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

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

Prediction of mortality in severe acute malnutrition in hospitalized children by faecal volatile organic compound analysis: proof of concept

Children with severe acute malnutrition (SAM) display immature, altered gut microbiota and have a high mortality risk. Faecal volatile organic compounds (VOCs) reflect the microbiota composition and may provide insight into metabolic dysfunction that occurs in SAM. Here we determine whether analysis of faecal VOCs could identify children with SAM with increased risk of mortality. VOC profiles from children who died within six days following admission were compared to those who were discharged alive using machine learning algorithms. VOC profiles of children who died could be separated from those who were discharged with fair accuracy (AUC) = 0.71; 95% CI 0.59-0.87; P = 0.004). We present the first study showing differences in faecal VOC profiles between children with SAM who survived and those who died. VOC analysis holds potential to help discover metabolic pathways within the intestinal microbiome with causal association with mortality and target treatments in children with SAM.Trial Registration: The F75 study is registered at clinicaltrials.gov/ct2/show/NCT02246296.

Risk factors for mortality and management of children with complicated severe acute malnutrition at a tertiary referral hospital in Malawi

BACKGROUND

Severe acute malnutrition (SAM) is a major cause of childhood mortality in resource-limited settings. The relationship between clinical factors and adherence to the 'WHO 10 Steps' and mortality in children with SAM is not fully understood.

METHODS

Data from an ongoing prospective observational cohort study assessing admission characteristics, management patterns and clinical outcome in children aged 6-36 months admitted to a tertiary hospital in Malawi from September 2018 to September 2019 were analysed. Data clerks independently collected data from patients' charts. Demographics, clinical and nutritional status, identification of SAM and adherence to the 'WHO 10 Steps' were summarised. Their relationship to in-hospital mortality was assessed using multivariable logistic regression.

RESULTS

Of the 6752 patients admitted, 9.7% had SAM. Mortality was significantly higher in those with SAM (10.1% vs 3.8%, p < 0.001). Compared with independent assessment anthropometrics, clinicians appropriately documented SAM on admission in 39.5%. The following factors were independently associated with mortality: kwashiorkor [adjusted odds ratio (aOR) 5.14, 95% confidence interval (CI) 1.27-20.78], shock (aOR 18.54, 95% CI 3.87-88.90), HIV-positive (aOR 5.32, 95% CI 1.76-16.09), SAM documented on admission (aOR 2.41, 95% CI 1.11-5.22), documentation of blood glucose within 24 hrs (aOR 3.97, 95% CI 1.90-8.33) and IV fluids given without documented shock (aOR 3.13, 95% CI 1.16-8.44).

CONCLUSION

HIV infection remains an important predictor of mortality in children with SAM. IV fluids should be avoided in those without shock. Early identification of SAM by the clinical team represents a focus of future quality improvement interventions at this facility.

Survival status and mortality predictors among severely malnourished under 5 years of age children admitted to Minia University maternity and children hospital

BACKGROUND

Though effective treatment programs for severely malnourished children are available, mortality rate among children with acute malnutrition continue to rise and little is known about its long-term outcomes and potential predictors of its in-hospital and post-discharge mortality. The aim of this study was to assess the survival status and predictors for mortality in severely malnourished children admitted to Minia University Maternity and Children Hospital.

METHODS

A retrospective cohort study which included 135 children under 5 years of age who were admitted to the nutrition rehabilitation ward with severe acute malnutrition (SAM) during the period from January to December 2018. Data were collected from the inpatient's hospital records and the children's parents/guardians were interviewed using a detailed structured questionnaire that inquired about demographic and socioeconomic variables. The logistic and Cox regressions were used to assess the factors associated with the SAM's mortality.

RESULTS

A total of 135 children were enrolled into the study. Death rate during hospitalization was 9.6%. The survival rate at the end of the fourth week of admission was 82.4%. There were 6.7% post-discharge deaths among 104 alive discharged children which occurred within 8 weeks after discharge. The adjusted HRs (95% CIs) for total SAM deaths were 1.57 (1.10-2.99) in children < 12 vs ≥ 12 months old; 4.79 (2.23-6.10) in those with WAZ < -3SD, 2.99 (1.16-4.66) in those with edema at admission and 3.44 (1.07-9.86) in children with complications. The respective ORs (95%CIs) for in-hospital SAM deaths in the same groups of children were 2.64 (1.22-6.43), 8.10 (2.16-11.67), 3.04 (1.70-6.06) and 3.71 (1.59-6.78). The main predictor for the SAM's post-discharge mortality was illiteracy of mothers; the adjusted HR (95%CI) was 7.10 (1.58-31.93; p = 0.01).

