Growth assessment in infants and toddlers using three different reference charts

OBJECTIVE

To determine if the proportion of children < or =24 months old in a tertiary care facility defined as at risk of undernutrition or overnutrition differs according to different references used for assessment: the Centers for Disease Control and Prevention (CDC), National Center for Health Statistics (NCHS) or Tanner-Whitehouse (Tanner) growth charts for weight-for-age and length-for-age.

METHODS

Lengths and weights were measured on infants (207 female, 341 male) aged < or =24 months admitted from or attending clinics in the General Pediatric or Respiratory Medicine Programs at The Hospital for Sick Children, Toronto. Weight-for-age and length-for-age percentiles and percent ideal body weight were electronically computed.

RESULTS

The proportion of all children whose weight-for-age was <3rd percentile (at risk of undernutrition) was greatest using the CDC growth charts (22.5%) compared with the NCHS (15.9%) or Tanner (19.2%) growth charts. Likewise, the proportion of all infants/toddlers with percent ideal body weight <90 (at risk of undernutrition) was greatest using the CDC (32.3%) compared with the NCHS (22.1%) or Tanner (25.9%) growth charts. In contrast, the percentage of children whose percent ideal body weight was > or =110% (at risk of overnutrition) was least using the CDC (18.1%) compared with the NCHS (26.1%) or Tanner (22.4%) growth charts.

CONCLUSION

More children aged < or =24 months will be defined as at risk of undernutrition and fewer at risk of overnutrition when using weight-for-age or percent ideal body weight and the CDC growth charts compared with the NCHS or Tanner growth charts. As a result, requests for a more detailed nutritional assessment for undernutrition will likely follow implementation of the CDC growth charts in a tertiary care setting. As the CDC, NCHS and Tanner growth charts are growth "references" rather than "standards," other than for screening purposes, they should not be used in isolation when assessing growth and nutritional status.

The frequency of nutritional rickets among hospitalized infants and its relation to respiratory diseases

This case control study was conducted to determine the frequency of nutritional rickets among hospitalized infants and to assess their relation to respiratory diseases. All infants between the age of 3 months and 2 years admitted to the pediatric ward of Queen Alia Military Hospital during the period February-October 2001 were examined and investigated to rule out nutritional rickets. Children admitted for the first time to hospital for acute illnesses were only included in the study. A special data collection sheet was designed for this study which includes information on the age, sex, causes of admission, family size, the rank of the child in the family, family monthly income, outdoor clothing habit of the mother, and the mode of feeding. Data were collected from the infant charts and/or by interviewing the child's mother or guardian. Clinical signs of rickets were also recorded, including rosary beads, craniotabes, wide anterior fontanel, delayed dentition, widening of epiphysis, bowing of the legs, and double malulous. Blood sample was collected for calcium, phosphorus, alkaline phosphatase, and hemoglobin level. Those infants with any clinical sign of rickets and/or abnormal chemical results had a wrist X-ray to confirm the diagnosis of rickets. The rachitic group (cases) was compared for statistical significance with the remaining non-rachitic infants (controls) for the data collected. Rachitic infants received intramuscular 600,000 IU of vitamin D; a follow-up wrist X-ray and blood sample for calcium, phosphorus and alkaline phosphatase was arranged 3 weeks later. Forty-seven infants (10.6 per cent) out of the 443 included in the study were found to have nutritional rickets. Forty (85.1 per cent) of the rachitic infants were admitted due to lower respiratory tract diseases compared with 30 per cent of the control group and the difference was statistically significant (p < 0.01). Duration of hospital stay in the rachitic infants was also significantly more prolonged than the non-rachitic control group (9.5 days vs. 7.4 days, p = 0.002). Rachitic infants were breastfed in 82.9 per cent, ranked second or more in the family in 87.2 per cent, and had mothers who wore head cover outdoors in 80.8 per cent compared with 60.8, 40.1, and 60.3 per cent, respectively, in the non-rachitic group (p < 0.01). High alkaline phosphatase, hypocalcemia, hypophosphatemia, and anemia was found in 100, 19, 50, and 78.7 per cent, respectively, in the rachitic group compared with 9.8, 2, 1.2, and 43.7 per cent, respectively, in the control group (p < 0.001). Nutritional rickets seems to be a common problem among infants in Jordan. Further studies at national level are needed to determine the prevalence of rickets in Jordan. Rachitic infants are commonly hospitalized due to lower respiratory tract infections, thus there is a high index of suspicion for rickets among hospitalized infants with lower respiratory tract diseases.

Prevalence and predictors of underweight, stunting, and wasting among children aged 5 and under in western Kenya

The health and nutritional status of children aged 5 and under was assessed in three villages in Siaya District of western Kenya. A cross-sectional survey was conducted among 121 adults and 175 children during July 2002. Primary caretakers were interviewed during home visits to assess agricultural and sanitation resources, child feeding practices, and the nutritional status of their children aged 5 years and under. Through anthropometry, the prevalence of underweight, stunting and wasting were determined: 30 per cent were underweight, 47 per cent were stunted, and 7 per cent were wasted. Predictors of undernutrition were analysed using logistic regression controlling for age, sex, and SES, and four major findings emerged. First, children in their second year of life were more likely to be underweight and stunted. Second, children who were introduced to foods early had an increased risk of being underweight. Third, up-to-date vaccinations were protective against stunting, while reports of having upper respiratory infections or other illness in the past month predicted underweight. Finally, living with non-biological parents significantly increased risk of stunting. Emphasis should be placed on current immunization, prolonging exclusive breastfeeding, and improving access to nutrient-rich foods among adopted children and their families via community-based nutrition interventions.

