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Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Mark J Manary
- Department of Community Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - Indi Trehan
- Department of Paediatrics and Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.,Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA.,Partners In Health - Liberia, Harper, Liberia
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Versloot CJ, Voskuijl W, van Vliet SJ, van den Heuvel M, Carter JC, Phiri A, Kerac M, Heikens GT, van Rheenen PF, Bandsma RHJ. Effectiveness of three commonly used transition phase diets in the inpatient management of children with severe acute malnutrition: a pilot randomized controlled trial in Malawi. BMC Pediatr 2017; 17:112. [PMID: 28446221 PMCID: PMC5406940 DOI: 10.1186/s12887-017-0860-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2016] [Accepted: 04/05/2017] [Indexed: 11/26/2022] Open
Abstract
Background The case fatality rate of severely malnourished children during inpatient treatment is high and mortality is often associated with diarrhea. As intestinal carbohydrate absorption is impaired in severe acute malnutrition (SAM), differences in dietary formulations during nutritional rehabilitation could lead to the development of osmotic diarrhea and subsequently hypovolemia and death. We compared three dietary strategies commonly used during the transition of severely malnourished children to higher caloric feeds, i.e., F100 milk (F100), Ready-to-Use Therapeutic Food (RUTF) and RUTF supplemented with F75 milk (RUTF + F75). Methods In this open-label pilot randomized controlled trial, 74 Malawian children with SAM aged 6–60 months, were assigned to either F100, RUTF or RUTF + F75. Our primary endpoint was the presence of low fecal pH (pH ≤ 5.5) measured in stool collected 3 days after the transition phase diets were introduced. Secondary outcomes were duration of hospital stay, diarrhea and other clinical outcomes. Chi-square test, two-way analysis of variance and logistic regression were conducted and, when appropriate, age, sex and initial weight for height Z-scores were included as covariates. Results The proportion of children with acidic stool (pH ≤5.5) did not significantly differ between groups before discharge with 30, 33 and 23% for F100, RUTF and RUTF + F75, respectively. Mean duration of stay after transitioning was 7.0 days (SD 3.4) with no differences between the three feeding strategies. Diarrhea was present upon admission in 33% of patients and was significantly higher (48%) during the transition phase (p < 0.05). There was no significant difference in mortality (n = 6) between diets during the transition phase nor were there any differences in other secondary outcomes. Conclusions This pilot trial does not demonstrate that a particular transition phase diet is significantly better or worse since biochemical and clinical outcomes in children with SAM did not differ. However, larger and more tightly controlled efficacy studies are needed to confirm these findings. Trial registration ISRCTN13916953 Registered: 14 January 2013.
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Affiliation(s)
- Christian J Versloot
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Wieger Voskuijl
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Sara J van Vliet
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Meta van den Heuvel
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Jane C Carter
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Ajib Phiri
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Marko Kerac
- Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK.,Leonard Cheshire Disability & Inclusive Development Centre, Department of Epidemiology & Public Health, University College London, London, UK
| | - Geert Tom Heikens
- Department of Pediatrics and Child Health, College of Medicine, Blantyre, Malawi
| | - Patrick F van Rheenen
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands
| | - Robert H J Bandsma
- Department of Pediatric Gastroenterology, Hepatology and Nutrition, University of Groningen, University Medical Center Groningen, Hanzeplein 1, 9700 RB, Groningen, The Netherlands.
