Comparison of milk and maize based diets in kwashiorkor

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

Kwashiorkor and marasmus are two clinical syndromes observed in severe acute malnutrition. In this review, we highlighted the differences between these two syndromes by reviewing the data comparing kwashiorkor and marasmus in literature, combined with recent microbiological findings and meta-analysis. Depletion of antioxidants, vitamins and minerals were more severe in kwashiorkor than marasmus. This was consistent with the severe and uncontrolled oxidative stress associated with the depletion of gut anaerobes and the relative proliferation of aerotolerant gut pathogens. This relative proliferation and invasion of gut microbes belonging to the aerotolerant Proteobacteria phylum and pathogens suggested a specific microbial process critical in the pathogenesis of kwashiorkor. Liver mitochondrial and peroxisomal dysfunction could be secondary to toxic microbial compounds produced in the gut such as ethanol, lipopolysaccharides and endotoxins produced by Proteobacteria, particularly Klebsiella pneumoniae, and aflatoxin produced by Aspergillus species. The gut-liver axis alteration is characterized by oedema and a fatty and enlarged liver and was associated with a dramatic depletion of methionine and glutathione, an excessive level of free circulating iron and frequent lethal bacteraemia by enteric pathogens. This was consistent with the fact that antibiotics improved survival only in children with kwashiorkor but not marasmus. The specific pathogenic characteristics of kwashiorkor identified in this review open new avenues to develop more targeted and effective treatments for both marasmus and/or kwashiorkor. Urgent correction of plasma glutathione depletion, alongside supply of specific essential amino acids, particularly methionine and cysteine, early detection of pathogens and an antibiotic more efficient than amoxicillin in supressing gut Proteobacteria including K. pneumoniae, and probiotics to restore the human gut anaerobic mature microbiota could save many more children with kwashiorkor.

Genome-nutrition divergence: evolving understanding of the malnutrition spectrum

Humans adapted over a period of 2.3 million years to a diet high in quality and diversity. Genome-nutrition divergence describes the misalignment between modern global diets and the genome formed through evolution. A survey of hominin diets over time shows that humans have thrived on a broad range of foods. Earlier diets were highly diverse and nutrient dense, in contrast to modern food systems in which monotonous diets of staple cereals and ultraprocessed foods play a more prominent role. Applying the lens of genome-nutrition divergence to malnutrition reveals shared risk factors for undernutrition and overnutrition at nutrient, food, and environmental levels. Mechanisms for food system shifts, such as crop-neutral agricultural policy, agroecology, and social policy, are explored as a means to realign modern diets with the nutritional patterns to which humans may be better adapted to thrive.

Milk with and without lactoferrin can influence intestinal damage in a pig model of malnutrition

Malnutrition remains a leading contributor to the morbidity and mortality of children under the age of five worldwide. However, the underlying mechanisms are not well understood necessitating an appropriate animal model to answer fundamental questions and conduct translational research into optimal interventions. One potential intervention is milk from livestock that more closely mimics human milk by increased levels of bioactive components that can promote a healthy intestinal epithelium. We tested the ability of cow milk and milk from transgenic cows expressing human lactoferrin at levels found in human milk (hLF milk) to mitigate the effects of malnutrition at the level of the intestine in a pig model of malnutrition. Weaned pigs (3 weeks old) were fed a protein and calorie restricted diet for five weeks, receiving cow, hLF or no milk supplementation daily from weeks 3-5. After three weeks, the restricted diet induced changes in growth, blood chemistry and intestinal structure including villous atrophy, increased ex vivo permeability and decreased expression of tight junction proteins. Addition of both cow and hLF milk to the diet increased growth rate and calcium and glucose levels while promoting growth of the intestinal epithelium. In the jejunum hLF milk restored intestinal morphology, reduced permeability and increased expression of anti-inflammatory IL-10. Overall, this pig model of malnutrition mimics salient aspects of the human condition and demonstrates that cow milk can stimulate the repair of damage to the intestinal epithelium caused by protein and calorie restriction with hLF milk improving this recovery to a greater extent.

