Malnourished children treated in day-hospital or outpatient clinics exhibit linear catch-up and normal body composition

Relation between changes in weight parameters and height parameters in prepubertal children: daily weight gain and BMIi changes in relation to linear growth during nutritional rehabilitation of underweight children

Background: Early detection of abnormal weight loss or gain in childhood may be important for preventive purposes. Variable growth response to nutrition rehabilitation have been reported in children with failure to thrive (FTT) who do not have any chronic disease or systematic illness due to different clinical and nutritional approach in their management. Aim of the study: To analyze the association of different body mass index (BMI) and BMI- SDS, to linear growth (Ht-SDS) in different BMI categories of prepubertal children. In addition, we studied the effect of weight changes on linear growth in a randomly selected group of prepubertal underweight children who received nutritional rehabilitation (NR) for 9±2 months. Subjects and methods: 102 children, between 1 and 9 years, followed at the General Pediatric Clinic, between January 2017 to December 2017, because of abnormal weight gain (decreased or increased) which was not associated with any acute or chronic illness were included in the study. Anthropometric measurements included weigh, height, Ht-SDS, BMI, and BMI-SDS. Children BMI-SDS were categorized into 4 groups: Group 1: BMI-SDS <-2, group 2: BMI-SDS <-1 but >-2, group 3 BMI-SDS >-1 but <2, group 4 BMI-SDS >2. We also evaluated the effects of weight changes on linear growth in a randomly selected group of underweight children who received nutritional counselling and oral nutritional supplementation (n = 51) for 9±months. Results: HT-SDS in children of groups 1 and 2 (underweight and at risk of underweight children) was significantly lower than Ht-SDS of groups 3 and 4 (normal and overweight children). Ht-SDS in children of group 4 was significantly higher than the Ht-SDS of children in group 3. A significant linear correlation was found between BMI-SDS and Ht-SDS in these prepubertal children. Discussion: After nutritional rehabilitation for a year, 55% of underweight children increased their BMI-SDS and 43% increased their Ht-SDS. Children who had weight gain >7g/d, over the whole period of follow-up, (n =14) increased their BMI-SDS and Ht-SDS significantly after versus before NR. The BMI-SDS and Ht-SDS did not increase significantly in the group of children who had weight gain <7 g/day. 28 children out of 51 improved their BMI-SDS after nutritional rehabilitation (group A) and 23 did not have improvement in their BMI-SDS (Group B). Group A had higher weight gain per day versus group B. Height growth velocity was significantly higher in Group B (7.4±3.6 cm/yr) versus group A (5.7±2.8 cm/yr). Ht-SDS increased significantly in the group of patients who had lower Ht-SDS before NR. Children who had faster linear growth velocity, after nutritional rehabilitation, did not increase their BMI-SDS. Linear regression showed a significant correlation between BMI-SDS and Ht-SDS supporting the notion that proper nutrition and maintaining normal BMI-SDS is essential for adequate gain in height. Conclusion: It appears that calculating the weight gain per day, BMI-SDS and Ht-SDS are clinically useful parameters to detect the effect of weight gain on linear growth and to monitor the nutritional management. Daily weight gain was correlated significantly to height growth rate during nutritional rehabilitation. Based on our findings and literature reports, we suggest an algorithm for follow-up of underweight/ malnourished children based mainly on anthropometric assessment. (www.actabiomedica.it)

Effectiveness of a stunting recovery program for children treated in a specialized center

BackgroundStunting is still very prevalent in many poor and developing regions in the world. This study assessed the effectiveness of a stunting recovery program in children and its associated factors.MethodsThe retrospective study was conducted in a center of stunting recovery. There, children stayed in a day-hospital system (9 h per day; 5 days per week), and received five meals per day, providing 80% of their energetic daily needs. The main outcome was the stunting recovery rate (i.e., the child present a height-for-age index (HAZ) >-1.0 at the time of data collection). A total of 75 children treated for at least 24 months, aged between 6 and 48 months and with an HAZ <-2.0 at the time of admission were included.ResultsThe average treatment time was 41 months. About 18 children (24.0%) recovered from stunting. The variable "age at admission >24 months" (prevalence rate (PR)=0.39, 95% confidence interval (CI): 0.15-0.99; P=0.04) and the variable "Household crowding index" (PR=0.65, 95% CI: 0.44-0.95; P=0.03) were associated with the success of the treatment.ConclusionThe environmental conditions in which the children live in their households and late admission to the center negatively influenced the success of stunting recovery, even with an intensive treatment.

