Assessment of marginal malnutrition

Nutrition Management in Pediatric Gastrointestinal Motility Disorders

Gastrointestinal (GI) motility disorders are associated with suboptimal nutrition in children, mainly because of malabsorption and symptoms limiting dietary intake. Apart from medical therapy, nutrition support has a crucial role in maintaining growth and improving clinical outcomes in children. Based on recent data and guidelines, this review provides an overview of nutrition assessment and specific interventions for common pediatric GI disorders including gastroesophageal reflux disease, esophageal motility disorders, gastroparesis, chronic intestinal pseudo-obstruction, and constipation. Several approaches including diet modification, enteral nutrition (gastric vs post-pyloric, temporary vs permanent access, bolus vs continuous), and parenteral nutrition need to be tailored based on patient's nutrition and clinical assessment.

[Clinical signs of malnutrition in children living around a mining area: a case study in the city of Lubumbashi and its surrounding]

INTRODUCTION

Malnutrition remains to this day a major public health problem, particularly in developing countries. This study aimed to determine the clinical signs observed in malnourished children admitted to a care unit.

METHODS

This is a descriptive cross-sectional study, conducted from July 2013 to December 2014. Our study included 311 cases (182 malnourished children and 129 well-nourished children), based on exhaustive sampling, with an active screening of malnourished and well-nourished children. The diagnosis was made clinically and was associated with anthropometry.

RESULTS

The main collected symptoms in malnourished children were: cough or pneumonia in 42.50%, gastroenteritis in 38.55%, skin lesions in 22.91% of cases, fever in 22.35% of cases, edema in 19.0% of children, pallor in 8.38% of children; finally splenomegaly and hepatomegaly were the less common symptoms (1.68% and 2.89% respectively). Well-nourished children, instead, showed splenomegaly and fever associated with malaria.

CONCLUSION

Malnourished children living around a mining area don't differ in symptomatology from the other malnourished children, except for hepatomegaly and splenomegaly which are very rare in our malnourished children.

Nutrition-focused physical examination in pediatric patients

A complete nutrition assessment includes several components: medical record review, anthropometric measurements, diet/nutrition intake, interview, and physical examination. The nutrition-focused physical examination (NFPE) can identify or confirm muscle wasting, subcutaneous fat loss, and edema and clarify information gathered during the medical record review. The physical examination component of the nutrition assessment is more critical in pediatric patients because pediatric patients can become malnourished more quickly than adults and because prolonged malnutrition can negatively affect growth and development. In addition, case studies of micronutrient deficiencies, essential fatty acid deficiency, and protein-calorie malnutrition with skin manifestations have been reported in developed countries. The etiologies of the deficiencies are chronic disease, long-term tube feedings, or long-term parenteral nutrition. An NFPE involves an in-depth examination of the patient from head to toe by a trained nutrition professional. Nutrition professionals recognize the importance and value of an NFPE, yet it is seldom completed, particularly in pediatrics, most likely due to lack of training and lack of pediatric-specific information or training opportunities. Although there are similarities between NFPE in pediatric and adult patients such as the techniques used (inspection, palpation, percussion, and auscultation), there are important differences related to growth and development. This review provides an overview of nutrition assessment with focus on the NFPE and aspects unique to the pediatric patient.

Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions

Lack of a uniform definition is responsible for underrecognition of the prevalence of malnutrition and its impact on outcomes in children. A pediatric malnutrition definitions workgroup reviewed existing pediatric age group English-language literature from 1955 to 2011, for relevant references related to 5 domains of the definition of malnutrition that were a priori identified: anthropometric parameters, growth, chronicity of malnutrition, etiology and pathogenesis, and developmental/ functional outcomes. Based on available evidence and an iterative process to arrive at multidisciplinary consensus in the group, these domains were included in the overall construct of a new definition. Pediatric malnutrition (undernutrition) is defined as an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes. A summary of the literature is presented and a new classification scheme is proposed that incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and its impact on outcomes. Based on its etiology, malnutrition is either illness related (secondary to 1 or more diseases/injury) or non-illness related, (caused by environmental/behavioral factors), or both. Future research must focus on the relationship between inflammation and illness-related malnutrition. We anticipate that the definition of malnutrition will continue to evolve with improved understanding of the processes that lead to and complicate the treatment of this condition. A uniform definition should permit future research to focus on the impact of pediatric malnutrition on functional outcomes and help solidify the scientific basis for evidence-based nutrition practices.