Undernourished Children and Milk Lactose

BACKGROUND

Lactose is an important energy source in young mammals, and in fully breast-fed human infants, it constitutes around 40% of the total daily energy intake. The role of lactose in feeding of undernourished infants and young children is not well described.

OBJECTIVE

A narrative review of the potential positive and negative effects of lactose in the treatment of undernourished children.

METHODS

Searches were conducted using PUBMED and Web of Science up to July 2015. Relevant references in the retrieved articles were included.

RESULTS

Lactose may exhibit several health benefits in young children, including a prebiotic effect on the gut microbiota and a positive effect on mineral absorption. Studies in piglets suggest there might also be a stimulating effect on growth, relative to other carbohydrates. Lactose intolerance is a potential concern for undernourished children. Most undernourished children seem to tolerate the currently recommended (low lactose level) therapeutic foods well. However, a subgroup of severely undernourished children with secondary lactase deficiency due to severe diarrhea or severe enteropathy may benefit from products with even more restricted lactose content. At limited extra costs, lactose or lactose-containing milk ingredients may have beneficial effects if added to food products for undernourished children.

CONCLUSIONS

Lactose may be an overlooked beneficial nutrient for young and undernourished children. Research is needed to define the balance between beneficial and detrimental effects of lactose in undernourished children at different ages and with different degrees of diarrhea and intestinal integrity.

Carbohydrate malabsorption in acutely malnourished children and infants: a systematic review

CONTEXT

Severe acute malnutrition (SAM) accounts for approximately 1 million child deaths per year. High mortality is linked with comorbidities, such as diarrhea and pneumonia.

OBJECTIVE

The aim of this systematic review was to determine the extent to which carbohydrate malabsorption occurs in children with SAM.

DATA SOURCES

The PubMed and Embase databases were searched. Reference lists of selected articles were checked.

DATA EXTRACTION

All observational and controlled intervention studies involving children with SAM in which direct or indirect measures of carbohydrate absorption were analyzed were eligible for inclusion. A total of 20 articles were selected for this review.

DATA SYNTHESIS

Most studies reported carbohydrate malabsorption, particularly lactose malabsorption, and suggested an increase in diarrhea and reduced weight gain in children on a lactose-containing diet. As most studies reviewed were observational, there was no conclusive scientific evidence of a causal relationship between lactose malabsorption and a worse clinical outcome among malnourished children.

CONCLUSION

The combined data indicate that carbohydrate malabsorption is prevalent in children with SAM. Additional well-designed intervention studies are needed to determine whether outcomes of SAM complicated by carbohydrate malabsorption could be improved by altering the carbohydrate/lactose content of therapeutic feeds and to elucidate the precise mechanisms involved.

Diagnosis and treatment of severely malnourished children with diarrhoea

Children with severe acute malnutrition complicated by diarrhoea require special care due to their unique physiological vulnerability and increased mortality risks. A systematic literature review (1950-2013) was conducted to identify the most effective diagnostic and therapeutic measures for the community-based management of severely malnourished children with diarrhoea. No studies directly addressed this question, so the search was broadened to include inpatient care. Of the 129 studies identified, 32 were selected for full review and found to contain varying degrees of indirectness, inconsistency and bias. Evidence from diagnostic studies point to the use of both prolonged and persistent diarrhoea as morbidity markers, rapid hypoglycaemia diagnosis and the frequent aetiological role of Cryptosporidium. Therapeutic studies suggest benefits from routine antiparasitic medication and feeding regimens with ready-to-use-therapeutic foods, lactose-free diets and zinc supplementation. Existing rehydration treatment guidelines were affirmed, but the utility of glutamine and low osmolarity feeds were inconclusive.

Locally-prepared ready-to-use therapeutic food for children with severe acute malnutrition: a controlled trial

OBJECTIVE

To compare the efficacy of locally-prepared ready-to-use therapeutic food (LRUTF) and locally-prepared F100 diet in promoting weight-gain in children with severe acute malnutrition during rehabilitation phase in hospital.

STUDY DESIGN

Non-randomized Controlled trial.

SETTING

Pediatric ward of tertiary care public hospital in Central India.

