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Antibiotics are recommended by the WHO as part of the management of uncomplicated severe acute malnutrition in children. We evaluated whether azithromycin, an antibiotic with antimalarial properties, improved malarial parasitemia outcomes in children with severe acute malnutrition compared with amoxicillin, an antibiotic commonly used for severe acute malnutrition that does not have antimalarial properties. Total of 301 children were randomized (1:1) to a single oral dose of azithromycin or a 7-day course of amoxicillin and followed for 8 weeks. We found no significant evidence that children receiving azithromycin had improved parasitemia outcomes relative to amoxicillin. Although azithromycin may have advantages over amoxicillin in terms of dosing and administration for uncomplicated severe acute malnutrition, it may not yield additional benefit for malaria outcomes.

Introduction: The consequences of severe acute malnutrition are measured in terms of health and survival, but also of cognitive development, its productivity and the overall national economy. Its management requires enormous financial resources. The purpose of this study was to assess the effectiveness of treating severe acute malnutrition versus cost of treatment of severe acute malnutrition in children., Methods: We conducted a retrospective study of 199 children aged 0-59 months admitted to the Centre for Nutritional Recovery and Education in Kaya, Burkina Faso, from January to December 2014. The cost of treatment, the length of stay in the Centre for Nutritional Recovery and Education, daily weight gain and the speed of recovery were analyzed based on the standards calculation methods. Mann-Whitney test and Kruskall-Wallis test were used to compare the medians (0.05 threshold)., Results: As expected, children aged 6-23 months were the most affected (51.8%) and acute respiratory infections were the most associated diseases (57.9%). The median length of stay in the Centre for Nutritional Recovery and Education was 9.0 (7.0-13.0) days, the mean speed of recovery was 100.0 (65.8 - 143.3) g/day and the average daily weight gain was 18.1 (11.6 - 27.7) g/kg/day. The average cost of treatment in a malnourished child is estimated to be 15 715,3 FCFA (25.2 USD)., Conclusion: The cost of treatment is hardly affordable by the parents of malnourished children; hence the necessity for government and development partners interventions., Competing Interests: Les auteurs ne déclarent aucun conflit d’intérêts., (© Bassibila Zoungrana et al.)

Background: The relationship between malaria infection and nutritional status is complex. Previous studies suggest malaria may increase the incidence and severity of malnutrition, while malnutrition may increase the risk of malaria infection. Here, we report bidirectional associations between malaria and nutritional status among children with uncomplicated severe acute malnutrition (SAM)., Methods: This study is a secondary analysis of a randomized, controlled trial for the treatment of uncomplicated SAM in Niger. Children aged 6-59 months were enrolled and followed for 12 weeks. Malaria infection was assessed using an histidine-rich protein 2 (HRP2) rapid diagnostic test at admission and at any follow-up visit with fever. We assessed the association of nutritional status at admission on malaria incidence using Cox proportional hazards regression and malaria infection at admission on nutritional recovery and weight and height gain using linear regression., Results: Of 2399 children included in the analysis, 1327 (55.3%) were infected with malaria at admission. Malaria incidence was 12.1 cases/100 person-months among those without malaria infection at admission. Nutritional status at admission was not associated with malaria incidence. Children with malaria infection at admission and subsequently treated with an artemisinin-based combination therapy had increased weight gain (0.38 g/kg/day; 95% confidence interval [CI], 0.07 to 0.69) and reduced height gain (-0.002 mm/day; 95% CI, -0.004 to -0.0008)., Conclusions: Malaria infection was common among children treated for uncomplicated SAM. Malaria infection may impair height gain. Proper medical and nutritional management should be ensured to prevent adverse effects of malaria infection., Clinical Trials Registration: NCT01613547.