[Vitamin B(12) deficiency anaemia in a 7.5 months old girl]

Vitamin B(12) stores at birth are adequate for infants until the end of the first year of life even if it 's concentration in maternal breast milk is low. However, there are some situations in which infants have depleted vitamin B(12) stores and in addition have a low dietary intake of cobalamin. Vitamin B(12) depletion occurs in infants who are exclusively breastfed by mothers who have unrecognized pernicious anemia or are strict vegetarians for many years. In those infants symptoms of bone marrow disfunction and impaired development of the central nervous system appear already in the first months of life. Unrecognized cobalamin deficiency may lead to serious neurologic consequences, and even to the death of the child. The authors present a case of a 7.5 month old girl admitted to the Department of Paediatrics, Haematology, Oncology and Endocrinology. Gdańsk Medical University suspected of acute leukaemia. Based on a detailed diagnostic procedure a final diagnosis of vitamin B(12) deficiency anaemia was established. The child was exclusively breast-fed. Results of investigations into the reason for cobalamin deficiency in the patient s organism. Led to the diagnosis of pernicious anaemia in the mother. Such a suspicion had been made during pregnancy, but no continuation of investigations nor appropriate treatment were implemented. After treatment with vitamin B(12) supplements and modification of the diet the patient improved quickly and remarkably. A few months follow-up was enough to observe remarkable improvement of psychomotor development of this child.

Neonatal enteropathies: defining the causes of protracted diarrhea of infancy

The underlying causes of chronic diarrhea beginning early in life are increasingly well defined. Infectious and post-infectious enteropathies and food sensitive/allergic enteropathy account for the majority of cases. Recent attention has focused on characterizing defined entities, which cause protracted diarrhea in infants and young children. Disorders of intestinal ion transport usually present at birth following a pregnancy complicated by polyhydramnios. Intestinal mucosal biopsies show normal architect with intact villus-crypt axis. Neonatal enteropathies, by contrast, are characterized by blunting of the villi. These include microvillus inclusion disease, tufting enteropathy, autoimmune enteropathy and IPEX syndrome - and it is these conditions that are the subject of the current review.

[Admission diagnosis and nutritional evolution of the beneficiaries of "Corporación para la Nutrición Infantil-CONIN"]

BACKGROUND

The nutritional impact of CONIN nutritional recovery centers must be evaluated, considering the current epidemiological situation in Chile and the new therapeutic focus giving more emphasis to ambulatory treatment.

AIM

To analyze the nutritional status of children treated at traditional CONIN centers, the reason for their admission and the factors associated with changes of weight for age index during the hospitalization.

PATIENTS AND METHODS

During the year 2000, the records of 561 patients discharged from the traditional CONIN centers throughout the country were retrospectively analyzed. The changes in weight and height during admission and the possible factors influencing these changes, were determined.

RESULTS

The average lapse of stay was 3.9 months; 78% of children had concomitant diseases at admission and 18.7% required to be admitted in a general hospital. One third was admitted with normal weight or even overweight according to the weight for age index, and 31.1% was undernourished. During admission in CONIN, the number of undernourished patients was reduced by 50%, while the proportion of children with normal nutritional status increased by 15% (p < 0.001). On admission, 7.8% of children had a low height for age, evidencing a chronic undernutrition. This figure did not change on discharge. The increase of weight/age and weight/height was substantially higher in children with a greater initial deficit (p < 0.001).

CONCLUSIONS

Admission to a CONIN center had a low nutritional impact, and a high risk of a lengthy stay. The most favorable impact could be appreciated in children that were effectively undernourished. Admissions are motivated mainly by social issues, over and above nutritional problems.

[Malnutrition in the infant]

Children are especially threatened by malnutrition, because of the high protein-energy cost of growth. Any nutritional deficiency impairs growth velocity, and growth retardation should suggest the presence of an underlying disease. Therefore, auxologic study is an important step of nutritional evaluation, which should belong to each clinical examination in a child. The protein-energy cost of catch-up growth is particularly high, and should lead to a rigorous adjustment of nutritional supply. Early identification of children who are at risk of malnutrition, especially for hospitalized children, is indispensable in order to provide adequate nutritional support on time and then to prevent hospital-acquired malnutrition. Such assessment should use validated pediatric nutritional risk scores.

Hypovitaminosis D and vitamin D deficiency in exclusively breast-feeding infants and their mothers in summer: a justification for vitamin D supplementation of breast-feeding infants

OBJECTIVE

To determine the prevalence of hypovitaminosis D in exclusively breast-feeding infants and their mothers in a community where maternal sunshine exposure is low.

STUDY DESIGN

Serum levels of calcium, phosphate, alkaline phosphatase, 25-hydroxy vitamin D (25-OHD), and intact parathyroid hormone were measured in 90 unsupplemented healthy term breast-feeding Arab/South Asian infants and their mothers in summer. Maternal dietary vitamin D intake was also estimated.

RESULTS

The median age of infants was 6 weeks. The median serum 25-OHD concentrations in mothers (8.6 ng/mL) and infants (4.6 ng/mL) were low, and 61% of the mothers and 82% of the 78 infants tested had hypovitaminosis D (serum 25-OHD <10 ng/mL). The infants with hypovitaminosis D had elevated serum alkaline phosphatase and a tendency to higher serum intact parathyroid hormone levels. The average daily maternal vitamin D intake from commercial milk was 88 IU.

CONCLUSIONS

Hypovitaminosis D is common in summer in exclusively breast-feeding infants and their mothers. The results provide justification for vitamin D supplementation of breast-feeding infants and mothers in the United Arab Emirates. Low vitamin D intake probably contributed to low maternal vitamin D status.

