Polyunsaturated fatty acids in erythrocyte and plasma lipids of children with severe protein-energy malnutrition

Effect of fatty acid profiles in varying recipes of ready-to-use therapeutic foods on neurodevelopmental and clinical outcomes of children (6-59 months) with severe wasting: a systematic review

CONTEXT

In 2020, 13.6 million children under 5 years suffered from severe acute malnutrition (SAM)/wasting. Standard ready-to-use therapeutic foods (RUTFs) improve polyunsaturated fatty acid (PUFA) status but contain suboptimal amounts of omega-3 (n-3) PUFAs with unbalanced n-6-to-n-3 PUFA ratios.

OBJECTIVES

The aim was to compare the effects of RUTFs with different essential fatty acid contents on PUFA status, neurodevelopmental, and clinical outcomes (mortality, comorbidities, and recovery) of children with severe wasting.

DATA SOURCES

Twelve databases, trial repositories, and article references with no publication limitations.

DATA EXTRACTION

Ten studies from randomized, quasi, and cluster-randomized controlled trials providing RUTFs as home treatment to children 6-59 months with SAM/wasting were included.

DATA ANALYSIS

Plasma phospholipid eicosapentaenoic acid content was higher in children receiving RUTF with altered essential fatty acid contents compared with standard RUTF (0.20 [0.15-0.25], P < 0.00001). Docosahexaenoic acid (DHA) status only improved in children receiving RUTF with added fish oil (0.33 [0.15-0.50], P = 0.0003). The Malawi Developmental Assessment tool (MDAT) global development and problem-solving assessment scores were higher in global assessment and gross motor domains in children receiving added fish oil compared with standard formulation (0.19 [0.0-0.38] and 0.29 [0.03-0.55], respectively). Children receiving high-oleic-acid RUTF (lowering the n-6:n-3 PUFA ratio of the RUTF) with or without fish oil had significantly higher scores in social domains compared with those receiving the standard formulation (0.16 [0.00-0.31] and 0.24 [0.09-0.40]). Significantly higher mortality risk was found in children receiving a standard formulation compared with RUTF with a lower n-6:n-3 PUFA ratio (0.79 [0.67-0.94], P = 0.008).

CONCLUSION

Although lowering n-6:n-3 PUFA ratios did not increase plasma DHA, it improved specific neurodevelopmental scores and mortality due to lower linoleic acid (high-oleic-acid peanuts), higher alpha-linolenic acid (altered oil), or both. Additional preformed n-3 long-chain PUFAs (fish oil) with RUTF improved the children's DHA status, neurodevelopmental outcomes, and weight-for-height z score. More research is needed regarding cost, availability, stability, acceptability, and the appropriate amount of n-3 long-chain PUFAs required in RUTFs for the best clinical outcomes.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42022303694.

A Physiologically-Based Pharmacokinetic Framework for Prediction of Drug Exposure in Malnourished Children

Malnutrition in children is a global health problem, particularly in developing countries. The effects of an insufficient supply of nutrients on body composition and physiological functions may have implications for drug disposition and ultimately affect the clinical outcome in this vulnerable population. Physiologically-based pharmacokinetic (PBPK) modeling can be used to predict the effect of malnutrition as it links physiological changes to pharmacokinetic (PK) consequences. However, the absence of detailed information on body composition and the limited availability of controlled clinical trials in malnourished children complicates the establishment and evaluation of a generic PBPK model in this population. In this manuscript we describe the creation of physiologically-based bridge to a malnourished pediatric population, by combining information on (a) the differences in body composition between healthy and malnourished adults and (b) the differences in physiology between healthy adults and children. Model performance was confirmed using clinical reference data. This study presents a physiologically-based translational framework for prediction of drug disposition in malnourished children. The model is readily applicable for dose recommendation strategies to address the urgent medicinal needs of this vulnerable population.

