Why do some hospitals achieve better care of severely malnourished children than others? Five-year follow-up of rural hospitals in Eastern Cape, South Africa

Staff at 11 rural hospitals in an under-resourced region of Eastern Cape Province, South Africa, participated in an intervention to improve the quality of care of severely malnourished children through training and support aimed at implementing the WHO case-management guidelines. Despite similar intervention inputs, some hospitals reduced their case-fatality rates by at least half, whereas others did not. The aim of this study was to investigate reasons for this disparity. Two successful and two poorly performing hospitals were purposively selected based on their case-fatality rates, which were <10% in the successful hospitals and >30% in those performing poorly. Comparative data were collected during June to October 2004 through structured observations of ward procedures, compilation of hospital data on case-loads and resources, and staff interviews and discussions related to attitudes, teamwork, training, supervision, managerial support and leadership. The four study hospitals had broadly similar resources, infrastructure and child:nurse ratios, and all had made changes to their clinical and dietary management following training. Case-management was broadly in line with WHO guidelines but the study revealed clear differences in institutional culture which influenced quality of care. Staff in the successful hospitals were more attentive and assiduous than staff in the poorly performing hospitals, especially in relation to rehydration procedures, feeding and the recording of vital signs. There was a strong emphasis on in-service training and induction of incoming staff in the successful hospitals and better supervision of junior staff and carers. Nurses had more positive attitudes towards malnourished children and their carers, and were less judgmental. Underlying factors were differences in leadership, teamwork, and managerial supervision and support. We conclude that unless there are supportive structures at managerial level, the potential benefits of efficacious interventions and related training programmes to improve health worker performance can be thwarted.     

Critical Role of Nutrition in Improving Quality of Care

The current era of healthcare delivery, with its focus on providing high‐quality, affordable care, presents many challenges to hospital‐based health professionals. The prevention and treatment of hospital malnutrition offer a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute posthospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following 6 principles: (1) create an institutional culture where all stakeholders value nutrition, (2) redefine clinicians’ roles to include nutrition care, (3) recognize and diagnose all malnourished patients and those at risk, (4) rapidly implement comprehensive nutrition interventions and continued monitoring, (5) communicate nutrition care plans, and (6) develop a comprehensive discharge nutrition care and education plan.     

Critical Role of Nutrition in Improving Quality of Care: An Interdisciplinary Call to Action to Address Adult Hospital Malnutrition

The current era of health care delivery, with its focus on providing high-quality, affordable care, presents many challenges to hospital-based health professionals. The prevention and treatment of hospital malnutrition offers a tremendous opportunity to optimize the overall quality of patient care, improve clinical outcomes, and reduce costs. Unfortunately, malnutrition continues to go unrecognized and untreated in many hospitalized patients. This article represents a call to action from the interdisciplinary Alliance to Advance Patient Nutrition to highlight the critical role of nutrition intervention in clinical care and to suggest practical ways to promptly diagnose and treat malnourished patients and those at risk for malnutrition. We underscore the importance of an interdisciplinary approach to addressing malnutrition both in the hospital and in the acute post-hospital phase. It is well recognized that malnutrition is associated with adverse clinical outcomes. Although data vary across studies, available evidence shows that early nutrition intervention can reduce complication rates, length of hospital stay, readmission rates, mortality, and cost of care. The key is to systematically identify patients who are malnourished or at risk and to promptly intervene. We present a novel care model to drive improvement, emphasizing the following six principles: (1) create an institutional culture where all stakeholders value nutrition; (2) redefine clinicians' roles to include nutrition care; (3) recognize and diagnose all malnourished patients and those at risk; (4) rapidly implement comprehensive nutrition interventions and continued monitoring; (5) communicate nutrition care plans; and (6) develop a comprehensive discharge nutrition care and education plan.     