Trace element status and early physical growth of exclusively breastfed normal and asphyxiated Nigerian babies

Serial anthropometry and assay of plasma iron (Fe), zinc (Zn) and copper (Cu) were done on 72 babies with birth asphyxia during the first six months of life to assess the pattern of their physical growth and trace element status, respectively. Eighty-seven non-asphyxiated babies served as controls. The mothers of babies in both groups also had their plasma assayed for Fe, Zn and Cu immediately following delivery. Asphyxiated babies were lighter than non-asphyxiated controls during the first two months of life and they also had smaller mean occipito-frontal circumference at birth. While Fe, Zn and Cu status was generally comparable in both groups, the newborn Cu concentrations were very low compared with earlier reports. No baby showed any overt signs of trace element deficiency.

Child feeding practices are associated with child nutritional status in Latin America: innovative uses of the demographic and health surveys

Data from the Demographic and Health Surveys (DHS) for 5 Latin American countries (7 data sets) were used to explore the feasibility of creating a composite feeding index and to examine the association between feeding practices and child height-for-age Z-scores (HAZ). The variables used for the index were as follows: current breast-feeding, use of complementary foods and liquids in the past 24 h, frequency of use over the past week and feeding frequency. The index was made age specific for 6- to 9-, 9- to 12- and 12- to 36-mo-old age groups, and age-specific feeding terciles were created. Bivariate analyses showed that feeding practices were strongly and significantly associated with child HAZ in all 7 data sets, especially after 12 mo of age. Differences in HAZ between child feeding terciles remained significant after controlling for potentially confounding influences, for all countries except Bolivia. Multiple regression analyses also revealed that better feeding practices were more important for children of lower, compared with higher socioeconomic status (in Colombia 1995 and Nicaragua 1998); among children of Ladino (Spanish speaking) compared with indigenous origin (in Guatemala 1995); and among children whose mothers had primary schooling compared with mothers with no schooling, or mothers with higher than primary school level (Peru 1996). The data available in DHS data sets can thus be used effectively to create a composite child feeding index and to identify vulnerable groups that could be targeted by nutrition education and behavior change interventions.

Evaluation of erythropoiesis in protein energy malnutrition

This study evaluated erythropoiesis in 50 infants hospitalized with protein energy malnutrition and in 50 control infants. The red cell count, mean corpuscular haemoglobin and reticulocyte index were significantly lower, while the white blood cell count, median corpuscular fragility and red cell distribution width were significantly higher on admission than in controls. Total serum protein, albumin, fasting blood glucose, and serum folate were significantly lower on admission than in controls. Serum ferritin was significantly higher and total iron-binding capacity was significantly lower on discharge compared to controls. The serum erythropoietin was significantly higher on admission and discharge than in controls. The anaemia of protein energy malnutrition is due to mixed deficiencies resulting in ineffective erythropoiesis despite an increased level of erythropoietin.

Assessment of nutritional status using anthropometric methods on 1-4 year old children in an urban ghetto in Lagos, Nigeria

This study assessed the nutritional status using anthropometry of 1-4 year old children in an urban slum in the Mushin Local Government Area of Lagos State, with a view to determining the impact of urbanization on child health. A total of 365 children were enrolled using multistage random sampling techniques. Anthropometric measurements used were weight and height. Height-for-age, weight-for-height, and weight-for-age Z-scores below -2.00 SD of the reference NCHS standard were used to define stunting, wasting and underweight, respectively. The study revealed a prevalence of underweight of 39.2%, stunting of 34.5% and wasting of 21.9%. The mean of weight-for-age, height-for-age, weight-for-height and mid-upper-arm-circumference were less than the mean of the NCHS reference population. This difference might be due to the socio economic backgrounds of the two populations. Using the modified Wellcome Classification of malnutrition, 37.8% of the children were malnourished. Most subjects came from homes with inadequate water supply and poor refuse disposal methods.

Sociocultural practices influencing under five nutritional status in an urban community in Osun State, Nigeria

Three hundred and forty four preschool children from Ilare district of Ife Central Local Government Area of Osun State, Nigeria were assessed for nutritional status using selected and sensitive anthropometric techniques. The sociocultural practices of the parents were also examined. Approximately 53.8% and 54.7% of the children were identified to be malnourished and stunted respectively. The socioeconomic situation of the family was identified to have a significant influence on the child's nutritional status. Female children were observed not to be as adequately nourished as their male counterparts. However parity and food taboo had no significant influence on the child's nutritional status. The need for improvement in the socioeconomic status of the family and education of the community on the importance of female nutrition are discussed.

Severe nutritional deficiencies in toddlers resulting from health food milk alternatives