Metabolic phenotyping of malnutrition during the first 1000 days of life

Nutritional restrictions during the first 1000 days of life can impair or delay the physical and cognitive development of the individual and have long-term consequences for their health. Metabolic phenotyping (metabolomics/metabonomics) simultaneously measures a diverse range of low molecular weight metabolites in a sample providing a comprehensive assessment of the individual's biochemical status. There are a growing number of studies applying such approaches to characterize the metabolic derangements induced by various forms of early-life malnutrition. This includes acute and chronic undernutrition and specific micronutrient deficiencies. Collectively, these studies highlight the diverse and dynamic metabolic disruptions resulting from various forms of nutritional deficiencies. Perturbations were observed in many pathways including those involved in energy, amino acid, and bile acid metabolism, the metabolic interactions between the gut microbiota and the host, and changes in metabolites associated with gut health. The information gleaned from such studies provides novel insights into the mechanisms linking malnutrition with developmental impairments and assists in the elucidation of candidate biomarkers to identify individuals at risk of developmental shortfalls. As the metabolic profile represents a snapshot of the biochemical status of an individual at a given time, there is great potential to use this information to tailor interventional strategies specifically to the metabolic needs of the individual.

Nutritional and other types of oedema, albumin, complex carbohydrates and the interstitium - a response to Malcolm Coulthard's hypothesis: Oedema in kwashiorkor is caused by hypo-albuminaemia

The various types of oedema in man are considered in relation to Starling's hypothesis of fluid movement from capillaries, with the main emphasis on nutritional oedema and the nephrotic syndrome in children. It is concluded that each condition has sufficient anomalous findings to render Starling's hypothesis untenable. The finding that the endothelial glycocalyx is key to control of fluid movement from and into the capillaries calls for complete revision of our understanding of oedema formation. The factors so far known to affect the function of the glycocalyx are reviewed. As these depend upon sulphated proteoglycans and other glycosaminoglycans, the argument is advanced that the same abnormalities will extend to the interstitial space and that kwashiorkor is fundamentally related to a defect in sulphur metabolism which can explain all the clinical features of the condition, including the formation of oedema.

Ready-to-use therapeutic food with elevated n-3 polyunsaturated fatty acid content, with or without fish oil, to treat severe acute malnutrition: a randomized controlled trial

BACKGROUND

Ready-to-use therapeutic foods (RUTF) are lipid-based pastes widely used in the treatment of acute malnutrition. Current specifications for RUTF permit a high n-6 polyunsaturated fatty acid (PUFA) content and low n-3 PUFA, with no stipulated requirements for preformed long-chain n-3 PUFA. The objective of this study was to develop an RUTF with elevated short-chain n-3 PUFA and measure its impact, with and without fish oil supplementation, on children's PUFA status during treatment of severe acute malnutrition.

METHODS

This randomized controlled trial in children with severe acute malnutrition in rural Kenya included 60 children aged 6 to 50 months who were randomized to receive i) RUTF with standard composition; ii) RUTF with elevated short chain n-3 PUFA; or iii) RUTF with elevated short chain n-3 PUFA plus fish oil capsules. Participants were followed-up for 3 months. The primary outcome was erythrocyte PUFA composition.

RESULTS

Erythrocyte docosahexaenoic acid (DHA) content declined from baseline in the two arms not receiving fish oil. Erythrocyte long-chain n-3 PUFA content following treatment was significantly higher for participants in the arm receiving fish oil than for those in the arms receiving RUTF with elevated short chain n-3 PUFA or standard RUTF alone: 3 months after enrollment, DHA content was 6.3% (interquartile range 6.0-7.3), 4.5% (3.9-4.9), and 3.9% (2.4-5.7) of total erythrocyte fatty acids (P <0.001), respectively, while eicosapentaenoic acid (EPA) content was 2.0% (1.5-2.6), 0.7% (0.6-0.8), and 0.4% (0.3-0.5) (P <0.001). RUTF with elevated short chain n-3 PUFA and fish oil capsules were acceptable to participants and carers, and there were no significant differences in safety outcomes.

CONCLUSIONS

PUFA requirements of children with SAM are not met by current formulations of RUTF, or by an RUTF with elevated short-chain n-3 PUFA without additional preformed long-chain n-3 PUFA. Clinical and growth implications of revised formulations need to be addressed in large clinical trials.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01593969. Registered 4 May 2012.