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Spoelstra MN, Mari A, Mendel M, Senga E, van Rheenen P, van Dijk TH, Reijngoud DJ, Zegers RGT, Heikens GT, Bandsma RHJ. Kwashiorkor and marasmus are both associated with impaired glucose clearance related to pancreatic β-cell dysfunction. Metabolism 2012; 61:1224-30. [PMID: 22386944 DOI: 10.1016/j.metabol.2012.01.019] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 01/19/2012] [Accepted: 01/19/2012] [Indexed: 10/28/2022]
Abstract
Severe malnutrition is a major health problem in developing countries and can present as kwashiorkor or marasmus. Kwashiorkor is associated with septicaemia, profound metabolic changes including hepatic steatosis, altered protein metabolism and increased oxidative stress. Limited data suggest that children with kwashiorkor have an impaired glucose tolerance and insulin secretion. Our objective was to determine glucose tolerance in children with kwashiorkor compared to marasmus and its relation to insulin secretion and sensitivity. Six children with kwashiorkor and 8 children with marasmus were studied. We were also able to include 3 healthy children for comparison. They received a primed (13 mg/kg), constant infusion (0.15 mg/kg/min) of [6,6-(2)H(2)]glucose for 4 h with serial blood sampling. In addition, an oral glucose tolerance test (OGTT) was performed with labeled 10 mg/g [U-(13)C]glucose. Glucose clearance was determined using mathematical modeling. Glucose clearance rates during the OGTT were -392 (range 309) mL/kg in children with kwashiorkor, -156 (426) mL/kg in marasmus and 279 (345) mL/kg in the control group. Glucose clearance rates correlated with plasma albumin concentrations (r=0.67, P=.001). Insulin responses were strongly impaired in both kwashiorkor and marasmus. There was no indication of peripheral or hepatic insulin resistance in the malnourished groups. We show that glucose clearance rates are affected in both children with marasmus as well as kwashiorkor, which correlate with plasma albumin concentrations. The disturbed glucose clearance in malnutrition is related to an impairment in insulin availability.
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Affiliation(s)
- Martijn N Spoelstra
- Center for Liver, Digestive and Metabolic Diseases, University Medical Center Groningen, Groningen, The Netherlands
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Smith E, Molyneux E, Heikens GT, Foster H. Acceptability and practicality of pGALS in screening for rheumatic disease in Malawian children. Clin Rheumatol 2011; 31:647-53. [PMID: 22183175 DOI: 10.1007/s10067-011-1901-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2011] [Accepted: 11/26/2011] [Indexed: 11/28/2022]
Abstract
The pGALS (paediatric Gait, Arms, Legs, Spine) Musculoskeletal (MSK) screen is validated in English-speaking school-aged children and has been shown to be useful in acute paediatric practice in the UK. The aim of this study is to evaluate the practicality and acceptability of pGALS in children in an acute hospital setting in Malawi. School-aged inpatients and children presenting to the Queen Elizabeth Hospital Blantyre, Malawi, participated. Practicality (time taken, degree of completion) and patient/parent assessed acceptability (time take, discomfort) were assessed using a 'smiley face' visual analogue scale. Fifty-one children (median age 8 years) were assessed; 23 out of 51 (45%) in the emergency department and the remainder were inpatients. Most presentations were infection or trauma related (n = 35, 69%). Practicality of pGALS was good [median time to complete pGALS--4 min (range 1.8-7.4)] and completed in 48 out of 51 children (94%). Acceptability was high; 98% of parents considered the time taken to be acceptable, 84% of children deemed little/no additional discomfort. Abnormalities using pGALS were found in 21 out of 51 (41%), mostly in the lower limbs. The pGALS MSK screen was practical and acceptable in this acute setting. Abnormal findings were common.
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Affiliation(s)
- Eve Smith
- Paediatric Rheumatology, Great North Children's Hospital, Newcastle upon Tyne NE1 4LP, England, UK.
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van den Heuvel M, Blencowe H, Mittermayer K, Rylance S, Couperus A, Heikens GT, Bandsma RHJ. Introduction of bubble CPAP in a teaching hospital in Malawi. ACTA ACUST UNITED AC 2011; 31:59-65. [PMID: 21262111 DOI: 10.1179/1465328110y.0000000001] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) is relatively inexpensive and can be easily taught; it therefore has the potential to be the optimal respiratory support device for neonates in developing countries. OBJECTIVE The possibility of implementing bubble CPAP in a teaching hospital with a large neonatology unit but very limited resources was investigated. METHODS A CPAP system was developed consisting of a compressor, oxygen concentrator, water bottle to control the pressure and binasal prongs. Neonates with birthweights between 1 and 2·5 kg with persistent respiratory distress 4 hours after birth were eligible for bubble CPAP. RESULTS In the 7-week introduction period from 11 March until 27 April 2008, 11 neonates were treated with CPAP. Five of these neonates met the inclusion criteria and six neonates did not meet these criteria. Of the five neonates who received CPAP and met the inclusion criteria, three survived. The six infants who did not meet the inclusion criteria included three preterm infants with apnoea (all died), two with birthweights <1 kg (both died) and a firstborn twin (1.2 kg) who survived. No major complications of CPAP occurred. Bubble CPAP could be used independently by nurses after a short training period. CONCLUSION Successful long-term implementation of CPAP depends on the availability of sufficient trained nursing staff.
