Anthropometry as a tool for measuring malnutrition: impact of the new WHO growth standards and reference.

Anthropometry is a useful tool, both for monitoring growth and for nutritional assessment. The publication by WHO of internationally agreed growth standards in 1983 facilitated comparative nutritional assessment and the grading of childhood malnutrition. New growth standards for children under 5 years and growth reference for children aged 5-19 years have recently (2006 and 2007) been published by WHO. Growth of children <5 years was recorded in a multi-centre growth reference study involving children from six countries, selected for optimal child-rearing practices (breastfeeding, non-smoking mothers). They therefore constitute a growth standard. Growth data for older children were drawn from existing US studies, and upward skewing was avoided by excluding overweight subjects. These constitute a reference. More indicators are now included to describe optimal early childhood growth and development, e.g. BMI for age and MUAC for age. The growth reference for older children (2007) focuses on linear growth and BMI; weight-for-age data are age-limited and weight-for-height is omitted. Differences in the 2006 growth pattern from the previous reference for children <5 are attributed to differences in infant feeding. The 2006 'reference infant' is at first heavier and taller than his/her 1983 counterpart, but is then lighter until the age of 5. Being taller in the 2nd year, he/she is less bulky (lighter for height) than the 1983 reference toddler. The spread of values for height and weight for height is narrower in the 2006 dataset, such that the lower limit of the normal range for both indices is set higher than in the previous dataset. This means that a child will be identified as moderately or severely underweight for height (severe acute malnutrition) at a greater weight for height than previously. The implications for services for malnourished children have been recognised and strategies devised. The emphasis on BMI-for-age as the indicator for thinness and obesity in older children is discussed. The complexity of calculations for health cadres without mathematical backgrounds or access to calculation software is also an issue. It is possible that the required charts and tables may not be accessible to those working in traditional health/nutrition services which are often poorly equipped.

The maintenance energy requirement for children: an estimate based on a study of children with infection associated underfeeding.

An estimate of the maintenance energy requirement (MER) has been based on energy balance data from children fed at different levels of intake during and after acute measles. The relationship between apparent energy balance (B) and the metabolizable energy intake (ME) was investigated by regression analysis. The relationship between B and ME in 34 balance studies is given by B = 0.79 ME -211.9 (r = 0.91). The ME at zero B [268.3 kJ (64.1 kcal)/kg X 24 h] is equivalent to the maintenance energy requirement (MER). Paired data on 16 children were used to study the relationship between MER and the resting metabolic rate (RMR). The relationship between MER and RMR during measles, ie at low levels of energy intake, is given by MER = 1.52 RMR -140.9 kJ/kg X 24 h (r = 0.79). The factorial relationship between MER and mean RMR was estimated, and also the safe level of intake to supply the MER when ME represents between 76% and 84% of gross energy (GE). The safe level of GE intake, between 381 and 416 kJ/kg X 24 h (ie between 91.1 and 99.4 kcal/kg X 24 h), is very close to the WHO/FAO (1973) recommendations for growing children.

Familial aplasia/hypoplasia of pelvis, femur, fibula, and ulna with abnormal digits in an inbred Pakistani Muslim family: a possible new autosomal recessive disorder with overlapping manifestations of the syndromes of Fuhrmann, Al-Awadi, and Raas-Rothschild.

We describe four affected children belonging to a large, highly inbred Muslim family originating from the North West Frontier Province of Pakistan. All children have a similar pattern of skeletal abnormalities, including aplasia/hypoplasia of the ulnae, hypoplasia of the pelvis, aplasia/hypoplasia of the femora, fibular aplasia, and variable digital abnormalities and absent/dysplastic nails. The phenotype overlaps with the syndromes of Fuhrmann, Al-Awadi, and Raas-Rothschild. The present and previously reported families probably share the same geographic and racial origin, indicating a common genetic basis of the reported skeletal abnormalities in these limb-pelvis aplasia and hypoplasia syndromes. A possibility of a new autosomal recessive syndrome in the present family cannot be excluded. Further delineation and molecular studies are required to clarify the genetic cause and phenotypic variation in Fuhrmann, Al-Awadi, and Raas-Rothschild syndromes.