Dermatosis in children with oedematous malnutrition (Kwashiorkor): a review of the literature

Children with oedematous malnutrition, known as kwashiorkor, may develop a characteristic skin lesion, named 'Dermatosis of Kwashiorkor' (DoK). Only a few studies have been concerned with this condition, and the reason for the development of DoK remains unexplained. This study review the existing studies concerning DoK, including its clinical manifestations, histopathology, suggested pathophysiology, current treatment and prognosis for children of the age of 6 months to 5 years. Standardized clinical studies are needed to further understand the implications of DoK. Such studies would suffer from the lack of consistency concerning the terminology and scoring of the lesions in DoK. We therefore stress the need for a standardized scoring of the degree of DoK. This would facilitate valid and comparable studies and the development of better treatment for this vulnerable group of patients.

Effect of fatty Amazon fish consumption on lipid metabolism

OBJECTIVE: The present study aimed to evaluate the effect of feeding diets enriched with fatty fish from the Amazon basin on lipid metabolism. METHODS: Male Wistar rats were divided into four groups: control group treated with commercial chow; Mapará group was fed diet enriched with Hypophthalmus edentatus; Matrinxã group was fed diet enriched with Brycon spp.; and, Tambaqui group was fed diet enriched with Colossoma macropomum. Rats with approximately 240g±0.60 of body weight were fed ad libitum for 30 days, and then were sacrificed for collection of whole blood and tissues. RESULTS: The groups treated with enriched diets showed a significant reduction in body mass and lipogenesis in the epididymal and retroperitoneal adipose tissues and carcass when compared with the control group. However, lipogenesis in the liver showed an increase in Matrinxã group compared with the others groups. The levels of serum triglycerides in the treated groups with Amazonian fish were significantly lower than those of the control group. Moreover, total cholesterol concentration only decreased in the group Matrinxã. High Density Lipoprotein cholesterol levels increased significantly in the Mapará and Tambaqui compared with control group and Matrinxã group. The insulin and leptin levels increased significantly in all treatment groups. CONCLUSION: This study demonstrated that diets enriched with fatty fish from the Amazon basin changed the lipid metabolism by reducing serum triglycerides and increasing high density lipoprotein-cholesterol in rats fed with diets enriched with Mapará, Matrinxã, and Tambaqui.

Effects of antioxidants on glutathione levels and clinical recovery from the malnutrition syndrome kwashiorkor – a pilot study

Kwashiorkor is a severe edematous form of malnutrition with high prevalence and lethality in many African countries, and repeatedly has been reported to be associated with oxidative stress. The therapy of kwashiorkor is still ineffective. In this pilot study, we tested the hypothesis that oral application of thiol-containing antioxidants increases glutathione status and is beneficial for the clinical recovery of kwashiorkor patients. The longitudinal clinical intervention study was carried out at St Joseph's Hospital, Jirapa, Ghana. Children with severe kwashiorkor were randomly assigned to either a standard treatment (ST) receiving a therapeutic protocol based on the recommendations of the WHO or to one of three study groups receiving in addition 2 x 600 mg reduced glutathione or 2 x 50 mg alpha-lipoic acid or 2 x 100 mg N-acetylcysteine per day. Patients were followed up clinically and biochemically for 20 days and compared with 37 healthy controls. Both glutathione and alpha-lipoic acid supplementation had positive effects on survival. Also, the blood glutathione concentrations correlated positively with survival rates. Furthermore, the initial skin lesions, glutathione and total protein concentrations were found to be strong predictors of survival. The data strongly suggest that a therapy restoring the antioxidative capacity by applying cysteine equivalents in the form of glutathione and/or alpha-lipoic acid is beneficial for biochemical and clinical recovery of kwashiorkor patients.

Nutrients for cognitive development in school-aged children

This review considers the research to date on the role of nutrition in cognitive development in children, with a particular emphasis on the relatively neglected post-infancy period. Undernutrition and deficiencies of iodine, iron, and folate are all important for the development of the brain and the emergent cognitive functions, and there is some evidence to suggest that zinc, vitamin B12, and omega-3 polyunsaturated fatty acids may also be important. Considerations for future research include a focus on the interactions between micronutrients and macronutrients that might be influential in the optimization of cognitive development; investigation of the impact of nutritional factors in children after infancy, with particular emphasis on effects on the developing executive functions; and selection of populations that might benefit from nutritional interventions, for example, children with nutrient deficiencies or those suffering from attention deficit-hyperactivity disorder and dyslexia.