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Bandsma RHJ, Spoelstra MN, Mari A, Mendel M, van Rheenen PF, Senga E, van Dijk T, Heikens GT. Impaired glucose absorption in children with severe malnutrition. J Pediatr 2011; 158:282-7.e1. [PMID: 20843523 DOI: 10.1016/j.jpeds.2010.07.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 06/28/2010] [Accepted: 07/26/2010] [Indexed: 01/29/2023]
Abstract
OBJECTIVE To quantify intestinal glucose absorption in children with two types of severe malnutrition, kwashiorkor and marasmus, compared with healthy children. STUDY DESIGN Children with kwashiorkor (n = 6) and marasmus (n = 9) and control subjects (n = 3) received a primed (13 mg/kg), constant infusion (0.15 mg/kg/min) of [6,6H2]glucose for 4.5 hours. Two hours after start of the infusion an oral bolus of glucose 1.75 g/kg labeled with [U-13C]glucose 10 mg/g was given and was followed by periodic blood sampling. Mathematical modeling was applied to determine oral glucose absorption. RESULTS Median total glucose absorption was 5.9 mmol/kg, interquartile range (IQR) 4.5-6.7 mmol/kg and 4.4 (IQR 2.9-5.9) mmol/kg in children with kwashiorkor and marasmus compared with 7.7 (IQR 5.8-9.0) mmol/kg in control subjects; P = .03 compared with marasmus). Children with the lowest glucose absorption were found specifically in the kwashiorkor group and marasmic children with hypoalbuminemia. Severe impairment in absorption correlated with urinary 8-hydroxydeoxyguanosine secretion (r = -0.62, P = .01). CONCLUSIONS Severe malnutrition is associated with an impaired glucose absorption and decreased glucose absorption correlates with oxidative stress in these children.
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Affiliation(s)
- Robert H J Bandsma
- Department of Biochemistry, College of Medicine, University of Malawi, Blantyre, Malawi.
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Bandsma RHJ, Mendel M, Spoelstra MN, Reijngoud DJ, Boer T, Stellaard F, Brabin B, Schellekens R, Senga E, Heikens GT. Mechanisms behind decreased endogenous glucose production in malnourished children. Pediatr Res 2010; 68:423-8. [PMID: 20657348 DOI: 10.1203/pdr.0b013e3181f2b959] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Severe malnutrition is a major health problem in developing countries and can present itself as kwashiorkor or marasmus. Although marasmus is characterized by clinical wasting, kwashiorkor is associated with peripheral edema, oxidative stress, hypoalbuminemia, and hypoglycemia. The etiology of the hypoglycemia is poorly understood. We determined endogenous glucose production (EGP) in children with severe malnutrition. Children with kwashiorkor, marasmus, and controls received a primed constant infusion of [6,6H2]glucose for 2 h. An i.v. bolus of 13C-ketoisocaproic acid (KIC) was given, and breath samples were obtained during 2 h. Isotope dilution was used to calculate EGP, and 13CO2/12CO2 production was determined. Mean EGP ± SEM was 5.5 ± 0.3 mg/kg/min in the kwashiorkor group and 6.9 ± 0.4 mg/kg/min and 7.6 ± 0.7 mg/kg/min in the marasmic and control group, respectively, (p < 0.05 kwashiorkor versus marasmus and controls). EGP correlated with serum albumin concentration (r = 0.67; p < 0.001) and urinary 8-hydroxydeoxyguanosine as a marker of oxidative stress (r = -0.62; p < 0.005). 13CO2 secretion as a marker of hepatic mitochondrial function was significantly higher in the marasmic group compared with kwashiorkor and controls. We conclude that decreased EGP in severely malnourished children is related to the degree of hypoalbuminemia and oxidative stress but is not associated with a clear defect in hepatic mitochondrial function.