STUDY PERIOD

1 October, 2009 to 30th May, 2010.

SUBJECTS

Children aged 6 to 60 months, diagnosed as severe acute malnutrition and hospitalized during study period.

INTERVENTION

Random group allocation followed for selection of intervention and control cohorts. The control cohort enrolled during October 1, 2009 to January 31, 2010 received F100 while the intervention cohort enrolled during 1 February to 15 May 2010 received LRUTF. Subjects receiving either of the two therapeutic foods were temporally separated to minimize the spillover effect. The study subjects and the technician delegated for measuring weight was blinded for type of intervention.

PRIMARY OUTCOME VARIABLE

Rate of weight-gain/kg/day.

RESULTS

There were 49 subjects in each group. Both groups were comparable. Rate of weight-gain was found to be (9.59 ± 3.39 g/kg/d) in LRUTF group and (5.41 ± 1.05 g/kg/d) in locally prepared F100 group. Significant difference in rate of weight gain was observed in LRUTF group (P<0.0001; 95% CI 3.17-5.19). No serious adverse effect was observed with use of LRUTF.

CONCLUSION

LRUTF promotes more rapid weight-gain when compared with F100 in patients with severe acute malnutrition during rehabilitation phase.

Reliable and inexpensive colorimetric method for determining protein-bound tryptophan in maize kernels

Biofortification programs in maize have led to the development of quality protein maize (QPM) with increased contents of the essential amino acids lysine and tryptophan, and increased nutritional value for protein deficient populations where maize is a staple food. Because multiple genetic systems control and modify the protein quality of QPM, tryptophan or lysine monitoring is required to maximize genetic gain in breeding programs. The objective of this work was to develop an accurate, reliable, and inexpensive method for tryptophan analysis in whole-grain maize flour to support QPM research efforts around the world. Tryptophan reacts with glyoxylic acid in the presence of sulfuric acid and ferric chloride, producing a colored compound that absorbs at 560 nm. A series of experiments varying the reagent concentrations, hydrolysis time, and length of the colorimetric reaction resulted in an optimized protocol which uses 0.1 M glyoxylic acid in 7 N sulfuric acid and 1.8 mM ferric chloride, and 30 min reaction time. This method produced stable and reproducible results for tryptophan concentration in whole-grain maize flour and was validated by comparison with data obtained using an acetic acid-based colorimetric procedure (r(2) = 0.80) and high pressure liquid chromatography (HPLC) (r(2) = 0.71). We describe adaptations that permit high throughput application of this tryptophan analysis method using a microplate platform.

Joint BAPEN and Nutrition Society Symposium on 'Feeding size 0: the science of starvation'. Severe malnutrition: therapeutic challenges and treatment of hypovolaemic shock

The systematic failure to recognise and appropriately treat children with severe malnutrition has been attributed to the elevated case-fatality rates, often as high as 50%, that still prevail in many hospitals in Africa. Children admitted to Kilifi District Hospital, on the coast of Kenya, with severe malnutrition frequently have life-threatening features and complications, many of which are not adequately identified or treated by WHO guidelines. Four main areas have been identified for research: early identification and better supportive care of sepsis; evidence-based fluid management strategies; improved antimicrobial treatment; rational use of nutritional strategies. The present paper focuses on the identification of children with sepsis and on fluid management strategies.

[Underweight prevention and treatment of the young child in Mono (Benin)]

BACKGROUND

This study aimed to assess the prevention and treatment effectiveness of underweight in less than two years old children admitted in 2001 to community nutrition programme of Mono area in Benin.

METHODS

A longitudinal retrospective survey took place in 30 villages chosen at random. It concerned a sample of 1799 children. Inside of those children, during the 2001 year, when they were admitted to the programme, 1545 were without underweight, have had more than one month following visit and about them the underweight effectiveness prevention had been analyzed; the others 111 were underweighted, have had more than one month following visit and about them the underweight treatment had been assessed. The 143 other children have been followed for only one month. The prevention effectiveness had been explored by the evolution of the cumulative incidence of underweight according to the number of following visit and the underweight incidence density. The treatment effectiveness has been analysed by calculating the recovery rate and incidence density.

