Effects of early malnutrition and nutritional rehabilitation in rats

OBJECTIVE: To verify the effects of malnutrition and nutritional rehabilitation regarding seizure threshold, body weight and brain weight in rats. METHODS: Pregnant Wistar rats and their pups were used. Part of the rat pups were submitted to a malnutrition protocol and the rest served as nourished controls. At P15, malnourished and control rats were submitted to status epilepticus induced by flurothyl; and the rehabilitation period started after recovery from seizures. At P30, all rats were submitted to single flurothyl-induced seizures and the threshold was determined. After the seizures, the rats were sacrificed, the brain removed and weighed. Rat pups were weighed daily from age P2 to P30. RESULTS: Significant differences as to body weight between malnourished and nourished rats were observed from P5 onwards. At P30, even after nutritional rehabilitation, there were still differences in terms of body weight. Nourished (mean 1.47 g -/+ 0.17) and male (mean 1.47 g -/+ 0.16) rats had brain weight slightly higher than that presented by malnourished (mean 1.42 g -/+ 0.17) and female (mean 1.38 g -/+ 0.12) rats; however, the difference was not significant. Differences observed in the threshold for the first clonic and tonic seizure at ages P15 and P30 between the groups were not statistically significant. CONCLUSIONS: Our results suggest that malnutrition does not influence seizure threshold in rat pups submitted to flurothyl-induced seizures. Early nutritional rehabilitation seems to have a protective effect on seizure threshold in previously malnourished animals.     

Quality of care in nutritional rehabilitation in HIV-endemic Malawi: caregiver perspectives

In Malawi, HIV and malnutrition are two of the most common causes of childhood morbidity and mortality. This qualitative study based in Nutrition Rehabilitation Units (NRU) in HIV‐endemic Malawi explores caregiver's (staff and family) perspectives on quality of care for severely malnourished children. Three carer focus groups and 30 carer and staff in‐depth interviews were conducted in two NRUs. The interviews and data analysis used a grounded theory approach, using both male and female Malawian researchers. Trustworthiness was enhanced through the researchers' prolonged engagement with the study setting and participants. The use of multiple methods – interviews, focus groups and observation – allowed for triangulation of the data. Data was then cross‐referenced between staff and family caregiver reports. The analysis generated five themes. ‘We have different blood’ referring to staff attitudes and underperformance, ‘What wrong did I do to God?’ referring to stigma and chronic illness, ‘My other children back home’ referring to the carer's multiple responsibilities and challenges, ‘Always in short supply’ referring to resources available in the NRU (milk, medicine, space, hygiene) and ‘you are always lagging behind’ referring to the need for change and participants recommendations. Quality of care is a complex issue, bound by resources and capacity, influenced by stigma and hierarchy and limited by caregivers' conflicting responsibilities. Valuing and involving caregivers is essential in improving quality of care. Care should be patient and family centred and HIV services should be integrated into malnutrition care at the hospital and community level.     

Insulin-like growth factor I response during nutritional rehabilitation of persistent diarrhoea

OBJECTIVE—Evaluation of nutritional recovery, intestinal permeability, and insulin-like growth factor I (IGF-I) response in malnourished children with persistent diarrhoea and their relation to concomitant systemic infection(s).STUDY DESIGN—Open study of severely malnourished children (aged 6-36 months) with persistent diarrhoea (? 14 days) admitted for nutritional rehabilitation with a standardised rice-lentil and yogurt diet. Successful recovery was defined prospectively as overall weight gain (> 5 g/kg/day) with a reduction in stool output by day 7of treatment. Data on coexisting infections and serum C reactive protein (CRP) were collected at admission.RESULTS—Of 63 children, 48 (group A) recovered within seven days of dietary treatment. These children had a significant increase in serum IGF-I (ΔIGF-I%) and, in contrast to serum prealbumin and retinol binding protein, ΔIGF-I% correlated with weight gain (r = 0.41). There was no correlation between the IGF-I response and intestinal permeability as assessed by urinary lactulose/rhamnose excretion. Treatment failures (group B) included more children with clinical (relative risk, 4.8; 95% confidence interval, 1.2to 19.7) and culture proven sepsis at admission and higher concentrations of serum CRP (median (range), 36 (0?182) v 10 (0?240) mg/l) at admission. There was a negative correlation between admission CRP concentration and ΔIGF-I% (r = ?0.45).CONCLUSIONS—In comparison with serum albumin, prealbumin, and retinol binding protein, serum IGF-I increment is a better marker of nutritional recovery in malnourished children with persistent diarrhoea. The possible association of systemic infections, serum IGF-I response, and mucosal recovery needs evaluation in future studies.     