Dietary assessment in Asian children--a comparison of the weighed inventory and diet history methods.

A cross-sectional study of the dietary intake of Indo-Asian children, in Sheffield, aged 4-40 months, was carried out during a 1 year period. Weighed dietary inventories (facilitated by use of the PETRA electronic recording scale) and diet histories were completed, and analysis was carried out on the records of 117 children. This number is equivalent to a quarter of the estimated target population and 53% of those approached. The diet history method gave higher estimates of the dietary intake of most nutrients than the weighed inventory method (Wilcoxon's rank sum method), the differences represented 7%, 9%, 3%, 9% and 6% of the mean intakes of energy, protein, fat, iron and vitamin C respectively, and were significant for energy, protein and iron. Analysed by age group, differences were significant for energy at 12 to < 18 months; for iron at 6 to < 12 months and 12 to < 18 months; and for vitamin C at < 6 months. There were no significant differences between the estimates of standardised energy or protein intakes, nor in the estimates, by the two methods, of total energy (%) derived from protein or fat. Mean energy intake per kg was equivalent to basal metabolic rate (BMR)* 1.49 by weighed inventory and BMR*1.58 by diet history. Energy intake was expressed as a ratio of age-adjusted 'reference' energy expenditure [A.M. Prentice et al. (1988) The Lancet 2, 1066-1069], the modal ratio energy intake/energy expenditure was 0.75 to < 1.0 for both weighed inventory and diet history methods, suggesting that the observed levels of energy intake were within a reasonable range.

Daily variation in food and nutrient intakes of Asian children in Sheffield.

Weighed intake data from a 1 year cross-sectional nutritional survey of Indo-Asian children (4-40 months of age), in Sheffield, were analysed with respect to the day-to-day variability of energy and selected nutrient intakes. 117 children (i.e. 53% of those approached) completed studies; this figure approximates one-quarter of the estimated target population. The between- and within-subject variability in dietary intakes was examined according to age group. For energy, the between-subject variability, measured by the coefficient of variation between subjects (CVb) rose from 26% at 4- < 12 months to 36% in the 12- < 24 month group. Within subject variation (CVw) for energy varied little between age groups (23-29%). Within-subject variability in protein and fat intakes showed a similar pattern to that of energy. However, the CVb for protein was maximal in the youngest group; it was lower than the CVw in the over 24 month group. Iron and vitamin C intakes were subject to much higher levels of within- and between-subject variation; the CVb for iron was maximal in the 12- < 24m group. Although the within-person variation was demonstrably greater than that of Caucasian infants (A. E. Black et al., 1983, Hum. Nutr.: Appl. Nutr. 37A, 448-458), the between-person variation, as measured over a 1 year period, was also high and comparatively larger than the CVw.(ABSTRACT TRUNCATED AT 250 WORDS)

An experimental estimate of the maintenance energy requirement in children with cystic fibrosis.

OBJECTIVE: To determine experimentally the maintenance energy requirement MER of children with Cystic Fibrosis (CF). DESIGN: Paired energy balance studies were undertaken on eight children with CF during an infection exacerbation, each child was his own control. SETTING: Paired energy balance (EB) studies at home over three days. SUBJECTS: Children known (from clinic records) to be susceptible to frequent infections were contacted. Four eligible children volunteered and completed two studies. INTERVENTION: Energy intake was estimated by weighted dietary inventory during days 1-3 and 16-18 of convalescence and obligatory energy losses determined by analysis of synchronous faecal and urinary collections using bomb calorimetry and urea concentration respectively Resting energy expenditure (EE) was determined using the DeltatrakTM100 Metabolic Monitor Apparent energy balance (B) was calculated by difference between metabolizable energy intake ME and EE such that B = ME - EE. RESULTS: The linear relationship between B (y) and ME (x) is given by y = 0.85x - 206.6 (1) when B = 0, ME = MER with a value of 243.1kJ/kg/24h(95% CL 136.9 and 410.3kJ/kg/24h). CONCLUSION: When MER = 243.1 + 167.2 - 106.2kJ/kg/24h and ME = 93% of gross energy (GE), a GE intake of 261kJ/kg/24h(95% CL of 440kJ/kg/24h) meets the MER, and negative EB is avoided. Agreement with previous estimates of MER suggests no enhancement of MER in CF.