CONCLUSIONS

Age, WAZ, edema and complications at admission were predictors for both in-hospital and total SAM mortality, while mother's education contributed to the early post-discharge mortality. The identification of predictors for mortality is an important preliminary step for interventions aiming to reduce morbidity and mortality.

Diarrhea, Dehydration, and the Associated Mortality in Children with Complicated Severe Acute Malnutrition: A Prospective Cohort Study in Uganda

OBJECTIVE

To assess predictors of diarrhea and dehydration and to investigate the role of diarrhea in mortality among children with complicated severe acute malnutrition.

STUDY DESIGN

A prospective cohort study, nested in a probiotic trial, was conducted in children with complicated severe acute malnutrition. Children were treated according to World Health Organization and national guidelines, and diarrhea and dehydration were assessed daily. Multiple linear and log-linear Poisson regression models were used to identify predictors of days with diarrhea and dehydration, respectively, and multiple logistic regression was used to assess their role in mortality.

RESULTS

Among 400 children enrolled, the median (IQR) age was 15.0 months (11.2-19.2 months), 58% were boys, and 61% had caregiver-reported diarrhea at admission. During hospitalization, the median (range) number of days with diarrhea was 5 (0-31), the median duration of hospitalization was 17 days (1-69 days), and 39 (10%) died. Of 592 diarrhea episodes monitored, 237 were admission episodes and 355 were hospital acquired. During hospitalization, young age was associated with days with diarrhea, and young age and HIV infection were associated with dehydration. Both days with diarrhea and dehydration predicted duration of hospitalization as well as mortality. The odds of mortality increased by a factor of 1.4 (95% CI, 1.2-1.6) per day of diarrhea and 3.5 (95% CI, 2.2-6.0) per unit increase in dehydration score.

CONCLUSIONS

Diarrhea is a strong predictor of mortality among children with complicated severe acute malnutrition. Improved management of diarrhea and prevention of hospital-acquired diarrhea may be critical to decreasing mortality.

Biomarkers of post-discharge mortality among children with complicated severe acute malnutrition

High mortality after discharge from hospital following acute illness has been observed among children with Severe Acute Malnutrition (SAM). However, mechanisms that may be amenable to intervention to reduce risk are unknown. We performed a nested case-control study among HIV-uninfected children aged 2-59 months treated for complicated SAM according to WHO recommendations at four Kenyan hospitals. Blood was drawn from 1778 children when clinically judged stable before discharge from hospital. Cases were children who died within 60 days. Controls were randomly selected children who survived for one year without readmission to hospital. Untargeted proteomics, total protein, cytokines and chemokines, and leptin were assayed in plasma and corresponding biological processes determined. Among 121 cases and 120 controls, increased levels of calprotectin, von Willebrand factor, angiotensinogen, IL8, IL15, IP10, TNFα, and decreased levels of leptin, heparin cofactor 2, and serum paraoxonase were associated with mortality after adjusting for possible confounders. Acute phase responses, cellular responses to lipopolysaccharide, neutrophil responses to bacteria, and endothelial responses were enriched among cases. Among apparently clinically stable children with SAM, a sepsis-like profile is associated with subsequent death. This may be due to ongoing bacterial infection, translocated bacterial products or deranged immune response during nutritional recovery.

Predictors of mortality among hospitalized children with severe acute malnutrition: a prospective study from Uganda

BACKGROUND

We determined the predictors of mortality among children admitted with severe acute malnutrition (SAM).

METHODS

This was a prospective study nested in a randomized trial among 6-59-month-old children admitted with SAM. Socio-demographic and medical history data were collected using questionnaires and clinical examination, anthropometry and laboratory tests were performed. They were monitored daily until discharge or death during hospitalization while receiving care according to national guidelines. Predictors of death were assessed using Cox regression.

RESULTS

Of 400 children, 9.8% (n = 39) died during hospitalization. Predictors of mortality included diarrhoea at admission [hazard ratio [HR] 2.19, 95% confidence interval (CI): 1.06; 4.51], lack of appetite [HR 4.50, 95% CI: 1.76; 11.50], suspected sepsis [HR 2.23, 95% CI: 1.18; 4.24] and skin ulcers [HR 4.23, 95% CI: 1.26; 4.17]. Chest indrawing [HR 5.0, 95% CI: 1.53; 16.3], oxygen saturation below 94% [HR 3.92, 95% CI: 1.42; 10.83] and confirmed HIV infection [HR 3.62, 95% CI: 1.69; 7.77] also predicted higher mortality.