Albuminuria, renal function and blood pressure in undernourished children and recovered from undernutrition

BACKGROUND

The objective of this study was to investigate some biomarkers of renal function and blood pressure in children who had recovered from undernutrition.

METHODS

This was cross-sectional, comparative study in which a convenience sample of children of both genders (n = 126; age range 6-16 years) treated at the Centre for Nutritional Recovery and Education (São Paulo, Brazil) was used. These children were classified into four groups for analysis: (1) children who were well nourished (control group; n = 50), (2) those showing stunted growth (stunted group; n = 22), (3) those who were underweight (underweight group; n = 23) and (4) those who had recovered from undernutrition (recovered group; n = 31).

RESULTS

No between-group differences were found for mean levels of albuminuria, serum creatinine and cystatin C, and similar mean estimates of glomerular filtration rate (eGFR; using either creatinine, cystatin C or both). Almost 14% of the stunted group, 4% of the underweight group and 3% of the recovered group had albuminuria of >30 mg/g creatinine (chi-square p = 0.034); none of the control children showed albuminuria of >30 mg/g creatinine. Mean systolic (SBP) and diastolic blood pressure (DBP) adjusted for age and gender of the children in the stunted [SBP (95% confidence interval): 92 (88-96) mmHg; DBP: 47 (44-49) mmHg] and recovered [SBP: 93 (90-96) mmHg; DBP: 49 (47-51) mmHg] groups were significantly lower than those of the controls [SBP: 98 (95-100) mmHg, P = 0.027; DBP: 53 (52-55) mmHg, P = 0.001]. After additional adjustment for height, mean DBP remained significantly lower in the recovered group compared with the control group [49 (46-51) vs. 53 (51-55) mmHg, respectively; P = 0.018). Logistic regression analysis showed that the stunted group had a 8.4-fold higher chance of developing albuminuria (>10 mg/g creatinine) than the control children (P = 0.006).

CONCLUSIONS

No alterations in renal function were found in underweight children and those who had recovered from undernutrition, whereas children with stunted growth presented with a greater risk for albuminuria. A lower DBP was found in children with stunted growth and those who had recovered from undernutrition.

Normal cortisol response to cold pressor test, but lower free thyroxine, after recovery from undernutrition

Undernutrition is a stressor with long-term consequences, and the effect of nutritional recovery on cortisol and thyroid hormone status is unknown. To investigate basal thyroid hormones and the cortisol response to a cold pressor test in children recovered from undernutrition, a cross-sectional study was undertaken on children (6–16 years) separated into four groups: control (n 41), stunted (n 31), underweight (n 27) and recovered (n 31). Salivary cortisol was collected over the course of 10 h: upon awakening, before and after an unpleasant and a pleasant stimulus. Cortisol upon awakening was highest in the stunted and lowest in the underweight groups: control=5·05 (95 % CI 3·71, 6·89) nmol/l, stunted=6·62 (95 % CI 3·97, 11·02) nmol/l, underweight=2·51 (95 % CI 1·75, 3·63) nmol/l and recovered=3·46 (95 % CI 2·46, 4·90) nmol/l (P=0·005). Girls had higher cortisol concentrations upon awakening compared with boys (P=0·021). The undernourished groups showed an elevated cortisol response both to the unpleasant stimulus and at the last measurement (16.00 hours) compared with that of the recovered group: AUC, control=2·07 (95 % CI 1·69, 2·45) nmol/l×30 min, stunted=2·48 (95 % CI 1·91, 3·06) nmol/l×30 min, underweight=2·52 (95 % CI 2·07, 2·97) nmol/l×30 min, recovered=1·68 (95 % CI 1·26, 2·11) nmol/l×30 min (P=0·042); and control=2·03 (95 % CI 1·75, 2·39) nmol/l×30 min, stunted=2·51 (95 % CI 1·97, 3·19) nmol/l×30 min, underweight=2·61 (95 % CI 2·16, 3·16) nmol/l×30 min, recovered=1·70 (95 % CI 1·42, 2·03) nmol/l×30 min (P=0·009). Lower free thyroxine (T4) was found in the recovered and stunted groups: control=1·28 (95 % CI 1·18, 1·39) pmol/l, stunted=0·98 (95 % CI 0·87, 1·10) pmol/l, underweight=1·10 (95 % CI 1·01, 1·21) pmol/l and recovered=0·90 (95 % CI 0·83, 0·99) pmol/l (P<0·001). Multivariate analysis showed a lower cortisol concentration along 10 h (06.00–16.00 hours) in the recovered compared with the other groups (P=0·017), and similar concentrations between the recovered and control group. In conclusion, the children with recovery in weight and height had a cortisol stress response similar to control but a lower basal free T4. Longitudinal studies are warranted to determine the extent of these endocrine changes after recovery of undernutrition and in adulthood.

