A New Murine Undernutrition Model Based on Complementary Feeding of Undernourished Children Causes Damage to the Morphofunctional Intestinal Epithelium Barrier.

BACKGROUND: Complementary feeding is critical in establishing undernutrition. However, experimental undernourished diets do not represent the amount of nutrients in the complementary diets of undernourished children. OBJECTIVES: To develop, validate, and evaluate the impact of a new murine model of undernutrition on the intestinal epithelium, based on the complementary diet of undernourished children from 7 countries with low-socioeconomic power belonging to the Malnutrition-Enteric Diseases (MAL-ED) cohort study. METHODS: We used the difference in the percentage of energy, macronutrients, fiber and zinc in the complementary diet of children without undernutrition compared with stunting (height-for-age Z-score < -2) for the MAL-ED diet formulation. Subsequently, C57BL/6 mice were fed a control diet (AIN-93M diet) or MAL-ED diet for 28 d. Weight was measured daily; body composition was measured every 7 d; lactulose:mannitol ratio (LM) and morphometry were evaluated on days 7 and 28; the cotransport test and analysis of intestinal transporters and tight junctions were performed on day 7. RESULTS: The MAL-ED diet presented -8.03% energy, -37.46% protein, -24.20% lipid, -10.83% zinc, +5.93% carbohydrate, and +45.17% fiber compared with the control diet. This diet rapidly reduced weight gain and compromised body growth and energy reserves during the chronic period (P < 0.05). In the intestinal epithelial barrier, this diet caused an increase in the LM (P < 0.001) and reduced (P < 0.001) the villous area associated with an increase in FAT/CD36 in the acute period and increased (P < 0.001) mannitol excretion in the chronic period. CONCLUSIONS: The MAL-ED diet induced undernutrition in mice, resulting in acute damage to the integrity of the intestinal epithelial barrier and a subsequent increase in the intestinal area during the chronic period. This study introduces the first murine model of undernutrition for the complementary feeding phase, based on data from undernourished children in 7 different countries.

Interlinkages between Climate Change and Food Systems: The Impact on Child Malnutrition-Narrative Review.

The pandemics of obesity, undernutrition, and climate change represent severe threats to child health. They co-occur; interact with each other to produce sequelae at biological, psychological, or social levels; and share common underlying drivers. In this paper, we review the key issues concerning child diet and nutritional status, focusing on the interactions with climate and food systems. Inadequate infant and young child feeding practices, food insecurity, poverty, and limited access to health services are the leading causes of malnutrition across generations. Food system industrialization and globalization lead to a double burden of malnutrition, whereby undernutrition (i.e., stunting, wasting, and deficiencies in micronutrients) coexists with overweight and obesity, as well as to harmful effects on climate. Climate change and the COVID-19 pandemic are worsening child malnutrition, impacting the main underlying causes (i.e., household food security, dietary diversity, nutrient quality, and access to maternal and child health), as well as the social, economic, and political factors determining food security and nutrition (livelihoods, income, infrastructure resources, and political context). Existing interventions have the potential to be further scaled-up to concurrently address undernutrition, overnutrition, and climate change by cross-cutting education, agriculture, food systems, and social safety nets. Several stakeholders must work co-operatively to improve global sustainable nutrition.

Child undernutrition and associated factors among children 6-23 months old in largely food insecure areas of rural Ethiopia.