Management of severe acute malnutrition in an urban nutritional rehabilitation center in Burkina Faso

BACKGROUND: Management of acute severe malnutrition greatly contributes to the reduction of childhood mortality rate. In developing countries, where malnutrition is common, number of acute severe malnutrition cases exceeds inpatient treatment capacity. Recent success of community-based therapeutic care put back on agenda the management of acute severe malnutrition. We analysed key issues of inpatient management of severe malnutrition to suggest appropriate global approach. METHODS: Data of 1322 malnourished children, admitted in an urban nutritional rehabilitation center, in Burkina Faso, from 1999 to 2003 were analyzed. The nutritional status was assessed using anthropometrics indexes. Association between mortality and variables was measured by relative risks. Kaplan-Meier survival curves and Cox model were used. RESULTS: From the 1322 hospitalized children, 8.5% dropped out. Daily weight gain was 10.18 (+/-7.05) g/kg/d. Among hospitalized malnourished children, 16% died. Patients were at high risk of early death, as 80% of deaths occurred during the first week. The risk of dying was highest among the severely malnourished: weight-for-height<-4 standard deviation (SD), RR=2.55 P<0,001; low MUAC-for-age, RR=2.05 P<0.001. Kaplan-Meier survival curves and Cox model showed that the variables most strongly associated with mortality were weight-for-height and MUAC-for-age. Among children discharged from the nutritional rehabilitation centre, 10.9% had weight-for-height<-3 SD. CONCLUSION: The nutrition rehabilitation centre is confronted with extremely ill children with high risk of death. There is need to support those units for appropriate management of acute severe malnutrition. It is also important to implement community-based therapeutic care for management of children still malnourished at discharge from nutritional rehabilitation centre. These programs will contribute to reduce mortality rate and number of severely malnourished children attending inpatient nutrition rehabilitation centers, by prevention and early management.     

Infections associated with severe malnutrition among hospitalised children in East Africa

Severe protein-energy malnutrition (PEM) predisposes affected children to various infections, which either worsens their nutritional status or causes malnutrition, hence complicating their management and outcome. This study was carried out to determine the infections associated with severe malnutrition among children admitted at Kilifi District Hospital (KDH) in Kenya and Muhimbili National Hospital (MNH) in Dar es Salaam, Tanzania. Data was collected from hospital register books and online system database. A total of 1121 children with severe malnutrition were admitted during a period of one year (2004-2005) (MNH = 781; KDH = 340). The proportion of male children with malnutrition was higher than that of female children. Non-oedematous malnutrition was more prevalent at MNH (N = 504; 64%) than KDH (N = 130; 38%). Conversely, oedematous was more prevalence than non-oedematous malnutrition among children admitted at KDH (N = 2 10; 61.7%). More than 75% of all patients with severe PEM were children < 2 years old. Thirty-six per cent of all severe PEM cases had malaria in both hospitals. Forty-five per cent of all admitted patients with severe PEM at KDH had diarrhoea. Two hundred twenty two (28%) and 64 (19%) of the children with severe malnutrition died at MNH and KDH, respectively. Oedematous PEM was associated with a higher case fatality rate than non-oedematous one (P < 0.05). At MNH, 86% of the patients who died with severe malnutrition had other co-morbidities. More (46%) oedematous malnourished patients with co-infections died at MNH than non-oedematous malnourished patients (19%). At KDH, septicaemia was the leading cause of death (55%) among severely malnourished patients. In conclusion, coinfections complicate the management of severe malnutrition and are associated with higher death rate. Management of such infections is of paramount importance to reduce case fatality rates.     

Plan régional d’amélioration de la qualité : démarche de soin diététique au sein des établissements de santé du Réseau des comités de liaison alimentation nutrition Champagne-Ardenne

Difficulties in the management of malnutrition in hospitals are multi causal. Although responsibilities are shared, dieticians are nonetheless very concerned by this situation. In some French area, i.e. Champagne-Ardenne, dietitians are organized within networks of committees responsible for the liaison between health staffs in charge of patient nutrition. This organization is engaged in a plan to improve the quality of care approach for malnourished patients. Through a process of evaluation of professional practice, an improvement plan and a new evaluation phase for four months, this committee prove that, despite an unsatisfactory initial inventory, an improvement plan lead them to take new requirements into consideration and to improve the nutritional management of malnourished patients.     