Background: Malnutrition is common in children in sub-Saharan Africa and is thought to increase the risk of infectious diseases, including malaria. The relationship between malnutrition and malaria was examined in a cohort of 6-59 month-old children in rural Gambia, in an area of seasonal malaria transmission. The study used data from a clinical trial in which a cohort of children was established and followed for clinical malaria during the 2011 transmission season. A cross-sectional survey to determine the prevalence of malaria and anaemia, and measure the height and weight of these children was carried out at the beginning and end of the transmission season. Standard anthropometric indices (stunting, wasting and underweight) were calculated using z-scores., Results: At the beginning of the transmission season, 31.7% of children were stunted, 10.8% wasted and 24.8% underweight. Stunting was more common in Fula children than other ethnicities and in children from traditionally constructed houses compared to more modern houses. Stunted children and underweight children were significantly more likely to have mild or moderate anaemia. During the transmission season, 13.7% of children had at least one episode of clinical malaria. There was no association between stunting and malaria incidence (odds ratio = 0.79, 95% CI: 0.60-1.05). Malaria was not associated with differences in weight or height gain., Conclusions: Chronic malnutrition remains a problem in rural Gambia, particularly among the poor and Fula ethnic group, but it was not associated with an increased risk of malaria., Trial Registration: Trial registration: ISRCTN, ISRCTN01738840 , registered: 27/08/2010 (Retrospectively registered).

Pediatric patients with chronic illnesses or diseases or who require long-term nutrition support are most vulnerable to nutrition-related issues. Malnutrition in a pediatric patient may negatively affect long-term growth and development. Children also become malnourished much more quickly than adults. A comprehensive nutrition assessment that includes food and nutrition-related history, anthropometric measurements, biochemical data, medical tests and procedures, nutrition-focused physical findings, and patient history should be completed on these patients as no one parameter is a comprehensive indicator of nutrition status. Anthropometric measurements provide important information on the growth and nutrition status of a child, yet many times it is difficult to get accurate and valid measurements due to physical limitations of the child or improper technique. Inaccurate measurements may result in a missed diagnosis of malnutrition or may lead to an incorrect diagnosis of a healthy child. Knowledge of appropriate anthropometric measurements and alternatives is crucial when assessing growth in all children and essential for those who are physically handicapped or critically ill. The purpose of this review is to present key components of a pediatric nutrition assessment so proper nutrition-related diagnosis, including malnutrition, can be accomplished, a nutrition care plan established, and expected outcomes documented.

The publication of the landmark paper "Defining Pediatric Malnutrition: A Paradigm Shift Toward Etiology-Related Definitions" launched a new era in diagnosing pediatric malnutrition. This work introduced the paradigm shift of etiology-related definitions-nonillness and illness related-and the use of anthropometric z scores to help identify and describe children with malnutrition (undernutrition) in the developed world. Putting the new definition into practice resulted in some interesting observations: (1) Etiology-related definitions result in etiology-related interventions. (2) Illness-related malnutrition cannot always be immediately "fixed." (3) Using z scores in clinical practice often puts the burden of proof on the clinician to show that a child is not malnourished, rather than the other way around. (4) Children with growth failure severe enough to be admitted with "failure to thrive" should always be assessed for malnutrition, and when they meet the criteria, malnutrition should be documented and coded. The publication of the consensus statement came next, announcing the evidence-informed, consensus-derived pediatric malnutrition indicators. Since the indicators are a work in progress, clinicians are encouraged to use them and give feedback through an iterative process. This review attempts to respond to the consensus statement's call to action by thoughtfully appraising the indicators and making recommendations for future review. Coming together as a healthcare community to identify pediatric malnutrition will ensure that this vulnerable population is not overlooked. Outcomes research will validate the indicators and result in new discoveries of effective ways to prevent and treat pediatric malnutrition.

Background: While malnutrition is an important concern in the developing world, Western countries are experiencing a pandemic of obesity and metabolic diseases., Objective: This work reviews the current state of knowledge of the effects of malnutrition during early life on metabolism in older age., Methods: The impact of early-life determinants on diabetes and related metabolic diseases in later life is elucidated by three different methodological approaches. First, results from animal studies in dietary manipulation models are reviewed. Second, findings from epidemiological studies that often use natural experiments to determine the effects of famines on the health status of the population are discussed. Finally, the relation between maternal or childhood malnutrition and diabetes in adulthood is explored in a big-data study using the entire population of a country across a century., Results: We present overwhelming evidence that the maternal or early childhood nutritional status negatively affects both the short- and long-term health status and development of the offspring, thereby providing starting points to formulate intervention and prevention strategies. In particular, it was found that in the case of early-life exposure to famine, the risk of the offspring to develop type 2 diabetes in older age is up to 125% higher than without famine exposure., Conclusion: Due to its inherent complexity, an understanding of the long-term effects of maternal and childhood malnutrition on metabolism in older age necessitates interdisciplinary and big-data approaches. Only then can we hope to prevent chronic diseases at their earliest beginning., (© 2014 S. Karger AG, Basel.)