Population dynamics and drought: A village in Niger

Summary The paper reports the results of demographic research in a rural village of about 1500 Hausaspeaking farmers in southern Niger, during the winter of 1973-74. The research site lies at the heart of the Sahel-sudanic zone just to the south of the Sahara, where drought, and in some areas, famine have exacted a heavy human, animal, and economic toll since 1968. The study was designed to measure and explain the change in the size and structure of the population during the years 1969-73. Social anthropological field techniques were used to ensure full and accurate reporting by community residents on all census topics. Data on rainfall and crop yields, on health and sanitary conditions, and on the political economy, social organization, and culture of the village were gathered in order to interpret the demographic situation The analysis of this data yields the following conclusions: 1. The population of the village appears younger (mean age: 15 years) and growing faster (mean doubling time: 23 years) than reported for Niger as a whole in 1972. 2. Contrary to what the researchers expected, the crude death rate, while relatively high to begin with, actually declined during the drought period (mean: 14.81); the crude birth rate remained very high (mean: 46.01), and the crude rate of increase rose from 1969 to 1973. 3. There was virtually no family out-migration from the target village during the drought, although the number of adult males participating in seasonal migrations to large West African towns rose from 35 per cent in 1969-70 to 75 per cent in 1973-74. 4. Problems of food production and distribution were acute, but thanks to the availability of donated foods, these were sufficiently short-lived during this drought cycle to make no discernible impact on population, although prolonged protein/calorie malnutrition among the very young may affect future fecundity.

Protein energy malnutrition

Protein energy malnutrition (PEM) is a common problem worldwide and occurs in both developing and industrialized nations. In the developing world, it is frequently a result of socioeconomic, political, or environmental factors. In contrast, protein energy malnutrition in the developed world usually occurs in the context of chronic disease. There remains much variation in the criteria used to define malnutrition, with each method having its own limitations. Early recognition, prompt management, and robust follow up are critical for best outcomes in preventing and treating PEM.

Serum ghrelin levels in children with primary protein-energy malnutrition

BACKGROUND

Ghrelin, an appetite-stimulating peptide, increases in cachectic conditions. It probably reflects peripheral nutritional status and influences nutrient intake and growth. The aim of the present study was to determine serum ghrelin levels in children with primary protein-energy malnutrition (PEM) and to find if any correlation exists between serum ghrelin levels and the clinical presentation of those patients.

METHODS

Twenty-eight children with primary PEM and 10 healthy children were included. Serum fasting ghrelin levels were measured using radioimmunoassay.

RESULTS

Mean serum ghrelin level of healthy children and those with PEM were 107.7 +/- 40.1 pg/mL and 141.6 +/- 123.8 pg/mL, respectively (P < 0.001). Ghrelin levels were independent of age and sex (P > 0.05). Ghrelin was negatively correlated with body mass index in healthy children (P < 0.01), but not in those with PEM (P > 0.05). Mean serum ghrelin level of children with moderate malnutrition was higher than that of children with severe malnutrition (199.2 +/- 154.1 pg/mL vs 98.4 +/- 74.3 pg/mL, P < 0.05). Mean serum ghrelin levels of patients with kwashiorkor, marasmic kwashiorkor, and marasmus were 127.9 +/- 97.8 pg/mL, 138.7 +/- 95.8 pg/mL, and 162.3 +/- 185.0 pg/mL, respectively (P > 0.05).

CONCLUSION

Serum ghrelin level is higher in patients with PEM, especially in those with marasmus, compared to healthy children. Although this observation suggests that ghrelin helps to fight malnutrition in children, it is obvious that further studies are needed to clarify the exact pathogenetic mechanism regarding this condition.

Mid-arm circumference and mid-arm/head circumference ratio in term newborns

CONTEXT

Mid-arm circumference of the newborn is strongly associated with birth weight and is a very good indicator of low and insufficient birth weight. However, there are few Brazilian studies on the relationship between mid-arm and head circumferences and, thus, this does not form part of the routine evaluation for newborns.

OBJECTIVES

To establish the mid-arm circumference and mid-arm/head circumference ratio in a population of term newborns.

TYPE OF STUDY

Cross-sectional study carried out between June 1997 and August 1999.

SETTING

Hospital Maternidade Leonor Mendes de Barros, São Paulo.

PARTICIPANTS

Term newborns (66 males and 65 females) of appropriate growth for gestational age, whose mothers were healthy, were included in the study.

MAIN MEASUREMENTS

Arm circumference, arm circumference/head circumference ratio, birth weight and gestational age were measured within 48 hours of birth. Data were considered significant when p < 0.01.

RESULTS

The mean values for the mid-arm circumference were 10.76 cm (standard deviation, SD = 0.68) for females and 10.76 (SD = 0.81) for males. The mean value for the mid-arm/head circumference ratio was 0.31 (SD = 0.02) for both sexes. Mid-arm circumference values were significantly related to birth weight and gestational age, whereas mid-arm/head circumference ratio was related only to birth weight.