The possible role of essential fatty acids in the pathophysiology of malnutrition: a review

Biochemical evidence of essential fatty acid deficiency (EFAD) may exist in protein-energy malnutrition (PEM). EFAD is characterised by low 18:2omega6, often in combination with low 20:4omega6 and 22:6omega3, and high 18:1omega9 and 20:3omega9. Some PEM symptoms, notably skin changes, impaired resistance to infections, impaired growth rate and disturbed development may at least partly be explained by EFAD. One or more of the following factors could induce EFAD in PEM: low EFA intake, poor lipid digestion, absorption, transport, desaturation and increased EFA beta-oxidation and peroxidation. EFAD may perpetuate itself by decreasing lipid absorption and transport, and aggravate PEM by impairing nutrient absorption and dietary calorie utilisation. Micronutrient deficiencies may contribute to the impaired EFA bioavailability and metabolism. Nutritional rehabilitation strategies in PEM may consider adequate intakes of EFA and micronutrients, e.g. by promoting breastfeeding. More research is required to gain detailed insight into the role of EFAD in PEM.

Essential fatty acid status in paediatric Crohn's disease: relationship with disease activity and nutritional status

BACKGROUND

Active paediatric Crohn's disease is associated with nutritional deficiencies and altered nutrient intake. The availability of essential fatty acids (linoleic and alpha-linolenic acids) or their derivatives (arachidonic and eicosapentaenoic acids) may alter in plasma and cell membrane phospholipid in protein-energy malnutrition in children and in Crohn's disease in adults.

AIM

To investigate the relationship of fatty acid phospholipid profiles with disease activity and nutritional status in paediatric Crohn's disease.

METHODS

The fatty acid (proportionate) composition of plasma and erythrocyte phosphatidylcholine was determined in 30 patients (10.3-17.0 years) stratified into active and quiescent Crohn's disease (paediatric Crohn's disease activity index) and high and low body mass (body mass index centile).

RESULTS

In plasma phosphatidylcholine, active disease activity was associated with a lower level of alpha-linolenic acid compared with that in quiescent disease (P < 0.05). A body mass index below the 50th centile was associated with active Crohn's disease, low linoleic and alpha-linolenic acids and high arachidonic acid (P < 0.05) in plasma phosphatidylcholine, and low alpha-linolenic acid in erythrocyte phosphatidylcholine. These findings could not be explained through differences in habitual dietary fat intake.

CONCLUSION

In paediatric Crohn's disease, a low body mass index centile and high disease activity are associated with altered profiles of essential fatty acids and their derivatives, which may reflect altered metabolic demand.

Plasma fatty acid status in Moroccan children: increased lipid peroxidation and impaired polyunsaturated fatty acid metabolism in protein-calorie malnutrition

In previous studies on plasma fatty acid and antioxidant status in 29 malnourished Moroccan children (12 with mild protein-calorie malnutrition, 17 with severe protein-calorie malnutrition) compared to 15 healthy control children from the same area, we pointed out that these populations were heterogeneous in terms of their essential fatty acid and antioxidant status. The aim of the present study was to classify the children using the Waterlow classification and their essential fatty acid status. The discrepancies in lipid parameters, nutritional and inflammatory markers, blood oxidative indexes, antioxidant micronutrients or trace elements (selenium, zinc, vitamin E) related to polyunsaturated fatty acids were checked in these populations. Eight of the control subjects and nine of the severe protein-calorie malnutrition children were essential fatty acid-deficient, compared to only one of the mild protein-calorie malnutrition group. Examination of the essential fatty acid-sufficient subjects with mild protein-calorie malnutrition, compared to the essential fatty acid-sufficient control subjects, showed only a decrease in Z scores and a non-significant decrease in selenium and vitamin E. In severely malnourished children, albumin, cholesterol and low density lipoprotein (LDL) cholesterol, plasma selenium, vitamin E and zinc were low, whereas inflammatory proteins and triglycerides were high. These features worsened with essential fatty acid deficiency. In all protein-calorie malnutrition subjects, there was oxidative stress (increase in thiobarbituric-acid reactants, imbalance between plasma polyunsaturated fatty acid, vitamin E and selenium levels), even in the absence of essential fatty acid deficiency. Monounsaturated fatty acids, oleic acid/stearic acid (C18:1 n-9/C18:0) delta9 desaturase and n-3 and n-6 elongase activity indexes increased. The C18:1/C18:0 delta9 desaturase activity index was negatively correlated to Z scores (r = -0.44, P< 0.01 for Z score weight, r = -0.39, P < 0.01 for Z score height), albumin (r = -0.82, P < 0.01) and zinc (r = -0.51, P< 0.01) levels. In essential fatty acid-deficient, severe protein-calorie malnutrition subjects, delta6 desaturase activity was impaired, and there was a non-significant decrease in arachidonic acid. Essential fatty acid deficiency is a type of malnutrition, and is associated with an aggravation of all parameters in severe protein-calorie malnutrition. The increase in the C18:1/C18:0 delta9 desaturase activity and enhanced lipid peroxidation without any essential fatty acid deficiency could be early markers of protein-calorie malnutrition.