Objective: The objective of this study was to determine the association between preoperative nutritional status and postoperative outcomes in children undergoing surgery for congenital heart defects (CHD)., Methods: Seventy-one patients with CHD were enrolled in a prospective, 2-center cohort study. We adjusted for baseline risk differences using a standardized risk adjustment score for surgery for CHD. We assigned a World Health Organization z score for each subject's preoperative triceps skin-fold measurement, an assessment of total body fat mass. We obtained preoperative plasma concentrations of markers of nutritional status (prealbumin, albumin) and myocardial stress (B-type natriuretic peptide [BNP]). Associations between indices of preoperative nutritional status and clinical outcomes were sought., Results: Subjects had a median (interquartile range [IQR]) age of 10.2 (33) months. In the University of California at San Francisco (UCSF) cohort, duration of mechanical ventilation (median, 19 hours; IQR, 29 hours), length of intensive care unit stay (median, 5 days; IQR 5 days), duration of any continuous inotropic infusion (median, 66 hours; IQR 72 hours), and preoperative BNP levels (median, 30 pg/mL; IQR, 75 pg/mL) were associated with a lower preoperative triceps skin-fold z score (P < .05). Longer duration of any continuous inotropic infusion and higher preoperative BNP levels were also associated with lower preoperative prealbumin (12.1 ± 0.5 mg/dL) and albumin (3.2 ± 0.1; P < .05) levels., Conclusions: Lower total body fat mass and acute and chronic malnourishment are associated with worse clinical outcomes in children undergoing surgery for CHD at UCSF, a resource-abundant institution. There is an inverse correlation between total body fat mass and BNP levels. Duration of inotropic support and BNP increase concomitantly as measures of nutritional status decrease, supporting the hypothesis that malnourishment is associated with decreased myocardial function., (Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.)

Objectives: To determine the prevalence of malnutrition among children admitted with acute diarrhoea disease at Moi Teaching and Referral Hospital and to establish the effect of malnutrition on duration of hospital stay., Design: Prospective observational study., Setting: Paediatric wards of Moi Teaching and Referral Hospital, Eldoret, Kenya., Subjects: A total of 191 children aged 6 and 59 months admitted with acute diarrhoea disease, without chronic co-morbidities or visible severe malnutrition, were systematically enrolled into the study between November 2011 and March 2012., Outcome Measures: Nutritional status based on WHO WHZ scores taken at admission and duration of hospital stay., Results: The mean age was 13.2 months with a male to female sex ratio of 1.16:1. Of all the children seen with acute diarrhoeal diseases, 43.9% had acute malnutrition (<-2 WHZ score), with 12% being severely malnourished (<-3 Z score). Average duration of hospital stay was 3.36 (SD=1.54) days. Among those with malnutrition the average duration of stay was 3.39 (SD=1.48) days while for those without malnutrition it was 3.21(SD=1.20) days, which was not statistically different. No death was reported. WHO weight for Height Z scores picked 12% of severe form of malnutrition missed out by Welcome Trust classification (weight for age)., Conclusion: Routine anthrometry including weight for height identifies more children with malnutrition in acute diarrhoeal diseases. Presence of malnutrition did not affect duration of hospital stay.