RESULTS

During 2001, there have been observed 10% for the underweight cumulative incidence and 51.4% for the cumulative incidence of underweight recovery. The underweight and recovery incidence density were respectively 14 cases for 1000 persons-months of following and 118 cases for 1000 persons-months of following. The children with serious underweight at their last following visit have had the number of following visits lower than those who were with moderate underweight. The recovery was arrived after two to twelve months. There was a significant increase of underweight prevalence with the increase of following visit number inside the children with a normal weight at their admission into the programme.

CONCLUSION

During the 2001 following, the underweight prevention and treatment activities of community nutrition workers have been little effectiveness. The low level of instruction of community nutrition workers, their low level of knowledge of essential community nutrition activities, their multiple tasks and the not used appropriate foods for the treatment of underweight are the possible causes of the poor performance observed.

Critical appraisal of the management of severe malnutrition: 3. Complications

The high case-fatality of severe malnutrition is due to infections, dehydration, electrolyte disturbances and heart failure. We focus on the evidence about managing these complications of severe malnutrition. Signs of circulatory collapse in severely malnourished children should be treated with intravenous or bone marrow infusion of Ringer's lactate with additional dextrose and potassium at a rate 20-40 mL/kg fast with close monitoring of vital signs. Recommendations for slow or restricted fluids in the face of shock are unsafe, and hypotonic or maintenance solutions must be avoided to prevent hyponatraemia. However, the evidence that severely malnourished children do not tolerate excessive fluid administration is good, so caution must be exercised with regards to fluids in the initial phase of treatment. There is also good evidence that wide spectrum antibiotics need to be given empirically for severe malnutrition to prevent the otherwise unavoidable early mortality. There is a need for improved protocols for tuberculosis diagnosis, HIV management and treatment of infants under 6 months with severe malnutrition. The contribution of environmental enteropathy to poor growth and nutrition during the weaning period means that there should be more priority on improving environmental health, particularly better hygiene and less overcrowding. A T-cell mediated enteropathy contributes to growth failure and malnutrition, and it is related to environmental contamination of enteric organisms in the weaning period rather than allergic responses.

Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomized trial

BACKGROUND

The World Health Organization recommends a liquid, milk-based diet (F100) during the rehabilitation phase of the treatment of severe malnutrition. A dry, solid, ready-to-use food (RTUF) that can be eaten without adding water has been proposed to eliminate the risk of bacterial contamination from added water. The efficacies of RTUF and F100 have not been compared.

OBJECTIVE

The objective was to compare the efficacy of RTUF and F100 in promoting weight gain in malnourished children.

DESIGN

In an open-labeled, randomized trial, 70 severely malnourished Senegalese children aged 6-36 mo were randomly allocated to receive 3 meals containing either F100 (n = 35) or RTUF (n = 35) in addition to the local diet. The data from 30 children in each group were analyzed.

RESULTS

The mean (+/- SD) daily energy intake in the RTUF group was 808 +/- 280 (95% CI: 703.8, 912.9) kJ x kg body wt(-1) x d(-1), and that in the F100 group was 573 +/- 201 (95% CI: 497.9, 648.7) kJ. kg body wt(-1) x d(-1) (P < 0.001). The average weight gains in the RTUF and F100 groups were 15.6 (95% CI: 13.4, 17.8) and 10.1 (95% CI: 8.7, 11.4) g x kg body wt(-1) x d(-1), respectively (P < 0.001). The difference in weight gain was greater in the most wasted children (P < 0.05). The average duration of rehabilitation was 17.3 (95% CI: 15.6, 19.0) d in the F100 group and was 13.4 (95% CI: 12.1, 14.7) d in the RTUF group (P < 0.001).

CONCLUSIONS

This study indicated that RTUF can be used efficiently for the rehabilitation of severely malnourished children.

Milk formulas in acute gastroenteritis and malnutrition: a randomized trial

OBJECTIVE

To compare three low-lactose milk formulas differing in osmolality and degree of protein hydrolysis in the treatment of diarrhoea and malnutrition in subjects with high rates of lactose intolerance, osmotic diarrhoea and a tropical/environmental enteropathy.

