.4 +/- 8.6 g; malnourished rats = 267.8 +/- 7.9 g). In the presence of 10(-6)M FLX, NO release by AMs in control rats was lower. The addition of agonists did not interfere with NO release by AMs in control rats. NO release by AMs from malnourished rats was modified neither by FLX nor by agonists. As a consequence of malnutrition, there were lower numbers of cells and AMs in the bronchoalveolar lavage fluid, and cell viability and NO release by AMs were impaired.

CONCLUSIONS

Nutritional manipulation in the perinatal period seems to interfere with the functional programming of macrophages; it also seems to affect their serotoninergic regulation through adulthood.

Neonatal programming of neuroimmunomodulation--role of adipocytokines and neuropeptides

Programming is an epigenetic phenomenon by which nutrition, environment and stress acting in a critical period earlier in life change the organism's development. This process was evolutionarily selected as an adaptive tool for the survival of organisms living in nutritionally deficient areas and submitted to stressful conditions. Thus, perinatal malnutrition turns on different genes that provide the organism with a thrifty phenotype. In conditions of abundant supply of nutrients, those programmed organisms can be at risk of developing metabolic diseases (obesity, dyslipidemia, diabetes and hypertension). How nutrition or neonatal stress can program the immune system is less well known. Here, we discuss some of the hormonal and metabolic changes that occur in mothers and neonates and how those factors can imprint hormonal or metabolic changes that program neuroimmunomodulatory effects. Some of these changes involve thyroid hormones, leptin, insulin, glucocorticoids and prolactin as potential imprinting factors. Most of them can be transferred through the milk and may change with malnutrition or stress. We discuss the programming effects of these hormones upon body weight, body composition, insulin action, thyroid, adrenal and immune and inflammatory responses, with special emphasis on leptin, a cytokine that seems to play a central role in these events.

Nutritional tryptophan restriction and the role of serotonin in development and plasticity of central visual connections

Tryptophan is an essential amino acid and metabolic precursor of serotonin. Serotonin is both a classical neurotransmitter and a signaling molecule that plays crucial roles in the development of neural circuits and plasticity. The specification of neural circuits in rodents occurs during the postnatal period with conspicuous influence of environmental factors including the nutritional status. Sensory, motor and cognitive systems develop during a critical period, a time window that is crucial to the use-dependent organization of neuronal circuits. This review presents recent experimental findings that disclose some mechanism of tryptophan- and serotonin-dependent plasticity in the developing and adult brain.

Subclinical hypovitaminosis D among exclusively breastfed young infants

OBJECTIVE

To determine Vitamin D status of mother-newborn diads at birth and of their exclusively breastfed (EBF) infants at 3 months.

DESIGN

Longitudinal study.

METHODS

Exclusively breastfed infants born at term with birth weight > 2.5 kg to normal, healthy mothers followed till 3 months. Serum calcium, phosphorous, heat labile alkaline phosphatase (HLAP) and 25(OH)D estimated in 42 mother / cord blood diads and in 35 (EBF) infants followed up at 3 months. Twenty five (OH)D < 15 ng/mL was considered low and 15 to 25 ng/mL low to normal.

RESULTS

Ca, P, HLAP were significantly higher in cord blood (P < 0.001) but mean 25 (OH)D, 19.36 ng/mL was comparable to maternal level of 22.9 ng/mL (r = 0.82, P < 0.001). At 3 months only HLAP was significantly higher compared to cord blood. Higher 25 (OH)D at 3 months correlated with higher 25 (OH)D values in cord blood (r = +0.616, P < 0.001) as well as higher antenatal maternal levels (r = + 0.552, P < 0.001). Serum 25 (OH)D values < 25 ng/mL was observed in 50 % mothers, 62 % cord blood specimens and 80 % infants at 3 months.

CONCLUSIONS

Subnormal maternal vitamin D status is associated with vitamin D deficiency in newborns and persists in exclusively breastfed infants.