Background: There is lack of information in the medical literature on predictors of hypoxemia in severely malnourished children with pneumonia, although hypoxemia is common and is often associated with fatal outcome in this population. We explored the predictors of hypoxemia in under-five children who were hospitalized for the management of pneumonia and severe acute malnutrition (SAM)., Methods: In this unmatched case-control design, SAM children of both sexes, aged 0-59 months, admitted to the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B) with radiological pneumonia and hypoxemia during April 2011 to April 2012 were studied. SAM children with pneumonia and hypoxemia (SpO(2)<90%) constituted the cases (n = 37), and randomly selected SAM children with pneumonia but without hypoxemia constituted controls (n = 111)., Results: The case-fatality was significantly higher among the cases than the controls (30% vs. 4%; p<0.001). In logistic regression analysis, after adjusting for potential confounders such as nasal flaring, head nodding, inability to drink, and crackles in lungs, fast breathing (95% CI = 1.09-13.55), lower chest wall in-drawing (95% CI = 2.48-43.41), and convulsion at admission (95% CI = 3.14-234.01) were identified as independent predictors of hypoxemia in this population. The sensitivity of fast breathing, lower chest wall in-drawing and convulsion at admission and their 95% confidence intervals (CI) to predict hypoxemia were 84 (67-93)%, 89 (74-96)%, and 19 (9-36)% respectively, and their specificity were 53 (43-63)%, 60 (51-69)% and 98 (93-100)% respectively., Conclusion and Significance: Fast breathing and lower chest wall in-drawing were the best predictors of hypoxemia in SAM children with pneumonia. There thus, in resources poor settings where pulse oximetry is not available, identification of these simple clinical predictors of hypoxemia in such children could be reliably used for early O(2) supplementation in addition to other appropriate management to reduce morbidity and deaths.

Background: Short-chain fatty acids (SCFAs) liberated by fermentation of complex carbohydrates might stimulate water and salt absorption, and provide energy. The aim of the study was to assess the number and proportion of faecal bacteria and the concentration of SCFAs of severely malnourished children with cholera receiving oral rehydration solution (ORS) containing glucose, amylase-resistant starch (ARS) or rice., Methods: Serial faecal samples were collected from 30 malnourished children with cholera until rehydration and partial nutritional recovery. SCFAs were identified and quantitated by high-performance liquid chromatography. In situ hybridization combined with flow cytometry was used to analyse the microbiota in the faeces., Results: Before treatment the concentration of total SCFA in faecal sample of cholera children was found to be 4.7±0.6 mmol/kg and it increased steadily until 95.0±8.7 mmol/kg at day 28. Among different ORS groups, concentration was significantly higher in the Rice-ORS group at day 1 (P<0.011) and at day 2 (P<0.025). During recovery faecal output was significantly reduced and the number of bacteria also increased faster in the Rice-ORS group than in the glucose-ORS group at day 1 and day 2 (P<0.01), and a modest increase in bacterial number was observed in the glucose-ORS plus ARS group (day 1, P=0.07; day 2, P=0.09)., Conclusion: Clinical recovery was associated with an increase in bacterial and SCFA concentrations with all three carbohydrates in ORS. However, the increases were significantly higher in children receiving Rice-ORS.

Objective: To improve nutrition of malnourished children in the community, using home based treatment., Methods: A prospective cohort study was conducted in a squatter settlement of Karachi (Khuda Ki Basti). The study was conducted from August 2006 to March 2007. All children <5 years who were <-3sd weight for height were included as per WHO guidelines. After initial screening for complications, the children were provided with high density diet (HDD). Daily weight, amount of HDD consumed and complications were recorded., Results: A total of 24 children were included in the study. Eleven children (45.8%) reached - 1SD at the end of 3 months while 10 patients (41.6%) took 4 months. Twenty two patients (91.6%) were at the median weight for height by the end of 5 months., Conclusion: Home based treatment with locally available foods can be used successfully to rehabilitate severely malnourished children.

Iodine deficiency during foetal development and early childhood is associated with cognitive impairment. Randomised clinical studies in school-aged children encountered in the literature indicate that cognitive performance can be improved by iodine supplementation, but most studies suffer from methodological constraints. Tests to assess cognitive performance in the domains that are potentially affected by iodine deficiency need to be refined. Maternal iodine supplementation in areas of mild-to-moderate iodine deficiency may improve cognitive performance of the offspring, but randomised controlled studies with long-term outcomes are lacking. Studies in infants or young children have not been conducted. The best indicators for iodine deficiency in children are thyroid-stimulating hormone (TSH) in newborns and thyroglobulin (Tg) in older children. Urinary iodine may also be useful but only at the population level. Adequate salt iodisation will cover the requirements of infants and children as well as pregnant women. However, close monitoring remains essential., (Copyright 2009 Elsevier Ltd. All rights reserved.)