Priorities in child health

A noted pediatrician in New Delhi, India, urges fellow pediatricians to promote the health and safeguard the interests of children. He advocates the establishment of comprehensive genetic units in the pediatric departments in teaching hospitals in India to reap the benefits of the genetic revolution. Specifically, advances in molecular genetics have led to advanced diagnostic and therapeutic concepts and uses (e.g., DNA probes to identify various pathogenic antigens and gene therapy). India needs to develop its infrastructure and facilities to acquire technology for diagnosis, monitoring, and providing life support to children with life-threatening conditions. For example, all teaching hospitals in India must set up neonatal and pediatric intensive care units as soon as possible. Since the government and hospital administrators fund expensive technology for coronary care units, postoperative intensive care units, and cancer hospitals, they can also afford to provide neonatal and pediatric intensive care units. Hospital pediatric departments must create extensive child development centers to monitor child development in order to diagnose and treat early neuromotor disability. Pediatricians should develop the art of child care which includes skills in listening, soothing, gaining confidence, explaining, and consoling as well as effective health education. During each visit, they should educate the family about health and nutrition. The lack of political will is the major reason India cannot meet its maternal and child health (MCH) targets. For example, the government allocates less than 2% of the gross national product to health and family welfare programs. The government and physicians pay more attention to expanding cancer and coronary care hospitals than to promoting MCH. Pediatricians should work together to do just that, but improved child health status cannot occur without addressing discrimination against female children.     

Insulin-like growth factor I response during nutritional rehabilitation of persistent diarrhoea.

OBJECTIVE: Evaluation of nutritional recovery, intestinal permeability, and insulin-like growth factor I (IGF-I) response in malnourished children with persistent diarrhoea and their relation to concomitant systemic infection(s). STUDY DESIGN: Open study of severely malnourished children (aged 6-36 months) with persistent diarrhoea (>/= 14 days) admitted for nutritional rehabilitation with a standardised rice-lentil and yogurt diet. Successful recovery was defined prospectively as overall weight gain (> 5 g/kg/day) with a reduction in stool output by day 7 of treatment. Data on coexisting infections and serum C reactive protein (CRP) were collected at admission. RESULTS: Of 63 children, 48 (group A) recovered within seven days of dietary treatment. These children had a significant increase in serum IGF-I (DeltaIGF-I%) and, in contrast to serum prealbumin and retinol binding protein, DeltaIGF-I% correlated with weight gain (r = 0.41). There was no correlation between the IGF-I response and intestinal permeability as assessed by urinary lactulose/rhamnose excretion. Treatment failures (group B) included more children with clinical (relative risk, 4.8; 95% confidence interval, 1.2 to 19.7) and culture proven sepsis at admission and higher concentrations of serum CRP (median (range), 36 (0-182) v 10 (0-240) mg/l) at admission. There was a negative correlation between admission CRP concentration and DeltaIGF-I% (r = -0.45). CONCLUSIONS: In comparison with serum albumin, prealbumin, and retinol binding protein, serum IGF-I increment is a better marker of nutritional recovery in malnourished children with persistent diarrhoea. The possible association of systemic infections, serum IGF-I response, and mucosal recovery needs evaluation in future studies.     

Priorities in tuberculosis research in India

India accounts for nearly 30% of all tuberculosis cases in the world today and more adults in India die from TB than from any other infectious disease. The problems of HIV and multidrug resistance will make tuberculosis epidemic in India much worse unless urgent action is taken. DOTS is being applied on individual basis in the country. Maintaining the momentum in order to achieve national coverage in a phased manner, while maintaining the quality of services will require constructive commitment from all sectors, both within and outside government. This much be accompanied by additional research inputs and critical data analysis. Operational research provides programme managers the data and tools they need to analyse continuously improve services they offer, hence this must be strengthened with an overall aim to improve diagnosis and treatment of TB patients by translating the results of research into policy and practice. At the same time one should aim to strengthening biomedical research which promises convenient diagnostic tests, new and cost effective drugs and safe an effective vaccines, shortening of treatment, improved treatment of latest infection and overcoming threat of MDR-TB. The challenge is how to achieve this formidable goal as well as gear up to efficiently handle the growing burden of HIV-TB infected patients. The key to success lies in making available to all what we already have, by strengthening operational aspects of programme and at the same time not focus on the research efforts being done in basic science. The solution lies in the link between basic science and public health.     

Priorities and practice in tropical paediatrics

More than 14 million children under 5 years of age die annually in the Third World, mainly due to diarrhoea, pneumonia, malaria and immunizable diseases. The problems of poverty, malnutrition, poor sanitation, illiteracy and high fertility that traditionally are associated with underdevelopment are now being compounded by social disruption due to rapid changes in lifestyle, new diseases such as AIDS and Third World debt. A vital part of the solution is provision of basic medical and education services to all, with emphasis on female literacy and improving the status of women. Key elements in providing basic medical services are delegation and empowerment. Doctors must delegate the delivery of essential child health services to appropriately trained and adequately supported auxiliaries. Parents, especially mothers, need to be empowered with the knowledge and resources to recognize and manage, or assist in the management of, their children's health problems.     