CONCLUSIONS

Mid-arm circumference and mid-arm/head circumference ratio values were established for the studied population. It was possible to obtain curves for both mid-arm circumference and mid-arm/head circumference ratio in relation to birth weight. However, for mid-arm circumference, it was only possible to obtain curves in relation to gestational age. The use of the regression curves did not seem powerful enough to predict the mid-arm circumference and mid-arm/head circumference ratio in this population of term newborns. There were no gender differences for either of the measurements studied.

Intestinal protein loss in acute and persistent diarrhea of early childhood

GOALS

To determine fecal protein loss in children with acute and persistent diarrhea.

BACKGROUND

In children with diarrhea, ongoing losses of endogenous proteins have been suggested as contributing to impairment of nutritional and immunologic status. However, there is a paucity of information and inconclusive data in the literature.

STUDY

Fecal protein loss was assessed prospectively in children (<3 years of age) with acute diarrhea (<7 days' duration) or persistent diarrhea (>14 days) and in controls using alpha-1-antitrypsin determination; fecal protein loss then was correlated with age, duration of diarrhea, nutritional status, plasma proteins, and stool pathogens.

RESULTS

Children with acute diarrhea (n = 43) and those with persistent diarrhea (n = 41) had significantly higher fecal alpha-1-antitrypsin levels compared with controls (n = 14) (2.26 +/- 1.71 and 2.25 +/- 1.51, respectively, vs. 1.02 +/- 0.73 mg/g stools; p = 0.002). However, there was no significant decrease of plasma albumin, globulin, or immunoglobulins. Fecal protein loss did not differ significantly among stool pathogens (bacterial, viral, and parasitic) and demonstrated no significant correlation with age, duration of diarrhea, or nutritional status (mild malnutrition).

CONCLUSIONS

Enhanced fecal protein loss was observed in more than 50% of children with acute and persistent diarrhea caused by various pathogens. This did not correlate with age, duration of diarrhea, or nutritional status and did not result in significant decrease of plasma proteins or immunoglobulins. This protein-losing enteropathy does not appear to have a causal role in perpetuation of diarrheal episodes in children with mild malnutrition.

Concentrations of riboflavin and related organic acids in children with protein-energy malnutrition

BACKGROUND

Riboflavin, flavin mononucleotide (FMN), and flavin adenine dinucleotide (FAD) concentrations have been little studied in cases of malnutrition.

OBJECTIVE

Our objective was to investigate the effects of malnutrition on riboflavin status and riboflavin's relation with thyroid hormones and concentrations of urinary organic acids.

DESIGN

Malnourished children from the savannah in Benin (group S, n = 30) and the coast in Togo (group C, n = 30), as well as 24 control subjects from both regions, were studied. Blood riboflavin, FMN, and FAD were analyzed by HPLC; urinary organic acids were analyzed by gas chromatography-mass spectrometry.

RESULTS

Children in group S were more severely malnourished than children in group C. Triiodothyronine concentrations were lower in group S than in group C or the control group (1.12 +/- 0.24 compared with 1.74 +/- 0.18 and 2.92 +/- 0.19 nmol/L, respectively; P < 0.0001). Plasma riboflavin concentrations in group S were higher than those in group C or the control group (66.90 +/- 12.75 compared with 28.09 +/- 9.12 and 20.08 +/- 3.03 nmol/L, respectively; P < 0.001). Plasma FAD concentrations in group S were lower than those in group C or the control group (31.57 +/- 10.19 compared with 59.02 +/- 5.60 and 65.35 +/- 5.23 nmol/L, respectively; P < 0.0001). Dicarboxylic aciduria was higher in group C than in group S or the control subjects.

CONCLUSIONS

Children in group S had low triiodothyronine concentrations and low conversion of plasma riboflavin into its cofactors, leading to a plasma FAD deficiency. Plasma FAD was not correlated with urinary dicarboxylic acid concentrations.

Assessment of nutritional status in clinical practice

As most diseases can have nutritional consequences, the assessment of nutritional status may help to detect an underlying disease, to identify nutritional disorders related to a given disease, and to quantify the impact of nutritional therapy. The aims and methods used for nutritional assessment depend on the circumstances in which nutritional assessment is performed. Whatever the context or aim, nutritional status is assessed through a simple, mainly clinical approach, based on the past history, dietary intake, auxological analysis, anthropometric measurements, body compartment and biological parameters. Accurate techniques for measuring body compartments are available in children such as dual-energy X-ray absorptiometry to assess fat body mass or bioelectrical impedance analysis for body water and lean body mass. Measuring energy expenditure allows for a more accurate monitoring of the patient's energy needs and decreases the risks associated with underfeeding or overfeeding. In clinical practice, the analysis should be longitudinal and take into account situations carrying a risk of malnutrition. Preventive use of nutritional assessment allows nutritional support to be introduced in a timely fashion, thereby avoiding morbidity/mortality and limiting the long-term impact of malnutrition on growth and development.