It is widely appreciated that health food beverages are not appropriate for infants. Because of continued growth, children beyond infancy remain susceptible to nutritional disorders. We report on 2 cases of severe nutritional deficiency caused by consumption of health food beverages. In both cases, the parents were well-educated, appeared conscientious, and their children received regular medical care. Diagnoses were delayed by a low index of suspicion. In addition, nutritional deficiencies are uncommon in the United States and as a result, US physicians may be unfamiliar with their clinical features. Case 1, a 22-month-old male child, was admitted with severe kwashiorkor. He was breastfed until 13 months of age. Because of a history of chronic eczema and perceived milk intolerance, he was started on a rice beverage after weaning. On average, he consumed 1.5 L of this drink daily. Intake of solid foods was very poor. As this rice beverage, which was fallaciously referred to as rice milk, is extremely low in protein content, the resulting daily protein intake of 0.3 g/kg/day was only 25% of the recommended dietary allowance. In contrast, caloric intake was 72% of the recommended energy intake, so the dietary protein to energy ratio was very low. A photograph of the patient after admission illustrates the typical features of kwashiorkor: generalized edema, hyperpigmented and hypopigmented skin lesions, abdominal distention, irritability, and thin, sparse hair. Because of fluid retention, the weight was on the 10th percentile and he had a rotund sugar baby appearance. Laboratory evaluation was remarkable for a serum albumin of 1.0 g/dL (10 g/L), urea nitrogen <0.5 mg/dL (<0.2 mmol/L), and a normocytic anemia with marked anisocytosis. Evaluation for other causes of hypoalbuminemia was negative. Therapy for kwashiorkor was instituted, including gradual refeeding, initially via a nasogastric tube because of severe anorexia. Supplements of potassium, phosphorus, multivitamins, zinc, and folic acid were provided. The patient responded dramatically to refeeding with a rising serum albumin and total resolution of the edema within 3 weeks. At follow-up 1 year later he continued to do well on a regular diet supplemented with a milk-based pediatric nutritional supplement. The mortality of kwashiorkor remains high, because of complications such as infection (kwashiorkor impairs cellular immune defenses) and electrolyte imbalances with ongoing diarrhea. Children in industrialized countries have developed kwashiorkor resulting from the use of a nondairy creamer as a milk alternative, but we were unable to find previous reports of kwashiorkor caused by a health food milk alternative. We suspect that cases have been overlooked. Case 2, a 17-month-old black male, was diagnosed with rickets. He was full-term at birth and was breastfed until 10 months of age, when he was weaned to a soy health food beverage, which was not fortified with vitamin D or calcium. Intake of solid foods was good, but included no animal products. Total daily caloric intake was 114% of the recommended dietary allowance. Dietary vitamin D intake was essentially absent because of the lack of vitamin D-fortified milk. The patient lived in a sunny, warm climate, but because of parental career demands, he had limited sun exposure. His dark complexion further reduced ultraviolet light-induced endogenous skin synthesis of vitamin D. The patient grew and developed normally until after his 9-month check-up, when he had an almost complete growth arrest of both height and weight. The parents reported regression in gross motor milestones. On admission the patient was unable to crawl or roll over. He could maintain a sitting position precariously when so placed. Conversely, his language, fine motor-adaptive, and personal-social skills were well-preserved. Generalized hypotonia, weakness, and decreased muscle bulk were present. Clinical features of rickets present on examination included: frontal bossing, an obvious rachitic rosary (photographed), genu varus, flaring of the wrists, and lumbar kyphoscoliosis. The serum alkaline phosphatase was markedly elevated (1879 U/L), phosphorus was low (1.7 mg/dL), and calcium was low normal (8.9 mg/dL). The 25-hydroxy-vitamin D level was low (7.7 pg/mL) and the parathyroid hormone level was markedly elevated (114 pg/mL). The published radiographs are diagnostic of advanced rickets, showing diffuse osteopenia, frayed metaphyses, widened epiphyseal plates, and a pathologic fracture of the ulna. The patient was treated with ergocalciferol and calcium supplements. The published growth chart demonstrates the dramatic response to therapy. Gross motor milestones were fully regained within 6 months. The prominent neuromuscular manifestations shown by this patient serve as a reminder that rickets should be considered in the differential diagnosis of motor delay. (ABSTRACT TRUNCATED)

Nutritional follow-up of the breastfeeding premature infant after hospital discharge

In summary, fortification of human milk may be beneficial in preterm infants, particularly those born at less than 34 weeks' gestation or less than 1800 g birth weight, during and after initial hospitalization. This fortification after hospital discharge is more crucial for infants who cannot consume ad libitum quantities of breast milk, have poor growth, or have abnormalities in the biochemical screen of nutritional status. Although data indicate that in-hospital, short-term gains in growth and mineral status are achieved, information is fragmentary regarding the influence on long-term growth and neurodevelopmental outcomes of feeding supplemented human milk. Also, no data are available on outcomes when providing these mixtures to premature infants after hospital discharge. It is recommended that a nutritional survey be accomplished before and approximately 1 month after discharge and that fortification or supplementation be initiated if an infant is failing to achieve normal growth and biochemical measures of nutrition.

[Infant malnutrition and associated maternal factors in a secondary city south of Benin, Ouidah]

BACKGROUND

The aim of this study was to find the needs and priorities for interventions to improve children's nutritional state in a secondary city in Bénin. It addressed the issues of the magnitude and distribution of infant malnutrition and related maternal factors. It also aimed to identify an easy to use and low cost, but valid, technique to diagnose malnutrition in children.

METHOD

First of all, the prevalence of infant malnutrition was assessed with a representative sample of 492 children aged less than 36 months, in all four communities of the city. Then the sensitivity and specificity of arm circumference were studied and the associations between the children's anthropometric indices were assessed. Secondly in a sub-group of 200 couples of mothers and children, an analysis was conducted to show the links between the indices of mothers' nutritional status, some of their social and economical variables, and the children's anthropometric indices.

RESULTS

The prevalences of wasting and stunting and all other forms confounded among children aged 0-3 years were respectively 5.7%, 22% and 25.9%. They represented 44.7% for the arm circumference. Wasting was more prevalent among children aged 6-23 months (9.6%) than those aged less than 6 months (1.1%) and those of 24 to 36 months (5.2%). The boys had a higher prevalence of stunting (25.1%; p = 0.049) than the girls (18.1%). The correlation between children arm circumference and their indices weight/height, weight/age and height/age were all significant (p < 0.001), but they were higher for weight/age (r = 0.48) and weight/height (r = 0.36) than for height/age (r = 0.30). Low, but significant correlation (r ranged from 0.17 to 0.25) were observed between anthropometric indices of mothers and children. Mothers' instruction level had a tendency to be associated positively and significantly with children z-score weight/height. The effect of socio-economic level on children's nutritional status was significant only at p < 0.10. Unlike the condition observed in the big cities of under-developed countries in general, the central area of Ouidah was more affected by infant malnutrition than peripheral area recently urbanized.

CONCLUSIONS

Infant malnutrition appears to be a really public health problem in this town and children at weaning age are more affected. The interventions to improve children's nutritional status must concern, not only children with malnutrition, but also their mothers. Those interventions must also improve mother's knowledge and practices about weaning foods and their instruction and socioeconomic levels. The cut-off-point 12.5 cm of arm circumference seems to be more appropriate to diagnose wasting among children aged less than 12 months; 13.5 cm is better for 12-36 months aged children.