Child malnutrition is the leading public health problem in Sub-Saharan Africa, resulting in poor health and economic losses. Ethiopia has one of the highest child undernutrition rates in the world that occurs to multifaceted factors, including food insecurity. Thus, we performed a cross-sectional study to assess the prevalence and risk factors for child undernutrition in largely food insecure areas of Ethiopia. Data were collected from 354 mother-child pairs from the Siraro district. Both bivariate and multivariate logistic regression was used for statistical analysis. Variables with a P-value of <0⋅05 in multivariate analysis were used to detect statistical significance at a 95 % confidence level. About 67 % of households are food insecure. The prevalence of stunting wasting and underweight were 42⋅7, 9⋅9 and 27⋅7 %, respectively. Female gender, higher age of the child (12-23 months v. 6-11 months), living in a household with five or more siblings, not getting therapeutic zinc supplement at least once, inadequate diet diversity, lack of growth monitoring service, and maternal own income increases the likelihood of child undernutrition. It can be concluded that child undernutrition is a severe public health problem in the study area. Improving primary healthcare services related to zinc supplementation, growth monitoring and promotion, and improving infant and child feeding practices can be considered as a strategy to address the problem.

Whole-blood PUFA and associations with markers of nutritional and health status in acutely malnourished children in Cambodia.

OBJECTIVE: To measure fatty acid composition, particularly whole-blood PUFA content, in acutely malnourished children and identify associations with markers of nutritional and health status. DESIGN: PUFA were assessed in dried blood spots obtained from a cross-sectional study. Nutritional and health status were assessed by anthropometry, haemoglobinopathies, inflammation and blood counts. SETTING: Cambodia. PARTICIPANTS: The study was conducted with 174 children aged 0·5-18 years with acute malnutrition. RESULTS: Among total fatty acids (FA), the relative percentage of total PUFA was 20 % FA, with 14 % of the children having very low PUFA (mead acid (MA):arachidonic acid (AA) >0·02, n-6 docosapentaenoic acid:DHA >0·2 and total n-6:n-3 PUFA >10·5). Wasting was not associated with any PUFA. Stunting and low height were consistently positively associated with total PUFA and positively with n-6 PUFA. Height was positively associated with n-3 long-chain PUFA (LCPUFA). The presence of haemoglobinopathies or inflammation was positively associated with MA:AA, but not total PUFA. Elevated blood platelet counts were positively correlated with linoleic acid and appeared to be influenced by anaemia (P = 0·010) and inflammation (P = 0·002). Monocyte counts were high during inflammation (P = 0·052) and correlated positively with n-6 LCPUFA and n-3 LCPUFA. CONCLUSIONS: Children with acute malnutrition or stunting had low PUFA, while elevated platelets and monocytes were associated with high PUFA. In acutely malnourished children, inflammation could lead to elevated blood cell counts resulting in increased whole-blood PUFA which does not reflect dietary intake or nutritional status.

A comparative study of the prevalence of zinc deficiency among children with acute diarrhoea in SouthWestern Nigeria.

BACKGROUND: Zinc deficiency has been associated with increased incidence, severity and duration of childhood diarrhoea. OBJECTIVE: The objective of the study was to determine the prevalence of zinc deficiency among under-five children with acute diarrhoea. METHODS: The study was a comparative cross-sectional study in which serum zinc levels were determined using atomic absorption spectrometry in under-five children with acute diarrhoea and in apparently healthy contols. Two hundred and fifty children with acute diarrhoea and 250 controls were studied at the Wesley Guild Hospital, Ilesa, Nigeria. RESULTS: The diarrhoea patients had a mean ± SD serum zinc level of 78.8 ± 35.6 µg/dl, while the controls had a mean of 107.3 ± 46.8 µg/dl. The mean serum zinc level was significantly lower in the patients than the controls (t = -7.66; p < 0.001). Furthermore, the prevalence of zinc deficiency was significantly higher among the patients (30.4% versus 12.4% in the controls; OR = 3.09; 95% CI = 1.94 - 4.90; χ2 = 24.08; p < 0.001). Low social class was associated with a significantly higher prevalence of zinc deficiency among the patients (p = 0.013). CONCLUSION: Zinc deficiency is significantly associated with diarrhoea among under-five children in the study community. Hence, routine zinc supplementation should be encouraged for the treatment of diarrhoea, and availability should be ensured.