Influence of long-chain polyunsaturated fatty acids on infant cognitive function

Long-chain polyunsaturated fatty acids (LCPUFA) are important for normal visual and cortical development. In a previous study of the effects of LCPUFA on cognitive function of term infants at the age of 3 mon, we indicated that infants with evidence of reduced growth parameters at birth and impaired attention control as manifested by a late peak fixation during infant habituation assessment may benefit from LCPUFA supplementation. The aim of this prospective study was to determine whether LCPUFA supplementation and late peak fixation are related to means-end problem-solving ability in these same infants at the age of 9 mon. Term infants (58) were randomized to one of two formulas containing either LCPUFA or no LCPUFA and completed 4 mon of feeding with their formula. Cognitive function was assessed at 3 mon of age by measures of infant habituation. Infants (20 LCPUFA and 20 no-LCPUFA) completed the problem-solving assessment at 9 mon. The no-LCPUFA group had lower scores on both measures of intention and number of solutions, but neither of these differences was significant. Analysis of covariance for the effects of group and peak fixation, covaried with gestation and birth weight, showed that the number of solutions was significantly reduced in the late peak-fixation infants receiving no LCPUFA (P<0.02). Intention scores tended to be reduced in this group (P<0.06). The late peak-fixation infants who received LCPUFA had solution and intention scores similar to early peak-fixation infants receiving LCPUFA or no LCPUFA. These findings suggest that in term infants who have reduced growth parameters at birth and who show evidence of impaired attention control, information processing and problem-solving ability in infancy may be enhanced by LCPUFA supplementation.

Metabolism of quinine in children with global malnutrition

Malnutrition and malaria are two important public health problems in Africa. Quinine is one of the major treatments of chloroquine-resistant malaria. Although some authors have shown that quinine clearance is decreased in kwashiorkor, this type of malnutrition is caused by protein deficiency that differs from global protein-energy malnutrition. In rats, hepatic metabolism of many drugs is decreased in protein deficiency and increased in global food restriction. Several studies have found that human hepatic metabolism of many drugs is decreased in kwashiorkor, but, as yet, no study has focused on human global energy-protein malnutrition. Thus, as quinine is a drug with a narrow therapeutic index, we compared the pharmacokinetics of quinine in two groups. One group included children with global malnutrition and the other was a control group of children with normal nutrition. Volume of distribution and plasma concentrations of unbound quinine did not differ between children with global malnutrition and children with normal nutritional status. Clearance was significantly faster, half-life shorter, and concentrations, 12 h after the beginning of treatment, lower in malnourished children compared with control subjects. The ratio between area under the curve of hydroxyquinine (metabolite of quinine in man) and area under the curve of quinine was significantly increased in malnourished children and correlated with mid-arm/ head circumference ratio (marker of malnutrition in children). Thus, as metabolism of quinine is increased in children with global malnutrition, we suggest that the administration interval should be reduced in these children to obtain the same plasma concentrations of quinine found in normally nourished children. A safe and effective dosing strategy is postulated.

Body composition in children based on anthropometric data. A presentation of normal values

Knowledge of the body composition in terms of fat and fat-free mass is used in paediatrics to estimate a child's nutritional status. To obtain the fat content or protein content sophisticated techniques exist. These techniques are often difficult to apply in daily practice. An anthropometric approach is therefore relevant because of its simplicity. In this study skinfold thicknesses and mid-upperarm circumference are presented as reference values and used to derive the fat-free mass fraction of the body and the arm muscle area.

CONCLUSION

Despite the shortcomings of an anthropometric approach in estimating the fraction of fat-free mass or protein content, its simplicity makes the method of calculating these fractions on skinfold thicknesses and mid-upperarm circumference valuable to apply in daily paediatric practice.

Chest circumference as an indicator of intrauterine growth retardation

Three hundred and fifty six intrauterine growth retarded (IUGR) and 356 appropriate birth weight (ABW) babies were studied for a range of different anthropometric measurements. Birth weights was highly correlated with chest circumference (r = 0.64, P < 0.001; r = 0.76, P < 0.001), length (r = 0.71, P < 0.001; r = 0.68, P < 0.001), and head circumference (r = 0.49, P < 0.001; r = 0.53, P < 0.001) either in IUGR and ABW babies, respectively. There were weak statistically significant correlations between birth weight and mid-upper arm circumference (MUAC) (r = 0.65, P < 0.001; r = 0.15, P < 0.001), MUAC/head circumference (r = 0.43, P < 0.001; r = 0.13, P < 0.001), triceps skinfold thickness (r = 0.31, P < 0.001; r = 0.14, P < 0.001), and ponderal index (r = 0.23, P < 0.001, r = 0.33, P < 0.001) in IUGR and ABW babies. All anthropometric measurements had a statistically significant sensitivity and specificity for identifying intrauterine growth retardation (IUGR). However, chest circumference < or = 29.0 cm; length < or = 47.5 cm; and head circumference < or = 33.0 cm has the highest sensitivity, specificity and predictive power. Chest circumference seems to be the easiest, cheapest and most reliable anthropometric measurement to assess IUGR.