[Visceral leishmaniasis and malnutrition: a case report]

BACKGROUND

Visceral leishmaniasis occurring in malnourished subjects can have an uncommon course, which explains difficulties in its diagnosis.

CASE REPORT

A 22-month-old infant was admitted because of malnutrition and prolonged fever. The bacteriological investigation was negative. When his nutritional status improved, he developed a splenomegaly. The medullogram confirmed the diagnosis of visceral leishmaniasis. The course was then favorable with treatment by pentavalent antimonial.

CONCLUSION

Malnutrition constitutes a risk factor of opportunist parasitic disease such as leishmaniasis. Its diagnosis can be very difficult.

Arm area measurements as indices of nutritional reserves and body water in African newborns

Although application of non-invasive techniques for early evaluation of body water, calorie and protein reserves has been available for more than two decades, there is a dearth of information on the evaluation of extracellular water, protein and calorie reserves in the African newborn. A cross-sectional study of arm area measurements was undertaken in 510 term new-born infants consisting of 318 infants who were normal weight term infants (NWTI) with a mean birth weight of 2898.5 +/- 287.7 g and 192 low birth weight term infants (LBWTI) with a mean birth weight of 2176.5 +/- 194.7 g. The triceps skin fold thickness (TSF), the arm fat area (AFA), percentage of arm area (AFA%) and arm water area (AWA) were significantly greater in females than males weighing > 2500 g at birth (P < 0.05), though the mean birth weight and mid-upper arm circumference (MUAC) were similar (P > 0.05). With the exception of AFA%, all measured and calculated indices were significantly lower in LBWTI than in the NWTI irrespective of sex (P < 0.05). The measurements may aid detection of newborns at risk of developing malnutrition in an area of the world where childhood undernutrition is common.

Iron deficiency anaemia in Nigerian infants

Hematological parameters and the iron status of 50 randomly selected infants who were attending the research infant welfare clinic of the Institute of Child Health, Ibadan (ICHI), for routine immunization were studied. Investigations included estimations of packed cell volume (PCV), haemoglobin (Hb), serum iron (Fe), unsaturated iron-binding capacity (UIBC) and total iron-binding Capacity (TIBC). Forty percent of the infants had PCVs below 0.32, 48% had Hbs below 10 g/dl and 27% had mean corpuscular volume (MVC) less that 70fl. Thirty-seven percent of the children had serum Fe below 3.58 mmol/l, but only 4% had UIBC above 320 mmol/l. Fifty-two percent had Transferin Saturation Index (TSI) below 10%. Eighteen percent had MCV below 70fl associated with TSI below 10% and 67% of these had Hbs below 10 g/dl. The prevalence of iron deficiency anaemia in infants as shown in this study is very high. The ill effects of iron deficiency in childhood have been well documented. It is suggested that screening for anaemia should be offered at 9 months as part of a Child Survival Programme and that infants found to be anaemic should be treated. However, for cost-effectiveness and taking into consideration the high prevalence rate of iron deficiency in this age group, it might be preferable to give iron and weekly prophylactic antimalarias routinely to infants aged 9 to 15 months in lieu of screening.

Validation of caregiver interviews to diagnose common causes of severe neonatal illness

The objective of this study was to validate retrospective caregiver interviews for diagnosing major causes of severe neonatal illness and death. A convenience sample of 149 infants aged < 28 days with one or more suspected diagnoses of interest (low birthweight/severe malnutrition, preterm birth, birth asphyxia, birth trauma, neonatal tetanus, pneumonia, meningitis, septicaemia, diarrhoea, congenital malformation or injury) was taken from patients admitted to two hospitals in Dhaka, Bangladesh. Study paediatricians performed a standardised history and physical examination and ordered laboratory and radiographic tests according to study criteria. With a median interval of 64.5 days after death or hospital discharge, caregivers of 118 (79%) infants were interviewed about their child's illness. Using reference diagnoses based on predefined clinical and laboratory criteria, the sensitivity and specificity of particular combinations of signs (algorithms) reported by the caregivers were ascertained. Sufficient numbers of children with five reference standard diagnoses were studied to validate caregiver reports. Algorithms with sensitivity and specificity > 80% were identified for neonatal tetanus, low birthweight/severe malnutrition and preterm delivery. Algorithms with specificities > 80% for birth asphyxia and pneumonia had sensitivities < 70%, or alternatively had high sensitivity with lower specificity. In settings with limited access to medical care, retrospective caregiver interviews provide a valid means of diagnosing several of the most common causes of severe neonatal illness and death.

A stepwise approach to evaluation of undernutrition and failure to thrive

The primary care physician is key to evaluating children who are undernourished or failing to thrive. The comprehensive stepwise approach to evaluation is simple and effective. Positive outcomes can be expected.

The development of a MUAC-for-height reference, including a comparison to other nutritional status screening indicators

Mid-upper-arm circumference (MUAC) based on a single cut-off value for all the children less than 5 years of age has been used for many years as an alternative nutritional status index for children during famines or refugee crises, and as an additional screening tool in nonemergencies. However, it has recently been questioned whether MUAC is age- and sex-independent. After reviewing the scientific evidence underlying the use and interpretation of MUAC, a WHO Expert Committee recommended a new MUAC-for-age reference for under-5-year-olds. In some settings, however, it is difficult to assess a child's age and in such circumstances MUAC-for-height may be a good alternative. The height-based QUAC stick is a simple means of adjusting MUAC cut-offs according to height, and the MUAC-for-height reference and the construction and use of the QUAC stick are described in this article. Described also is the use of the receiver operating characteristic (ROC) curve method to evaluate the performance of MUAC, MUAC-for-age, and MUAC-for-height in screening malnourished children.