Outcome of severely malnourished children treated according to UNICEF 2004 guidelines: a one-year experience in a zone hospital in rural Ethiopia

Malnutrition still has a dramatic impact on childhood mortality in sub-Saharan African countries. Very few studies have tried to evaluate the outcome of severely malnourished children treated according to the UNICEF 2004 guidelines and reported fatality rates are still very high. During 2006, 1635 children were admitted to the paediatric ward of St. Luke Catholic Hospital in Wolisso, South West Shewa, Ethiopia. Four hundred and ninety-three (30.15%) were severely malnourished and were enrolled in the study. We reviewed the registration books and inpatient charts to analyze their outcome. A mortality rate of 7.1% was found, which is significantly lower than reported in the literature. 28.6% of deaths occurred within 48h of admission; the recovery rate was 88.4%; the drop-out rate was 4.5%. Early deaths were due to the poor condition of the children on admission, leading to failure of treatment. Late mortality was considered to be related to electrolyte imbalances, which we were unable to measure. The clinical skills of nursing and medical staff were considered an important factor in improving the outcome of malnourished patients. We found that proper implementation of WHO guidelines for the hospital treatment of severely malnourished children can lead to a relatively low mortality rate, especially when good clinical monitoring is assured.     

Challenges to improving case management of childhood pneumonia at health facilities in resource-limited settings

Effective case management is an important strategy to reduce pneumonia-related morbidity and mortality in children. Guidelines based on sound evidence are available but are used variably. This review outlines current guidelines for childhood pneumonia management in the setting where most child pneumonia deaths occur and identifies challenges for improved management in a variety of settings and different "at-risk" groups. These include appropriate choice of antibiotic, clinical overlap with other conditions, prompt and appropriate referral for inpatient care, and management of treatment failure. Management of neonates, and of HIV-infected or severely malnourished children is more complicated. The influence of co-morbidities on pneumonia outcome means that pneumonia case management must be integrated within strategies to improve overall paediatric care. The greatest potential for reducing pneumonia-related deaths in health facilities is wider implementation of the current guidelines built around a few core activities: training, antibiotics and oxygen. This requires investment in human resources and in equipment for the optimal management of hypoxaemia. It is important to provide data from a variety of epidemiological settings for formal cost-effectiveness analyses. Improvements in the quality of case management of pneumonia can be a vehicle for overall improvements in child health-care practices.     

A Position Paper on How Cost and Quality Reforms Are Changing Healthcare in America

Healthcare spending in the United States is the highest in the world, yet quality indicators such as life expectancy and infant mortality lag other countries. U.S. reforms are under way to lower costs and raise quality of care, notably the Patient Protection and Affordable Care Act (PPACA). Value‐based purchasing (VBP) and programs for reducing the incidence of hospital‐acquired conditions (HACs) and hospital readmissions represent initial changes. With these programs, overarching themes are to coordinate care during and beyond hospitalization and to ensure that physicians and hospitals are aligned in their treatment strategies. Hospital malnutrition represents a large, hidden, and costly component of medical care; hospital administrators and caregivers alike must harness the benefits of nutrition as a vital component of healthcare. Medical, nursing, and allied health training programs must find places in their curricula to increase awareness of nutrition and promote knowledge of best‐practice nutrition interventions. Hospitals use dietitians and nutrition support teams as critical members of the patient care team, but more work needs to be done to disseminate and enforce best nutrition practices. Such training, nutrition interventions, and practice changes can help prevent and treat malnutrition and thus help avert HACs, reduce hospital readmissions, lower infection and complication rates, and shorten hospital stays. Nutrition care is an effective way to reduce costs and improve patient outcomes. This article calls hospital executives and bedside clinicians to action: recognize the value of nutrition care before, during, and after hospitalization, as well as develop training programs and policies that promote nutrition care.     