Antioxidant status and nitric oxide in the malnutrition syndrome kwashiorkor

The pathophysiology of kwashiorkor, a severe edematous manifestation of malnutrition, is still poorly understood. The syndrome is, however, known to be associated with alterations in redox metabolism. To further elucidate the role of oxidative stress in kwashiorkor, we carried out a longitudinal study on the major blood antioxidants at the St. Joseph's Hospital, Jirapa, Ghana. All kwashiorkor patients (K) were followed up for 20 d. In comparison with local healthy controls (C), the plasma total antioxidant status was reduced to less than 50% in the patients (C, 0.87 +/- 0.21 mM; K, 0.40 +/- 0.20 mM; p<0.001). Similarly, the major plasma antioxidant albumin (C, 40.9 +/- 2.5 g/L; K, 19.1 +/- 7.4 g/L; p < 0.001) and erythrocyte glutathione (C, 2.39 +/- 0.28 mM; K, 1.01 +/- 0.33; p < 0.001) were decreased, whereas the levels of bilirubin and uric acid were not significantly altered. Nitrite and nitrate were found to be increased by a factor of 2 in kwashiorkor (C, 120 +/- 46 microM; K, 235 +/- 107 microM; p < 0.001). Over the observation period, the trends of albumin and glutathione levels were related to clinical outcome. These concentrations rose in patients who recovered and fell in patients who did not. Our study strongly supports the hypothesis that oxidative and nitrosative stress play a role in the pathophysiology of edematous malnutrition. Prophylactic and therapeutic strategies should aim at the careful correction of the reduced antioxidant status of the patients.

Effects of protein-energy malnutrition and human immunodeficiency virus-1 infection on essential fatty acid metabolism in children

This report summarizes data on the availability of essential fatty acids (EFAs) and their long-chain polyunsaturated fatty acid (LCPUFA) metabolites in protein-energy malnutrition (PEM), in human immunodeficiency virus-1 (HIV-1) infection for which less information is available, and the combination of both PEM and HIV-1. The contribution of different EFAs and LCPUFAs to the fatty-acid composition of plasma and erythrocyte membrane lipids was found to be reduced in children with PEM in comparison with well-nourished children. In addition to limited dietary EFA supply, reduced bioconversion of EFAs to their respective LCPUFA metabolites and/or peroxidative degradation of LCPUFAs may contribute to the reduction of LCPUFA status in malnourished children. Restoration of normal energy, protein, and EFA intakes does not appear to readily correct abnormalities of plasma and erythrocyte membrane LCPUFA values. Enhanced dietary supply of LCPUFAs and/or improved supply of antioxidant vitamins may represent novel therapeutic modalities in severe PEM. With and without PEM, HIV infection was related to altered availability of various EFAs and LCPUFAs in HIV-seropositive children. The plasma total lipid fatty-acid profiles seen in well-nourished children with HIV infection were compatible with an HIV infection-related enhancement of the metabolic activity of the conversion of EFAs to their respective LCPUFA metabolites. However, the plasma phospholipid EFA and LCPUFA profiles seen in severely malnourished children with HIV infection more closely resembled those seen in children with PEM but without HIV infection than in those in children with HIV infection but no PEM. Metabolic studies using stable isotope-labeled fatty acids may contribute to better understanding of the HIV-related changes in EFA metabolism and clearly are needed before therapeutic conclusions can be drawn.

Fish oil supplementation improves docosahexaenoic acid status of malnourished infants

AIM

To investigate whether the low docosahexaenoic acid (DHA) status of malnourished, mostly breast fed, Pakistani children can be improved by fish oil (FO) supplementation.