Catch up growth and pancreatic function in growth retarded neonates

To test the hypothesis that relative pancreatic dysfunction is a determinant of catch up growth in small for gestational age (SGA) babies, 47 such babies (median gestation 38 weeks; range 27-41) and 41 appropriate for gestational age (AGA) babies matched for sex, race, and gestational age were recruited. Anthropometry was performed within 48 hours of birth and at 6 months. Faecal chymotrypsin activities were measured at 0-2 days, 14 days, 6 weeks and 6 months. At 6 months 30 SGA infants and 25 AGA infants were remeasured. In each group, median stool chymotrypsin activities doubled between 0-2 days and 6 months (9.0-25.5 IU/g SGA group; 11.6-25.3 IU/g AGA group). SGA babies had significantly lower chymotrypsin activities at 14 days (10.9 U/g) than AGA babies (15.5 U/g). In the SGA group faecal chymotrypsin activities at 0-2 days were strongly correlated with both catch up weight and with catch up length when corrected for the effects of birthweight. These data show that impaired pancreatic exocrine function at birth is associated with severe intrauterine malnutrition and with impaired catch up growth during the first 6 months of life.

Postnatal growth and mental development: evidence for a "sensitive period"

For many years it has been suspected that severely impaired somatic growth during early postnatal life can be associated with the subsequent impairment of mental abilities. This study aimed to test that hypothesis on the basis of data gathered from a prospective whole population survey of infant development in south London. A year's birth cohort of 1558 full-term singletons was monitored; 47 otherwise healthy cases with serious growth faltering in the first year were recruited. Mental and psychomotor abilities were assessed at 15 months. Potentially confounding psychosocial variables, including cognitive stimulation received at home, were measured contemporaneously. A statistical model was constructed that enabled the timing, duration and severity of growth faltering to be used as predictors of mental functioning. Up to 37% of the variance in cognitive and psychomotor outcome at 15 months can be explained by the model. The first few postnatal months appear to constitute a "sensitive period" for the relationship between growth and mental development.

Arm/head ratio in the nutritional evaluation of newborn infants: a report of an African population

A total of 848 appropriate-for-gestational age (AGA) infants were recruited for the study, and fully analysed, from three hospitals in Benin City, Nigeria. They were examined in order to develop a standard of arm/head ratio for nutritional assessment of the newborn in an African population. The anthropometric measurements were correlated with gestational age and the standard was developed from the regression line of arm/head ratio and gestational age and the corresponding 95% confidence belt. There was a highly significant positive correlation between arm/head ratio and gestational age (r = 0.89; p less than 0.001). Using clinical nutritional status as the reference, the standard had a good sensitivity of 85.5% and a specificity of 92.9%. Comparatively, age, weight classification had a sensitivity and a specificity of 67.7% and 85.3%, respectively. The arm/head ratio is simple and reliable. It is recommended for routine use, particularly in an African population.

Standard curves for mid arm circumference and mid-arm/head circumference ratio in newborns

One Thousand singleton neonates, between 28 and 44 weeks of estimated gestational age (EGA) were measured within 48 hours of their birth for upper mid-arm circumference (MAC), head circumference (HC) and birth weight (BW). Regression analysis was used to draw standard curves for MAC versus EGA and mid-arm circumference/head circumference ratio (MAC/HC) versus EGA. Correlation coefficients were 0.961 for MAC versus EGA and 0.889 for MAC/HC versus EGA (p less than 0.001). MAC, MAC/HC and HC were also highly correlated with birth weight (p less than 0.001). These standard curves make available a discriminating method for evaluation of intra-uterine growth and a non-invasive technique for following somatic protein status in growing preterm infants.

Mid-arm circumference and mid-arm circumference: head circumference ratio for assessing longitudinal growth in hospitalized preterm infants

In order to study the usefulness of upper mid-arm circumference (MAC) and mid-arm circumference:head circumference ratio (MAC:HC) measurements in assessing longitudinal growth in hospitalized preterm infants, we prospectively measured weights, lengths, occipitofrontal head circumferences (OFC), MACs, MAC:HCs, weight/length for age, nutritional intakes, and serum transthyretin and albumin levels in 50 preterm, low-birth-weight, appropriate for gestational age newborn infants during their first 4 postnatal weeks and at hospital discharge. At some time during hospitalization, weight measurements were abnormal (greater than or equal to 2SD from the gestational age mean) in 48% of the infants as compared with 24% with abnormal MAC measurements (p = 0.002). Abnormal MAC:HCs occurred in 25% of the infants as compared with 68% with abnormal weight/length for age values (p less than 0.001). During weeks 2-4, when nutritional intakes were adequate and serum transthyretin and albumin levels were normal, mean weight gain velocity was less than intrauterine rates and was significantly slower than MAC velocities, which were at or greater than intrauterine rates (p less than 0.001). At discharge, when all infants were gaining weight at intrauterine rates, weight measurements were still abnormal in 28% of the infants as compared with 10% of infants who had abnormal MACs (p = 0.005). Similarly, only 12% of infants had abnormal MAC:HCs as compared with 25% of infants with abnormal weight/length for age values at discharge (p = 0.05). The MAC and MAC:HC are useful for assessing longitudinal growth in preterm infants since they do not overestimate the prevalence of malnourishment during periods of apparent protein-calorie sufficiency.