Copper deficiency-induced bicytopenia caused by poor compliance in a paediatric patient with chronic malnutrition: A case report.

A 12-year-old boy who underwent gastric wedge resection was transferred to our hospital because of vomiting, growth failure, and weight loss in January, 2016. We tried to restore his general condition by maintaining additional nutritional supply through peripheral parenteral nutrition (PN). However, continuous vomiting, weight loss, and superior mesenteric artery syndrome persisted because of low treatment compliance. The findings of hyponatraemia and bicytopenia did not improve. Bone marrow biopsy was performed, and it revealed copper deficiency. PN with additional micronutrient agents, including copper, were administered. In particular, invasive diagnosis and treatment, and adequate education improved the treatment compliance of the child. His copper deficiency and bicytopenia improved, and his weight and dietary intake also increased. We confirmed that treatment compliance is important in paediatric patients with malnutrition. In chronic malnutrition, attention should also be paid to deficiency of micronutrients such as copper, which can lead to haematologic problems.

El helado elaborado de musa paradisíaca y probióticos mejora los niveles séricos de calcio, hierro y potasio en una población infantil / Ice cream prepared with musa paradisiaca and probiotic improves the serum levels of calcium, iron and potassium in a children population

La desnutrición afecta la sociedad, principalmente a niños de recursos limitados, siendo los bajos niveles de minerales su consecuencia directa. Se desarrolló una investigación explicativa, con diseño experimental para evaluar la efectividad del consumo de un helado a base de Musa paradisiaca suplementado con probióticos en una población infantil de Cúcuta-Colombia. De una población de 238 escolares, 33 niños de 4 a 6 años tuvieron déficit séricos de Ca, Fe y K y se dividieron aleatoriamente en dos grupos. Durante 60 días se les suministró diariamente el helado prueba al Grupo A y al Grupo B un helado placebo, registrándose peso, talla, niveles séricos de Ca, Fe y K antes, durante y después del suministro. Incrementaron significativamente (p = 0,01) los niveles de hierro y calcio en el Grupo A; mientras en el Grupo B permanecieron sin cambios. En ambos grupos aumentaron significativamente los niveles de potasio (p<0.05), con (p = 0.01) en el Grupo A. El peso corporal y talla de los niños evidenció un cambio significativo dentro de cada grupo (p < 0,05), aunque, no se observaron diferencias significativas entre grupos luego de la intervención. El consumo del helado a base de plátano suplementado con probióticos representa una alternativa para el abordaje del déficit de minerales en la población infantil(AU)

Malnutrition affects society, mainly children with limited resources, with low levels of minerals being the direct consequence. An explanatory research was developed, with experimental design to evaluate the effectiveness of the consumption of an ice cream of Musa paradisiaca supplemented with probiotics in a child population of Cúcuta-Colombia. From 238 schoolchildren, a sample of 33 children aged 4 to 6 years with serum deficits of Ca, Fe and K participated and they were randomly divided into two groups. For 60 days the ice cream was supplied to Group A and Group B a placebo ice cream, registering weight, height, serum levels of Ca, Fe and K before, during and after the ice cream administration. There was a significant increase (p = 0.01) in the iron and calcium levels in Group A; with no significant changes for Group B. In both groups potassium was significantly increased (p <0.05). The body weight and height of the children was increased although there were no differences (p>0.05) between both groups. The consumption of banana-based ice cream supplemented with probiotics represents an alternative to address the deficit of minerals in children(AU)

Use of low-level laser therapy on children aged 1 to 5 years with energy-protein malnutrition: A clinical trial.

