Severe feeding disorder and malnutrition in 2 children with autism

Leanna, a 10-year-old girl with autism, was hospitalized for severe malnutrition and 20 pound weight loss secondary to reduced intake over 4 months. Her food choices became increasingly restrictive to the point where she only ate certain types and brands of foods. She gradually stopped drinking and developed severe constipation and encopresis. A new behavior of collecting saliva in her mouth and spitting onto napkins also emerged. Vital signs and electrolytes were normal on admission. A nasogastric tube was placed because she refused to eat. A behavior modification plan was implemented that awarded points for completing specific tasks related to feeding, which could later be redeemed for specific rewards, such as computer time. Although her ideal body weight increased from 68% to 75% (due to continuous nasogastric tube feeds), her refusal to eat persisted. Upon further data gathering, the staff learned that she moved and changed schools 5 months ago. She was cared for by either a family friend or paid caregiver while her mother worked. Although she could conduct basic self-care activities without assistance and write and draw at a third-grade level, she functioned cognitively at a 4-year-old level. The behavior plan was modified, breaking the tasks into shorter components with immediate and tangible rewards. She soon began eating small portions of food and spitting less frequently. Toileting was later incorporated into this plan. She was referred to a behavioral therapist in the community to work with her at home and school. Weekly visits with her pediatrician and appointments with a child psychiatrist and dietician were made. Orlando, a 3-year-old boy with autism, was evaluated in the emergency room for lethargy and generalized edema for 6 weeks. The history revealed a restrictive diet of commercial pureed fruit and coconut juice for 2 years. He only ate a particular brand and with specific containers; the limited food intake occurred only with his favorite blanket. He refused to eat other types of food. Outpatient treatments were unsuccessful. On physical examination, he was irritable with an erythematous, scaly rash throughout his body. His hair was thin, coarse, and blonde. He had nonpitting edema in his arms, legs, and periorbital region. The laboratory evaluation was significant for anemia, hypoalbuminemia, and hypoproteinemia. He was admitted to the pediatric service where nutritional formula feedings were initiated through a nasogastric tube. Weight gain was adequate, and the hemoglobin, serum albumen, and protein became normal. The rash improved with zinc supplementation. He was transferred to an inpatient feeding disorders unit where a team of occupational therapists implemented a behavioral modification program to overcome his severe food aversion.     

Sweat test results in children with primary protein energy malnutrition

OBJECTIVES: In underdeveloped and developing countries where protein energy malnutrition (PEM) is common, it is sometimes difficult to exclude the diagnosis of cystic fibrosis (CF) in malnourished children because both primary PEM and CF share similar symptoms, signs, and laboratory findings, such as elevated sweat chloride value. This study was performed to investigate sweat test results and determine percentile values in children with primary PEM. METHODS: A total of 90 children with PEM and 30 healthy children were included. PEM was classified according to criteria defined by Gomez, Waterlow, and McLaren. Sweat tests were performed using the Macroduct conductivity system. RESULTS: Patient age and gender did not affect the test results (P > 0.05). The mean sweat conductivity (equivalent NaCl mMol/L) of patients with PEM was higher than that of controls (P < 0.001) and increased with the degree of malnutrition (P < 0.001). Inverse correlations between sweat conductivity and weight for age, height for age, and weight for height were detected (P < 0.001). The highest value was found in children with wasting and stunting, followed by those with stunting (P < 0.05) and those with marasmic kwashiorkor (P < 0.01). Of all children with PEM, 6.7% had elevated sweat test results that normalized after nutritional management; of children with third degree PEM, the figure was 20%. Ninety-fifth percentile values of first, second, and third degree malnutrition were 47 mMol/L, 49 mMol/L, and 69 mMol/L, respectively. CONCLUSION: Elevated sweat test result is not an important problem, especially in first and second degree PEM, but borderline values can be detected in as many as 20% of cases of third degree malnutrition. Sweat conductivity may increase to 69 mMol/L in children with stunting, those with wasting and stunting, and in those with third degree PEM.     