Growth and metabolic response of premature infants fed whey- or casein-dominant formulas after hospital discharge

We conducted a double-blind, randomized study to test the hypothesis that a whey-dominant formula permits a growth and metabolic advantage over a casein-dominant formula in preterm infants after hospital discharge. Nineteen low birth weight infants were studied for 6 months from the time of discharge. Ten received a casein-dominant formula, and nine received a whey-dominant formula. Growth (weight, length, head circumference, mid-arm circumference, and skin-fold thickness), biochemical measurements (alkaline phosphatase activity, acid-base status, and hemoglobin, serum total protein, albumin, and urea nitrogen levels), and quantity of formula intake did not differ significantly between the groups over a 6-month study period. Serum transthyretin and urea nitrogen concentrations differed significantly between the two feeding groups at the day of entry into the study only. The results indicate that, after hospital discharge, premature infants fed a whey-dominant formula do not differ in growth or biochemical measurements from those fed a casein-dominant formula.

Evaluation of three oral rehydration solutions designed for use in developed communities

One hundred and sixteen children (less than 2 years old) admitted to a London hospital with acute gastroenteritis were randomized to receive either an oral rehydration solution (ORS) with low sodium and high glucose concentration (Na+ 35, glucose 200 mmol/L), an ORS with a high sodium but low glucose concentration (Na+ 60, glucose 111 mmol/L), or an ORS containing glycine and a glucose polymer (Na+ 50, glucose 50, glycine 50 mmol/L). Clinical, biochemical and haematological features of the three groups were similar on admission. Rotavirus was common (31%); the majority of children had minimal dehydration or acid-base disturbance. The clinical outcome, including ORS intake, prevention of dehydration, rehydration, and duration of hospital stay was similar in the three treatment groups. All initial electrolyte abnormalities were corrected; no child developed hypernatraemia or hyponatraemia. At 24 h, the mean serum urea was higher in those who received the ORS containing glycine than in other groups, and it had not fallen significantly since admission. Eighteen per cent of children had carbohydrate intolerance: four children with greater than or equal to 2% reducing substances in their stool had all received ORS with a high glucose content and had numerous watery green stools containing rotavirus. All ORS solutions were safe and effective for rehydration and correction of biochemical abnormalities, however carbohydrate intolerance was more prevalent in children who received the ORS with a high glucose content.

Catch-up growth, muscle and fat accretion, and body proportionality of infants one year after newborn intensive care

We studied catch-up growth, muscle and fat accretion, and body proportionality at 4 and 12 months of age corrected for prematurity in 30 very low birth weight (VLBW) (less than 1500 gm), 30 low birth weight (LBW) (1500 to 2499 gm) and 30 normal birth weight (greater than or equal to 2500 gm) infants who required newborn intensive care. At 4 and 12 months, the VLBW infants had significantly lower mean weight and length (p less than 0.01), but not lower occipitofrontal circumference percentiles, than the LBW and normal birth weight groups, and showed no catch-up weight or length growth between 4 and 12 months. All three groups had significant increases in mean upper mid-arm circumferences, mid-arm muscle circumferences, and arm muscle areas between 4 and 12 months. Mean mid-arm muscle circumferences and arm muscle areas were similar among the three groups at 4 months but became significantly stratified by birth weight groups by 12 months, with VLBW infants having the lowest mean value. In contrast, analysis of fat stores by triceps skin-fold thickness and arm fat area demonstrated no significant increases in any group between 4 and 12 months, except for arm fat area in the LBW group. The VLBW infants had significantly less fat than normal birth weight infants at 4 and 12 months. All three groups had proportional growth at both visits, as assessed by mid-arm circumference/head circumference ratio and weight-length percentile for age. The VLBW infants were significantly lighter for their length than normal birth weight infants. We conclude that VLBW infants have no first-year catch-up growth, remaining smaller than higher birth weight infants, although appropriately proportional. Somatic growth during the first year is due more to muscle than to fat accretion, especially in VLBW infants.