Impact of nutritional recovery with linear growth on the concentrations of adipokines in undernourished children living in Brazilian slums

Undernutrition in early life has been reported to be closely associated with the development of non-communicable diseases in adulthood. Adequate treatment is important for reversing these effects. In the present study, we investigated the effects of undernutrition and anthropometric recovery on the weights and heights of children in relation to the concentrations of leptin, adiponectin and plasminogen activator inhibitor-1 (PAI-1). A total of 119 children (aged 6-16 years) from the slums of São Paulo were selected according to their nutritional status and divided into three groups as follows: control (healthy without intervention, n 38) with a height-for-age Z score (HAZ) and a BMI-for-age Z score (BAZ) > -1·6; undernourished (HAZ and/or BAZ < -1·6, n 54); recovered from undernutrition (after treatment in a rehabilitation centre; HAZ and BAZ > -1·6, n 27). Blood samples were collected to determine insulin, glucose, leptin, adiponectin and PAI-1 concentrations. Leptin concentrations in the undernourished group were lower than those in the control and recovered groups (mean 0·92 (95% CI 0·67, 1·25), 2·03 (95% CI 1·46, 2·82) and 1·66 (95% CI 1·15, 2·44) ng/ml, P=0·003), which had similar leptin concentrations. There were no differences in adiponectin and PAI-1 concentrations among the groups. A positive correlation between waist circumference and leptin concentrations was observed in all the girls and boys of the control group (control: r 0·729, P<0·01; undernourished: r 0·490, P<0·05; and recovered: r 0·829, P<0·01; r 0·673, P<0·05). Stronger correlations between leptin and insulin concentrations were observed in the recovered group. The results of the present study indicate that normal leptin concentrations are found when normal height and weight are achieved.

Evolution of the biochemical profile of children treated or undergoing treatment for moderate or severe stunting: consequences of metabolic programming?

OBJECTIVE

to evaluate changes in the biochemical profile of children treated or being treated for moderate or severe stunting in a nutrition recovery and education center.

METHODS

this was a retrospective longitudinal study of 263 children treated at this center between August of 2008 to August of 2011, aged 1 to 6 years, diagnosed with moderate (z-score of height-for-age [HAZ] < -2) or severe stunting (HAZ < -3). Data were collected on socioeconomic conditions, dietary habits, and biochemical changes, as well as height according to age.

RESULTS

the nutritional intervention showed an increase in HAZ of children with moderate (0.51 ± 0.4, p = 0.001) and severe (0.91 ± 0.7, p = 0.001) stunting during the monitoring. Increased levels of insulin-like growth factor 1 (IGF-1) (initial: 71.7 ng/dL; final: 90.4 ng/dL; p = 0.01) were also observed, as well as a reduction in triglycerides (TG) in both severely (initial: 91.8mg/dL; final: 79.1mg/dL; p = 0.01) and in moderately malnourished children (initial: 109.2mg/dL; final 88.7mg/dL; p = 0.01), and a significant increase in high-density lipoprotein cholesterol HDL-C only in the third year of intervention (initial: 31.4mg/dL; final: 42.2mg/dL). The values of total cholesterol (TC) and low-density lipoprotein cholesterol (LDL-C) levels remained high throughout the treatment (initial: 165.1mg/dL; final: 163.5mg/dL and initial: 109.0mg/dL; final: 107.3mg/dL, respectively).

