[Effects of refeeding on serum immunoglobulin (IgA, IgG, IgM) concentrations in children with severe protein-energy malnutrition]

BACKGROUND

Published studies on the serum immunoglobulin concentrations of patients with protein-energy malnutrition (PEM) have been contradictory. This report describes such a study in 21 Senegalese children.

POPULATION AND METHODS

Twenty one Senegalese infants (mean age: 19 +/- 2 months) with severe PEM were included in the study. Their weight was less than 32% of the normal range-for-height and all had sparse, thin hair and dyspigmentation of the skin. They were all suffering from hypoproteinemia (less than 70% of normal) and hypoalbuminemia (less that 61% of normal). The presence or absence of edema, loss of subcutaneous fat and mental changes were used to classify them into three groups. 1) kwashiorkor: eight infants; 2) marasmus: eight infants; 3) kwashiorkor plus marasmus: five infants. The control group comprised 27 infants living in the same area and having the same dietary habits as the 21 sick infants. The 21 infants with malnutrition were refed for 3 weeks with a diet supplying 100-150 Kcal/kg/d and 5-8 g/kg/d protein. The plasma concentration of proteins, prealbumin and immunoglobulins was measured on days 0, 8, 15 and 21.

RESULTS

The only significant change was in the IgG concentrations of group 1, which increased to normal levels by day 15 as did the total protein and prealbumin.

CONCLUSION

Severe PEM can lead to a loss of one class of immunoglobulins, but this can be restored by refeeding.

Role of zinc supplementation in the rehabilitation of severely malnourished children

A double-blind study was conducted to assess the role of zinc supplementation in the rehabilitation of severely malnourished children. Thirty-three children with severe protein-energy malnutrition received either 40 mg of zinc as zinc sulphate or a placebo during their rehabilitation in addition to the diet containing about 700 kJ and 3-4 g protein per kg body weight/day. Their clinical and biochemical responses were examined. Clinical response and serum albumin synthesis were found to be similar in both the groups. The leukocyte (micrograms/10(10) cells) and plasma zinc levels (micrograms/dl) showed a significant (P < 0.001 and P < 0.01) increase from 46.9 +/- 5.490 to 107.2 +/- 13.224 and 80.4 +/- 9.972 to 107.5 +/- 11.822, respectively, after zinc supplementation. The placebo group also showed a significant (P < 0.025) increase in leukocyte zinc from 45.7 +/- 4.409 to 70.9 +/- 8.414. However, the plasma zinc in the placebo group fell from 83.6 +/- 10.363 to 68.2 +/- 7.031. Plasma copper showed a significant improvement in both zinc supplemented (P < 0.01) and placebo (P < 0.025) groups. The results indicate that zinc supplementation along with the diet would result in rapid restoration of zinc status, though there is no effect on the weight gain or other responses.

Response of Blood Serum Constituents to Production of and Recovery from a Kwashiorkor-Like Syndrome in the Young Pig

Twenty-six 3-week-old genetically obese pigs were fed in two experiments to determine the serum chemistry profile during severe protein malnutrition and repletion. Severe protein deficiency was produced in pigs fed the high-fat, low-protein diet (growth failure, rough hair, low serum total protein and albumin). In Experiment 1, blood was sampled from the anterior vena cava of each pig five times during depletion and three times during repletion to determine serum total cholesterol, high density lipoprotein (HDL)-cholesterol, triglycerides, total protein, albumin, glucose, Ca, inorganic P, Mg, Na, K, Cl, total bilirubin, urea N, creatinine, alkaline phosphatase, alanine aminotransferase, aspartate aminotransferase, and gamma-glutamyltransferase. In Experiment 2, blood was sampled weekly for 8 weeks for serum total cholesterol, HDL-cholesterol, triglycerides, albumin, glucose, Ca, P, Mg and alkaline phosphatase. HDL-cholesterol was increased (P less than 0.01) and albumin was decreased (P less than 0.01) in protein-deficient pigs in both experiments. Creatinine, total bilirubin, gamma-glutamyltransferase, alanine aminotransferase, and aspartate aminotransferase were elevated in protein-deficient pigs compared with controls after 7 weeks of depletion. Inorganic P (P less than 0.01), Ca (P less than 0.01), and Mg (P less than 0.05) concentrations were depressed in protein-depleted pigs compared with controls in both experiments. After 8 weeks of repletion in Experiment 1, all elements except inorganic P were similar in the two groups. Short-term, severe, protein malnutrition affected lipid, electrolyte, and structural mineral metabolism and indices of liver function in the absence of parasites, diarrhea, and infection. The effects were reversed after 8 weeks of repletion. We conclude that the elevated serum cholesterol in protein deficiency is related primarily to an increase in the HDL fraction.