The development of MUAC-for-age reference data recommended by a WHO Expert Committee

Low mid-upper-arm circumference (MUAC), determined on the basis of a fixed cut-off value, has commonly been used as a proxy for low weight-for-height (wasting). The use of a fixed cut-off value was based on the observation that MUAC showed small age- and sex-specific differences. However, in 1993, a WHO Expert Committee concluded that age independence is not reflected in the true pattern of mid-upper arm growth, recommended the use of MUAC-for-age, and presented age- and sex-specific MUAC reference data developed with observations obtained from a representative sample of children in the USA aged 6-59 months. In this article, we explain the methodology for the development of these data, present age- and sex-specific growth curves and tables and discuss the applications and limitations of MUAC as a nutritional indicator. To develop the reference data, estimates were first obtained for the mean and standard deviation of MUAC for each month of age using 7-month segmental regression equations; a 5th-degree and a 3rd-degree polynomial in age was then used to describe the mean and standard deviation, respectively, of MUAC-for age. These curves show important age-specific differences, and significant sex-specific differences for boys and girls < 24 months of age. Correct interpretation of MUAC with regard to nutritional status requires the use of MUAC-for-age reference data such as those presented here.

Breast-feeding and the nutritional status of nursing children in Chile

The work reported here sought to describe the feeding patterns of Chilean children up to 18 months old and their relation to nutritional status. To this end, a survey was conducted in 1993 of 9330 Chilean children under 18 months old who were receiving care through the National Health Service System-which provides care for 75% of all children under age 6. The children, whose mothers or caretakers were interviewed, constituted 94% of a sample selected at random from 102 of the 320 urban health clinics located throughout the country. The interview served to identify the type of feeding (exclusive breast-feeding, breast-feeding plus bottle-feeding, breast-feeding plus solid food, exclusive bottle-feeding, or bottle-feeding plus solid food) and to determine the nutritional status of the participants in terms of standards used by the United States National Center for Health Statistics and the World Health Organization. Children were deemed at risk of malnutrition if they had z scores on the weight-for-age distribution between 1.0 and 2.0 standard deviations below the US/WHO standard and as actually malnourished if they had z scores of over 2.0 standard deviations below the standard. The survey found exclusive breast-feeding prevalences of 86.5%, 66.7%, and 25.3% among infants 1, 3, and 6 months old. Some 12.1% of the participants were found to have a weight-for-age deficiency, 30.7% exhibited a height-for-age deficiency, and 35.7% were found to be over-weight. The prevalence of weight-for-age and height-for-age deficiencies were found to be considerably higher among bottle-fed children than among breast-fed children. In general, the results demonstrated the benefits of exclusive breast-feeding through the first 6 months of life, the need to complement exclusive breast-feeding with solid food after that time, and the superior nutritional status of breast-fed children within the age groups studied.

An evaluation of clinical indicators for severe paediatric illness

To help reduce paediatric morbidity and mortality in the developing world, WHO has developed a diagnostic and treatment algorithm that targets the principal causes of death in children, which include acute respiratory infection, malaria, measles, diarrhoeal disease, and malnutrition. With this algorithm, known as the Sick Child Charts, severely ill children are rapidly identified, through the presence of any one of 13 signs indicative of severe illness, and referred for more intensive health care. These signs are the inability to drink, abnormal mental status (abnormally sleepy), convulsions, wasting, oedema, chest wall retraction, stridor, abnormal skin turgor, repeated vomiting, stiff neck, tender swelling behind the ear, pallor of the conjunctiva, and corneal ulceration. The usefulness of these signs, both in current clinical practice and within the optimized context of the Sick Child Chart algorithm in a rural district of western Kenya, was evaluated. We found that 27% of children seen in outpatient clinics had one or more of these signs and that pallor and chest wall retraction were the signs most likely to be associated with hospital admission (odds ratio (OR) = 8.6 and 5.3, respectively). Presentation with any of these signs led to a 3.2 times increased likelihood of admission, although 54% of hospitalized children had no such signs and 21% of children sent home from the outpatient clinic had at least one sign. Among inpatients, 58% of all children and 89% of children who died had been admitted with a sign. Abnormal mental status was the sign most highly associated with death (OR = 59.6), followed by poor skin turgor (OR = 5.6), pallor (OR = 4.3), repeated vomiting (OR = 3.6), chest wall retraction (OR = 2.7), and oedema (OR = 2.4). Overall, the mortality risk associated with having at least one sign was 6.5 times higher than that for children without any sign. While these signs are useful in identifying a subset of children at high risk of death, their validation in other settings is needed. The training and supervision of health workers to identify severely ill children should continue to be given high priority because of the benefits, such as reduction of childhood mortality.

Rehabilitation of grade III protein energy malnutrition on out patients basis

Malnutrition is an important yet preventable and curable cause of morbidity and mortality. One hundred and thirty-five children suffering from grade III Protein Energy Malnutrition (PEM) from a poor urban population of Karachi city were enrolled for rehabilitation by health education and growth monitoring as out patient. Of these, 89% showed satisfactory recovery during a mean follow-up period of 3.2 months. Mainstay of this study was simple health messages adapted according to local cultural practices in native language. This simple strategy can go a long way in prevention and treatment of PEM in all the developing countries.

Malnutrition in children under five in Zimbabwe: effect of socioeconomic factors and disease

Using data from the Zimbabwe Demographic and Health Survey (1988), this study investigates the factors that determine the nutritional status of children under five years of age. Several sociocultural, economic, and demographic variables were selected for the study. These independent variables were regressed against three proxy measures of malnutrition: height-for-age, weight-for-age, and weight-for-height. The results show that the nutritional status of a child is determined by a variety of factors that are biological, social, cultural, and economic in nature, namely, birth status, birth weight, diarrhoeal status, duration of breastfeeding, and residence. The study concludes that most of the factors that account for malnutrition in children in Zimbabwe are preventable.