Urinary excretion of 3-methylhistidine, creatinine and total nitrogen by Kenyan children during acute measles and after recovery.

The urinary excretion of 3-methylhistidine (3MH), creatinine and total nitrogen was measured during the course of energy balance studies on 20 black Kenyan children. Studies were carried out over 24 h during an acute attack of measles with a second (control) study after recovery, and complete urinary collections were obtained on 14 ill and 18 recovered children. The nutritional status was assessed by anthropometry, and energy intake was determined by duplicate diet analysis. Twelve out of 13 acutely ill and 6 out of 17 recovered children were in negative energy balance. No effect on the rate of excretion of 3MH or of creatinine attributable to differences in nutritional status, of energy intake or to infection was observed. The linear relationship between the excretion rate of all three metabolites and body weight which was observed in recovered children was absent during acute infection. Nitrogen excretion was correlated (P less than 0.05) with the level of energy intake. The linear relationship between the rate of excretion of 3MH and creatinine and of 3MH and nitrogen was significantly closer in recovered than in ill children. The simultaneous effects of infection, underfeeding (and oliguria) on the rate of excretion of protein metabolites may be complex and contradictory. Our results suggest that the excretion of 3MH, creatinine and nitrogen is sustained during infection accompanied by negative energy balance. Disruption during infection of the relationship between the excretion of all three metabolites and body weight, and between 3MH and the other two metabolites suggests perturbation in protein metabolism at this time.

Preparing for the CRNO examination: it's time to get started.

The focus of this article is to suggest ways in which a nurse can prepare for the certification examination for ophthalmic registered nurses (CRNO).

Epilepsy and its effects on children and families in rural Uganda.

BACKGROUND: This report aims to assess the impact of childhood epilepsy in an isolated rural area in Western Uganda, with little access to medical care, via its effect on children and families. Basic information on 440 affected children, clinically examined at 19 rural centres, was collated and data on seizure pattern and duration analysed, together with information on school attendance of older children. OBJECTIVE: To publicise the consequences of undertreated illness, and to encourage improved management of this condition. RESULTS: Distribution by seizure type was: generalised 61%, focal 33%, and miscellaneous 6%. When information on all seizure types was combined, a 'typical seizure' lasted < 1 hour, followed by coma. The typical age of onset and duration of illness approximated 2½ and 4 years respectively. Modal frequency and duration of seizures suggested that ∼96 hours might be 'lost' to seizures over 4 years. Twenty four children had delayed global or motor development; a further 93 were reported to have 'poor understanding'. Information on school attendance available on 162 of 231 school aged children indicated that 92 were attending and 70 not attending school. Fifty eight percent of children >10 yrs old attending school and 68% of non-attendees, had never progressed beyond the entry class. CONCLUSION: The unexpected prevalence of apparent cognitive delay is discussed, together with strategies for prevention and management of epilepsy at community level.

Epilepsy in rural Ugandan children: seizure pattern, age of onset and associated findings.

INTRODUCTION: Much information on childhood epilepsy in sub Saharan Africa is hospital based. A survey was considered necessary before integrating epilepsy management into a Ugandan community programme. METHOD: Using an 'outreach' method, children with recurrent seizures were offered assessment at 19 sites in Rukungiri District. A brief history and neurological and developmental assessment was carried out on each child. A clinical diagnosis of epilepsy, including seizure type, was given to 440 of 618 children <18 years with 178 exclusions. RESULTS: The age-specific prevalence of epilepsy in children < 15 years was 2.04‰ (95% CI 1.94‰ to 2.24 ‰) based on 395 cases in an <15 years population of 193,126. Percentage distribution by seizure type was:-generalised tonic-clonic (53%), complex partial seizures CPS (27%), simple partial and miscellaneous seizures (6% each), with some diagnostic overlap between seizure types. Cerebral palsy, evident or evolving, was most strongly associated with CPS. A positive perinatal or infantile history was noted in 12 and 6% respectively, and 50.2% of seizures began in infancy. CONCLUSIONS: The prevalence of epilepsy is similar in Gambian children. The high contribution from early-onset CPS, resembles Kenyan reports of malaria-associated CPS, suggesting a causal association with malaria.