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Abstract
An 8-year-old girl presented with severe muscular weakness, peripheral neuropathy, ataxia, fever and macrocytic anaemia. Clinically, vitamin B(12) (cobalamin) deficiency was considered. Despite the lack of pre-treatment laboratory confirmation of the diagnosis, a therapeutic trial of hydroxocobalamin injections was begun. After several days, a partial clinical response was seen. Within 5 months all symptoms had resolved. After treatment was initiated, laboratory analysis of pre-treatment blood samples confirmed the presence of vitamin B(12) deficiency. Auto-antibodies to intrinsic factor and parietal cells, pathognomonic for pernicious anaemia, were confirmed. Vitamin B(12) deficiency owing to dietary deficiency is not uncommon in children in developing countries. Although nutritional deficiency might have played a role in our patient, this case illustrates that the neurological manifestations of pernicious anaemia can present at a young age in African populations.
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Affiliation(s)
- M van Loon
- Department of Paediatrics & Child Health, College of Medicine, University of Malawi, Blantyre, Malawi.
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Heikens GT, Manary M, Sandige H. Child survival in sub Sahara Africa: the role of CAPGAN and regional child health practitioners & scientists. Malawi Med J 2009; 21:94-5. [PMID: 20345015 PMCID: PMC3717487 DOI: 10.4314/mmj.v21i3.45626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Affiliation(s)
- Mark J Manary
- Department of Pediatrics, Washington University School of Medicine, USA
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Heikens GT, Bunn J, Amadi B, Manary M, Chhagan M, Berkley JA, Rollins N, Kelly P, Adamczick C, Maitland K, Tomkins A. Case management of HIV-infected severely malnourished children: challenges in the area of highest prevalence. Lancet 2008; 371:1305-7. [PMID: 18406865 DOI: 10.1016/s0140-6736(08)60565-6] [Citation(s) in RCA: 87] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
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Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre 3, Malawi.
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Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi.
| | - Elizabeth Molyneux
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Robin Broadhead
- Department of Paediatrics, College of Medicine, University of Malawi, Blantyre, Malawi
| | - Nigel Rollins
- Department of Paediatrics and Child Health, Nelson R Mandela Medical School University of Kwa Zulu-Natal, Durban, South Africa
| | - Miriam Adhikari
- Department of Paediatrics and Child Health, Nelson R Mandela Medical School University of Kwa Zulu-Natal, Durban, South Africa
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Abstract
Heikens discusses a new study published inPLoS Medicine that is helpful in reconsidering the applicability of the WHO treatment guidelines.
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Affiliation(s)
- Geert Tom Heikens
- Department of Paediatrics and Child Health, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi.
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Geerdink N, Rotteveel JJ, Lammens M, Sistermans EA, Heikens GT, Gabreëls FJM, Mullaart RA, Hamel BCJ. MECP2 mutation in a boy with severe neonatal encephalopathy: clinical, neuropathological and molecular findings. Neuropediatrics 2002; 33:33-6. [PMID: 11930274 DOI: 10.1055/s-2002-23598] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
We describe the clinical and neuropathological presentation of a male with an MECP2 mutation whose sister has Rett syndrome (RS). He presented with severe neonatal encephalopathy and died at the age of 13 months. Mutation analysis of the MECP2 gene demonstrated a 488 - 489 del mutation in his and his sister's copies of the gene. Post mortem examination revealed bilateral polymicrogyria in the perisylvian region. This malformation was visibly more severe than previously described in females with RS and another male with an MECP2 mutation. As bilateral polymicrogyria was described in congenital perisylvian syndrome, the presented patient could be regarded as having suffered from a severe form of this syndrome. We conclude that MECP2 screening should be considered in males with severe neonatal encephalopathy and in males and females with a bilateral polymicrogyria syndrome.