CONCLUSION

Infections were major contributors to mortality. This underscores the need for improved prevention and management of these infections among children with severe malnutrition.

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM.

Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18 ^th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration.

Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities.

Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18 th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines.

Oral rehydration of malnourished children with diarrhoea and dehydration: A systematic review

Background: Diarrhoea complicates over half of admissions to hospital with severe acute malnutrition (SAM). World Health Organization (WHO) guidelines for the management of dehydration recommend the use of oral rehydration with ReSoMal (an oral rehydration solution (ORS) for SAM), which has lower sodium (45mmols/l) and higher potassium (40mmols/l) content than old WHO ORS. The composition of ReSoMal was designed specifically to address theoretical risks of sodium overload and potential under-treatment of severe hypokalaemia with rehydration using standard ORS. In African children, severe hyponatraemia at admission is a major risk factor for poor outcome in children with SAM complicated by diarrhoea. We therefore reviewed the evidence for oral rehydration therapy in children with SAM. Methods: We conducted a systematic review of randomised controlled trials (RCTs) on 18th July 2017 comparing different oral rehydration solutions in severely malnourished children with diarrhoea and dehydration, using standard search terms. The author assessed papers for inclusion. The primary endpoint was frequency of hyponatraemia during rehydration. Results: Six RCTs were identified, all published in English and conducted in low resource settings in Asia. A range of ORS were evaluated in these studies, including old WHO ORS, standard hypo-osmolar WHO ORS and ReSoMal. Hyponatraemia was observed in two trials evaluating ReSoMal, three children developed severe hyponatraemia with one experiencing convulsions. Hypo-osmolar ORS was found to have benefits in time to rehydration, reduction of stool output and duration of diarrhoea. No trials reported over-hydration or fatalities. Conclusions: Current WHO guidelines strongly recommend the use of ReSoMal based on low quality of evidence. Studies indicate a significant risk of hyponatraemia on ReSoMal in Asian children, none have been conducted in Africa, where SAM mortality remains high. Further research should be conducted in Africa to evaluate optimal ORS for children with SAM and to generate evidence based, practical guidelines

Severe childhood malnutrition

The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.

Effect of Probiotics on Diarrhea in Children With Severe Acute Malnutrition: A Randomized Controlled Study in Uganda

OBJECTIVES

The aim of the study was to assess the effect of probiotics on diarrhea during in- and outpatient treatment of children with severe acute malnutrition (SAM).

METHODS

A randomized, double-blind, placebo-controlled study was conducted involving 400 children admitted with SAM. Patients received 1 daily dose of a blend of Bifidobacterium animalis subsp lactis and Lactobacillus rhamnosus (10 billion colony-forming units, 50:50) or placebo during hospitalization followed by an 8- to 12-week outpatient treatment period, depending on patients' recovery rate. All outcomes were reported for in- and outpatient treatment separately. The primary outcome was number of days with diarrhea during hospitalization. Secondary outcomes included other diarrhea outcomes, pneumonia, weight gain, and recovery.

RESULTS

There was no difference in number of days with diarrhea between the probiotic (n = 200) and placebo (n = 200) groups during inpatient treatment (adjusted difference +0.2 days, 95% confidence interval -0.8 to 1.2, P = 0.69); however, during outpatient treatment, probiotics reduced days with diarrhea (adjusted difference -2.2 days 95% confidence interval -3.5 to -0.3, P = 0.025). There were no effects of probiotics on diarrhea incidence and severity or pneumonia, weight gain or recovery during in- or outpatient treatment. Twenty-six patients died in the probiotic versus 20 in the placebo group (P = 0.38).

CONCLUSIONS

Bifidobacterium animalis subsp lactis and Lactobacillus rhamnosus had no effect on diarrhea in children with SAM during hospitalization, but reduced the number of days with diarrhea in outpatient treatment by 26%. Probiotics may have a role in follow-up of hospitalized children with SAM or in community-based treatment of malnourished children, but further studies are needed to confirm this.

Inpatient management of children with severe acute malnutrition: a review of WHO guidelines

Objective

To understand how the World Health Organization’s (WHO’s) guidelines on the inpatient care of children with complicated severe acute malnutrition may be strengthened to improve outcomes.