Programmed metabolic syndrome: prenatal undernutrition and postweaning overnutrition

Maternal nutrient restriction results in intrauterine growth restriction (IUGR) newborns that develop obesity despite normal postweaning diet. The epidemic of metabolic syndrome is attributed to programmed "thrifty phenotype" and exposure to Western diets. We hypothesized that programmed IUGR newborns would demonstrate greater susceptibility to obesity and metabolic abnormalities in response to high-fat diet. From day 10 to term gestation and lactation, control pregnant rats received ad libitum (AdLib) food, whereas study rats were 50% food restricted (FR). Cross-fostering techniques resulted in three offspring groups: control (AdLib/AdLib), FR during pregnancy (FR/AdLib), and FR during lactation (AdLib/FR). At 3 weeks, offspring were weaned to laboratory chow or high-fat calorie diet (9% vs. 17% calorie as fat). Body composition, appetite hormones, and glucose and lipid profiles were determined in 9-mo-old male and female offspring. High-fat diet had no effect on body weight of AdLib/AdLib, but significantly increased weights of FR/AdLib and AdLib/FR offspring. High-fat diet significantly increased body fat, reduced lean body mass, and accentuated plasma leptin but not ghrelin levels in both sexes in all groups. In males, high-fat diet caused a significant increase in glucose levels in all three groups with increased insulin levels in AdLib/AdLib and AdLib/FR, but not in FR/AdLib. In females, high-fat diet had no effect on glucose but significantly increased basal insulin among all three groups. High-fat diet caused hypertriglyceridemia in all three groups although only food-restricted females exhibited hypercholesterolemia. Sex and offspring phenotype-associated effects of high-fat diet indicate differing pathophysiologic mechanisms that require specific therapeutic approaches.

[Determinants of weight and linear growth deficits in children under two years of age]

OBJECTIVE

To identify determinants of protein-energy malnutrition resulting in weight and linear growth deficits in children.

METHODS

A cross-sectional study was carried out among 1,041 children (under two years of age) from 10 municipalities in Bahia, Northeastern Brazil, during 1999-2000. Both logistic regression and a hierarchical approach were used to identify factors associated with the anthropometric measures.

RESULTS

The basic determinant found in the final model for linear growth retardation was having up to two household appliances (OR=2.9; 95% CI: 1.74-4.90); as an underlying determinant, not attending prenatal visits (OR=2.7; 95% CI: 1.47-4.97); and, among immediate determinants were low birth weight (OR=3.6; 95% CI: 1.72-7.70) and reported hospitalization within 12 months before the interview (OR=2.4; 95% CI: 1.42-4.10). Determinants of weight deficit at the basic, underlying and immediate levels were: per capita monthly income of less than one-fourth of the minimum wage (OR=3.4; 95% CI: 1.41-8.16), not attending prenatal visits (OR=2.1; 95% CI: 1.03-4.35) and low birth weight (OR=4.8; 95% CI: 2.00-11.48) respectively.

CONCLUSIONS

Children's weight and linear deficits were accounted for the overlapping of poor material living conditions, limited access to health care and disease burden. Interventions aimed at improving living conditions and better access to health care programs are strategies towards equity in children's health and nutrition.

Children recovered from malnutrition exhibit normal insulin production and sensitivity

Protein-energy malnutrition promotes adaptive hormonal changes that result in stunting. A previous study showed that stunted children had increased insulin sensitivity and diminished pancreatic beta-cell function. The objectives of the present study were to analyse the glucose, insulin, homeostasis model assessment of insulin sensitivity (HOMA-S) and homeostasis model assessment of pancreatic beta-cell function (HOMA-B) levels after nutritional recovery. The recovered group (n 62) consisted of malnourished children after treatment at a nutrition rehabilitation centre. At the beginning of treatment their age was 2.41 (sd 1.28) and 2.31 (sd 1.08) years, weight-for-age Z score - 2.09 (sd 0.94) and - 2.05 (sd 0.55) and height-for-age Z score - 1.85 (sd 1.11) and - 1.56 (sd 0.90), for boys and girls respectively. The control group consisted of well-nourished children without treatment (n 26). After treatment, boys of the recovered group gained 1.29 (sd 1.06) Z scores of height-for-age and 1.14 (sd 0.99) Z scores of weight-for-age, and girls, 1.12 (sd 0.91) and 1.21 (sd 0.74) Z scores respectively. No differences were found between control and recovered groups in insulin levels for boys (P = 0.704) and girls (P = 0.408), HOMA-B for boys (P = 0.451) and girls (P = 0.330), and HOMA-S (P = 0.765) for boys and girls (P = 0.456) respectively. The present study shows that the changes observed previously in glucose metabolism and insulin were reverted in children who received adequate treatment at nutritional rehabilitation centres and showed linear catch-up.

Abnormal flash visual evoked potentials in malnourished infants: an evaluation using principal component analysis

OBJECTIVE

To characterize the morphology of flash visual evoked potentials (fVEPs) obtained from infants hospitalized with severe, chronic malnutrition (marasmus).

METHODS

A covariance-based principal component analysis with Promax factor rotation was applied to fVEPs obtained from malnourished infants and age-matched control subjects.