Reversible cerebral shrinkage in kwashiorkor: an MRI study

Protein energy malnutrition is associated with cerebral atrophy which may be detrimental to intellectual development. The aim of this study was to document the anatomical abnormalities which lead to the appearance of cerebral atrophy using magnetic resonance imaging (MRI) in the acute stage of kwashiorkor and to monitor changes during nutritional rehabilitation. Twelve children aged 6 to 37 months requiring admission to hospital for the treatment of kwashiorkor were studied. The children were evaluated clinically, biochemically, and by MRI of their brains on admission and 30 and 90 days later. Brain shrinkage was present in every child on admission. White and grey matter appeared equally affected and the myelination was normal for age. At 90 days, the cerebral changes had resolved in nine and improved substantially in the remainder, by which time serum proteins and weight for age were within the normal range. The findings of this study suggest that brain shrinkage associated with kwashiorkor reverses rapidly with nutritional rehabilitation.

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations in children with kwashiorkor in the acute stage and during refeeding

Plasma zinc, copper, selenium, ferritin and whole blood manganese concentrations were measured in 22 children with kwashiorkor on admission to hospital and on days 5, 10 and 30 of refeeding. Twenty similarly aged, healthy, well nourished children served as controls. The mean (SEM) zinc, copper and selenium concentrations of 7.5 (0.93), 10.8 (0.64) and 0.29 (0.02) mumol/l, respectively, in the children with kwashiorkor on admission were all significantly lower than the values of 13.7 (0.66), 25.6 (1.72) and 0.72 (0.04) mumol/l in the controls. In contrast, the erythrocyte manganese level of 1.67 (0.09) micrograms/gHb and the median ferritin concentration of 293 micrograms/dl were significantly higher than in the controls. After 30 days there was full clinical recovery with significant weight gain and a return of the plasma albumin, caeruloplasmin, copper and ferritin to normal. However, manganese remained elevated and zinc and selenium concentrations remained significantly low. Our results suggest that nutritional rehabilitation of children with kwashiorkor is incomplete by 30 days and cannot be judged purely by a return of the plasma proteins to normal. Addition of selected trace elements to the diet may hasten full recovery.

Computed tomography of the brain in kwashiorkor: a follow up study

Computed tomography of the brain was performed initially and after nutritional rehabilitation on 12 children with kwashiorkor. The severe cerebral shrinkage evident initially resolved after nutritional rehabilitation. The mechanism and significance of this reversible abnormality remains to be determined.

Nondairy-creamer-induced kwashiorkor: 5-year follow-up

Failure to thrive may not be a result of organ disease, physical abuse, or intentional neglect. We describe an infant who developed kwashiorkor with a high-fat, low-protein, nondairy coffee creamer diet. The elimination diet was administered on the advice of a family friend for a facial rash. The child presented at 10 months of age with decreased weight for height, rash, hepatomegaly, edema, hypoproteinemia, hypoalbuminemia, anemia, hypoglycemia, and evidence of hepatic sequestration of lipids. A rapid recovery of biochemical abnormalities was evident on reinstitution of a full diet. An intellectual assessment at age 5 years showed normal results.

Kwashiorkor

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Clinical studies of a vegetarian food diet mixture

A vegetarian food mixture when incorporated into a commercially prepared diet can be used as a supplement or in a vegetarian protein-sparing modified fast. A modification of this diet was given to protein-energy deficient malnourished children in Ethiopia, and it reversed their biochemical defects. The soluble or gel-forming fiber in the mixture also gives the product a favorable glycemic index and reduces glycemic excursion as well as fasting blood glucose and insulin levels. This accounts for the improvements seen in glucose tolerance in type II diabetic patients. These results, however, were preceded by a study of the effects of the mixture in improving glucose tolerance in diabetic rats. A clinical study among New Orleans police officers also suggests that this mixture helps people, without much self-motivation, to lose weight.