Background: HIV infection predisposes children with malnutrition to recurrent bacterial infections and a high risk of bacteraemia., Methods: A cross-sectional descriptive study to determine the prevalence, causative organisms, antibiotic sensitivity and factors associated with bacteraemia in malnourished children was undertaken at Mulago Hospital, Kampala. The prevalence of HIV infection was also determined. A total of 134 children aged 6-59 months with severe malnutrition were recruited., Results: Sixty-one (45.5%) had oedematous malnutrition and 73 (54.5%) had severe wasting. Fifty-nine (44.0%) were HIV-infected. The prevalence of bacteraemia was 22%. The predominant organisms isolated were gram-negative enteric bacilli (77%) with Salmonella species and E. coli contributing 67% of the isolates. Hypoglycaemia was significantly associated with bacteraemia (p=0.007). Most organisms were resistant to cotrimaxazole (93.3%), ampicillin (76.7%), gentamicin (66.7%) and chloramphenicol (60%). All isolates were sensitive to ceftriaxone. Sensitivity to ciprofloxacin was 97%. There was no strong association between HIV infection and bacteraemia. The relative risk of death in malnourished children with bacteraemia was ten times higher than in those without bacteraemia., Conclusions: Nearly a quarter (22%) of children admitted with severe malnutrition had bacteraemia and gram-negative organisms were the predominant cause. Forty-four per cent were HIV-infected. Most of the bacteria were sensitive to ceftriaxone and ciprofloxacin and resistant to commonly used antibiotics. In the absence of culture and sensitivity, ciprofloxacin or ceftriaxone should be considered as first-line antibiotics for severely malnourished children.

Protein-energy malnutrition is the primary cause of immune deficiency in children across the world. It has been related to changes in peripheral T-lymphocyte subsets. The aim of the present study was to evaluate the effects of infection and malnutrition on the proportion of peripheral-lymphocyte subsets in well-nourished non-bacterium-infected (WN), well-nourished bacterium-infected (WNI), and malnourished bacterium-infected (MNI) children by flow cytometry. A prospectively monitored cohort of 15 MNI, 12 WNI, and 17 WN children was studied. All the children were 3 years old or younger and had only bacterial infections. Results showed a significant decrease in the proportion of T CD3(+) (P < 0.05 for relative and P < 0.03 for absolute values), CD4(+) (P < 0.01 for relative and absolute values), and CD8(+) (P < 0.05 for relative values) lymphocyte subsets in WNI children compared to the results seen with WN children. Additionally, B lymphocytes in MNI children showed significant lower values (CD20(+) P < 0.02 for relative and P < 0.05 for absolute values) in relation to the results seen with WNI children. These results suggest that the decreased proportions of T-lymphocyte subsets observed in WNI children were associated with infection diseases and that the incapacity to increase the proportion of B lymphocyte was associated with malnutrition. This low proportion of B lymphocytes may be associated with the mechanisms involved in the immunodeficiency of malnourished children.

Objective: To analyze the prognostic value of malnutrition in children with idiopathic dilated cardiomyopathy., Methods: This is a retrospective study of 165 patients with idiopathic dilated cardiomyopathy, diagnosed from September 1979 to March 2003. It analyzed the following variables: gender, age, previous viral illness in the preceding 3 months, functional class according to the New York Heart Association (NYHA), evaluation of nutritional status (normal vs. malnutrition), percentile and standard deviation (z index) of weight. Weight was measured 744 times during the first 72 months, 93 during the first month. Statistical analysis was performed by Chi Squared, Student t test and analysis of variance for repeated measures (ANOVA). Ninety-five percent confidence intervals (CI95) and odds ratios (OR) were calculated. An alpha value of 0.05 and beta of 0.80 were used., Results: Mean age at presentation was 2.2+/-3.2 years with higher incidence in those younger than 2 years (75.8%-CI95 = 68.5% to 82.1%) (p < 0.0001). NYHA classes III and IV were observed in 81.2% (CI95 = 74.4% to 86.9%) (p < 0.0001) and all 40 deaths were this group (p = 0.0008). At presentation, myocarditis occurred in 39.4% (CI95 = 31.9% to 47.3%) (p = 0.0001) and a high level of association between myocarditis and previous viral illness was observed (p = 0.0005) (OR = 3.15-CI95 = 1.55 to 6.44). Malnutrition at presentation did not influence death (p = 0.10), however progressive malnutrition was a marker for death (p = 0.02) (OR = 3.21-CI95 = 1.04 to 9.95). No significant differences weight percentiles (p = 0.15) or in z scores (p = 0.14) were observed. Observed mean weight percentiles (34.9+/-32.6 vs. 8.6+/-16.0) (p < 0.0001) and z scores (-0.62+/-1.43 vs. -2.02+/-1.12) (p < 0.0001) during the study period were greater among survivors. ANOVA demonstrated significant differences in weight percentile progression (p = 0.0417) and z scores (p = 0.0005) from the first month onwards., Conclusion: The evaluation of nutritional status is easy to perform, it does not imply additional costs and should become routine for children with chronic heart failure.