Effects of nutritional rehabilitation on intestinal function and on CD4 cell number in children with HIV

BACKGROUND: A complex interplay of malnutrition, intestinal dysfunction, and immune impairment increases the progression of human immunodeficiency virus (HIV) disease in children. The authors tested the hypothesis that nutritional support improves intestinal and immune functions in children infected with human immunodeficiency virus (HIV). METHODS: A questionnaire was circulated through reference centers for pediatric HIV infection to evaluate the effects of nutritional rehabilitation, total parenteral nutrition (TPN) and enteral nutrition (EN), in children. Information included changes in body weight, CD4 cell numbers, and intestinal absorption-as judged by the xylose load-before and after clinical nutritional support and the outcome of children. RESULTS: Sixty-two children underwent nutritional support: 46 received TPN and 16 received EN. All but three had full-blown acquired immunodeficiency syndrome, and all were severely malnourished. Baseline clinical conditions were worse in children receiving TPN than in those receiving EN. Intestinal dysfunction was detected in all children who received xylose oral load. A significant increase in CD4 cell count, xylose levels, and body weight followed EN. A similar pattern was observed after TPN, but none of the parameters significantly changed. Twenty-seven children who received TPN and three who received EN eventually died. Fourteen who received TPN and eight who received EN were shifted to oral feeding, and five who received TPN and five who received EN continued with clinical nutritional support at the end of the observation period. CONCLUSIONS: Nutritional intervention may restore intestinal absorption and increase CD4 cell numbers. The efficacy of nutritional intervention is enhanced if provided before a terminal stage of HIV infection. These data provide evidence of a close association among nutritional condition, intestinal absorption, and immune impairment.     

The effect of nutritional rehabilitation on whole body protein metabolism of children with cystic fibrosis

The effect of an increased energy and protein intake was studied on the whole body protein metabolism of 4- to 9-yr-old children with cystic fibrosis. The study was divided into an initial 1-yr period, followed by a treatment period of the same length. Rates of protein turnover were determined using a [15N]glycine label and the Picou and Taylor-Roberts model. The children had significantly higher intakes during the treatment year and grew faster. Nitrogen retention and utilization were significantly increased during the treatment year (p less than 0.01). There were no changes seen in whole body amino nitrogen flux, or protein synthesis rates. However, protein breakdown rates were significantly reduced during the treatment period, with the result that net anabolism (synthesis-breakdown) was increased (p less than 0.05). The protein synthesis rates of about 6 g/kg/day were similar to those reported for healthy children of the same age. It was concluded that the changes in protein turnover seen were in response to the nutritional intervention and not to the children's basic genetic disease process.     

Long term nutritional rehabilitation by gastrostomy in Israeli patients with cystic fibrosis: clinical outcome in advanced pulmonary disease

OBJECTIVES: Several studies have shown a linear correlation between nutritional status and pulmonary function in patients with cystic fibrosis. Our study aims were: 1) To evaluate the effect of nutritional supplementation via gastrostomy on nutritional, clinical, and pulmonary parameters, and 2) To identify predicting factors for success of long-term nutritional rehabilitation. METHODS: Twenty-one Israeli patients, aged 8 months to 20 years, underwent gastrostomy insertion from 1992 to 2001. All patients were pancreatic insufficient, and all carried severe mutations (W1282X in 62% of the patients). Anthropometric and clinical data were obtained for each patient: 0-12 months before and 6-12 months and 18-24 months after gastrostomy placement. Standard deviation scores (SDS) for height, weight, and body mass index as well as percent of height-appropriate body weight were calculated. RESULTS: The mean percent-of-predicted forced expiratory volume in 1 second (FEV1) decreased significantly during the first year of gastrostomy feeding (n = 16), from 44.2% +/- 13.9 to 41% +/- 13.3 (P = 0.05). However, during the second year of therapy (n = 10), a trend toward improvement was observed (from 39.4 +/- 12.1 to 41.4 +/- 16.1). Weight, and BMI z-scores as well as weight percent-of ideal body weight increased significantly. Height z-score for age decreased during the first year (from -1.9 +/- 1.3 to -2.1 +/- 1.4), However, a trend toward improvement was observed during the second year. A significant correlation was found between the change in weight z-score and height z-score during the first (r = 0.488, P = 0.016) and the second (r = 0.825, P < 0.001) years. There was no difference between compliers and noncompliers regarding height, weight, and BMI either before or after gastrostomy placement. A significant correlation between age at insertion of gastrostomy and improvement in height z-score (r = 0.52, P = 0.016) was observed. Cystic fibrosis related diabetes (n = 8) did not affect the response to supplemental feeding. CONCLUSIONS: We observed a trend toward improvement of pulmonary disease during the second year, and a significant improvement in weight, height, and BMI z-scores. Compliance, diabetes, and young age prior to tube insertion did not predict success of nutritional rehabilitation.