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Affiliation(s)
- N Geerdink
- Department of Pediatric Neurology, University Medical Center St. Radboud, Nijmegen, The Netherlands
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Heikens GT. Treatment of malnutrition. Lancet 1995; 345:788. [PMID: 7891496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
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Heikens GT, Schofield WN, Dawson SM, Waterlow JC. Long-stay versus short-stay hospital treatment of children suffering from severe protein-energy malnutrition. Eur J Clin Nutr 1994; 48:873-82. [PMID: 7889896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To contrast early discharge versus attempted full nutritional rehabilitation in hospital of children suffering from severe protein-energy malnutrition (PEM). DESIGN Field experiment, two-way analysis of variance with one between group (short- versus long-stay) and one repeated measures factor (admission, then 12, 18, 24, 30 and 36 months post-admission). Covariates introduced. SETTING Primary health care, Kingston, Jamaica. SUBJECTS n = 81; mean age 11 months; 79 contribute longitudinal data; 44 every measurement. INTERVENTIONS When concurrent illnesses had been treated and normal feeding re-established (weight gain 5 g/kg.day-1), subjects were randomly allocated to short-stay (SS) or long-stay (LS) group. LS retained in hospital for full nutritional rehabilitation mean 40 days). SS discharged immediately (mean 18 days) for standard Health Service care at home for 6 months plus high-energy supplement (3.31 MJ with 20.6 g protein daily) for first 3 months. After discharge LS received 6 months home care, but without supplementation. RESULTS Significant advantages for LS group on NCHS weight & length for age at discharge, and at 12, 18, 24 and for length also 30 months (P < 0.05 to P < 0.001). Weight advantage peaked at 12 and 18 months, length later at 18 and 24 months. CONCLUSIONS Contrary to earlier reports, full nutritional rehabilitation can be achieved in hospital for children suffering from PEM. Although in the long-term both groups move towards expected levels in their home community, a significant advantage maintained for approximately 2 years is developmentally advantageous during the critical time after weaning.
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Affiliation(s)
- G T Heikens
- Nijmegen Institute for International Health, Faculty of Medical Sciences, University of Nijmegen, The Netherlands
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Heikens GT, Schofield WN, Dawson S. The Kingston Project. II. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: anthropometry. Eur J Clin Nutr 1993; 47:160-73. [PMID: 8458314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Malnourished children (mean age 1.2 years) referred from public health clinics to a paediatric metabolic ward in Kingston, Jamaica, were enrolled for treatment in a community-based health care project and were randomly allocated to one of two groups. The first group was treated at home with metronidazole and then for 6 months using the standard health care provided from local clinics by community health aides. The second group was given the same drug and home treatment, but in addition received a high energy supplement of 3.31 MJ daily for 3 months. We have previously shown a significant advantage in both weight and height gain for a group given the same supplement in contrast with standard health care controls (Heikens et al., 1989, Eur. J. Clin. Nutr. 43, 145-160), and in this study test the addition of a drug treatment aimed at reducing malabsorbtion due to a possible microbial overgrowth of the small bowel in malnourished children. This paper reports anthropometric findings showing significant benefits from both the drug and nutritional treatments. Greatest gains were by the group given both treatments, but the group given the antibiotic treatment, without energy supplementation, also made better growth recovery than did controls. Only 8% of the children treated with metronidazole failed to respond to community-based intervention and were admitted to hospital, compared with 19% for the other groups (P < 0.05). These findings support targetted high-energy supplementation for the rehabilitation of moderately malnourished children receiving health clinic care, and suggest further that such programs should include antibiotic treatment directed at SBBO.
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Affiliation(s)
- G T Heikens
- Tropical Metabolism Research Unit, University of the West Indies, Kingston, Jamaica
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Heikens GT, Schofield WN, Christie CD, Gernay J, Dawson S. The Kingston Project. III. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: morbidity and growth. Eur J Clin Nutr 1993; 47:174-91. [PMID: 8458315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65% of the sample were found to have additional illnesses at enrollment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic, treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group.