Methods

In December 2015, we searched Google scholar and WHO’s website for WHO recommendations on severe acute malnutrition management and evaluated the history and cited evidence behind these recommendations. We systematically searched WHO International Clinical Trials Registry Platform, clinicaltrials.gov and the Controlled Trials metaRegister until 10 August 2015 for recently completed, ongoing, or pending trials.

Findings

WHO’s guidelines provide 33 recommendations on the topic. However, 16 (48.5%) of these recommendations were based solely on expert opinion – unsupported by published evidence. Another 11 (33.3%) of the recommendations were supported by the results of directly relevant research – i.e. either randomized trials (8) or observational studies (3). The other six recommendations (18.2%) were based on studies that were not conducted among children with complicated severe malnutrition or studies of treatment that were not identical to the recommended intervention. Trials registries included 20 studies related to the topic, including nine trials of alternative feeding regimens. Acute medical management and follow-up care studies were minimally represented.

Conclusion

WHO’s guidelines on the topic have a weak evidence base and have undergone limited substantive adjustments over the past decades. More trials are needed to make that evidence base more robust. If the mortality associated with severe malnutrition is to be reduced, inpatient and post-discharge management trials, supported by studies on the causes of mortality, are needed.

Daily co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition: a multicentre, double-blind, randomised placebo-controlled trial

Background

Children with complicated severe acute malnutrition (SAM) have a greatly increased risk of mortality from infections while in hospital and after discharge. In HIV-infected children, mortality and admission to hospital are prevented by daily co-trimoxazole prophylaxis, despite locally reported bacterial resistance to co-trimoxazole. We aimed to assess the efficacy of daily co-trimoxazole prophylaxis on survival in children without HIV being treated for complicated SAM.

Methods

We did a multicentre, double-blind, randomised, placebo-controlled study in four hospitals in Kenya (two rural hospitals in Kilifi and Malindi, and two urban hospitals in Mombasa and Nairobi) with children aged 60 days to 59 months without HIV admitted to hospital and diagnosed with SAM. We randomly assigned eligible participants (1:1) to 6 months of either daily oral co-trimoxazole prophylaxis (given as water-dispersible tablets; 120 mg per day for age <6 months, 240 mg per day for age 6 months to 5 years) or matching placebo. Assignment was done with computer-generated randomisation in permuted blocks of 20, stratified by centre and age younger or older than 6 months. Treatment allocation was concealed in opaque, sealed envelopes and patients, their families, and all trial staff were masked to treatment assignment. Children were given recommended medical care and feeding, and followed up for 12 months. The primary endpoint was mortality, assessed each month for the first 6 months, then every 2 months for the second 6 months. Secondary endpoints were nutritional recovery, readmission to hospital, and illness episodes treated as an outpatient. Analysis was by intention to treat. This trial was registered at ClinicalTrials.gov, number NCT00934492.

Findings

Between Nov 20, 2009, and March 14, 2013, we recruited and assigned 1778 eligible children to treatment (887 to co-trimoxazole prophylaxis and 891 to placebo). Median age was 11 months (IQR 7–16 months), 306 (17%) were younger than 6 months, 300 (17%) had oedematous malnutrition (kwashiorkor), and 1221 (69%) were stunted (length-for-age Z score <–2). During 1527 child-years of observation, 122 (14%) of 887 children in the co-trimoxazole group died, compared with 135 (15%) of 891 in the placebo group (unadjusted hazard ratio [HR] 0·90, 95% CI 0·71–1·16, p=0·429; 16·0 vs 17·7 events per 100 child-years observed (CYO); difference −1·7 events per 100 CYO, 95% CI −5·8 to 2·4]). In the first 6 months of the study (while participants received study medication), 63 suspected grade 3 or 4 associated adverse events were recorded among 57 (3%) children; 31 (2%) in the co-trimoxazole group and 32 (2%) in the placebo group (incidence rate ratio 0·98, 95% CI 0·58–1·65). The most common adverse events of these grades were urticarial rash (grade 3, equally common in both groups), neutropenia (grade 4, more common in the co-trimoxazole group), and anaemia (both grades equally common in both groups). One child in the placebo group had fatal toxic epidermal necrolysis with concurrent Pseudomonas aeruginosa bacteraemia.

Interpretation

Daily co-trimoxazole prophylaxis did not reduce mortality in children with complicated SAM without HIV. Other strategies need to be tested in clinical trials to reduce deaths in this population.