BACKGROUND: Episodes of malnutrition in early childhood can produces alterations in the salivary glands. The investigation of mechanisms that can reduce the impact of malnutrition on the defenses of the organism is of the utmost important and interest to public health. The aim of this study is to evaluate the effect of low-level laser on the saliva of children aged 1 to 5 years with energy-protein malnutrition. METHODS: Mandatory inclusion criteria are diagnosis of malnutrition. The sample will consist of 50 men and women malnourished children aged 12 to 71 months. Saliva will be collected and the volume of saliva will be measured and the salivary flow rate will be determined (mL/min). Concentrations of salivary IgA in all samples will be measured using a commercial Enzyme-Linked Immunosorbent Assay (ELISA) kit. Low-level laser (laser diode) will be administered in the region of the parotid glands bilaterally as well as in the regions of the submandibular and sublingual glands. DISCUSSION: This study will be the first that investigate the effects of local laser therapy on the salivary glands of malnourished children. TRIAL REGISTRATION: Clinical.trials.gov as NCT03355313, first received in 21 November 2017.

Cut-off Serum Zinc Concentration Affecting the Appetite, Growth, and Nutrition Status of Undernourished Children Supplemented With Zinc.

BACKGROUND: Zinc supplementation has varied effects on the linear growth of children who exhibited stunted growth. MATERIALS AND METHODS: This observational study involved 761 undernourished children, aged 2-10 years, who received a 24-week course of 10-mg elemental zinc per day. The clinical parameters for evaluation included appetite, height, weight, and body mass index (BMI). Evaluation of the effect of zinc supplementation was stratified by the initial serum zinc concentration. RESULTS: The enrolled participants comprised 390 boys and 371 girls. The mean age was 5.63 years. The height-for-age, weight-for-age, and BMI-for-age z scores increased gradually during the study period. When compared with the children with a serum zinc concentration ≥75 µg/dL, the height, weight, weight-for-age, and BMI-for-age z scores increased significantly in the patients with serum zinc concentrations of <75 µg/dL after 12- and 24-week zinc supplementation (all P < .001). BMI, height-for-age z score, and appetite also increased significantly in patients with serum zinc concentrations of <75 µg/dL after 24-week zinc supplementation (P = .003, .019, and <.001, respectively). CONCLUSION: The findings of this study indicate that undernourished children with serum zinc concentrations of <75 µg/dL experienced greater increments in appetite and growth as a result of zinc supplementation.

From Treating Childhood Malnutrition to Public Health Nutrition.

BACKGROUND: This analysis sets out an overview of an IUNS presentation of a European clinician's assessment of the challenges of coping with immediate critical clinical problems and how to use metabolic and a mechanistic understanding of disease when developing nutritional policies. SUMMARY: Critically ill malnourished children prove very sensitive to both mineral and general nutritional overload, but after careful metabolic control they can cope with a high-quality, energy-rich diet provided their initial lactase deficiency and intestinal atrophy are taken into account. Detailed intestinal perfusion studies also showed that gastroenteritis can be combatted by multiple frequent glucose/saline feeds, which has saved millions of lives. However, persisting pancreatic islet cell damage may explain our findings of pandemic rates of adult diabetes in Asia, the Middle East and Mexico and perhaps elsewhere including Africa and Latin America. These handicaps together with the magnitude of epigenetic changes emphasized the importance of a whole life course approach to nutritional policy making. Whole body calorimetric analyses of energy requirements allowed a complete revision of estimates for world food needs and detailed clinical experience showed the value of redefining stunting and wasting in childhood and the value of BMI for classifying appropriate adult weights, underweight and obesity. Lithium tracer studies of dietary salt sources should also dictate priorities in population salt-reduction strategies. Metabolic and clinical studies combined with meticulous measures of population dietary intakes now suggest the need for far more radical steps to lower the dietary goals for both free sugars and total dietary fat unencumbered by flawed cohort studies that neglect not only dietary errors but also the intrinsic inter-individual differences in metabolic responses to most nutrients. Key Messages: Detailed clinical and metabolic analyses of physiological responses combined with rigorous dietary and preferably biomarker of mechanistic pathways should underpin a new approach not only to clinical care but also to the development of more radical nutritional policies.

Severe acute malnutrition.