Everyone's problem but nobody's job: Staff perceptions and explanations for poor nutritional intake in older medical patients

Aim: Up to 60% of older medical patients are malnourished with further decline during hospital stay. There is limited evidence for effective nutrition intervention. Staff focus groups were conducted to improve understanding of potential contextual and cultural barriers to feeding older adults in hospital. Methods: Three focus groups involved 22 staff working on the acute medical wards of a large tertiary teaching hospital. Staff disciplines were nursing, dietetics, speech pathology, occupational therapy, physiotherapy, pharmacy. A semistructured topic guide was used by the same facilitator to prompt discussions on hospital nutrition care including barriers. Focus groups were tape‐recorded, transcribed and analysed thematically. Results: All staff recognised malnutrition to be an important problem in older patients during hospital stay and identified patient‐level barriers to nutrition care such as non‐compliance to feeding plans and hospital‐level barriers including nursing staff shortages. Differences between disciplines revealed a lack of a coordinated approach, including poor knowledge of nutrition care processes, poor interdisciplinary communication, and a lack of a sense of shared responsibility/coordinated approach to nutrition care. All staff talked about competing activities at meal times and felt disempowered to prioritise nutrition in the acute medical setting. Staff agreed education and ‘extra hands’ would address most barriers but did not consider organisational change. Conclusions: Redesigning the model of care to reprioritise meal‐time activities and redefine multidisciplinary roles and responsibilities would support coordinated nutrition care. However, effectiveness may also depend on hospital‐wide leadership and support to empower staff and increase accountability within a team‐led approach.     

Severe malnutrition in children: high case-fatality rates can be reduced

This article offers a protocol for reducing high case fatality rates from malnutrition. Most child deaths from malnutrition occur in the first few days of treatment. Treatment should involve stabilization followed by rehabilitation. The article describes the treatment procedures for hypoglycemia, hypothermia, dehydration, and missed infections and discusses feeding during the stabilization and rehabilitation phases of treatment. All severely malnourished children have excess body sodium but high intracellular and low plasma levels. Malnourished children have deficiencies of potassium and magnesium that may take 2 weeks to correct. Edema is partly due to deficiencies in potassium and magnesium. A high sodium intake can be corrected by rehydrating with a modified oral rehydration solution and the special starter formula. Family food should be prepared without salt. Magnesium and potassium should be added directly to foods. All severely malnourished children have vitamin and mineral deficiencies. Deficiencies may include vitamin A, zinc, copper, selenium, and folic acid. Multivitamin supplements can correct for micronutrient deficiencies. It is advised that zinc should not be ignored, since it is responsible for repair of intestinal mucosa, halting diarrhea, healing of ulcerated skin lesions, restoration of appetite, improved immune function, and lean tissue synthesis. Iron should not be given until growth starts, infections are controlled, and antioxidant status is improved (usually 1 week after admission). Early introduction of iron poses a risk of enhancing pathogen increases and stimulating production of toxic free radicals. Relapses can be reduced by training parents how to feed their child frequently with energy and nutrient dense foods. The regimen was tested in a South African project and found to reduce mortality from 30% to 20%. After greater hospital attention to treatment of sepsis and hypoglycemia, case fatality declined to 6%.     

Application of severity measurement systems for hospital quality measurement

As hospitals increasingly emphasize efforts to measure and improve quality of care, the related issue of severity measurement emerges as a topic of strong interest. Severity measures can support hospital quality management in at least two areas: selection of medical records for individual case review and monitoring of patterns of care including analysis of rates of adverse outcomes. Some systems currently available for measuring the severity of general medical and surgical admissions in acute care hospitals base severity scores on data available in computerized discharge abstracts, while others use detailed clinical data abstracted directly from patient medical records. One is based on both detailed medical record data and International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnosis codes. This article discusses issues important to the definition and measurement of patient severity and examines the strengths and limitations of specific systems and their potential contributions to quality management.     

CINI's Approaches to Intervention: An Innovative Strategy to Combat Malnutrition in India

The Child in Need Institute (CINI) has been working toward sustainable health and nutrition development for women and children for the last twenty-six years. During the initial stages, the Institute focused on treatment and prevention of malnutrition in children under five years of age. Over the years, the program strategies have shifted to a more holistic lifecycle approach. This approach targets individuals during crucial periods of their lives—pregnant women, children (0–2 years of age) and adolescents (10 –19 years of age)—as well as other vulnerable segments of the population. To reach out to these target groups, the Institute uses a three-pronged strategy that includes case management, behavior change communication, and linkage formation. Programs are either community- or center-based depending upon the need of the populations. CINI's current strategy has shown positive trends in improving the health and nutrition status of women, children, and adolescents in the community. Results include reduction of low birth weight babies, increase in proper antenatal care, reduction of severely malnourished children, decrease in maternal and infant mortality and morbidity rates, and improvement in community involvement in all reproductive and child health programs. CINI is currently monitoring its performance and activities to carry out operations research for providing further evidence for the effectiveness of its interventions.     