METHODS

A randomized double-blind trial of 180 Aboriginal children under 3 years of age admitted with acute diarrhoea and/or malnutrition was carried out. The intervention milk formulas were: (i) De-Lact, a low-osmolality lactose-free formula; (ii) O-Lac, a lactose-free formula; and (iii) Alfaré, a partially hydrolysed formula. Outcome measures were diarrhoeal severity, weight gain, formula palatability and changes in intestinal permeability (L/R ratios).

RESULTS

The duration of diarrhoea in days (mean; 95% confidence interval) was significantly longer on Alfaré (8.5; 7.0-10.0) compared to De-Lact (6.1; 5.0-7.2) and O-Lac (6.9; 5.6-8.1; P = 0.04). There were no differences in mean intake between formulas, but palatability of Alfaré was significantly worse (P < 0.01) than the other formulas. Over the trial 5 days, improvement in L/R ratios was significantly greater (P = 0.05) for De-Lact (18.6; 10.6-26.6) than for Alfaré (8.5; 2.1-14.9). Weight gain was not significantly different between the three formulas, except in a malnourished subgroup who had better weight gain on De-Lact (P = 0.05).

CONCLUSIONS

In these Aboriginal children with diarrhoea and growth failure, a low osmolality milk was associated with better outcomes and a partially hydrolysed formula with less improvement in mucosal recovery, suggesting that cow's milk protein intolerance is not contributing to greater diarrhoeal severity or enteropathy in Aboriginal children.

The impact of HIV infection on the clinical presentation of severe malnutrition in children at QECH

A study was undertaken in a central nutritional rehabilitation unit (NRU) in southern Malawi to assess the impact of HIV infection on clinical presentation and case fatality rate. The HIV seroprevalence for 250 severely malnourished children over 1 year of age was 34.4% and the overall mortality was 28%. HIV infection was significantly more associated with marasmus (62.2%) than with kwashiorkor (21.7%) [p<0.0001]. Clinical and radiological features were not helpful in distinguishing HIV infected from non HIV infected children. The in-hospital case fatality rate was significantly higher for HIV infected children (38.4%) compared to severely malnourished children without HIV infection (22.7%) [p<0.05]. Though HIV infection contributes to the high mortality experienced in NRU's in Malawi, we argue that more remediable contributing factors still need to be addressed.

Contribution of villous atrophy to reduced intestinal maltase in infants with malnutrition

BACKGROUND

It has been known for many years that small intestinal maltase activities are reduced in malnourished infants and in other patients with villous atrophy. The recent availability of human maltase-glucoamylase cDNA provides the opportunity to test the hypothesis that villous atrophy accounts for the reduced maltase enzyme activity in malnourished infants.

METHODS

Mucosal biopsy specimens obtained for clinical evaluation of malnourished infants with poor responses to refeeding were examined by quantitative methods for enzyme activity and mRNA levels.

RESULTS

Maltase activity and maltase-glucoamylase mRNA were reduced (approximately 45% of normal). When maltase-glucoamylase message was normalized to villin message, a structural protein expressed only in enterocytes, a preservation of maltase messages in surviving enterocytes was documented. The luminal glucose transporter-villin message was also preserved.

CONCLUSIONS

The loss of maltase-glucoamylase message paralleled the reduction in villin message and degree of villous atrophy. The reduced maltase-glucoamylase message also paralleled sucrase-isomaltase message, previously found to be decreased in proportion to villous atrophy of malnourished infants. The data directly demonstrate, for the first time, that the terminal steps of starch 1-4 starch digestion and sucrase-isomaltase 1-6 starch digestion are decreased in malnourished infants, secondary to villous atrophy. These data in prior and present reports suggest that mechanisms underlying the chronic villous atrophy of malnutrition should be a priority for investigations in malnourished infants with slower than expected weight gain during refeeding.