PURPOSE OF REVIEW: Advances in our understanding of the treatment of severe acute malnutrition (SAM) in a resource-limited environment are needed to improve outcome. RECENT FINDINGS: Ready-to-use therapeutic foods (RUTFs) made from local products and with reduced milk content lower costs and may be effective in older children. None of the therapeutic foods used to treat severely malnourished children correct long chain polyunsaturated fatty acid deficiencies.Routine short-term antibiotic (amoxicillin) treatment, in the context of adequate healthcare supervision, does not improve the recovery rate. Long-term antibiotic (cotrimoxazole) treatment also does not provide significant benefit to non-HIV-infected children.Increased pathogenic bacteria have been found in the intestinal microbiome of malnourished children and candidate organisms for use as probiotics have been identified. There is, however, no evidence to support the routine use of probiotics in these children. Although exocrine pancreatic function is reduced in malnourished children, routine pancreatic enzyme supplementation does not lead to accelerated recovery. SUMMARY: Alternative RUTF may provide a cheaper and more acceptable alternative to standard RUTF in the near future. Further research is needed to understand the implications of fatty acid deficiencies and dysbiosis that occur in malnourished children. Routine antibiotic administration in the appropriate setting is unnecessary.

A mixed methods study to assess the effectiveness of food-based interventions to prevent stunting among children under-five years in Districts Thatta and Sujawal, Sindh Province, Pakistan: study protocol.

BACKGROUND: Maternal and child malnutrition is widely prevalent in low and middle income countries. In Pakistan, widespread food insecurity and malnutrition are the main contributors to poor health, low survival rates and the loss of human capital development. The nutritional status trends among children exhibit a continuous deteriorating with rates of malnutrition exceeding the WHO critical threshold. With the high prevalence of maternal and child malnutrition, it is important to identify effective preventative approaches, especially for reducing stunting in children under-five years of age. The primary aim of this study is to assess the effectiveness of food-based interventions to prevent stunting in children under-five years. METHODS: A mixed methods study design will be conducted to evaluate the effectiveness of food-based interventions to prevent stunting among children under-five years in districts Thatta and Sujawal, Sindh Province, Pakistan. The study will include cross sectional surveys, a community-based cluster randomized controlled trial and a process evaluation. The study participants will be pregnant women, lactating mothers and children under-five years. The cross-sectional surveys will be conducted with 7360 study participants at baseline and endline. For the randomized control trial, 5000 participants will be recruited and followed monthly for compliance of food-based supplements, dietary diversity, pregnancy outcomes, and maternal and child morbidity and mortality. Anthropometric measurements and hemoglobin levels will be measured at baseline, quarterly and at endline. The interventions will consist of locally produced lipid-based nutrient supplement (Wawamum) for children 6-23 months, micronutrient powders for children 24-59 months, and wheat soya blends for pregnant and lactating mothers. Government lady health workers will deliver interventions to participants. The effectiveness of the project will be measured in terms of the impact of the proposed interventions on stunting, nutritional status, micronutrient deficiencies, and other key indicators of the participants. The process evaluation will assess the acceptability, feasibility and potential barriers of project implementation through focus group discussions, key informant interviews and household surveys. Data analysis will be conducted using STATA version 12. DISCUSSION: There is considerable evidence on the effectiveness of food-based interventions in managing stunting in developing countries. However, these studies do not account for the local environmental factors and widespread nutrient deficiencies in Pakistan. These studies are often conducted in controlled environments, where the results cannot be generalized to programs operating under field conditions. The findings of this study will provide sufficient evidence to develop policies and programs aimed to prevent stunting in children 6-59 months and to improve maternal and child health and growth outcomes in poor resource settings. TRIAL REGISTRATION: NCT02422953 . Registered on April 15, 2015.

Effects of prenatal multiple micronutrient supplementation on growth and cognition through 2 y of age in rural Bangladesh: the JiVitA-3 Trial.