Volunteer experience of an American dietitian in Liberia, West Africa

An American volunteer dietitian can make significant contributions in a developing country with the support of local personnel. Three objectives were achieved during a recent experience. The first objective was to become familiar with local foods and food customs and to revise the hospital diet manual to reflect Liberian food habits. Clinical observation of malnourished pediatric patients was the second objective, and this led to evaluation of the ELWA Hospital's kwashiorkor formula. The third objective was to provide in-service education to nurses and physicians at the ELWA and JFK Memorial Hospitals in Monrovia. Presentations were made on basic nutrition, diet manual revisions, and a kwashiorkor literature review. These objectives were set at the request of the ELWA Hospital administrator and accomplished with the support of the medical staff.

Active and passive transport of sodium and potassium ions in erythrocytes of severely malnourished Jamaican children

Erythrocytes of normal and malnourished children, both marasmic and oedematous (kwashiorkor), were equilibrated in standard incubation medium and their ion transport via the Na/K pump and the pathways of passive permeation were measured as unidirectional fluxes of 86Rb (as a congener of K) and 22Na. Cells of children with kwashiorkor exhibited a 65 per cent higher ouabain-sensitive K(Rb) influx ('pump rate') than those of normal or marasmic children. When allowance was made for cytoplasmic Na concentration, the pump rate was slower in younger (12 months and under) normal children than in older children. Judged by the same criterion, cells of older marasmic children also had slower steady-state pump activity. The passive permeation of K through the residual 'leak' pathway (ie, ouabain-and-bumetanide-insensitive influx) and Na permeation (ouabain-and-bumetanide-insensitive Na efflux) were greater in malnourished children than in normal children by a factor of two or more. During treatment for malnutrition, both Na-pump activity and ouabain binding increased rapidly in marasmic children. Passive permeation did not return to normal levels in malnourished children during the period of hospitalization.

Growth in length of children recovering from severe malnutrition

The linear growth of 369 children treated for severe malnutrition at the Tropical Metabolism Research Unit, University Hospital of the West Indies, was examined retrospectively. Mean age was 12.6 months and 58 per cent of the children were oedematous on admission. Mean length for age was the same at admission and discharge (SD score - 3.4). Therefore when the sample is considered as a whole there was no catch-up in length for age. A sub-group of 108 children began to show catch-up growth in length. This sub-group did not differ in age or sex from the total sample but contained a greater proportion of non-oedematous children. Children in the sub-group were also more stunted initially (P less than 0.0001) than the group as a whole. The absolute rate of linear growth was similar in oedematous and non-oedematous children. Change in length for age during recovery was significantly less in children who were oedematous on admission. Two-thirds of the children attained at least 85 per cent weight for length before they began to increase in length. Thus in most cases linear growth followed replenishment of body weight. The data point to the need for further investigations to determine why some children were capable of early catch-up growth in length while others, with similar characteristics, showed minimal or no linear growth during recovery.

Serum insulin-like growth factors I and II concentrations and growth hormone and insulin responses to arginine infusion in children with protein-energy malnutrition before and after nutritional rehabilitation

Serum insulin, growth hormone (GH), insulin-like growth factors (IGFs) I and II, cortisol, and albumin concentrations were measured in 15 children with kwashiorkor, 15 with marasmic-kwashiorkor, and 21 with marasmus, before and in the survivors, after nutritional rehabilitation, as well as in 10 underweight and eight normal Egyptian children. We also evaluated arginine-induced insulin and GH secretion. IGF-I concentrations were reduced in the three severely malnourished groups (0.07 +/- 0.03, 0.05 +/- 0.03, and 0.09 +/- 0.09 U/ml, respectively) but returned to normal after refeeding. IGF-II concentrations were low in the kwashiorkor (175 +/- 79 ng/ml), marasmic-kwashiorkor (111 +/- 57 ng/ml), and marasmic children (128 +/- 70.9 ng/ml) and returned to normal after nutritional rehabilitation. Basal GH levels were high in the three severely malnourished groups (21.9, 28.8, and 16.6 ng/ml, respectively) and returned to normal after refeeding (8.1, 6.5, and 6.0 ng/ml, respectively). GH responses to arginine were depressed in the three malnourished groups and improved significantly in marasmic-kwashiorkor and marasmic children after nutritional rehabilitation. Insulin responses to arginine were impaired in kwashiorkor, and marasmic-kwashiorkor children and improved significantly after refeeding. IGF-I levels correlated significantly with percent of expected weight (r = 0.52, p less than 0.001), percent of expected height (r = 0.42, p less than 0.001), and weight/(height)2 index (r = 0.34, p less than 0.01). IGF-I levels correlated positively with insulin levels (r = 0.421, p less than 0.001) and negatively with cortisol concentrations (r = -0.400, p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Kwashiorkor in Baltimore

Advanced cases of malnutrition are rare in the United States. Since it is rarely suspected, a correct diagnosis of malnutrition, even in extreme form, may easily be missed. We present a recent case of the kwashiorkor form of the syndrome of protein-energy malnutrition to emphasize its diagnostic features and to enhance early recognition and initiation of proper therapy. The misunderstanding of a physician's recommendations by a teen-aged mother may have initiated this illness.