Oral rehydration therapy without bicarbonate for prevention and treatment of dehydration: a double-blind controlled trial

Forty children (less than or equal to 2 years of age) were admitted to hospital with acute gastroenteritis and were randomly assigned to receive either an oral rehydration solution (ORS) containing bicarbonate (Na 35, K 20, Cl 37, HCO3 18, glucose 202 mmol litre-1) or an identical solution in which bicarbonate was replaced by chloride ions. Groups were matched for age, sex, ethnic origin, duration of diarrhoea and nutritional status. On admission, degree of dehydration, biochemical and haematological parameters were similar. The majority had minimal or no dehydration and only 30% had moderate to severe dehydration. All children were treated successfully with no complications. Oral rehydration solution intake by each group was similar. Clinical outcome, as judged by speed of rehydration or maintenance of hydration, duration of diarrhoea, stool frequency and length of hospital stay, was the same in both groups. After 24 h of ORS there was no difference between groups in venous pH, serum bicarbonate, urea and electrolytes. In hospitalized children with acute gastroenteritis in the United Kingdom an ORS without bicarbonate is a safe, effective means to prevent dehydration and maintain hydration and acid-base status where dehydration is not severe. Exclusion of bicarbonate would simplify production, increase stability and reduce the cost of ORS without apparent impairment of efficacy.

Vietnamese child health in a Hong Kong closed camp

Vietnamese refugees arriving in Hong Kong since 1982 have been confined to restricted areas. In this study, 241 children in one of these areas were screened to identify their health status. Using NCHS standards, 48% were found to be below the fifth percentile for both weight-for-age and height-for-age. Anaemia was found in 8% and hepatitis B antigenaemia in 25%. Intestinal parasites were identified in 62% of faecal specimens and 26% of these contained more than one parasite. Although all children had received BCG, 41% had a negative PPD skin test. Chronic bacterial skin infections, lice and otitis media with perforation were identified as other common problems. Screening of this population revealed a high prevalence of health problems, some of which would respond to appropriate public health measures.

The ratio of mid-arm circumference to occipital frontal circumference in Chinese babies: a marker of late gestation growth retardation

The ratio of mid-arm circumference to occipital frontal circumference (MAC/OFC), an index of late gestation growth retardation, was determined in 175 healthy newborn term Chinese babies. The ratio of 0.31 (S.D., 0.02) was significantly higher than in recent data published for Asian, White and Black neonates: whether this is due to differences in measuring techniques or better intra-uterine nutrition remains to be seen. As an initial test of its potential usefulness this ratio was determined in 12 term Chinese babies who showed clinical signs of undernutrition. All but one had a ratio 2S.D. or more below the mean. The MAC/OFC ratio, with its ease of measurement, simplicity and cheapness, is a useful addition to existing methods for assessing late gestation nutritional status.

Physical growth of infants 7 to 13 months of age: results from a national survey

This study considers measurements of weight, recumbent length, head circumference, triceps skinfold, and arm circumference of 1,100 infants aged 7 to 13 months from a cross-sectional sample representative of the U.S. infant population. Based on these data, smoothed percentiles of weight, recumbent length, head circumference, triceps skinfold, and arm circumference by sex and age (in months) and weight for recumbent length were calculated. Compared with the percentile values from the National Center for Health Statistics (NCHS; Hamill et al., 1977, DHEW Publ. No. PHS 78-1650), percentile values from the 1984 Ross Laboratories Infant Nutrition Survey (RNS) for weight, recumbent length, and weight for recumbent length tended to be smaller (p less than .05). We attribute these variations to differences in sampling design and conclude that they are not of sufficient magnitude to warrant new growth charts. Smoothed percentiles for triceps skinfold and arm circumference presented herein are new reference values that can be used for assessment of the nutritional and growth status of older infants.

Efficacy of trimethoprim-sulfamethoxazole in treatment of acute diarrhea in a Mexican pediatric population

The efficacy of trimethoprim-sulfamethoxazole (TMP-SMX) and placebo were compared in a randomized double-blind study of 141 Mexican children with acute diarrhea. Patients who met specific entry criteria received TMP-SMX or an identical appearing placebo for 5 days. Stools were examined for bacterial, viral, and parasitic pathogens. Enterotoxigenic Escherichia coli were the most commonly isolated pathogens (22% of total). Patients given TMP-SMX had a significantly shorter time to "last illness stool" than did those given placebo, but no difference in number of unformed stools in 5 days was found between treatment groups. However, TMP-SMX significantly shortened the illness in patients with fever or many fecal leukocytes. When stool cultures positive for any bacterial pathogen or for enterotoxigenic E. coli were analyzed as separate groups, a significantly faster recovery was observed in patients given TMP-SMX. TMP-SMX is efficacious in the treatment of Mexican children with diarrhea and culture-proved bacterial infection or when the clinical signs and symptoms suggest bacterial enteritis.

