Protein deficiency, energy deficiency, and the oedema of malnutrition

The role of dietary protein deficiency in kwashiorkor is uncertain, although it has been shown not to be involved in the famine oedema of adults. A study of six different diets given to 103 children with oedematous malnutrition showed that the rate of loss of oedema was strongly correlated with the dietary energy intake (r = 0.75) but not with the protein intake (r = 0.03). 66 patients given a very-low protein diet (2.5% protein energy) lost oedema as fast as those given five times as much protein. The energy intake above which oedema resolved and below which oedema accumulated was 245-270 KJ/kg/day. Because energy deficiency is not invariably associated with oedema it cannot be the only factor involved, and the necessary dietary component(s) must therefore have been present in surfeit in all the therapeutic diets. This could be potassium together with factors necessary for its retention. The accessory ingredients must be low in foods associated with human and experimental nutritional oedema. It is suggested that protein deficiency is not the cause of the oedema of kwashiorkor and that there is no need to postulate a different pathogenesis for this oedema from starvation oedema of adults.

Plasma zinc and copper levels during the acute phase of protein-energy malnutrition (PEM) and after recovery

The fasting plasma levels of zinc and copper during the acute phase of protein-energy malnutrition (PEM) and after recovery have been measured in 51 malnourished children and 10 healthy control subjects. Recovery time was four weeks after the initial presentation when oedema had disappeared and both appetite and temperament had improved. There was no statistically significant difference between the zinc and copper values, both initially and at recovery in all the malnourished children; besides all these values were significantly lower than those for the control group. The evidence was that the dietary intake of these two trace elements was inadequate. It is suggested that in order to hasten catch-op growth during recovery from PEM, both zinc and copper should be added to the rehabilitating diets.

Effect of renutrition on humoral and cell-mediated immunity in severely malnourished children

Forty-three Colombian children suffering from either kwashiorkor (21), combined protein-calorie malnutrition (11), or maramus (11) were hospitalized and provided a high protein, high calorie diet for 4 to 5 wk. Improvement in clinical and nutritional status was accompanied by significant increases in levels of serum immunoglobulins G and M and C3 complement and by significant decreases in serum immunoglobulin A concentrations, especially in infants with kwashiorkor. Skin test reactions to purified protein derivative and candidin improved during renutrition. Lymphocyte blastogenesis after stimulation in vitro with phytohemagglutinin and pokeweed mitogen increased rapidly during hospitalization. After 1 yr posttreatment, cell-mediated immune responses, both in vivo and in vitro, had diminished. These results indicate that some aspects of the immune response are affected to a different degree in kwashiorkor, maramus, and combined malnutrition. Short-term nutritional rehabilitation has a differential effect on the long-term restoration of various aspects of immunity.

Antipyrine metabolite formation in children in the acute phase of malnutrition and after recovery

1. The plasma elimination rate of antipyrine and the urinary excretion of antipyrine and its primary metabolites 4-hydroxy-antipyrine, norantipyrine, 3-hydroxymethyl-antipyrine and 3-carboxyantipyrine were measured in five children in the acute phase of malnutrition and after recovery. The results were compared with those obtained in 3 normal children. 2. Upon nutritional rehabilitation antipyrine clearance increased from 0.65 +/- 0.14 ml min-1 kg-1 to 1.07 +/- 0.20 ml min-1 kg-1. 3. The urinary excretion of 4-hydroxy-antipyrine increased from 6.1 +/- 4.5 to 14.7 +/- 5.9%, norantipyrine from 8.8 +/- 5.7 to 14.3 +/- 5.4 and 3-hydroxy-methyl-antipyrine from 11.8 +/- 8.3 to 20.5 +/- 5.6% (% of dose/24h urine). Excretion of unchanged antipyrine decreased from 5.2 +/- 3.7 to 2.7 +/- 0.9% dose. The metabolite profile (ratio between the amounts of the various metabolites excreted) was not significantly different. 4. It is concluded that malnutrition decreases the rate of antipyrine metabolism, but it does not affect the three oxidative pathways differently.

Albumin and nutritional oedema

The nature of the association between plasma albumin and nutritional oedema has been examined by observing the changes in albumin during loss of oedema in patients on a restricted diet. Since there was no difference in the concentration of plasma albumin before and after loss of oedema, the association is not causal. These results provide no support for the assertion that nutritional oedema should be treated with a high-protein diet or an albumin infusion.

