Difference between kwashiorkor and marasmus: Comparative meta-analysis of pathogenic characteristics and implications for treatment

Epidemiology and clinical characteristics of acute malnutrition among under-5 children attending a rural hospital in the Democratic Republic of Congo: a cross-sectional study

Background

Malnutrition, a public health problem in a low-income country such as the Democratic Republic of Congo (DR Congo), is a major killer among children under 5 who are most at risk of acute malnutrition. This study aims to describe the epidemiological and clinical characteristics of acute malnutrition in children under 5 years old.

Methods

The authors conducted a retrospective and descriptive cross-sectional study on children under 5 with acute malnutrition from April 2022 to April 2023. A total of 287 malnourished children were consulted, hospitalized in a rural hospital, and registered for participation in this study.

Results

Two hundred eighty-seven (25%) children were victims of acute malnutrition. The age group between 13 and 24 months is the most affected by acute malnutrition with 30%. The male-to-female(M/F) sex ratio was 1.17. Kwashiorkor is the most common form of acute malnutrition with 171 (59.6%) cases. Abdominal bloating, weight loss as well as diarrhea and vomiting were the more frequent clinical signs. Shock is the most complication of acute malnutrition. Therapeutic milk (Food 75 and Food 100) was the most effective in management. Twenty-nine (10.1%) other children died from acute malnutrition and 258 (89.9%) children progressed to full recovery.

Conclusion

Acute malnutrition in children remains a public health problem worldwide and particularly in low-income countries such as DR Congo. It is associated with multiple physiological vulnerabilities and has many short- and long-term complications in children who have suffered from it.

Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations

Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).

Malnutrition as a Risk Factor in the Development of Oral Cancer: A Systematic Literature Review and Meta-Analyses

This systematic review and meta-analyses aimed to assess whether malnutrition may increase the incidence of oral cancer. Following the PRISMA statement, the research was conducted on PubMed, Scopus, and MEDLINE via OVID without any time restrictions. The risk of bias was assessed, and the quality of evidence for each performed meta-analysis was evaluated using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Sixty-one articles met the inclusion criteria and seven studies underwent quantitative evaluation. For our meta-analysis on hypovitaminosis B, three studies with a total of 90,011 patients were included. An odds ratio of 2.22 was found. Our meta-analysis on the correlation between vitamin C and oral cancer included one study with a total of 866 patients and the derived odds ratio was 1.06. Our meta-analysis on the relationship between vitamin D deficiency and the incidence of oral cancer included three studies with a total of 12,087 patients and the odds ratio was -2.58. The GRADE system showed a moderate strength of evidence due to the presence of studies with a high risk of bias and high indirectness of the data given. The present findings suggest that an inadequate intake of vitamins, particularly vitamin D, poses a risk for the onset of oral cancer.

Treatment Outcomes of Severe Acute Malnutrition and Its Determinants Among Paediatric Patients in Quetta City, Pakistan

Purpose

Severe acute malnutrition (SAM) is the most prevalent reason for admission to a paediatric unit, and it is a leading cause of mortality in many countries, including Pakistan. This study aimed to assess treatment outcomes and associated factors among children aged 6-59 months with severe acute malnutrition.

Patients and Methods

A retrospective cohort study was conducted at the Outpatient Therapeutic Feeding Program Centre established at the Sheikh Khalifa bin Zayed Al Nahyan Medical Complex Quetta. Out of 225 patients' records, data from 182 (80.8%) records were analysed based on the inclusion criteria. The SAM logbook was used as a source of data. Predictors of treatment outcomes were identified by applying a regression model with p<0.05 taken as significant.

Results

One hundred and twenty (65.9%) of the children were diagnosed with SAM, while the remaining 34.1% had Moderate Acute Malnutrition. Ninety-five (52.2%) children were included in the marasmus, while 47.8% were included in the Kwashiorkor cohort. The recovery rate was 68.6%; 22.5% were non-responsive, 11% defaulted on the program, and 3.5% died during management. The multivariate logistic regression identified the presence of diarrhea and the use of amoxicillin as significant prognosticators of treatment outcomes. Consequently, the odds of recovery on SAM among children with diarrhea [AOR = 0.60, 95% CI: (0.35-0.75)] were lower than those without diarrhea. Likewise, children on PO amoxicillin had higher chances of recovery [AOR = 2.45, 95% CI: (2.21-4.68)].

Conclusion

This study found that the recovery rate among children treated for SAM was poor based on the established Sphere Standard recommendation. In addition to community-based educational campaigns, capacity enhancement of OTP and frequent monitoring of services as well as program evaluation based on the management protocol is recommended to reduce the frequency of SAM among children.