Creating a clinical nutrition registry: prospects, problems, and preliminary results

There is a tremendous gap in the information available to support the practice of hospital-based dietitians and to address the issue of how the risk of developing protein-energy malnutrition can be avoided in the majority of patients. This article describes the rationale and benefits of creating a nutrition registry of within-hospital clinical nutrition care. A nutrition registry is made up of observational data, collected on an ongoing basis, of nutritional interventions provided to hospitalized patients. It is the first step in data gathering to demonstrate the effectiveness of clinical nutrition interventions. The methods and preliminary results of a nutrition registry that was established at The University of Illinois Medical Center, Chicago, III, are presented. Using subjective global assessment, 55% (257 of 467) of patients at admission and 60% (280 of 467) of patients at discharge were moderately or severely malnourished. Patients that were normal nourished at admission and became moderately or severely malnourished had higher hospital charges ($40,329 for moderately malnourished patients, $76,598 for severely malnourished patients) than those that remained normal nourished ($28,368). This pattern held independent of admission nutritional status. Major challenges in implementation of a registry into the responsibilities of the staff dietitian are reviewed. The conclusion of this study is that nutrition registries can be established and will provide the much needed baseline data to document the impact of nutrition interventions on outcomes of medical care.     

Hospital volume, calendar age, and short term outcomes in patients undergoing repair of abdominal aortic aneurysms: the Ontario experience, 1988-92.

OBJECTIVE: To determine, for abdominal aortic aneurysm surgery, whether a previously reported relationship between hospital case volume and mortality rate was observed in Ontario hospitals and to assess the potential impact of age on the mortality rate for elective surgery. DESIGN: Population based observational study using administrative data. SETTING: All Ontario hospitals where repair of abdominal aortic aneurysm as a primary procedure was performed during 1988-92. PATIENTS: These comprised 5492 patients with unruptured abdominal aortic aneurysms and 1203 patients with ruptured abdominal aortic aneurysms admitted to hospital between 1988-92 for repair of abdominal aortic aneurysm as a primary procedure. MAIN OUTCOMES: In-hospital death and length of in-hospital stay. RESULTS: The case fatality rate was 3.8% for unruptured abdominal aortic aneurysms and 40.0% for ruptured abdominal aortic aneurysms. For unruptured cases, after adjustment for patient and hospital covariates, each 10 case per year increase in hospital volume was related to a 6% reduction in relative odds of death (odds ratio (OR) 0.94, 95% confidence intervals 0.88, 0.99) and 0.29 days reduction (95% CI -0.22, -0.35) in postoperative in-hospital stay. Female sex (OR 1.53, 95% CI 1.08, 2.18) and transfer from another acute care hospital (OR 4.37, 95% CI 2.62, 7.29) were associated with increased case fatality rates among patients in the unruptured category. For ruptured cases, neither the case fatality rate nor postoperative in-hospital stay were significantly related to hospital volume. The case fatality rates increased linearly and substantially with advancing age both for unruptured and ruptured aneurysms, and the excess risk of postoperative death in ruptured as compared to unruptured aneurysms was substantially higher in older patients. CONCLUSION: The relationship between hospital volume and mortality or morbidity was very modest and observed only for elective surgery. Case fatality rates in patients with ruptured abdominal aortic aneurysms remained 10 times higher than for patients with unruptured abdominal aortic aneurysms, despite improvements in overall mortality in comparison to previously published data. More effective detection of aneurysms, including elective repair for those once considered "high risk" older patients, might further reduce the toll from ruptured aortic aneurysms.     