Mid-arm circumference and mid-arm/head circumference ratios: standard curves for anthropometric assessment of neonatal nutritional status

Two hundred four neonates, 25 to 42 weeks estimated gestational age (EGA), were measured on day 2 or 3 of life for upper mid-arm circumference (MAC) and head circumference. Regression analysis was used to construct standard curves for MAC versus EGA and mid-arm circumference/head circumference ratio (MAC/HC) versus EGA. Correlation coefficients were 0.93 for MAC versus EGA, and 0.84 for MAC/HC versus EGA. MAC, MAC/HC, and head circumference were also highly correlated with birth weight. These measurements may more accurately assess intrauterine growth and body proportionality at birth than weight, length, and head circumference.

Mid-arm circumference/head circumference ratios for identification of symptomatic LGA, AGA, and SGA newborn infants

Mid-arm circumference/head circumference ratios (MAC/HC) and birth weights obtained in 73 neonates were studied to compare which of these growth measurements could more accurately predict risk of metabolic complications resulting from either acceleration or retardation of fetal growth. The MAC/HC ratio was more sensitive than birth weight in distinguishing symptomatic large for gestational age (LGA) infants who were born to diabetic mothers from other LGA infants who were asymptomatic, and symptomatic from asymptomatic small for gestational age infants. In addition, the MAC/HC ratio identified symptomatic appropriate for gestational age (AGA) infants born to diabetic mothers and AGA infants with signs and symptoms of growth retardation. The MAC/HC is more useful than birth weight in assessing newborn infants at risk for the metabolic complications associated with fetal growth disorders.

Screening for intrauterine growth retardation using ratio of mid-arm circumference to occipitofrontal circumference

Uncritical application of standard weight percentile charts, derived from white infants, to infants from different ethnic groups may result in an overestimate of the incidence of intrauterine growth retardation in those groups. The ratio of mid-arm circumference to occipitofrontal circumference was studied in 194 babies (49 Asian, 58 black, and 87 white). In contrast with birth weight the ratio did not vary among the ethnic groups; it was also independent of sex. In a prospective study of 64 neonates whose weight was below the 10th percentile on standard charts the ratio of mid-arm circumference to occipitofrontal circumference was a more accurate predictor than weight of those infants who would develop symptoms associated with intrauterine growth retardation. The ratio of mid-arm circumference to occipitofrontal circumference therefore provides a simple, accurate, and cheap way of assessing intrauterine growth retardation in areas with a large multiethnic population, where birth weight varies greatly.

Assessment of the nutritional status of Nigerian rural children and mothers' perceptions of quality of life

One hundred and fourteen preschool school children and their 30 mothers from three selected villages in Ile-Ife, Nigeria were assessed for nutritional status using selected and sensitive anthropometric techniques. The mothers' dietary patterns, their perceptions as to components of a good quality of life, infants' immunization status and major cause of infant death were also examined. Approximately 56% of the children and 80% of the women were identified to be suffering from mild to moderate malnutrition. The major cause of infant death as reported by the mothers was high fever and convulsion. Practically all the children under 3 years had not received any form of immunization. Ability to have plenty of children, good health and money, were highly perceived as measures of essential components of quality of life by all the mothers, while 20% listed good feeding, housing, clothing, and only 7% listed potable water. The need for effective health services, regular home visits, supplementary feeding programmes for school children and an effective health education campaign on the importance of immunization and nutrition for rural people are discussed. The training of agricultural extension workers in the use of simple anthropometric techniques to identify covert malnutrition is also highlighted.

Age-independent anthropometry: an examination of data from rural Khartoum, Sudan

The data collected in a mixed cross-sectional longitudinal survey of children in a village in rural Khartoum, Sudan, were analysed in order to identify age-independent anthropometric indices. The mean values of weight/height, weight/height, mid arm circumference, mid arm fat area and triceps skinfold thickness all change little with age over certain parts of the age range. 15% of the boys and 22% of the girls had weights less than 75% of standard weight for age. The ability of age-independent indices to identify these low-weight individuals was investigated in terms of their sensitivity and specificity. Weight/height discriminated best, correctly classifying 85% of the low weight boys and 78% of the normal weight boys in the under-five age group. Weight/height and mid arm circumference were also useful, but triceps skinfold thickness and mid arm fat area did not discriminate usefully. All tests performed better in the under-five age group than in the older age bands.

Detection of moderate protein-energy malnutrition in pre-school children

Several biochemical and anthropometric tests were used to define the states of mild or moderate protein-energy malnutrition among 810 children aged under five years in the forest region of Southern Cameroon. The results show that the percentage and the identity of children classified as undernourished may be different according to the anthropometric test employed. The mean values of most of the biochemical variables assayed decrease in the groups affected with moderate weight and arm deficiencies. A system is proposed for the evaluation of the nutritional status based on the simultaneous use of four anthropometric tests. Some biochemical parameters may be useful for establishing a diagnosis.