BACKGROUND: Childhood undernutrition may have prenatal origins, and the impact of prenatal interventions on postnatal growth is not well known. OBJECTIVE: We assessed the effects of prenatal multiple micronutrient (MM) supplementation on child growth and cognitive development. DESIGN: In a cluster-randomized controlled trial in rural Bangladesh, prenatal MM supplementation compared with iron-folic acid (IFA) supplementation was examined for its impact on growth assessed longitudinally from birth up to 24 mo of age (n = 8529) and, in a subsample (n = 734), on cognitive function at 24 mo of age by use of the Bayley scales of infant and toddler development-third edition test. RESULTS: Prevalence of stunting at birth [length for age z score (LAZ): <-2] was 31.9% in the MM and 35.7% in the IFA groups (P < 0.001); however, LAZ increased during the first 3-4 mo in both groups. With the use of a linear random-effects model, prenatal MM-exposed children sustained a higher mean predicted LAZ of ∼0.10 at 1 and 3 mo and 0.06 at 6 mo of age compared with children in the IFA group. Supplementation reduced the prevalence of stunting at 1 (RR: 0.95; 95% CI: 0.92, 0.98) and 3 (RR: 0.91; 95% CI: 0.88, 0.94) mo of age. Differences between groups were absent by 6, 12, and 24 mo of age, when nearly 50% of children had stunted growth. Ponderal and linear growth velocities were somewhat slower from 3 to 12 mo of age in the MM group than in the IFA group, but not from 12 to 24 mo of age. There was no difference between groups on composite scores of cognition, language, and motor performance at 24 mo of age. CONCLUSIONS: In this Bangladeshi trial, maternal pre- and postnatal MM supplementation resulted in improvements in LAZ and reduction in stunting through 3 mo of age, but not thereafter and had no impact on cognitive and motor function at 2 y. This trial was registered at clinicaltrials.gov as NCT000860470.

Mal de Simioto: práticas de saúde às crianças no interior do Brasil / Simioto's disease: health practice for children in the interior of Brazil

The "Simioto'sDisease" is a disease that has popular legitimacy and influences the search for treatment for infant health problems. This study aimed to understand the health practices related to Simioto'sDisease in a city in the interior of Brazil, from the perspective of parents of treated children. This is a qualitative and descriptive study performed by obtaining data using a semi-structured questionnaire with parents of children who were diagnosed and treated for the Simioto'sDisease. The data were subjected to content analysis. The categories discussedwere: The Simioto'sDisease pathology and its cultural aspects: symptoms, diagnosis, treatment and its indications and effectiveness; Relationship between Simioto'sDisease and professionalhealth care; The profile of healers or informal care and religiosity in the care of Simioto'sDisease. It was concluded that diagnosis and treatment are practices based on symptoms that generate a popular diagnosis. By describing the parent perspective, this practice is based on the belief of the treatmentefficacy and is legitimized by the healer reception, guidelines and precautionary measures of the disease that are passed, among other care, in addition to the baths performing frequency.

O "Mal de Simioto" é uma doença que possui legitimidade popular e queinfluencia a busca por tratamento para problemas de saúde infantil. Objetivou-se compreender as práticas de saúde relacionadas ao Mal de Simioto em um município no interior do Brasil, na perspectiva dos pais das crianças tratadas. Estudo qualitativo, descritivo, realizado através da obtenção de dados com o uso de questionário semiestruturado com os pais de crianças que foram diagnosticadas e tratadas com o Mal de Simioto. Os dados foram submetidos à análise de conteúdo.As categorias discutidas foram: A patologia Mal de Simioto e seus aspectos culturais: os sintomas, o diagnóstico, o tratamento e sua indicação e eficácia; Relação entre Mal de Simioto e os cuidados profissionais de saúde;Operfil dos curandeiros ou cuidadores informais e a religiosidade no cuidado ao Mal de Simioto. Concluiu-se queo diagnóstico e o tratamento são práticas baseadas em sintomas que geram um diagnóstico popular. Através da descrição pela perspectiva dos pais, essa práticabaseia-se na crença da eficácia do tratamento e é legitimada pelo acolhimento do curandeiro,das orientações e medidas de precaução da doença que são repassadas, entre outros cuidados, além da periodicidade de realização dos banhos.