Perspective: Nutrition’s Next Chapter – Bioactive Gaps & the Microbiome-Mitochondria Axis

Food has the power to heal. Our bodies transform and are transformed by the elements in food and the adage that we are what we eat is figuratively and literally true. Twentieth century nutrition science focused on decoding the processes and building blocks of this transformation -- the proteins, fats, carbohydrates, vitamins, and minerals. Twenty-first century nutrition science is aimed at better understanding the increasingly appreciated bioactives within the food matrix that help regulate this transformation - fibers, phytonutrients, bioactive fats, and ferments. Our microbiome and the mitochondria play a key function in orchestrating the role of bioactives in health and are inspiring next-generation nutritional approaches for addressing over- and undernutrition.

Antibiotic use and resistance in children with severe acute malnutrition and human immunodeficiency virus infection

Severe acute malnutrition (SAM) and human immunodeficiency virus (HIV) infection underlie a major proportion of the childhood disease burden in low- and middle-income countries. These diseases commonly co-occur and lead to higher risk of other endemic infectious diseases, thereby compounding the risk of mortality and morbidity. The widespread use of antibiotics as treatment and prophylaxis in childhood SAM and HIV infections, respectively, has reduced mortality and morbidity but canlead to increasing antibiotic resistance. Development of antibiotic resistance could render future infections untreatable. This review summarises the endemic co-occurrence of undernutrition, particularly SAM, and HIV in children, and current treatment practices, specifically WHO-recommended antibiotic usage. The risks and benefits of antibiotic treatment, prophylaxis and resistance are reviewed in the context of patients with SAM and HIV and associated sub-populations. Finally, the review highlights possible research areas and populations where antibiotic resistance progression can be studied to best address concerns associated with the future impact of resistance. Current antibiotic usage is lifesaving in complicated SAM and HIV-infected populations; nevertheless, increasing baseline resistance and infection remain a significant concern. In conclusion, antibiotic usage currently addresses the immediate needs of children in SAM and HIV endemic regions; however, it is prudent to evaluate the impact of antibiotic use on resistance dynamics and long-term child health.

Protein malnutrition in BALB/C mice: A model mimicking clinical scenario of marasmic-kwashiorkor malnutrition

Protein malnutrition continues to be a major global issue. A stable animal model to address protein malnutrition and its effect on various disease conditions is necessary. In the present study, we have formulated and standardized a low protein diet (LPD) to develop a protein malnutrition model using Balb/C mice. Healthy male Balb/C mice were weaned and exposed to LPD combinations while another group exposed to normal diet (18% protein). Animal survival, change in body weight, body mass index (BMI), biochemical parameters, antioxidant status, and liver histopathology were used to confirm the development of malnourished mice model (marasmic-kwashiorkor). Mice receiving 10% protein diet showed moderate weight gain, higher BMI, and no mortality compared to the 6% protein group. The former group showed remarkable differences in BMI, biochemical and antioxidant parameters. Further, histopathological changes against the normal group at weeks 20 and 30 confirmed the development of protein malnutrition in mice on 10% protein diet. The study confirms the development of a stable, economical, reproducible, and clinically relevant protein malnutrition model using the formulated 10% protein diet. Further, the model can be used for short and long-term studies to investigate the pathophysiology of malnutrition in any disease/condition.

V, Chakraborthy A, B. MK, A. VS, Badanthadka M. Protein Malnutrition in BALB/c Mice: An Experimental Model Resembling Clinical Scenario

Objectives The study aims to develop a stable malnourished experimental mice model resembling the human population for future experimental studies.

Materials and Methodology At weaning, female BALB/c mice are separated into two groups: one receiving a low protein diet (LPD, 10% protein) and the other receiving a commercially available normal pellet diet (ND, 18% protein). Model development and stability were assessed using body mass index (BMI), biochemical parameters such as glucose, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, total protein, albumin, total cholesterol, calcium, and phosphorus using serum samples at the 12th and 15th weeks of the study, antioxidant assay, and liver histopathology observation. Antioxidant assay and histopathology observation using liver tissue sample excised after euthanasia.

Results LPD mice are categorized under grade I malnutrition based on the body weight change with respect to ND as per the principles of Gomez's classification of malnutrition. A significant long-term decrease in BMI of the malnourished group indicates the development of the stable malnourished model. Elevated serum enzyme levels in the 15th week and decreased antioxidant activity suggest liver injury and oxidative stress at the cellular level in the malnourished group. Histopathology alterations in the liver tissue further strengthen these observations reported in the human population of malnutrition.