The impact of the human immunodeficiency virus type 1 on the management of severe malnutrition in Malawi

A study was undertaken in a central nutritional rehabilitation unit in southern Malawi to assess the impact of HIV infection on clinical presentation and case fatality rate. HIV seroprevalence in 250 severely malnourished children over 1 year of age was 34.4% and overall mortality was 28%. HIV infection was associated significantly more frequently with marasmus (62.2%) than with kwashiorkor (21.7%) (p < 0.0001). Breastfed children presenting with severe malnutrition were significantly more likely to be HIV-seropositive (p < 0.001). Clinical and radiological features were generally not helpful in distinguishing HIV-seropositive from HIV-seronegative children. The case fatality rate was significantly higher for HIV-seropositive children (RR 1.6 [95% CI 1.14-2.24]). The increasing difficulties of managing the growing impact of HIV infection on severely malnourished children in Malawi are discussed in the context of reduced support for nutritional rehabilitation units.

Dual sugar permeability testing in diarrheal disease

OBJECTIVE

To assess the validity of the use of a blood specimen for the sugar permeability test because of the high failure rate of 5-hour urine collection in young children with diarrhea.

STUDY DESIGN

Simultaneous 5-hour urine collections and timed blood tests were taken after ingestion of an isotonic solution of lactulose (L) and L-rhamnose (R) in 24 children with acute gastroenteritis and 25 children without diarrhea in a control group. Sugars were measured with high performance liquid chromatography, and the percent of recovered sugars was expressed as an L-R ratio.

RESULTS

With acute gastroenteritis the geometric mean L-R ratios (95% confidence intervals) were 12.4 (9.3 to 16.3) in urine and 9.4 (6.7 to 13.1) in blood compared with 6.7 (5.0 to 8.8) and 5.9 (4.4 to 7.8), respectively, in the control group. The level of agreement (kappa) among normal, intermediate, and high ratios for blood and urine was 0.71 (0.51 to 0.92). The failure rate of L-R tests was significantly reduced with a blood specimen (urine 37% vs blood 10%; P <.0001).

CONCLUSIONS

Intestinal permeability testing on a blood specimen is a valid alternative to urine collection in young children and has a significantly lower test failure rate.

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.

Intestinal permeability and diarrhoeal disease in Aboriginal Australians

BACKGROUND

Northern Territory Aboriginal children hospitalised with acute gastroenteritis have high rates of acidosis, hypokalaemia, and dehydration.

AIMS

To determine whether Aboriginal children with and without diarrhoea have greater impairment in intestinal function than non-Aboriginal children, as assessed by increased permeability ratios.

METHODS

A descriptive study of 124 children (96 Aboriginal and 28 non-Aboriginal) hospitalised with and without diarrhoea. Intestinal permeability was assessed by the lactulose to rhamnose (L-R) ratio from a five hour urine collection.

RESULTS

In Aboriginal children, mean L-R ratios (95% confidence intervals) were 18.3 (17.1 to 19.6) with diarrhoea and 9.0 (7.3 to 11.0) without diarrhoea, and in non-Aboriginal children they were 5.9 (2.8 to 12. 3) and 4.2 (3.3 to 5.2), respectively. In patients with diarrhoea, L-R ratios were significantly raised when accompanied by acidosis (mean, 22.8; 95% CI, 17.0 to 30.5), hypokalaemia (mean, 20.7; 95% CI, 15.4 to 27.9), and >/= 5% dehydration (mean, 24.3; 95% CI, 19.0 to 29.6) compared with none of these complications (mean, 7.0; 95% CI, 3.5 to 13.8).

CONCLUSION

The high incidence of acidosis, hypokalaemia, and dehydration in Aboriginal children admitted with diarrhoeal disease is related to underlying small intestinal mucosal damage.

The sensitivity of the lactulose/rhamnose gut permeability test

BACKGROUND

The lactulose/rhamnose (L/R) intestinal permeability test is widely used. However, different quantities and proportions of lactulose and rhamnose are used. The aim of this study was to determine whether a low dosage of lactulose is able to discriminate between normal and increased permeability.

MATERIALS AND METHODS

Two groups of 10 healthy subjects were studied. In group 1, three different iso-osmolar test solutions were administered on 3 days. The solutions consisted of 10 g of L with 1 g of R, 5 g of L with 0.5 g of R and 1 g of L with 0.1 g of R in 65 mL of water. Group 2 ingested these solutions 1 h after ingestion of 750 mg of chenodeoxycholeic acid (CDCA), which is known to increase permeability. The urinary L/R ratio was determined using high-performance liquid chromatography. Data are presented as medians (range).