RESULTS

The analysis suggests the presence of a late positive complex in the fVEP, with at least one of its components being significantly diminished in marasmic infants. The N3 component was also diminished in marasmic infants. Following remediation, the marasmic group no longer differed with respect to these components. However, an abnormally large late, positive deflection was evident at discharge.

CONCLUSIONS

The fVEP morphology of infants hospitalized with severe malnutrition was found to be significantly different from age-matched controls. Moreover, although there was evidence of recovery following remediation, fVEPs continued to show abnormality at discharge, suggesting the possibility that nutritional rehabilitation did not fully eliminate the physiological deficit.

SIGNIFICANCE

Malnourishment during early infancy results in altered neurophysiological functioning, possibly in cortical areas responsible for higher order visual processing.

Stress/aggressiveness-induced immune changes are altered in adult rats submitted to neonatal malnutrition

BACKGROUND/AIMS

Neonatal malnutrition induces metabolic and endocrine changes that have beneficial effects on the neonatal in the short term but, in the longer term, these alterations lead to maladaptations. We investigated the effect of neonatal malnutrition on immune responses in adult rats submitted or not to an aggressiveness test.

METHODS

Male Wistar rats were distributed to one of two groups according to their mothers' diet during lactation: the well-nourished group (group C, n = 42, receiving 23% of protein) and the malnourished group (group MN, n = 42, receiving 8% of protein). After weaning, all rats received normoproteic diet. Ninety days after birth, each group was subdivided into three subgroups: control rats (n = 14, respectively), aggressive rats (n = 14, respectively) and rats receiving foot shock (FS; n = 14, respectively). Plasma corticosterone concentration was measured after FS sessions. Leukocyte counts and humoral immunity were evaluated.

RESULTS

In neonatal malnourished animals, FS-induced stress reduced plasma corticosterone concentration. Intraspecific aggressiveness induced alterations in leukocyte counts and antibody titers 7 and 15 days after immunization. Neonatal malnourished animals showed no changes in the immune parameters evaluated.

CONCLUSIONS

Expression of intraspecific aggressiveness activates the immune system. Neonatal malnutrition seems to have a long-lasting effect on components of both neuroendocrine and immune functions.

[Social determinants, feeding practices and nutritional consequences of intestinal parasitism in young children]

INTRODUCTION

Studies on intestinal intestinal parasitism in children under 2 years of age have rarely been performed. The nutritional consequences and feasibility of parasite prevention justify the current study.

OBJECTIVES

The study was undertaken with 3 goals: (1) to identify the prevalence of pathogenic intestinal parasites (PIP), (2) to determine the social factors, sanitary conditions and nutritional practices that predict PIP, and (3) to evaluate PIP effects on infant nutritional status.

MATERIALS AND METHODS

All mothers with children under 18 months of age and living in an urban community of coastal Colombia were invited to participate in the PIP study. A fecal sample was obtained from each of 136 children; they represented 62% of the total 7-18 month-old population in the community. Presence of intestinal parasites was identified by direct microscopy and confirmed by a concentration test (Ritchie-Frick procedure). Logistic regressions were used to predict presence of PIP. The Z scores of length-for-age (< -2 SD-chronic malnutrition) and weight-for-length (< -2 SD-acute malnutrition) and covariance analysis were done to detect associations between intestinal parasitism and nutritional status.

RESULTS

Of the 136 children, 30.6% were infected; 26.2% had helminth infections (A. lumbricoides, T. trichiura, S. stercoralis), 14.9% had protozoan infections (G. lamblia) and 11.8% had mixed infections. Wasting and stunting were present in 2.9% and 12.5%, respectively. Lack of sanitary toilet facilities and low maternal education were related to mixed infections and presence of helminths (p < 0.05). Weaned children were at greater risk of mixed infections (Odds Ratio (OR) 6.5; 90% CI: 1.9-21.5) and of G. lamblia infections (OR: 2.89; 90% CI: 1.0-8.34). Children infected with T. trichiura and with mixed infections were more likely to show wasting (p < 0.05).

CONCLUSION

The high infections in young children indicate that they be included in periodic antiparasitic chemotherapy. Burden of disease associated to intestinal parasitism may be reduced if breastfeeding is continued beyond 6 months of age.