CONCLUSION

the nutritional treatment for children with short stature was effective in reducing stunting and improving TG and HDL-C after three years of intervention. However, the levels of LDL-C and TC remained high even in treated children. It is therefore speculated that these changes may result from metabolic programming due to malnutrition.

A 15-year study on the treatment of undernourished children at a nutrition rehabilitation centre (CREN), Brazil

Objective

To build a life table and determine the factors related to the time of treatment of undernourished children at a nutrition rehabilitation centre (CREN), São Paulo, Brazil.

Design

Nutritional status was assessed from weight-for-age, height-for-age and BMI-for-age Z-scores, while neuropsychomotor development was classified according to the milestones of childhood development. Life tables, Kaplan–Meier survival curves and Cox multiple regression models were employed in data analysis.

Setting

CREN (Centre of Nutritional Recovery and Education), São Paulo, Brazil.

Subjects

Undernourished children (n 228) from the southern slums of São Paulo who had received treatment at CREN under a day-hospital regime between the years 1994 and 2009.

Results

The Kaplan–Meier curves of survival analysis showed statistically significant differences in the periods of treatment at CREN between children presenting different degrees of neuropsychomotor development (log-rank = 6·621; P = 0·037). Estimates based on the multivariate Cox model revealed that children aged ≥24 months at the time of admission exhibited a lower probability of nutritional rehabilitation (hazard ratio (HR) = 0·49; P = 0·046) at the end of the period compared with infants aged up 12 months. Children presenting slow development were better rehabilitated in comparison with those exhibiting adequate evolution (HR = 4·48; P = 0·023). No significant effects of sex, degree of undernutrition or birth weight on the probability of nutritional rehabilitation were found.

Conclusions

Age and neuropsychomotor developmental status at the time of admission to CREN are critical factors in determining the duration of treatment.

Long-lasting effects of undernutrition

Undernutrition is one of the most important public health problems, affecting more than 900 million individuals around the World. It is responsible for the highest mortality rate in children and has long-lasting physiologic effects, including an increased susceptibility to fat accumulation mostly in the central region of the body, lower fat oxidation, lower resting and postprandial energy expenditure, insulin resistance in adulthood, hypertension, dyslipidaemia and a reduced capacity for manual work, among other impairments. Marked changes in the function of the autonomic nervous system have been described in undernourished experimental animals. Some of these effects seem to be epigenetic, passing on to the next generation. Undernutrition in children has been linked to poor mental development and school achievement as well as behavioural abnormalities. However, there is still a debate in the literature regarding whether some of these effects are permanent or reversible. Stunted children who had experienced catch-up growth had verbal vocabulary and quantitative test scores that did not differ from children who were not stunted. Children treated before 6 years of age in day-hospitals and who recovered in weight and height have normal body compositions, bone mineral densities and insulin production and sensitivity.

Estado nutricional de crianças e adolescentes hospitalizados em enfermaria de cirurgia pediátrica

OBJETIVO: Avaliar o estado nutricional, o tempo de internação e as especialidades clínicas de pacientes internados na enfermaria de Cirurgia Pediátrica do Hospital São Paulo da Unifesp-EPM. MÉTODOS: Estudo transversal retrospectivo, com 749 crianças e adolescentes de ambos os gêneros acompanhados por equipe interdisciplinar durante o período de agosto de 2007 a julho de 2008. Foram coletados dados antropométricos, dias de internação e procedimento cirúrgico segundo a especialidade. Para a classificação do estado nutricional, utilizou-se o escore Z do índice de massa corporal (Z IMC) e da estatura/idade (Z E/I) segundo a curva da Organização Mundial de Saúde (OMS, 2007). As crianças foram classificadas segundo diagnóstico estabelecido previamente à cirurgia. Utilizou-se o programa STATA 8.0 para análise dos dados e aplicou-se o teste ANOVA e comparações múltiplas de Bonferroni, considerando-se significante p<0,05. RESULTADOS: A mediana de idade foi sete anos (0 a 18), predominando o gênero masculino (59%) e as internações para cirurgia otorrinolaringológica (18%). Dos pacientes internados, 66% tinham estatura adequada para idade, 43% eutróficos e 31% obesos/sobrepeso. Os pacientes desnutridos permaneceram mais dias internados quando comparados aos obesos/sobrepeso (7,2 versus 4,1 dias; p=0,035). Os lactentes apresentaram maior tempo de internação (p=0,006) e menor valor de Z IMC, comparados aos outros grupos etários (p=0,001). Os lactentes com programação de cirurgia cardíaca apresentaram Z IMC menor em relação às demais especialidades (p=0,002). CONCLUSÕES: O perfil dos pacientes internados condiz com a atual transição nutricional, aumento da prevalência de obesidade concomitante à desnutrição. Entretanto, a desnutrição ainda constitui fator agravante para a permanência hospitalar