METHODS

Ten malnourished children (aged 8-30 months) received 500 mg FO daily for nine weeks. The supplement contained 62.8 mol% (314 mg) long chain polyunsaturated fatty acids of the omega3 series (LCPUFAomega3) and 22.5 mol% (112 mg) DHA. Seven FO unsupplemented children served as controls. Red blood cell (RBC) fatty acids were analysed at baseline and at the study end.

RESULTS

FO supplementation augmented mean (SD) RBC DHA from 2.27 (0.81) to 3.35 (0.76) mol%, without significantly affecting the concentrations of LCPUFAomega6. Unsupplemented children showed no RBC fatty acid changes. One FO supplemented child with very low initial RBC arachidonic acid showed a remarkable increase from 4.04 to 13.84 mol%, whereas another with high RBC arachidonic acid showed a decrease from 15.64 to 10.46 mol%.

CONCLUSION

FO supplementation improves the DHA status of malnourished children. The supplement is apparently well absorbed and not exclusively used as a source of energy.

New concepts on nutritional management of severe malnutrition: the role of protein

Current guidelines for the management of severe malnutrition are mainly based on new concepts regarding the causes of malnutrition and on advances in our knowledge of the physiological roles of micronutrients. In contrast to the early 'protein dogma', there is a growing body of evidence that severely malnourished children are unable to tolerate large amounts of dietary protein during the initial phase of treatment. Similarly, great caution must be exercised to avoid excessive supply of iron and sodium in the diet, while keeping energy intake at maintenance levels during early treatment. Because severely malnourished children require special micronutrients, a mineral-vitamin mix is added to the milk-based formula diets, which are specially designed for the initial treatment and the rehabilitation phase. To further improve nutritional rehabilitation and reduce cases of relapse, 'ready-to-use therapeutic food' and 'ready-to-eat nutritious supplements' with relatively low protein (10% protein calories) and high fat content (54-59% lipidic calories) have been developed. Although current dietary recommendations do not differentiate between oedematous and nonoedematous forms of malnutrition or between adults and children, there are indications that further clarification is still needed for applying dietary measures for specific target groups.

Lipids, lipoproteins, and fatty acids during infantile marasmus in the Fès area of Morocco

The lipid composition of plasma, including total HDL and LDL cholesterol, triglycerides, apo AI, apo B, and fatty acids was investigated in 29 malnourished Moroccan children in two groups: 12 children with mild PCM, and 17 with severe PCM. Normally nourished children from the same area (n = 15) served as controls. The severe malnourished children showed a significant reduction of apo AI, total and LDL cholesterol, and an increase in the levels of triglycerides. Furthermore, these children showed a decrease in the saturated fatty acids myristic and stearic acid, and a similar decrease in the essential fatty acid (EFA) metabolites, especially eicosatrienoic acid, arachidonic acid, and eicosapentaenoic acid, with an increase in the oleic and cisvaccenic monounsaturated fatty acids. In contrast, the PCM group showed only an increase of docosatetraenoic and docosapentaenoic, with an associated decrease in myristic acid and palmitic acid. On the other hand, the indexes of delta 9 desaturase and elongase n-3 and n-6 were increased, and this was found to be related to the severity of the malnutrition. These results suggest that the severity of malnutrition is associated with an increase of desaturation and elongation of PUFA, EFA deficiency and/or peroxidation.

Nutritional support in malnourished paediatric patients

An imbalance between a person's energy requirements and his or her dietary protein and caloric supply is the source of protein energy malnutrition (PEM), which compounds the problems of any underlying disease. Malnutrition may occur quite rapidly in critically ill patients, particularly those suffering from sepsis, setting up a vicious cycle with worsening of the PEM. This chapter examines the main consequences of PEM, the means whereby appropriate nutrition may be provided, and risks for severely malnourished paediatric patients in hospital. If the gastrointestinal tract can be used for refeeding, it should be used. When the gastrointestinal tract is unable to meet the protein and energy requirements, parenteral nutrition (PN) is required. PN is efficient but carries a high risk of metabolic complications known as the refeeding syndrome and directly related to the homeostatic changes secondary to severe PEM. Catch-up growth may be achieved by using appropriate nutritional support. Changes in body composition have to be assessed during the course of renutrition.