Early Malnutrition and Metabolic Abnormalities Later in Life

Early malnutrition has been significantly associated with chronic diseases later in life. The finding of metabolic abnormalities in individuals with malnutrition in fetal life and early in postnatal life may have important public health implications in developing countries, although only a few studies have examined the relationship between body weight at the first year of life and later metabolic abnormalities. We assessed the effects of malnutrition during the first year of life (independent of birth weight) on several metabolic parameters in young men. The areas under the curves of glucose and insulin were significantly higher in 52 individuals with a history of malnutrition during the first year of life (cases) than in controls. An insulin sensitivity index was derived and was lower in cases than in controls. In cases, the insulin sensitivity index worsened as body mass index (BMI) increased within the normal range of BMI. A euglycemic insulin clamp as well as an abdominal CT scan were performed in 26 cases and 27 controls. Higher levels of abdominal adipose tissue were more detrimental to insulin sensitivity in previously malnourished individuals. This study suggests that metabolic programming early in life is not restricted to intrauterine growth. We conclude that early malnutrition in extrauterine life independent of birth weight has an adverse effect on insulin sensitivity, glucose tolerance, and lipid profile in young men. This appears to worsen as body mass index increases, even within "normal" limits.

Dietary diversity, child nutrition and health in contemporary African communities

Many infants in sub-Saharan Africa (SSA) begin to receive cereal-based supplemental feeds well before the age (6 months) recommended for the introduction of 'safe and nutritionally adequate' complementary foods, or in rarer instances, do not receive these until the second year. The diets offered are monotonous and bulky, and rarely cover the shortfall left by breast milk in providing the energy and nutrients required to support rapid growth, build nutrient stores and assure resistance to infection. The pattern of growth and prevalence of malnutrition observed from birth through the first 5 years in SSA are suggestive of the nutrient inadequacies of the diet and the experience of infection. However, it is difficult to link poor growth and specific nutrient deficiencies in epidemiological studies because multiple nutrients are required for growth and deficiencies usually involve several nutrients. Moreover, accurate measurement of nutrient intakes is no small challenge. In this regard, qualitative and easier-to-measure characteristics of diet which are associated with nutrient adequacy could serve as alternative determinant factors in studies looking at causes of malnutrition. Dietary diversity is proposed as a candidate indicator of food security and predictor of nutritional status, but there is need for further research to standardize definitions and methodology before it can be applied widely.

Efficacy of zinc supplementation on the severity and duration of diarrhea in malnourished Turkish children

BACKGROUND

Intervention trials have shown that zinc may be efficacious in treating acute diarrhea in children of developing countries. A double-blind placebo-controlled study was designed to evaluate the effects of zinc supplementation on the clinical course and duration of diarrhea in malnourished Turkish children.

METHODS

The study group comprised 40 subjects with low zinc levels (Group 1a) and 52 subjects with normal zinc levels (Group 1b). The control group was also comprised of two subgroups: 36 subjects with low zinc levels (Group 2a) and 54 subject with normal zinc levels (Group 2b). Forty-three percent of children in the study group and 40% of controls had low serum zinc levels (<14 micromol/L), and 43% of subjects in both groups had very low serum zinc concentrations (<10 micromol/L). The study group were given 20 mg zinc per day for 10 days and the control group were given 750 mg glucose per day as a placebo for 10 days.

RESULTS

The mean duration of diarrhea was shorter and the percentage of children with consistent diarrhea for more than 3-7 days was lower in the study subgroups than in the control subgroups. Prolonged diarrhea was present in 12% of children in the study group, and in 44% and 37% of children in the hypozincemic and normozincemic control subgroups, respectively. The was no significant difference among the four subgroups of children in the number of cases with post-enrollment diarrhea of a duration of>14 days. Stool frequency over the first 4 days after enrollment was lower in children in the study group.

CONCLUSION

It was concluded that zinc supplementation in malnourished children with acute diarrhea may reduce the severity and duration of diarrhea, especially in children with low zinc levels.

Losses of vitamin A and E in parenteral nutrition suitable for premature infants

OBJECTIVE

To assess the bioavailability of vitamins A and E administered parenterally with either water-soluble or lipid-soluble preparations.

STUDY DESIGN

A water soluble preparation (MVI Pediatric) administered with a glucose-amino acid solution and a lipid soluble preparation (Vitalipid N Infant) infused with a lipid emulsion were subjected to phototherapy light, different flow rates, light protection, different tubing materials and tubing sizes, and concentrations in the effluents were determined.

RESULTS

Recovery of retinol in glucose-amino acid solution was poor under all conditions (16-30% without; 21-42% with light protection tubing) and increased to 61% with polyethylene and to 44% with polyurethane tubings. Polyurethane tubings with reduced volume improved retinol delivery to 56%. Retinylpalmitate (Vitalipid) losses were low, with recovery of 86 and 77% with and without light protection, respectively. Recoveries of alpha-tocopherylacetate in GLUC-AA were 103-107% without and 94-102% with light protection and of alpha-tocopherol in LIPID 89% without and 85% with light protection.