Objective: To determine if there is an association between carriage of oral yeasts and malnutrition in infants., Design: A case-control study within a cross-sectional study. The dependent variable was carriage of oral yeasts. The exposure variable was malnutrition and confounders to be adjusted for were age, sex, and breast-feeding., Setting: A maternal and child health clinic in Dar-es-Salaam, Tanzania that offers routine medical check-ups to all expectant mothers and children aged between 0 and 5 years in its catchment areas., Subjects and Methods: 972 infants aged 6-24 months participated. Smears from the tongue and cheek mucosa were examined for candidal hyphae and blastospores. Malnutrition was categorized according to Tanzanian standards (weight-for-age) and World Health Organization (WHO) standards (weight-for-height and height-for-age)., Main Outcome Measure: Carriage of oral yeasts (hyphae and blastospores)., Results: Carriage of oral yeasts was significantly higher in the 227 malnourished compared with the 745 well nourished adjusted for confounders. Odds ratio for presence of hyphae in smears from the severely malnourished (weight-for-age) was 4.5 (90% CI: 2.0-10.0). Odds ratio for presence of hyphae was 2.3 (90% CI: 1.1-4.8) when weight-for-height were used to categorize for malnutrition., Conclusion: The study tends to confirm the generally held view that malnutrition may predispose to carriage of oral yeasts and subsequent oral candidiasis.

Although malnourished children are stunted, their bone maturity is usually retarded to a comparable degree. This is seen in impoverished societies as well as in diseases such as coeliac disease, inflammatory bowel disease and hormonal deficiency. When these children are followed to adulthood they normally have some degree of spontaneous catch-up. With a change in environment, through adoption, emigration or with treatment of the disease there is usually definite catch-up growth, although it is often not to the NCHS standards. If puberty is delayed and/or growth continues into the early or mid twenties, then an acceptable final adult height is achieved. However, there may be a limitation imposed on an individual's maximum height by genetic imprinting in very early development. This may be the case where full catch-up appears to have taken place but is followed by an advanced puberty and early cessation of growth (Proos, Hofvander & Tuvemo, 1991a). The data from US slaves and cases of hormonal replacement, where treatment was initiated after age 18, each show that, if the circumstances of children in the Third World change, almost complete reversal of stunting is possible. The children can reach their own height potentials. Total reversal to affluent societal norms would probably require cross-generational catch-up. The most obvious reason why catch-up is not seen regularly is that an appropriate diet is not available over a sufficient period of time. We do not know the optimum ingredients for such a diet. Sulphur has been neglected as an essential nutrient; its economy should be examined in relation to skeletal growth in stunted populations.

The first section of this paper reviews what is known about the roles of specific nutrients in the general linear growth faltering that occurs in developing countries. Those reviewed are energy, protein, zinc, iron, copper, iodine and vitamin A. For none of these nutrients was there clear, consistent evidence that supplementation with the nutrient benefited linear growth. Rather, interventions with each specific nutrient had a positive effect on length gain in some studies, while in others these affected only weight gain or had no effect. Reasons for these conflicting results are suggested, including the strong probability that growth is limited by multiple, simultaneous deficiencies in many populations. This point is illustrated with data from the Nutrition Collaborative Research Support Program (CRSP) and other reports. Most interventions with single nutrients have been tested on children older than the age when linear growth faltering is most rapid, that is, within a few months of birth. Possible reasons why growth stunting begins so early in life are presented, but these are mostly hypothetical because of the paucity of information on this topic.