Early Child Development and Nutrition: A Review of the Benefits and Challenges of Implementing Integrated Interventions.

Poor nutrition (substandard diet quantity and/or quality resulting in under- or overnutrition) and the lack of early learning opportunities contribute to the loss of developmental potential and life-long health and economic disparities among millions of children aged <5 y. Single-sector interventions representing either early child development (ECD) or nutrition have been linked to positive child development and/or nutritional status, and recommendations currently advocate for the development and testing of integrated interventions. We reviewed the theoretical and practical benefits and challenges of implementing integrated nutrition and ECD interventions along with the evidence for best practice and benefit-cost and concluded that the strong theoretical rationale for integration is more nuanced than the questions that the published empirical evidence have addressed. For example, further research is needed to 1) answer questions related to how integrated messaging influences caregiver characteristics such as well-being, knowledge, and behavior and how these influence early child nutrition and development outcomes; 2) understand population and nutritional contexts in which integrated interventions are beneficial; and 3) explore how varying implementation processes influence the efficacy, uptake, and cost-benefit of integrated nutrition and ECD interventions.

Global challenges in acute diarrhea.

PURPOSE OF REVIEW: Childhood diarrhea is the most common cause of morbidity and mortality, especially in the low and middle-income countries. The burden of child mortality because of diarrhea has declined, but still a lot is desired not only to reduce diarrhea-specific mortality but reduce the overall incidence, and hence the morbidity associated with childhood diarrhea. RECENT FINDINGS: A recent Lancet series on diarrhea suggests that amplification of the current interventions can eliminate virtually all preventable diarrhea deaths. A refocused attention and strategy and collective effort from the multilateral entities to promote water sanitation and hygiene, rotavirus vaccination, nutrition, and improved case management can bridge gaps and tackle the existing undue burden of deaths because of diarrhea. SUMMARY: Investment toward preventing and controlling childhood diarrhea should be a priority, especially when the existing solution is plausible for implementation at scale and in underprivileged settings.

Wasting and stunting--similarities and differences: policy and programmatic implications.

Wasting and stunting are often presented as two separate forms of malnutrition requiring different interventions for prevention and/or treatment. These two forms of malnutrition, however, are closely related and often occur together in the same populations and often in the same children. Wasting and stunting are both associated with increased mortality, especially when both are present in the same child. A better understanding of the pathophysiology of these two different forms of malnutrition is needed to design efficient programs. A greatly reduced muscle mass is characteristic of severe wasting, but there is indirect evidence that it also occurs in stunting. A reduced muscle mass increases the risk of death during infections and also in many other different pathological situations. Reduced muscle mass may represent a common mechanism linking wasting and stunting with increased mortality. This suggests that to decrease malnutrition-related mortality, interventions should aim at preventing both wasting and stunting, which often share common causes. Also, this suggests that treatment interventions should focus on children who are both wasted and stunted and therefore have the greatest deficits in muscle mass, instead of focusing on one or the other form of malnutrition. Interventions should also focus on young infants and children, who have a low muscle mass in relation to body weight to start with. Using mid-upper-arm circumference (MUAC) to select children in need of treatment may represent a simple way to target young wasted and stunted children efficiently in situations where these two conditions are present. Wasting is also associated with decreased fat mass. A decreased fat mass is frequent but inconsistent in stunting. Fat secretes multiple hormones, including leptin, which may have a stimulating effect on the immune system. Depressed immunity resulting from low fat stores may also contribute to the increased mortality observed in wasting. This may represent another common mechanism linking wasting and stunting with increased mortality in situations where stunting is associated with reduced fat mass. Leptin may also have an effect on bone growth. This may explain why wasted children with low fat stores have reduced linear growth when their weight-for-height remains low. It may also explain the frequent association of stunting with previous episodes of wasting. Stunting, however, can occur in the absence of wasting and even in overweight children. Thus, food supplementation should be used with caution in populations where stunting is not associated with wasting and low fat stores.