Serum ghrelin levels in children with primary protein–energy malnutrition

Background: Ghrelin, an appetite-stimulating peptide, increases in cachectic conditions. It probably reflects peripheral nutritional status and influences nutrient intake and growth. The aim of the present study was to determine serum ghrelin levels in children with primary protein–energy malnutrition (PEM) and to find if any correlation exists between serum ghrelin levels and the clinical presentation of those patients.
Methods: Twenty-eight children with primary PEM and 10 healthy children were included. Serum fasting ghrelin levels were measured using radioimmunoassay.
Results: Mean serum ghrelin level of healthy children and those with PEM were 107.7 ± 40.1 pg/mL and 141.6 ± 123.8 pg/mL, respectively ( P  < 0.001). Ghrelin levels were independent of age and sex ( P  > 0.05). Ghrelin was negatively correlated with body mass index in healthy children ( P  < 0.01), but not in those with PEM ( P  > 0.05). Mean serum ghrelin level of children with moderate malnutrition was higher than that of children with severe malnutrition (199.2 ± 154.1 pg/mL vs 98.4 ± 74.3 pg/mL, P  < 0.05). Mean serum ghrelin levels of patients with kwashiorkor, marasmic kwashiorkor, and marasmus were 127.9 ± 97.8 pg/mL, 138.7 ± 95.8 pg/mL, and 162.3 ± 185.0 pg/mL, respectively ( P  > 0.05).
Conclusion: Serum ghrelin level is higher in patients with PEM, especially in those with marasmus, compared to healthy children. Although this observation suggests that ghrelin helps to fight malnutrition in children, it is obvious that further studies are needed to clarify the exact pathogenetic mechanism regarding this condition.     

Severe acute malnutrition in low- and middle-income countries

Low- and middle-income countries bear the greatest burden of malnutrition, especially those in sub-Saharan Africa and Asia. Children are particularly vulnerable. This article provides an overview for healthcare professionals working with children, giving definitions and practical advice for intervention and management. Severe acute malnutrition (SAM) is diagnosed in under 5s with severe wasting (“marasmus”) and/or nutritional oedema (“kwashiorkor”). Wasting is identified using weight-for-height and comparing the child's value with WHO reference data or by measurement of mid-upper arm circumference. SAM is thought to result from a complex interaction between infections and poor diet or feeding practices occurring in the context of multiple adverse social-economic factors, with poor sanitation and hygiene increasing exposure to infection. The clinical management of SAM depends on whether there are complications such as anorexia and infections. Children with uncomplicated SAM are best managed in community programmes using ready-to-use therapeutic food and with close monitoring. The management of complicated SAM requires in-patient care and presents a huge challenge especially in health facilities with limited resources. Management guided by the WHO “Ten Steps”, which account for the reductive adaptation that occurs in malnutrition reduces case-fatality but this often remains high. Prevention of SAM requires addressing the multifactorial underlying causes associated with poverty and food insecurity. Addressing malnutrition in children is essential to achieving many of the UN Sustainable Development Goals.     

Serum lipids in malnutrition of children

Indian Journal of Pediatrics -     

正确评价儿童营养状况

一、我国儿童健康状况 1.儿童死亡率:联合国儿童基金会(UNICEF)采用的新生儿死亡率、婴儿死亡率和5岁以下儿童死亡率是国际社会公认的反映一个国家或地区儿童健康状况的指标.自新中国成立以来,我国新生儿死亡率、婴儿死亡率和5岁以下儿童死亡率逐年下降.1990年至2008年,5岁以下儿童从4.6%下降到2.1%,降低了54%;新生儿从3.31%下降到1.02%;婴儿从3.7%下降到1.8%.5岁以下儿童死亡率的明显下降,充分反映了我国社会的进步和经济的发展.UNICEF将193个国家的5岁以下儿童死亡率从高到低排序,中国从2003年第85位上升到2008年第102位,接近发达国家水平[1],显示我国儿童健康状况显著改善.     

Indicators of malnutrition in leukaemic children.

In 24 children with acute leukaemia a low serum albumin concentration (31 g/l or less) and a median weight:height ratio of less than 0.95 on admission were indicators of severe weight loss.     

Lactose intolerance in children with protein-energy malnutrition

Lactose tolerance test was performed on 40 children suffering from protein energy malnutrition (PEM) and 10 control children. Lactose intolerance was documented in two cases of kwashiorkor by a flat curve, diarrhea, low stool pH, and presence of reducing substances in the stools. Of 38 marasmic children, four had a maximum blood sugar rise below 20–30 mg/dl, but they did not exhibit any other signs of intolerance. It is suggested that marasmic infants can adequately hydrolyse lactose in milk.     

Infections in children with severe protein-energy malnutrition

The infections occurring in 68 black children admitted to hospital with kwashiorkor, marasmus or marasmic-kwashiorkor were studied prospectively. Fifteen episodes of bacteraemia, most commonly due to Gram-negative enteric bacilli, occurred in 13 children (19%), six of these episodes being nosocomial. Urinary tract infection, diagnosed on suprapubic urine specimens and all due to Escherichia coli, occurred in five out of 16 cases (31%). In the 48 cases admitted with gastro-enteritis and 18 with pneumonia, a causative organism was found in the minority. Fifteen episodes of nosocomial infection occurred in 14 children (20.6%), of whom four died. Of the 14 deaths, eight were associated with bacteraemia. Skin infections were due mainly to staphylococci and streptococci. Infections in severely malnourished children appear to be due largely to the same microorganisms as cause infection in well-nourished children of the same community. Nosocomial infections pose a major threat to these children.