Funding

Wellcome Trust, UK

Integration of HIV Care into Community Management of Acute Childhood Malnutrition Permits Good Outcomes: Retrospective Analysis of Three Years of a Programme in Lusaka

BACKGROUND

While HIV has had a major impact on health care in southern Africa, there are few data on its impact on acute malnutrition in children in the community. We report an analysis of outcomes in a large programme of community management of acute malnutrition in the south of Lusaka.

PROGRAMME ACTIVITIES AND ANALYSIS

Over 3 years, 68,707 assessments for undernutrition were conducted house-to-house, and children with severe acute malnutrition (SAM) or moderate acute malnutrition (MAM) were enrolled into either Outpatient Therapeutic Programme (OTP) or Supplementary Feeding Programme (SFP) respectively. Case records were analysed using tabulation and unconditional logistic regression.

FINDINGS

1,859 children (889 boys, 970 girls; median age 16 months) with MAM (n = 664) or SAM (n = 1,195) were identified. Of 1,796 children whose parents consented to testing, 185 (10.3%) were HIV positive. Altogether 1,163 (62.6%) were discharged as recovered from acute malnutrition. Case fatality while in the programme was 4.2% in children with SAM and 0.5% in those with MAM (RR of SAM 10.9; 95%CI 3.4,34.8; P<0.0001), and higher in children with HIV infection (RR 5.2, 95%CI 2.9, 9.0; P<0.0001). In multivariate analysis, HIV (OR 5.2; 95%CI 2.6, 10.1; P<0.0001), MUAC <11.5 cm (OR 4.1; 95%CI 2.2, 7.4; P<0.0001) and the first year of the programme (OR 1.9; 95%CI 1.0, 3.4; P = 0.04) all increased mortality. Children with HIV infection who were able to initiate antiretroviral therapy had lower mortality (RR 0.23; 95%CI 0.10, 0.57; P = 0.0008).

INTERPRETATION

Our programme suggests that a comprehensive community malnutrition programme, incorporating HIV care, can achieve low mortality even in a population heavily affected by HIV.

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.

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.

Management of severe acute malnutrition in low-income and middle-income countries

Kwashiorkor and marasmus, collectively termed severe acute malnutrition (SAM), account for at least 10% of all deaths among children under 5 years of age worldwide, virtually all of them in low-income and middle-income countries. A number of risk factors, including seasonal food insecurity, environmental enteropathy, poor complementary feeding practices, and chronic and acute infections, contribute to the development of SAM. Careful anthropometry is key to making an accurate diagnosis of SAM and can be performed by village health workers or even laypeople in rural areas. The majority of children can be treated at home with ready-to-use therapeutic food under the community-based management of acute malnutrition model with recovery rates of approximately 90% under optimal conditions. A small percentage of children, often those with HIV, tuberculosis or other comorbidities, will still require inpatient therapy using fortified milk-based foods.

Clinical dietetic practice in the treatment of severe acute malnutrition in a high HIV setting

BACKGROUND

In Sub-Saharan Africa, children commonly present with severe acute malnutrition (SAM) complicated by HIV/AIDS. In 2005, the South African Department of Health implemented the World Health Organization (WHO) Ten Step programme for the inpatient treatment of SAM. Dietary management with F75 and F100 (where the terms F75 and F100 refer to a mixture of milk, sugar, oil and a vitamin and mineral mix) may not be appropriate for relatively well resourced settings such as South Africa.

METHODS

A structured questionnaire aiming to determine current clinical practice was e-mailed to all dietitians working in hospitals (n = 53) in KwaZulu-Natal who routinely treated SAM.

RESULTS

When initially refeeding with no diarrhoea (ND), F75 was used exclusively by 16% of dietitians to treat infants, and by 42% of dietitians to treat children. If diarrhoea, 16% of dietitians used F75 to treat infants/children. Acidified infant formula (IF) was given if ND and lactose-free IF was given if diarrhoea. Children were often started on a lactose-free F100 equivalent omitting cautious refeeding. Some gave reduced amounts for cautious refeeding; however, the feeds osmolality was too high. The use of partially hydrolysed feeds increased if the child/infant presented with diarrhoea and/or hypoalbuminea. In the post-initial feeding phase, approximately 14% of dietitians used F100 to treat infants/children. Most gave F100 equivalents as high-energy infant/paediatric formulas.

CONCLUSIONS

The dietetic practices for infants with SAM followed current expert opinion closely rather than the WHO protocol. The omission of cautious refeeding follows neither current expert opinion, nor the WHO protocol, and may predispose to the refeeding syndrome. Limited evidence indicates that partially hydrolysed formulas are less effective than low lactose low osmolality feeds in the treatment of SAM.