The etiology of the early onset of stunting is diverse among populations of varying biological, environmental and cultural circumstances. This is exemplified within the Nutrition CRSP project, which took place in three different populations and ecological conditions. Within each study area a different mix and varying proportions of causative factors were identified. At least in Kenya, and probably in Mexico, the problem has its antecedents in prepregnancy and pregnancy. Powerful determinants of the infants' size at birth and during the first 6 months of life are maternal size upon entry into pregnancy, and weight and fat gain during pregnancy and lactation. In all three countries a low pregnancy weight gain was observed. Notably in Kenya, where the energy intake of the mother decreases progressively throughout pregnancy, not only do mothers gain only half as much as European or North American women, but they even lose weight and fat in the last month of pregnancy, and some mothers gain no weight or lose weight during the whole of pregnancy. Mothers in Kenya start lactation with relatively poor fat stores. Although their energy intake increases somewhat during lactation, preliminary estimates suggest that these increases may be insufficient to maintain their bodily integrity, to carry out their normal tasks of daily living, and to produce a sufficient amount of milk for optimal infant growth. In addition to an energy deficit, diet quality is a problem, particularly in Kenya and Mexico and less so in Egypt. Intakes of animal products and animal protein are very low. Zinc and iron intakes are not only low, but the bioavailability of these nutrients is poor because of the high phytate, fiber and tea content of the diet. Also vitamin B12 intake is extremely low, and at least mild-to-moderate iodine deficiency (IDD) is present in Kenya. The above micronutrients have been demonstrated to affect the linear growth of the Kenyan children, even after confounding factors have been controlled. The early use of supplemental feeding in Kenya is a double-edged sword. On the one hand, there is a slight increase in febrile illness and possible displacement of breast milk intake in the supplemented infants, although mothers do not decrease breast feeding frequency and duration. On the other hand, even the modest amounts of available zinc and B12 in supplemental foods appear to have a positive effect on linear growth.(ABSTRACT TRUNCATED AT 400 WORDS)

The evidence on the relationship between dietary mineral supply and bone development in children has been extensively reviewed. Data from children and primates suggest that overt deficiencies of Ca, P and Zn are likely to produce rickets and growth retardation, while the effects of Mg deficiency on human bone are unknown. The manifestations of marginal deficiencies are little understood. The biological needs for Ca, P, Mg and Zn in childhood have been calculated based on mineral deposition rates, using published values for the mineral content of the human body, and on obligatory endogenous losses. As a rough guide, the estimated biological requirements for the Ca, P, Mg and Zn can be taken as 200, 100, 4 and 1 mg/d respectively. A comparison of measured daily intakes of children in developing countries with biological requirements was made. This revealed that P and Mg intakes were many times higher than estimated needs. Ca intakes at all ages were found to be close to the biological requirement for children in many Third World societies, before any allowance for possible poor absorption. Zn intakes approach estimated needs in breast-fed infants, particularly during weaning, but are 4-5 times higher in older children. Poor absorption from phytate-rich diets could affect Zn supply. Supplementation studies indicate that raising Zn intakes can increase height gains in certain vulnerable groups, such as infant and adolescent boys. In conclusion, the evidence suggests that inadequate dietary intakes of Ca and Zn may contribute to linear growth retardation in children of developing countries but more research is needed.

In order to study the relationship between diet and growth, we have assessed growth patterns in children 0-10 years old on macrobiotic diets. A cross-sectional anthropometric study (0-8 years old children, n = 243) indicated that deviation from the reference growth curve occurred during the weaning period. Between 2 and 4 years there was a partial catch-up for weight and arm circumference but not for height. As a next step, a mixed-longitudinal study was performed in 4-18-month-old macrobiotic infants (n = 53) and matched omnivorous controls (n = 57). For a period of 6 months, data on growth and dietary intake were collected. The data on linear growth supported the findings on growth stagnation observed cross-sectionally. Linear growth was associated with the protein content of the diet, but not with energy intake. On the basis of our findings nutritional modifications to the macrobiotic diet (addition of fat and fish) were recommended for all macrobiotic families. Six months later (two years after the first cross-sectional data collection) the anthropometric study was repeated in the same cohort (n = 194). This follow-up study revealed that children from families which, since the initial study, had increased the consumption of fatty fish, dairy products, or both, had grown in height more rapidly than the remaining children (P < 0.05). Since no indications were found for the presence of adverse social circumstances, infectious diseases or other confounding factors, our data clearly demonstrate that linear growth retardation in children on macrobiotic diets is caused by nutritional deficiencies alone.