[Mineral balance during nutritional recuperation of infants with protein deficiency]

Mineral requirements of normal infants change according to growth velocity. They are directly associated to needs for obtaining an adequate composition of new tissue, assure an optimal bone mineralization and for maintaining normal plasma mineral levels. Nutritional rehabilitation of malnourished infants determines increased mineral requirements, which may be not satisfied with usual infant formulas. We studied mineral retention (Ca, P, Mg, Zn and Cu) during nutritional recovery of 9 malnourished male infants (age: 2-7 mo; weight/age < 70%), fed two formulas, both with 85 Kcal/dL (356 KJoule/dL): the first based on whole cow's milk (LP) and the second on a modified cow's milk containing mineral recommendations for normal infants (LPM); balances were compared to normal for age and for length. Infants received each formula for 6 days, with the last 3 days on a metabolic balance Ca, Mg, and P showed high intakes and very low urinary excretions, calcium retention (68.5 +/- 22.7 and 61.4 +/- 16.7 mg/kg/d, for LP and LPM, respectively) were 3 times over normal mean for age (130 mg/d) and 2.5 times over the normal for length (155 mg/d). Mg retention (7.4 +/- 2.0 and 3.4 +/- 1.2 mg/kg/d)), for LP and LPM) were higher than normal for age (2.7 mg/d) or length (3.3 mg/d) and also those of P (LP: 74.8 +/- 7.1; LPM: 52.2 +/- 9.3 mg/kg/d), compared to a mean of 66 mg/d for the same age, or 79 mg/d for length. Zn retentions were comparable with both formulas (LP: 0.14 +/- 0.07 vs LPM: 0.18 +/- 0.06 mg/kg/d) and over normal requirements for age (0.3 mg/d) or length (0.5 mg/d). Copper retentions were significantly lower with LP than LPM (13.8 +/- 14.0 vs 40.0 +/- 13.2 micrograms/kg/d; p < 0.01), due to low intake with LP. We conclude that a high mineral retention is observed in infants recovering from malnutrition, when they are fed formulas with mineral content over its normal recommendations.

Evaluation of anthropometric indices of malnutrition in under five children

Anthropometric indices in the assessment of malnutrition in under five children are being indiscriminately used especially when a community based survey is conducted and so the estimated prevalence of malnutrition varies in different methods. In this study a comparison of these common anthropometric measurements is done in order to find out the best method suitable for individual assessment of malnutrition. The evaluation technique discussed in this paper consists of comparison of the efficiency of various anthropometric measurements in detecting malnutrition and was judged in terms of specificity, sensitivity and predictive value. The test is most efficient when the sensitivity and specificity attain unity. In this study it is shown that weight for age and Body Mass Index (BMI) attain higher value of delta [delta = 1-(alpha + beta)], where - alpha is false positive value and beta is false negative value) and low value of delta standard error of which proves that the best method of assessing malnutrition using various anthropometric measurements is weight for age as against body mass index.

Bioelectrical impedance analysis in small- and appropriate-for-gestational-age newborn infants

OBJECTIVE

To determine the reliability of bioelectrical impedance analysis, and to compare and contrast the anthropometric and BIA status of newborns.

DESIGN

BIA and anthropometric parameters were compared in the few days after birth and at about 3 weeks of age.

SETTING

At the maternity hospital or in a paediatric care unit.

SUBJECTS

Small- or appropriate-for-gestational-age newborns, with birth weight below or above the 10th percentile of the reference value, respectively. Measurements were performed on 36 and 47 newborns at birth, and for a subgroup (21 and 11) again about 3 weeks later, respectively.

RESULTS

At birth, length2/resistance was 4.3 +/- 0.6 and 6.1 +/- 1.2 cm2/omega (P = 10(-7)), and at 3 weeks of age length2/resistance was 5.0 +/- 0.6 and 5.7 +/- 0.8 cm2/omega (P = 0.11), for small- and appropriate-for-gestational-age newborns, respectively. Percentage reliability was 2.2% and 2.6% for intra- and inter-observer measurements of resistance. Importance of a correct placement of the sensor electrode was demonstrated.

CONCLUSIONS

Ease of measurement and reliability of BIA in neonates were shown. Evolution of BIA values is in agreement with the known increase in total body water linked to regrowth of cell mass in small-for-gestational-age infants. Additional study is required before BIA should be used in usual clinical setting in newborns due to the lack of prediction equation.

Exocrine pancreatic dysfunction in malnourished Australian aboriginal children

Pancreatic exocrine dysfunction has been frequently recorded in protein-energy malnutrition in underdeveloped countries. In addition, the pancreas requires optimal nutrition for enzyme synthesis and potentially correctable pancreatic enzyme insufficiency may play a role in the continuation of protein-energy malnutrition. This problem has not been previously evaluated in Australian Aborigines. We have applied a screening test for pancreatic dysfunction (human immunoreactive trypsinogen [IRT] assay) to the study of 398 infants (6-36 months) admitted to the Alice Springs Hospital over a 20-month period. All infants were assessed by anthropometric measures and were assigned to three nutritional groups (normal, moderate or severely malnourished) and two growth groups (stunted or not stunted). Of the 198 infants who had at least a single serum cationic trypsinogen measurement taken, normal values for serum IRT (with confidence limits) were obtained from 57 children, who were normally nourished. IRT levels were significantly correlated with the degree of underweight but there was no correlation with the degree of stunting or age. Mean IRT levels for the moderate and severely underweight groups were significantly greater than the mean for the normal group (P less than 0.01). Seventeen children (8.6%) had trypsinogen levels in excess of the 95th percentile for the normally nourished group, reflecting acinar cell damage or ductal obstruction. We conclude that pancreatic dysfunction may be a common and important overlooked factor contributing to ongoing malnutrition and disease in malnourished Australian Aboriginal children.