RESULTS

In group 1, no differences were observed between the three solutions. In Group 2, there was a significant difference (P = 0.045) between the three solutions. The L/R ratios were 0.0079 (0.0024-0.0152) (1L to 0.1R), 0.0138 (0.0066-0.0192) (5L to 0.5R) and 0.0144 (0.0074-0.0374) (10L to 1R). The L/R ratio differed significantly between Groups 1 and 2 (P < 0.001) using the 5L to 0.5R and 10L to 1R solutions respectively.

CONCLUSION

If the permeability is increased, the urinary L/R ratio depends on the quantity of lactulose and rhamnose administered in equal proportion. 5L to 0.5R is sufficient to discriminate between a normal and a moderately increased permeability.

Sensitization to cow's milk proteins during refeeding of guinea pigs recovering from polydeficient malnutrition

We have previously shown that milk sensitization aggravates intestinal dysfunction in the malnourished guinea pigs, suggesting that it may also impair the recovery from malnutrition. To test this hypothesis, the growing guinea pigs were malnourished by feeding only maize for 7 d and then were refed for 21 d with a balanced diet containing either intact or hydrolyzed cow's milk proteins. The control animals received the hydrolyzed milk protein diet for 28 d. After an initial period of total inhibition of growth owing to maize, guinea pigs gained weight regularly, with both balanced diets, and there was no evidence of mucosal damage at the end of the refeeding period. However, refeeding with intact milk proteins induced milk sensitization, which was demonstrated on the systemic level by the presence of anti-beta-lactoglobulin IgG1 antibodies, and on the local level by the intestinal anaphylaxis measured by the increase in short circuit current induced by beta-lactoglobulin (16.4 +/- 2.6 microA/cm2) in jejunal segments mounted in Ussing chambers. Such an immune sensitization was associated with impaired intestinal permeability, as both the ionic conductance (21.0 +/- 1.6 versus 14.6 +/- 0.7 mS/cm2) and the transepithelial fluxes of horseradish peroxidase (537 +/- 203 versus 152 +/- 28 ng/h x cm2) were significantly increased in guinea pigs refed with the intact milk proteins compared with controls. In contrast, there was no difference in intestinal permeability between controls and guinea pigs refed with the hydrolyzed milk protein diet. These data show that sensitization to cow's milk proteins can develop in guinea pigs recovering from severe malnutrition and may impair full intestinal repair.

Intestinal permeability in kwashiorkor

Intestinal permeability can be assessed non-invasively using the lactulose-rhamnose (L-R) test, which is a reliable measure of small intestinal integrity.

AIMS

To determine risk factors for abnormal intestinal permeability in kwashiorkor, and to measure changes in L-R ratios with inpatient rehabilitation.

DESIGN

A case-control study of 149 kwashiorkor cases and 45 hospital controls. The L-R test was adapted to study kwashiorkor in Malawi, with testing at weekly intervals during nutritional rehabilitation. Urine sugars were measured by thin layer chromatography in London.

RESULTS

The initial geometric mean L-R ratios (x100) (with 95% confidence interval) in kwashiorkor were 17.3 (15.0 to 19.8) compared with 7.0 (5.6 to 8.7) for controls. Normal ratios are < 5, so the high ratios in controls indicate tropical enteropathy syndrome. Abnormal permeability in kwashiorkor was associated with death, oliguria, sepsis, diarrhoea, wasting and young age. Diarrhoea and death were associated with both decreased L-rhamnose absorption (diminished absorptive surface area) and increased lactulose permeation (impaired barrier function) whereas nutritional wasting affected only L-rhamnose absorption. Despite, clinical recovery, mean L-R ratios improved little on treatment, with mean weekly ratios of 16.3 (14.0 to 19.0), 13.3 (11.1 to 15.9) and 14.4 (11.0 to 18.8).

CONCLUSION

Abnormal intestinal permeability in kwashiorkor correlates with disease severity, and improves only slowly with nutritional rehabilitation.