The importance of nutritional care in HIV-infected children in resource-limited settings.

Renewed efforts to provide proper nutritional care are essential for appropriate pediatric HIV management. Current studies support the use of vitamin A and macronutrients that increase caloric and protein intake. With additional research on key issues such as the needed composition and timing for nutritional supplementation, we can determine the best strategies to support the growth and development of HIV-infected children in resource-limited settings. Malnutrition among children is common in the resource-limited settings where HIV infection is most prevalent. While malnutrition is associated with higher morbidity and mortality for HIV-infected children, there is only limited evidence to guide the use of nutritional support for HIV-infected children. The best studied is vitamin A, which is associated with improved mortality and clinical outcomes. Zinc and multivitamin supplementation have not consistently been associated with clinical benefits. Limited research suggests macronutrient supplementation, which typically uses enriched formulas or foods, improves key anthropometrics for HIV-infected children, but the optimal composition of nutrients for supplementation has not been determined. More research is needed to understand the most efficient and sustainable ways to ensure adequate nutrition in this vulnerable population.

Post-discharge mortality in children with severe malnutrition and pneumonia in Bangladesh.

BACKGROUND: Post-discharge mortality among children with severe illness in resource-limited settings is under-recognized and there are limited data. We evaluated post-discharge mortality in a recently reported cohort of children with severe malnutrition and pneumonia, and identified characteristics associated with an increased risk of death. METHODS: Young children (<5 years of age) with severe malnutrition (WHO criteria) and radiographic pneumonia on admission to Dhaka Hospital of icddr,b over a 15-month period were managed according to standard protocols. Those discharged were followed-up and survival status at 12 weeks post-discharge was determined. Verbal autopsy was requested from families of those that died. RESULTS: Of 405 children hospitalized with severe malnutrition and pneumonia, 369 (median age, 10 months) were discharged alive with a follow-up plan. Of these, 32 (8.7%) died in the community within 3 months of discharge: median 22 (IQR 9-35) days from discharge to death. Most deaths were reportedly associated with acute onset of new respiratory or gastrointestinal symptoms. Those that died following discharge were significantly younger (median 6 [IQR 3,12] months) and more severely malnourished, on admission and on discharge, than those that survived. Bivariate analysis found that severe wasting on admission (OR 3.64, 95% CI 1.66-7.97) and age <12 months (OR 2.54, 95% CI 1.1-8.8) were significantly associated with post-discharge death. Of those that died in the community, none had attended a scheduled follow-up and care-seeking from a traditional healer was more common (p<0.001) compared to those who survived. CONCLUSION AND SIGNIFICANCE: Post-discharge mortality was common in Bangladeshi children following inpatient care for severe malnutrition and pneumonia. The underlying contributing factors require a better understanding to inform the potential of interventions that could improve survival.

Case of extreme growth deceleration after burns.

Studies have demonstrated deceleration in both weight and height following burns in children. It is expected patients will display catch up growth and return to normal weight within three years but continued height deficiency may remain in cases of severe burns. We describe a case of severe growth retardation of 8 years old orphan child from Ukraine who suffered of burn less than 40% of total body surface area when he was a 3 years of life. His case was complicated by domestic abuse, neglect and limited medical care. He initially presented to the United States for surgical care of his contractures but his treatment quickly focused on his profound growth retardation. Despite aggressive nutritional supplementation and evaluation he did not demonstrate any weight gain.