[Nutritional recovery in infants with congenital heart disease and severe malnutrition using a hypercaloric diet]

Protein-energy malnutrition is commonly observed in infants with congenital heart disease (CHD). The effect of a hypercaloric formula on nutritional recovery was evaluated in malnourished infants with congenital heart diseases. We retrospectively studied 30 infants (mean age 9 months, range 2 to 21) with CHD along 60 to 90 days in a closed nutritional recovery center. All patients were fed a hypercaloric whole cow's milk formula with sucrose, butter oil and corn starch (1.29 kcal.ml). Mean daily energy intake was 220 +/- 19.8 kcal.kg body weight.day. Mean weight gain was 2.7 g.kg.day. No effect of cyanosis, cardiac failure, degree of malnutrition or number of illness-free days was observed on nutritional recovery. Patients older than 9 months had significantly greater weight gain than younger infants. Those infants with worse CHD and severe intercurrent illnesses had the worst nutritional recovery. We suggest that a hypercaloric formula induces good nutritional weight gain infants with severe congenital heart disease.

Fat-soluble-vitamin status during the first year of life in infants with cystic fibrosis identified by screening of newborns

We investigated the fat-soluble-vitamin status during the first year of life in 36 infants with cystic fibrosis (CF) consecutively identified by screening of newborns. At initial evaluation (at age 51.0 +/- 26.7 d) 36% of patients were hypoalbuminemic, 21% had low serum retinol, 35% had low serum 25-hydroxyvitamin D. 38% had low serum alpha-tocopherol and low ratios of serum vitamin E to total lipids, and none had elevated protein in vitamin K absence (PIVKA). Hypoalbuminemia was more common in breast-fed than in formula-fed infants. Seventy-two-hour fecal fat excretion correlated inversely with serum alpha-tocopherol. Treatment with oral pancreatic enzyme supplements, a multiple vitamin, and additional vitamin E was associated with normalization of serum albumin, retinol, and 25-hydroxyvitamin D and negative PIVKA at age 6 and 12 mo. Approximately 10% of patients remained vitamin E deficient. Biochemical evidence of fat-soluble-vitamin deficiencies is common before age 3 mo in patients with CF and, except for vitamin E, these deficiencies corrected with standard therapy.

Retinol-binding protein and prealbumin: useful measures of protein repletion in critically ill, malnourished infants

Plasma prealbumin (PA) and retinol-binding protein (RBP) concentrations were serially measured in 25 critically ill, malnourished infants requiring parenteral nutrition to determine if these visceral protein markers are useful in assessing acute protein repletion. Significant increases in both proteins (p less than 0.05) were noted as early as 5 to 7 days after institution of parenteral nutrition and continued significantly above baseline values through 2 weeks of observation. Gestational development (in infants less than 4 weeks old) and mean protein intake influenced visceral protein responses. Appropriate for gestational age neonates had more rapid and quantitatively greater PA responses (p less than 0.05) than small for gestational age neonates. Small for gestational age neonates never exceeded baseline RBP responses. Average protein intake of less than or equal to 2 g/kg/day resulted in PA and RBP concentrations below baseline and significantly lower than infants on higher protein intakes (p less than 0.05), at the end of 2 weeks. Average calorie intake of greater than 100 cal/kg/day had no differential influence on PA or RBP when compared with infants on less calories. Prealbumin values correlated with RBP values observed simultaneously (r = 0.588, p less than 0.0001). We conclude that PA and RBP are useful measures of protein repletion in critically ill infants requiring parenteral nutrition.

[Severe protracted diarrhea in infancy ("intractable diarrhea")]

In most cases, protracted diarrhea in infants is due to lack of human breast milk, and iatrogenic malnutrition. Damage to the mucosa of the small intestine maintained by cow's milk proteins and malnutrition constitute main parts of a vicious circle interrupted by completely parenteral nutrition for some time, and slow reintroduction of human breast milk. This kind of therapy reduced mortality significantly. The best prophylaxis is the full support of breast feeding. As differential diagnosis the familial lethal diarrhea of the breast fed infant has to be considered. Furthermore, in case of diarrhea lasting for longer than two weeks, other less frequent causes have to be thought of, as pointed out briefly.

Infants with low rate of weight gain. I. A study of organic factors and growth patterns

To evaluate the clinical significance of low rate of weight gain 81 infants wer investigated with a deviation of weight corresponding to a decrease of at least one S.D.-score of weight attained in the current Swedish growth chart. In 28 patients this decrease was of organic origin, notably intestinal disease. Three different growth variables were compared: attained weight (transformed to S.D.-score), change in S.D.-score of attained weight per time unit (= rate of change of deviation in S.D.-score/year) and rate of weight gain in kg/year (transformed to S.D.-score). Twenty-two of 28 infants with organic diseases had a subnormal rate of weight gain whereas only 12 attained subnormal weight for age. The use of rate of weight gain is the most sensitive growth variable and is far better than the use of attained weight as an indicator of ill-health. Change in S.D.-score of attained weight for screening purposes give good agreement with rate of weight gain, provided that age is taken into account.

[Monocytosis in pediatrics]

We report a retrospective survey of monocytosis occurring in children hospitalized at the Hospital Infantil de México. Patients with monocyte count exceeding the mean for age by more than 4 standard deviations were considered to have monocytosis. The cases with monocytosis had more infections than children without monocytosis and those with abscesses were found to have a high frequency of monocytosis. Monocytosis and neutrophilia were frequently associated. Malnutrition was found to have no effect on the frequency of monocytosis. There was no relationship of monocytosis with age, hemoglobin level, lymphocyte count, drugs administered and final outcome. We comment on these findings.