Cause and cure for iron deficiency in toddlers.

Iron deficiency is the commonest cause of anaemia in Britain. Maureen B Duggan asks: How does toddler iron deficiency aris? How is it reliably diagnosed? And how can it be prevented in the community? Is iron supplementation of foods, especially of breast milk substitutes and follow-on formulae important in communities at risk?

Enteric fever in young Yoruba children.

Ninety-seven Nigerian children under 5 years of age had typhoid or paratyphoid fever proved by blood culture. The presented with fever, anaemia, gastrointestinal or neurological disturbances, and typhoid and paratyphoid appeared clinically indistinguishible. In this holoendemic malarial area, malaria was the most important differential diagnosis, and may have contributed to the concomitant anaemia seen in the majority of patients. Despite vigorous therapy with chloramphenicol or trimethoxazole, and blood transfusion where indicated, the mortality in both typhoid and paratyphoid was high (18% in both groups).

Composition of weight gain by Kenyan children during recovery from measles.

The pattern and composition of weight change in 19 Kenyan children convalescing from measles, while eating a traditional diet at home, was investigated by serial anthropometry. The majority of children gained weight satisfactorily, 9 (47 per cent) quadrupling the reference rates of weight gain during this period, although 4 remained severely underweight throughout the study. The significant mean improvement in nutritional status, estimated by weight/length, was the result of weight gain accompanied by faltering in linear growth. Rapid weight gain was characterized by an early increase in the fat-free weight and a later rise in subcutaneous fat weight, similar to that shown in children recovering from malnutrition. Children who gained weight poorly demonstrated alternate spurts of weight gain and weight loss. Poor weight gain was significantly (P less than 0.05) associated with anorexia and with diarrhoea. Nutritional and metabolic factors influencing the pattern of weight gain and linear growth after infection are discussed.

Energy metabolism in healthy black Kenyan children.

1. Twenty-four healthy black Kenyan children, mean age 29 (SD 19) months, were studied over a 24 h period. Energy expenditure (EE) was determined using a ventilated-hood indirect calorimeter; measuring oxygen consumption and carbon dioxide production. Metabolizable energy intake was measured in twenty children. Anthropometric measurements were used to estimate surface area and lean body-weight. 2. The mean daily intake of metabolizable energy was 338.4 (SE 28.4) kJ/kg; 70% of gross dietary energy being provided by carbohydrate. The level of postprandial EE was significantly (P less than 0.05) higher than the resting level (12.6 (SE 0.47) and 11.38 (SE 0.37) kJ/kg per h respectively) while the level of the postprandial respiratory quotient (RQ) was similar to the resting level (0.94 (SE 0.02) and 0.98 (SE 0.03 respectively). In 33% of total observations of the resting RQ the value was more than 1.0. These findings suggest that short-term fat storage may be a normal feature of metabolism in children, and also that the energy cost of (postprandial) fat synthesis is increased by a high-carbohydrate diet. 3. Values for the resting metabolic rate and various estimators of body size were compared using regression analysis. It was evident that, in these young children with considerable variation in body composition, body-weight remained a satisfactory metabolic-size estimator.

Energy cost of measles infection.

A model predicting the nutritional cost of measles has been based on data from a study of energy balance in Kenyan children during and after measles. The energy shortfall, consequent upon a reduction in energy intake and a sustained level of energy expenditure, is met by tissue catabolism. The magnitude of resulting weight loss will be greater in lean than in plump children. During recovery, the intake of gross dietary energy to regain lost weight must take account of obligatory energy losses in stool and urine and also of the energy cost of biosynthesis. The speed of recovery is influenced both by the energy density of the available food and its palatability. The nutritional cost of infection and other illnesses causing negative energy balance will be greater to lean people whose diet is of low energy density.