CONCLUSIONS

Parenteral vitamin A delivery is improved by the infusion of retinylpalmitate with lipids. Light protecting tubings provide only a marginal benefit with artificial light and none with phototherapy light. Polyethylene and polyvinylchloride tubings adsorb less retinol than polyurethane tubings. Small tubing diameters resulting in higher flow rates enhance retinol delivery.

Early diet and growth: impact on ageing

The modification of ageing by nutritional intervention is well recognised. Post-weaning diet restriction is the only widely reproducible method to slow ageing, but the effects of prenatal and preweaning diet restriction have been less well characterised. There is some evidence that diet restriction instituted in utero or shortly after birth may have an opposite effect and be associated with increased ageing, and recent work suggests that it may shorten lifespan. Interest in this area has been rekindled by the growing body of epidemiological evidence showing that a number of age-related diseases are associated with poor growth and inadequate nutrition in early life. The relevance of this association to structural and functional ageing changes in different systems is now being considered. Work on musculo-skeletal ageing has demonstrated that loss of muscle strength and bone mass is greater in individuals who did not grow well in early life, and a range of studies suggests that maternal, developmental and nutritional factors are important. The underlying mechanisms remain speculative, and it remains to be determined whether they are system-specific or universal throughout the body. A new cohort of subjects aged between 60 and 70 years is being established to investigate how genetic factors interact with growth and nutritional influences to programme musculo-skeletal ageing in later life.

Early nutrition and later adiposity

The objective was to review whether nutrition during pregnancy and the first 3 y of life predisposes individuals to be fatter as adults. The roles of undernutrition, overnutrition and breastfeeding were considered. The evidence that poor nutrition in early life is a risk factor for increased fatness later in life is inconclusive. Overnutrition, as proxied by high birthweight or gestational diabetes, on the other hand, is associated with subsequent fatness. Two large, well-conducted studies in developed countries suggest that breastfeeding has a protective effect. Nutrition in early life has a demonstrable but small impact on adult obesity.

Echocardiographic evaluation of cardiac functions and left ventricular mass in children with malnutrition

OBJECTIVE

This study was undertaken to assess the left ventricular mass (LV Mass) and systolic and diastolic functions of the left ventricle in children with protein energy malnutrition (PEM).

METHODOLOGY

Thirty children, aged between 2 months and 2 years with PEM (four kwashiorkor, seven marasmic- kwashiorkor, 19 marasmus), and 17 healthy, age-matched children, using Doppler echocardiography were studied.

RESULTS

The mean LV Mass in the patients was lower than that in the controls (14.5 +/- 5.2 vs 19.8 +/- 4.7 g, P < 0.05). However, the LV Mass/body surface area was not different in the patients with PEM and in the control group (52 +/- 9.2 vs 53.9 +/- 8.2g/m(2), P > 0.05), indicating that LV Mass was reduced in proportion to decrease in body size in malnutrition. Left ventricular septal and posterior wall thickness in PEM were also lower than that in the controls, and the most significant reduction in the LV Mass, septal and posterior wall thickness were found in the kwashiorkor group. Cardiac output was reduced in proportion to decrease in body size in the patient group (1.6 +/- 0.5 vs 2.1 +/- 0.8 L/min, P < 0.05), therefore cardiac index was not significantly different between the patients and the control subjects (5.9 +/- 1.4 vs 5.7 +/- 1.6 L/min/m(2), P > 0.05). Systolic function indices including ejection fraction, fractional shortening, and diastolic function indices were not significantly different in the groups.

CONCLUSIONS

We demonstrated that LV Mass and cardiac output were reduced in proportion to decrease in body size in patients with PEM, and LV systolic and diastolic functions were preserved in atrophic hearts.

Maternal sensitivity in a developing society: the context of urban poverty and infant chronic undernutrition

This study focuses on young children's chronic undernutrition and its association with maternal sensitivity, sociodemographic variables, children's play, and problem-solving measures. Data were obtained with home observations and laboratory procedures on 85 mothers and infants (M age = 18 months) in a low-income urban population in Santiago, Chile. Maternal sensitivity was correlated with maternal education, maternal weight, and marital satisfaction. Observed in a variety of maternal roles, maternal sensitivity was also significantly associated with children's nutritional status, attachment security, and mastery behavior. These findings demonstrate the relevance of the maternal sensitivity construct outside industrialized societies and underline the need for intervention strategies to extend beyond nutritional supplementation to address deficits of maternal care associated with specific caregiver's roles.