Malnutrition and Clinical Outcomes: The Case for Medical Nutrition Therapy

Malnutrition is not a new or a rare problem. In studies involving more than 1,327 hospitalized adult patients, 40% to 55% were found to be either malnourished or at risk for malnutrition, and up to 12% were severely malnourished. Surgical patients with likelihood of malnutrition are two to three times more likely to have minor and major complications as well as increased mortality; and their length of stay can be extended by 90% compared with the stay of well-nourished patients. Hospital charges are reported to be from 35% to 75% higher for malnourished patients than for well-nourished patients. Obtaining data to assess the nutritional status of patients is essential to optimal patient care, especially for patients at high risk for malnutrition. Nutrition assessment can be done with readily available and relatively inexpensive methods. But it is not enough to assess and identify malnutrition. Outcomes are improved and costs are saved only when appropriate intervention follows. This article identifies many well-conducted, published studies that support the findings that health outcomes of malnourished patients can be improved and that overall use of resources can be reduced by nutrition counseling, oral diet and oral supplements, enteral formula delivered via tube, and parenteral nutrition support via central or peripheral line. Early nutrition assessment and appropriate nutrition intervention must be accepted as essential for the delivery of quality health care. Appropriately selected nutrition support can address the problem of malnutrition, improve clinical outcomes, and help reduce the costs of health care. J Am Diet Assoc. 1996; 96:361-366,369.     

The impact of computerization of the nutrition support process on the nutrition support program in a tertiary care hospital in the Philippines: report for the years 2000-2003

BACKGROUND & AIMS: To improve hospital health care delivery by identifying malnutrition in all admitted patients and following up those identified to be malnourished and "at risk of developing malnutrition" a hospital nutrition support program based on the JCAHO system was initiated in 1999. Two major problems were encountered: first, the inability to perform a nutrition surveillance process due to failure by the staff to implement existing nutrition screening tools and second, the lack of awareness and support from the medical staff in this initiative. Two solutions were implemented in 2000: computerization of the nutrition screening and nutrition support process and synchronizing this with the whole nutrition support program. METHODS: A computer program was developed which performs BMI-based nutrition screening, produces lists of all malnourished patients, and computes the different formulas for either nutritional requirement or parenteral and/or enteral formulation. It also generates patient status reports based on encoded data from the nutrition support team, which prioritized these patients for management based on the data output. RESULTS: From 2000 to 2003, improvement was seen in these areas: entry of height and weight in the patient record increased from 30% to 90%; nutrition surveillance shows nutritional status distribution to be: normal (58%), underweight (9%), overweight (25%), and obese (8%), referrals to the nutrition support team based on the screen notification increased from 37% to 100%, patient coverage by nutrition support services increased from 7374 (38.8%) in 2000 to 11,369 (83%) in 2003, and critical care patients seen increased from 10% in 2000 to 99% in 2003. More improvement is needed in physician response to nutrition support recommendations, which still remains low (11.2-24%). CONCLUSIONS: Computerization helps to improve nutrition support delivery in the hospital, but more cooperation and support from the medical staff is still needed for better results.     

Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.     

Colonization of the oropharynx with Gram-negative bacilli in children with severe protein-calorie malnutrition

Oral pharyngeal isolation of Gram-negative bacteria was compared in four groups of Bengali children; acutely ill, severely malnourished outpatients swabbed on hospital admission; ill but less severely malnourished outpatients from the same area as the malnourished children; orphans also less severely malnourished but not acutely ill; and well controls drawn from a priviledged socioeconomic group. The expected weight for height percentage (National Center Health Statistics/Center for Disease Control median) of the four groups was respectively 67, 91, 97, and 97%. Isolation of Gram-negative bacteria from 74 of 87 (85%) severely malnourished children was significantly greater (p less than 0.01) compared to 43 of 113 (38%) outpatients, to 20 of 93 (22%) orphans, and to five of 51 (10%) controls. A total of 71 malnourished children under 5 yr of age (90%) had higher rates of Gram-negative throat colonization than did 16 older children (63%) (p less than 0.01). Thus there was an increased rate of Gram-negative colonization in severely malnourished children especially among the younger age group. In the subset of ill children, Gram-negative pharyngeal colonization was significantly associated inversely with nutritional indices and age. The high rate of such carriage may be partly responsible for the increased susceptibility of Gram-negative infection demonstrated in these children.