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Affiliation(s)
- G T Heikens
- Tropical Metabolism Research Unit, University of the West Indies, Kingston, Jamaica
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Abstract
Immunosuppression increases the susceptibility to infection and changes the inflammatory response in children with severe protein-energy malnutrition. In this 5-year prospective study bacteremia was documented in 16% of 336 severely malnourished children, 2 to 34 months of age, who were hospitalized consecutively in the Tropical Metabolism Research Unit, Kingston, Jamaica. The 53 children had 60 episodes of nosocomial and community-acquired bacteremia with 69 blood isolates. Community-acquired bacteremia accounted for 72% (43 of 60) of bacteremic episodes. Thirty-five percent (24 of 69) of the strains were coagulase-negative staphylococci, 19% (13 of 69) were Staphylococcus aureus and 11% (8 of 69) were Streptococcus Group D. Seventeen episodes of coagulase-negative staphylococcal bacteremia were acquired in the community and 7 were nosocomial. These patients were more likely to have pneumonic consolidation than children with all other bacteremias combined (P < 0.02, Fisher's exact test). The bacteremia-related case fatality rate was 8% (5 of 60). Polymicrobial and Gram-negative septicemia were independent positive predictive factors for mortality when compared with single-agent and Gram-positive sepsis (P < 0.02). This 71% (49 of 69) prevalence of Gram-positive organisms suggests a change in the epidemiology from the predominant Gram-negative etiologies (76%) described in previous reports.
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Affiliation(s)
- C D Christie
- Tropical Metabolism Research Unit, University Hospital of the West Indies, Kingston, Jamaica
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Abstract
We studied the aetiological agents of acute respiratory infections occurring in an ambulatory population of 83 malnourished Jamaican-born children aged 6 to 32 months using serological methods for diagnosis. In 60% (38/63) of symptomatic children and in 25% (5/20) of those without reported disease the following microorganisms were observed: parainfluenza viruses in 15 children, influenza viruses in 12, adenovirus in 10, respiratory syncitial virus in 7 and Mycoplasma pneumoniae in 7 children. The prevalence of the viral infections apparently increased with the severity of malnutrition.
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Affiliation(s)
- C D Christie
- Yale University School of Medicine, Department of Epidemiology and Public Health, New Haven, Connecticut
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Heikens GT, Schofield WN, Dawson S, Grantham-McGregor S. The Kingston project. I. Growth of malnourished children during rehabilitation in the community, given a high energy supplement. Eur J Clin Nutr 1989; 43:145-60. [PMID: 2659312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Moderate and severely malnourished children referred from public health clinics in Kingston, Jamaica, to a metabolic ward were treated at home for 6 months using community health aides and standard health care similar to that offered by the local health service. A randomly selected subgroup of these children received in addition a daily high energy food supplement of 3.31 MJ for the first 3 months of the 6-month intervention period. Both groups received full nutritional and medical surveillance and care. The supplemented gained significantly more in weight than the unsupplemented children, but the advantage was lost once supplementation ceased. They also gained significantly more in length and this gain was maintained at the end of the intervention period. However, this increase in length, without continuing superior weight gain, left the supplemented children significantly more wasted than the unsupplemented, as measured by a body mass index (weight divided by height squared). These findings remained stable after interactions with morbidity measures had been taken into account. It is concluded that (1) high-energy supplementation assists rehabilitation of malnourished children brought to public health service clinics and treated in the community, and (2) supplementation should be continued until there is catch-up growth to within an acceptable distance from expected length for age.
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Affiliation(s)
- G T Heikens
- Tropical Metabolism Research Unit, University of the West Indies, Kingston, Jamaica
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Christie CD, Heikens GT, McFarlane DE. Nosocomial and community-acquired infections in malnourished children. J Trop Med Hyg 1988; 91:173-80. [PMID: 3404564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
A total of 206 community-acquired and 73 nosocomial infections in 50 malnourished Jamaican children were studied prospectively. Predominant community-acquired infections in the 50 children, included gastroenteritis (68%), otitis media (60%), rhinopharyngitis (60%), oral candidiasis (46%), skin infections (40%), pneumonia (28%), bacteraemia (24%) and bacteriuria (18%). The most frequent nosocomial infections were rhinopharyngitis (34%), lower respiratory tract infections (24%) and septicaemia (18%). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen, Staphylococcus epidermidis, the most frequent blood culture isolate and Klebsiella sp. were recovered from the majority of urines. The lack of clinical signs and symptoms and atypical clinical presentation in some infected malnourished children were attributed to impairment of the acute inflammatory response. Diagnosis of infection in these children required a high index of suspicion and a comprehensive screening system. Nasal, throat and axilla swabs taken on admission revealed significant colonization with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Four of the 50 children died and two of these deaths were attributed to infection.
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Affiliation(s)
- C D Christie
- Tropical Metabolism Research Unit, University of the West Indies, Kingston, Jamaica
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