Higher prevalence of osteoporosis among female Holocaust survivors

The prevalence of osteoporosis was statistically significantly higher among female Holocaust survivors than among those who were not exposed to the Holocaust. These findings support the importance of nutrition and environmental conditions during childhood and adolescence on BMD in older adults.

INTRODUCTION

Holocaust survivors during childhood and adolescence experienced undernutrition and lack of exercise and sunlight. The study aimed to establish if Holocaust survivors have higher prevalence of osteoporosis than subjects who were not Holocaust survivors.

METHODS

Seventy-three female Jewish Holocaust survivors > or = 60 years old and 60 female European-born Jews > or =60 years old who were not in the Holocaust were examined. BMD was measured using DXA of the lumbar spine and hips. The Cochran-Armitage trend test was used to test for an increasing trend in decreased BMD in the Holocaust survivors versus controls.

RESULTS

Among Holocaust survivors 54.8% had osteoporosis, 39.7% osteopenia, and 5.5% normal BMD, whereas among controls 25.0% had osteoporosis, 55.0% osteopenia, and 20.0% normal BMD (p = 0.0001). In those who were <17 years old in 1945, among Holocaust survivors 58.0% had osteoporosis, 34.0% osteopenia, and 8.0% normal BMD, whereas among controls 20.0% had osteoporosis, 57.8% osteopenia, and 22.2% normal BMD (p = 0.0003). In those > or =17 years old in 1945, among Holocaust survivors 47.8% had osteoporosis, 52.2% osteopenia and none had normal BMD, whereas among controls 40.0% had osteoporosis, 46.7% osteopenia, and 13.3% normal BMD (p = 0.28).

CONCLUSION

The prevalence of osteoporosis was significantly higher among Holocaust survivors.

Children recovered from malnutrition exhibit normal insulin production and sensitivity

Protein-energy malnutrition promotes adaptive hormonal changes that result in stunting. A previous study showed that stunted children had increased insulin sensitivity and diminished pancreatic beta-cell function. The objectives of the present study were to analyse the glucose, insulin, homeostasis model assessment of insulin sensitivity (HOMA-S) and homeostasis model assessment of pancreatic beta-cell function (HOMA-B) levels after nutritional recovery. The recovered group (n 62) consisted of malnourished children after treatment at a nutrition rehabilitation centre. At the beginning of treatment their age was 2.41 (sd 1.28) and 2.31 (sd 1.08) years, weight-for-age Z score - 2.09 (sd 0.94) and - 2.05 (sd 0.55) and height-for-age Z score - 1.85 (sd 1.11) and - 1.56 (sd 0.90), for boys and girls respectively. The control group consisted of well-nourished children without treatment (n 26). After treatment, boys of the recovered group gained 1.29 (sd 1.06) Z scores of height-for-age and 1.14 (sd 0.99) Z scores of weight-for-age, and girls, 1.12 (sd 0.91) and 1.21 (sd 0.74) Z scores respectively. No differences were found between control and recovered groups in insulin levels for boys (P = 0.704) and girls (P = 0.408), HOMA-B for boys (P = 0.451) and girls (P = 0.330), and HOMA-S (P = 0.765) for boys and girls (P = 0.456) respectively. The present study shows that the changes observed previously in glucose metabolism and insulin were reverted in children who received adequate treatment at nutritional rehabilitation centres and showed linear catch-up.