Conclusion This study confirms the development of a stable malnourished experimental model using a LPD (10% protein). This model may be used to study the role of malnutrition in the pathophysiology of any disease, drug action, and its kinetics in the future.

Nonalcoholic Fatty Liver Disease and the Gut-Liver Axis: Exploring an Undernutrition Perspective

Nonalcoholic fatty liver disease (NAFLD) is a chronic condition affecting one quarter of the global population. Although primarily linked to obesity and metabolic syndrome, undernutrition and the altered (dysbiotic) gut microbiome influence NAFLD progression. Both undernutrition and NAFLD prevalence are predicted to considerably increase, but how the undernourished gut microbiome contributes to hepatic pathophysiology remains far less studied. Here, we present undernutrition conditions with fatty liver features, including kwashiorkor and micronutrient deficiency. We then review the gut microbiota-liver axis, highlighting key pathways linked to NAFLD progression within both overnutrition and undernutrition. To conclude, we identify challenges and collaborative possibilities of emerging multiomic research addressing the pathology and treatment of undernourished NAFLD.

Validation of a Feed Protocol in a Mouse Model That Mimics Marasmic Malnutrition

Host nutritional status directly interferes with immunity and/or susceptibility to infectious diseases. To understand the mechanisms behind this relationship, the use of animal models and feeding protocols is necessary. In the literature, studies reporting marasmic malnutrition in mice are not common. In this context, the objective of this study was to validate a feed methodology that mimics marasmic malnutrition, examining the nutritional, biochemical, and hematological status in BALB/c mice. Weaned BALB/c mice were or were not fed a Restricted diet (36.26% carbohydrate, 8.79% protein, 4.95% fat, and 7.62 kJ/100 g). Some malnourished mice underwent a refed process with a Control diet (65.93% carbohydrate, 24.18% protein, 9.89% fat, and 15.24 kJ/100 g). The nutritional status of the mice was evaluated through phenotypic markers and hematological and biochemical parameters. Our results showed that the Restricted diet was able to induce mild malnutrition in mice, resulting in mouse weight loss of 12%, which could be reversed after refeeding. Malnourished mice demonstrated slow body growth and low body mass index (BMI) values. Malnourished mice also showed physical and behavioral changes, a reduction of 47.5% in leukocyte counts and a 2-fold increase in cholesterol levels. In conclusion, our feeding protocol was able to generate mild malnutrition and cause changes in the nutritional status of mice that could be similar to those observed in marasmic malnutrition.

Virgibacillus doumboii sp. nov., a halophilic bacterium isolated from the stool of a healthy child in Mali

A moderately halophilic and strictly aerobic bacterium was isolated from a human stool as part of a study on the diagnosis of childhood malnutrition in Mali. Strain Marseille-Q1616T is a Gram-stain-positive, rod-shaped, catalase-positive and oxidase-negative bacterium. It has a genome size of 3.91 Mbp with 39.79% G+C content, which contains 3954 protein-coding genes including genes encoding phosphomycin resistance and Listeria monocytogenes, 16 rRNA genes and 64 tRNA genes. Strain Marseille-Q1616T exhibited a 96.3% 16S rRNA gene sequence similarity and shared an OrthoANI value of 70.64% (the highest observed) with Virgibacillus kekensis, the phylogenetically closest validly published species. Based on phenotypic and phylogenetic evidence and genomic average nucleotide identity values, we suggest the creation of a new species within the Virgibacillus genus, named Virgibacillus doumboii sp. nov., type strain Marseille-Q1616T (= CSURQ1616).

A Listeria monocytogenes clone in human breast milk associated with severe acute malnutrition in West Africa: A multicentric case-controlled study

Background

Severe acute malnutrition (SAM) is a major public health problem affecting children under the age of five in many low- and middle-income countries, and its resolution would contribute towards achieving the several sustainable development goals. The etiology of SAM is pluri-factorial, including delayed maturation of the gut microbiota, suboptimal feeding practices and dysfunctional breastfeeding. The recent serendipitous detection of Listeria monocytogenes in the breast milk of Malian women, in contrast to French women, suggests a possible association with SAM.