The effect of dietary lactose on the early recovery from protein-energy malnutrition. I. Clinical and anthropometric indices

To assess the advisability of using lactose-containing formulas in the rehabilitation of severely malnourished children, indices of clinical recovery, growth and restoration of body proteins and gastrointestinal function were measured longitudinally during the initial 45 days of hospitalization in 20 male, preschool children with kwashiorkor and marasmic-kwashiorkor. All patients received a diet based on cows' milk, but half were allocated to a formula pretreated with beta-galactosidase to hydrolyze the lactose, while the others received the untreated, intact milk. The groups were identical with respect to clinical criteria on admission. For the final 37 days of the protocol, the subjects received 4 g of protein and 150 kcal of energy per kg per day. More diarrhea was experienced by the intact lactose group during early hospitalization. Overall, recovery was satisfactory in both cohorts, and there were no differences in rates of growth, body protein repletion, restoration of energy reserves nor intestinal functions. In conclusion, the routine reduction of lactose content from a milk-based diet for severe protein-energy malnutrition offers no advantages.

The effect of dietary lactose on the early recovery from protein-energy malnutrition. II. Indices of nutrient absorption

Absorption of dietary energy, nitrogen, carbohydrates and calcium, and retention of nitrogen and calcium were studied in 20 children with protein-energy malnutrition of the edematous type, using metabolic balance techniques and breath H2 analysis, to assess the advisability of using lactose-containing formulas in the rehabilitation of severely malnourished children. Ten patients received for 45 days a diet formula based on cows' milk (intact milk) and 10 similar children received the same formula pretreated with beta-galactosidase to hydrolyze the lactose (hydrolyzed milk). Dietary intakes were gradually increased to reach, on the 8th day, 4 g of protein and 150 kcal/kg. There were no differences between groups with respect to absorption or retention of the index nutrients. Postprandial carbohydrate malabsorption was occasionally observed in two patients with servings of the intact milk formula, and in one with the hydrolyzed milk diet. When the nutritional quality of a diet is assessed, the amount of nutrients that are absorbed and utilized are more important than the small, incompletely absorbed fractions that do not have significant metabolic or clinical implications. Therefore, the use of milk as the protein source for recovery diets is not contraindicated in the routine treatment of PEM.

Depressed natural killer cell activity in children with protein--calorie malnutrition. II. Correction of the impaired activity after nutritional recovery

Natural killer (NK) cell activity and responsiveness to interferon (IFN) were measured in the peripheral blood of infants having kwashiorkor or marasmus and of nutritionally recovered malnourished children. Depression of NK activity in the peripheral blood lymphocytes (PBLs) of the malnourished children was noted, while normal levels of activity were observed in the nutritionally recovered infants. Addition of exogeneous interferon in vitro potentiated the NK levels of PBLs from well-nourished and nutritionally recovered infants, but had either a nonsignificant impact on cells from the marasmic infants or a suppressive effect on the cells from infants with kwashiorkor. The success of exogenous interferon to potentiate the NK levels of PBLs from nutritionally recovered infants suggests that nutritional repletion corrects the impaired cellular responsiveness in these patients.

[Initiation of a cure for kwashiorkor patients using a whey milk product. A comparison with cows milk]

Whey milk, a side-product of cheese production, is not utilized for human nutrition. Whey protein is of good nutritional quality with a high biological value, exceeding that of whole-milk protein. A whey milk product consisting of liquid whey milk 60%, whole cow's milk 40% and skimmed milk powder 0.5% was mixed, spray-dried and prepared in instant form. After reconstitution with water, it was compared with sterilized whole cow's milk for the initiation of cure in 30 acute kwashiorkor patients randomly allocated to the two feeds. The diets were given for 3 weeks. There were no statistically significant differences between the two diets with regard to weight gain or levels of serum albumin, globulin, calcium, phosphorus, alkaline phosphatase, sodium, potassium, chloride, bicarbonate, urea or haemoglobin. Judging from this limited investigation, whey milk deserves consideration for human utilization. Should economical production be possible, it could contribute towards preventing and treating protein energy malnutrition.