Background: Although malnutrition is frequently associated with diarrhea, most oral rehydration solutions have been tested in well-nourished children. The study tests efficacy of rice, a traditional treatment for diarrhea in Madagascar., Patients and Methods: 150 severely malnourished children, aged 6 months to 3 years, took part in this randomized trial. All the children were given oral rehydration solution, (100 ml/kg) in the first 6 hours. The first group (68 children) was given a solution containing glucose, (20 g/l). The second group (82 children) was given a solution containing rice powder (50 g/l). Treatment was then continued according to WHO recommendations, including feeding after rehydration (mixture of milk, oil and sugar)., Results: The age, weight, height, duration of diarrhea before admission, degree of dehydration and pathogens in stools of the two groups were comparable on admission. Only 2 patients were withdrawn from the trial. The percentage of death was the same in both groups: 16% of those given glucose and 15% of those given rice-based rehydration solution. The weight gains were similar in both groups; the duration of diarrhea was 89 +/- 6 hours in the glucose-fed groups and 68 +/- 4 hours for those given the rice-based rehydration solution (p < 0.02)., Conclusions: Both glucose and rice-based rehydration solutions are equally effective for rehydrating severely malnourished children with acute diarrhea. The rice-based rehydration solution also reduces the duration of diarrhea.

Disordered growth of the bones by length was found in infants with chronic disorders of nutrition and perinatal encephalopathy. Roentgenogrammetry helped make a more objective assessment of bone changes as against visual methods. The authors distinguish the x-ray characteristics most typical of such patients.

Six malnourished children presenting with acute flaccid paralysis caused by hypokalaemia are described. Their ages ranged from 6 to 36 months. The extent of paralysis varied from neck flop to quadriparesis. Two cases had respiratory paralysis requiring ventilatory support for 48-72 hours. All were successfully treated with potassium supplementation. Hypokalaemia should be considered in the differential diagnosis of acute flaccid paralysis in malnourished children.

Urinary tract infection (UTI) is a well recognized complication in malnourished children. The need to investigate these patients for underlying renal pathology has not been clearly defined. Seventy-five children with malnutrition were evaluated for UTI by culture of urine obtained suprapubically prior to antibiotic therapy. All patients with UTI were investigated with renal ultrasonography, intravenous pyelography (IVP) and voiding cystourethrography (VCU). Haemoglobin, white cell count, serum urea, creatinine and electrolytes were determined in all the children. The mean age of the children was 15.5 months (range 3-60 months). UTI was diagnosed in 26 (34.7%), of whom 21 (81%) were boys. The overall prevalence of UTI in those with kwashiorkor/marasmic kwashiorkor was 42%. Escherichia coli was the organism most commonly cultured (84.6%). Renal sonography, IVP and VCU were normal in all infected cases and vesicoureteric reflux was not detected in any. This study confirms the high prevalence of UTI in malnourished children. As no anatomical abnormalities were demonstrated in the patients with UTI, imaging of the renal tract other than real sonography does not appear to be indicated in the malnourished child in a first episode of UTI with normal renal function.

Malnutrition and respiratory disease commonly occur together, and the immunologic defects caused by malnutrition may affect clinical responses and the impact of vaccines. These defects include impaired maturation and function of T lymphocytes, diminished secretory immune responses, poor humoral antibody responses to polysaccharide antigens, deficient complement activity (especially the alternative pathway), and impaired antimicrobial mechanisms by phagocytic cells. In addition, protein-energy malnutrition often leads to very high serum levels of IgE as a result of altered T cell regulation of IgE production and may contribute to IgE-mediated pathologic responses to respiratory syncytial virus or parainfluenza virus infection. Correction of these deficits may improve host response to infection and enhance vaccine-related protection. Both vitamin A and iron deficiency states have been epidemiologically associated with increased morbidity due to respiratory infection. The impact of preventive therapy with either vitamin A or iron is still uncertain, but such therapy has the potential for diminishing the incidence of respiratory infections and their consequences.