Methodology/ Principal findings

To investigate the possible association of L. monocytogenes carriage in breast milk and SAM, a case-control study was performed in Senegal, with subjects recruited from two areas. Using 16S amplicon sequencing, a culture independent method, 100% (152/152) of the mothers were positive for L. monocytogenes in their breast milk while qPCR analysis gave lower recovery rates. Interestingly, after enrichment in Fraser broth and seeding on PALCALM agar, all 10 isolated strains were isolated from the milk of 10 mothers who had SAM children which also had a significantly increased relative abundance of L. monocytogenes (0.34 (SD 0.35) vs 0.05 (SD 0.07) in controls, p<0.0001). The high genomic similarity between these strains and Malian breast milk strains from a previous study supports the hypothesis of endemic clone carriage in West Africa. Moreover, the in vitro growth inhibition of L. monocytogenes using breast milk samples was obtained from only 50% of the milk of mothers who had SAM children, in contrast to control samples which systematically inhibited the growth of L. monocytogenes with a higher inhibition diameter (15.7 mm (SD 2.3) in controls versus 3.5 mm (SD 4.6) in SAM, p = 0.0001). Lactobacillus and Streptococcus isolated from the breast milk of controls inhibit L. monocytogenes in a species-dependent manner.

Conclusions/Significance

Our study reveals a previously unsuspected carriage of L. monocytogenes in the breast milk of West African women, which is associated with SAM. The inhibitory effect of human selected lactic acid bacterial species against L. monocytogenes might provide new therapeutic and inexpensive options to prevent and treat this neglected public health issue.

Severe acute malnutrition is a global public health issue which greatly impacts childhood mortality rates. Although still not fully understood, the multi-factorial pathology of severe acute malnutrition has been associated, among other factors, with sub-optimal feeding practices (including dysfunctional breastfeeding) and an altered gut microbiota. The serendipitous detection of Listeria monocytogenes in the breast milk of Malian women has raised the possibility of its involvement in the pathogenesis of severe acute malnutrition. To investigate this possibility, the presence of L. monocytogenes was assessed in a cohort of lactating Senegalese women, both mothers of healthy children as well as those of severely malnourished children using culture-dependent and independent methods. Our study confirms the previously unsuspected presence of L. monocytogenes in the breast milk of Senegalese women, which is increased in the milk of mothers of severely malnourished children. Moreover, breast milk samples from the mothers of healthy children more frequently induced a potent inhibition of L. monocytogenes than those from the mothers of severely malnourished children. An inhibition was also achieved using potential probiotics, Lactobacillus and Streptococcus species, isolated from breast milk. Our study reveals the previously unsuspected carriage of L. monocytogenes in the breast milk of West African women, which is associated with severe acute malnutrition. The inhibitory effect of human selected lactic acid bacterial species against L. monocytogenes might provide new therapeutic and inexpensive options to prevent and treat this neglected public health issue.

Influence of Malnutrition on the Pharmacokinetics of Drugs Used in the Treatment of Poverty-Related Diseases: A Systematic Review

Background

Patients affected by poverty-related infectious diseases (PRDs) are disproportionally affected by malnutrition. To optimize treatment of patients affected by PRDs, we aimed to assess the influence of malnutrition associated with PRDs on drug pharmacokinetics, by way of a systematic review.

Methods

A systematic review was performed on the effects of malnourishment on the pharmacokinetics of drugs to treat PRDs, including HIV, tuberculosis, malaria, and neglected tropical diseases.

Results

In 21/29 PRD drugs included in this review, pharmacokinetics were affected by malnutrition. Effects were heterogeneous, but trends were observed for specific classes of drugs and different types and degrees of malnutrition. Bioavailability of lumefantrine, sulfadoxine, pyrimethamine, lopinavir, and efavirenz was decreased in severely malnourished patients, but increased for the P-glycoprotein substrates abacavir, saquinavir, nevirapine, and ivermectin. Distribution volume was decreased for the lipophilic drugs isoniazid, chloroquine, and nevirapine, and the α1-acid glycoprotein-bound drugs quinine, rifabutin, and saquinavir. Distribution volume was increased for the hydrophilic drug streptomycin and the albumin-bound drugs rifampicin, lopinavir, and efavirenz. Drug elimination was decreased for isoniazid, chloroquine, quinine, zidovudine, saquinavir, and streptomycin, but increased for the albumin-bound drugs quinine, chloroquine, rifampicin, lopinavir, efavirenz, and ethambutol. Clinically relevant effects were mainly observed in severely malnourished and kwashiorkor patients.

Conclusions

Malnutrition-related effects on pharmacokinetics potentially affect treatment response, particularly for severe malnutrition or kwashiorkor. However, pharmacokinetic knowledge is lacking for specific populations, especially patients with neglected tropical diseases and severe malnutrition. To optimize treatment in these neglected subpopulations, adequate pharmacokinetic studies are needed, including severely malnourished or kwashiorkor patients.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40262-021-01031-z.