Antipyrine pharmacokinetics and D-glucaric excretion in kwashiorkor

Hepatic microsomal oxidation and glucuronidation were studied in 15 children with kwashiorkor on admission to the hospital and again after 3 weeks of nutritional rehabilitation. Microsomal oxidation as measured by antipyrine half-life and clearance was shown to be depressed in the acute phase of malnutrition (T 1/2 = 7.9 +/- 5.0 hr, clearance = 8.4 +/- 5.1 ml/min) improving with nutritional rehabilitation (T 1/2 = 4.3 +/- 2.3 hr, clearance = 15.5 +/- 8.7 ml/min). Urinary D-glucaric acid excretion increased from 60.6 +/- 42.2 mumoles/24 hr to 121.8 +/- 105.0 mumoles/24 hr over the same time period. Evidence is thus presented that both hepatic microsomal oxidation and glucuronidation are depressed in the acute phase of kwashiorkor but recover with nutritional rehabilitation.

Selective deficiency of hepatic triglyceride lipase and hypertriglyceridaemia in kwashiorkor

1. Serum postheparin lipolytic activities (PHLA), triglyceride and free fatty acid concentrations were determined in children with kwashiorkor before and after treatment and also in normal control children. 2. Using the range (571-1650 mumol/l) of serum triglyceride of the control children as normal, five (20%) of the twenty-five children with kwashiorkor had low (less than 570 mumol/l), thirteen (52%) had normal (571-1650 mumol/l) and seven (28%) had high (more than 1650 mumol/l) serum triglyceride levels. 3. The serum PHLA did not show any definite correlation with the level of circulating triglycerides, although the lowest levels of PHLA were found in the malnourished children with highest triglyceride level. 4. While the hepatic PHLA in the malnourished children was significantly less than control value, the extrahepatic PHLA did not differ significantly. 5. After treatment, serum PHLA rose significantly and the mean levels were within normal range. 6. Our findings suggest that a defect in catabolism of very-low-density lipoprotein caused by a low hepatic PHLA may cause hypertriglyceridaemia in children with kwashiorkor.

Lactose intolerance in protein-energy malnutrition: a clinical case study and family study using a hydrogen (H2) breath-analysis test for carbohydrate malabsorption

A non-invasive, interval sampling hydrogen (H2) breath-analysis test for carbohydrate malabsorption was used in a 3 year-old Guatemalan child with severe protein-energy malnutrition (kwashiorkor) and in this relatives: mother half-sister and step-father to examine genetic and nutritional factors in lactose intolerance in young children. Clinical lactose intolerance was present in the patient on admission, and lactose malabsorption, even of 0.88 g per kg of weight, persisted after complete nutritional recobly due to gastric retention of the substrate. Malabsorption of a physiological dose of lactose, 12.5 g, was detected in the mother and step-father while their daughter exhibited normal growth and development and normal lactose absorption at 8 months of age. The H2 breath test proved to be a sensitive, well-tolerated procedure for both adults and young children. Pitfalls, such as delayed gastric emptying, absence of normal bacterial flora, prior use of antibiotics, must be considered in interpreting H2 breath test results in children.

Evaluation of high-protein supplements in children with protein energy malnutrition

The present study was designed to test the comparative efficacy of cow's milk, a protein, vitamin and mineral mixture (PVM) and soybean textured vegetable protein (SOMOS) as supplements to maize meal porridge in the dietary treatment of children with protein energy malnutrition (PEM). Each diet was designed to provide approximately 480 kJ/kg with 2 protein/kg from the test protein, and 1,8 g protein/kg from maize. Response to treatment was measured by loss of oedema, subsequent weight gain, rate of generation of serum albumin, and serum amino acid patterns. In 36 children studied to date the three dietary regimens all produced satisfactory rates of cure of PEM. The clinical and economic implications of these results are discussed.

Successful use of a soya-maize mixture in the treatment of kwashiorkor

Forty-eight children aged 5 years or less admitted consecutively with a clinical diagnosis of kwashiorkor were randomly allocated to two groups. One group was treated with milk while the other group was fed soya-maize porridge; both groups received the same supportive treatment. The recovery rate in both groups was comparable. Protein intake and the rate of rise in serum albumin and transferrin concentrations were greater in the milk-fed group. The incidence of diarrhoea was significantly less in the children fed soya-maize. Soya-maize porridge is recommended as an effective and inexpensive treatment for kwashiorkor.

Malnutrition and malabsorption. Effect of nutritional rehabilitation on gastrointestinal function in kwashiorkor and marasmus--a longitudinal study

The effects of long-term feeding of an adequate diet on the progressive changes in the biochemical parameters including gastrointestinal functions in children suffering from marasmus and kwashiorkor are presented. In both groups fasting bloos sugar, blood urea nitrogen, hemoglobin, serum total proteins and albumin at admission were significantly lower than in matched controls. These parameters improved after proper dietary therapy over a period of two years. The improvement in the biochemical parameters correlated with clinical and anthropological measurement. On admission, the gastrointestinal function as assessed by various tests was poor in both the groups. This returned to normal or near normal after nutritional rehabilitation. The return was much quicker for glucose and fat absorption than for lactose and d-xylose absorption. The rate of improvement in marasmus was slower than that in kwashiorkor.