Plasma concentration of taurine is higher in malnourished than control children: differences between kwashiorkor and marasmus

Plasma free amino acids were determined in the plasma of severely malnourished children under two years of age. A total of thirty-one patients and eleven controls were evaluated: seventeen cases of kwashiorkor, eight cases of marasmus, and six cases of marasmic-kwashiorkor. Fasting plasma samples were taken in the morning on the day of admission. Fasting plasma samples were also taken from nine patients at discharge after two months in the hospital where they received a balanced diet as treatment. A partial reversal of the signs of malnutrition was observed at discharge. In the whole group of patients ad admission, lower concentrations of tyrosine, methionine, tryptophan, and leucine and higher concentrations of aspartate, glutamate, and taurine were observed compared to controls. Taurine continued to be elevated in the malnourished group at the time of discharge. Marasmic children, as compared to controls, had high aspartate and low tryptophan levels, but taurine levels were not significantly different from controls. Kwashiorkor patients had low tyrosine, methionine, tryptophan, and lysine, and significantly higher taurine plasma levels. The elevated concentration of taurine might be the result of a redistribution of this amino acid to provide specific tissues with the required amount for development.

The clinical manifestation of the kwashiorkor syndrome is related to increased lipid peroxidation

Along with the onset of severe kwashiorkor symptoms, a 20-month-old child showed biochemical signs of markedly increased lipid peroxidation, with a decrease of plasma antioxidants and decreased proportions of polyunsaturated fatty acids in plasma and red cell phospholipids. Additionally, plasma concentrations of the lipid peroxidation products malondialdehyde and hexanal, as well as the urinary excretion of leukotriene E4, were found to be increased. All biochemical alterations normalized along with subsequent clinical improvement. These findings suggest that the extent of lipid peroxidation is strongly related to the severity of the kwashiorkor syndrome.

Low levels of linoleic acid in plasma total lipids of HIV-1 seropositive children

OBJECTIVE

To assess the plasma fatty acid status of a group of well-nourished children with the human immunodeficiency virus type-1 (HIV-1) and how this relates to the blood total CD4+ lymphocyte count.

SUBJECTS

Fourteen HIV-1 seropositive children at various stages of disease and with adequate growth indices were assessed and compared to a control group of 30 healthy children.

RESULTS

The concentrations (mg/dL) of plasma total fatty acids were not different between the two groups. HIV-1 seropositive children presented lower levels of 18-C essential polyunsaturated fatty acids (PUFA: linoleic acid, LA, and alpha-linolenic acid) and higher levels of their 20-C long-chain derivatives (di-homo-gamma-linolenic acid, arachidonic acid, AA, and eicosapentaenoic acid) and docosahexaenoic acid in their plasma total lipids. The lowest plasma LA levels were observed in the subgroup of patients with more advanced stages of disease. In bivariate analyses the plasma LA levels related positively (Spearman r = 0.50, p = 0.06), while the LA/AA ratio related negatively (Spearman r = -0.51, p = 0.06), to the total CD4+ count.

CONCLUSIONS

Childhood HIV-1 infection is associated with changes in plasma fatty acid profile suggestive of an increased PUFA turnover. Decreased levels of LA (together with higher plasma AA levels) appear to be associated with more advanced clinical and biochemical stages of disease.

Effects of malnutrition on the erythrocyte fatty acid composition and plasma vitamin E levels of Pakistani children

Erythrocyte fatty acids and plasma vitamin E concentrations were determined in 47 grade 2 and 21 grade 3 malnourished Pakistani children (ages 4-56 months). Data were compared with those of 26 age- and sex-matched apparently healthy controls. Evaluation with three statistical approaches revealed that both grade 2 and grade 3 malnourished children had decreased erythrocyte omega6 fatty acids and to a lesser extent decreased omega3 fatty acids. These decreases were compensated for by increased omega9 fatty acids. The patients tended to have lower plasma vitamin E concentrations. We conclude that malnourished Pakistani children have low essential fatty acid status, notably those of the omega6 series. The combination of low erythrocyte 22:6omega3 and a low 22:5omega6/22:4omega6 ratio in grade 2 patients suggests low delta4-desaturation activity, which may be due to impaired peroxisomal beta-oxidation.