The Rise and Fall of Protein Malnutrition in Global Health.

BACKGROUND: From the 1950s to the mid-1970s, United Nations (UN) agencies were focused on protein malnutrition as the major worldwide nutritional problem. The goal of this review is to examine this era of protein malnutrition, the reasons for its demise, and the aftermath. SUMMARY: The UN Protein Advisory Group was established in 1955. International conferences were largely concerned about protein malnutrition in children. By the early 1970s, UN agencies were ringing the alarm about a 'protein gap'. In The Lancet in 1974, Donald McLaren branded these efforts as 'The Great Protein Fiasco', declaring that the 'protein gap' was a fallacy. The following year, John Waterlow, the scientist who led most of the efforts on protein malnutrition, admitted that a 'protein gap' did not exist and that young children in developing countries only needed sufficient energy intake. The emphasis on protein malnutrition waned. It is recently apparent that quality protein and essential amino acids are missing in the diet and may have adverse consequences for child growth and the reduction of child stunting. Key Messages: It may be time to re-include protein and return protein malnutrition in the global health agenda using a balanced approach that includes all protective nutrients.

Malnutrition stratified by marasmus and kwashiorkor in adult patients with heart failure.

Malnutrition is classified into marasmus and kwashiorkor in children. However, the clinical significance of these aspects is unclear in adult patients with heart failure (HF). We divided 2308 adult patients with HF into four groups according to marasmus type (body mass index < 18.5 kg/m2) and kwashiorkor type (serum albumin < 3.4 g/dL) malnutrition: Group C (no malnutrition, n = 1511, 65.5%), Group M (marasmus type malnutrition, n = 133, 5.8%), Group K (kwashiorkor type malnutrition, n = 554, 24.0%) and Group MK (marasmic-kwashiorkor type malnutrition, n = 110, 4.8%). Group M showed the lowest blood pressure. Groups K and MK showed higher levels of B-type natriuretic peptide. Right atrial pressure was lowest in Groups M and MK. Kaplan-Meir analysis demonstrated that Group MK had the lowest event-free rate of all-cause death and cardiac death. In the multivariable Cox proportional hazard analysis, Groups M, K, and MK were associated with all-cause death (hazard ratio 1.790, 1.657 and 2.313, respectively) and cardiac death (hazard ratio 2.053, 1.855 and 3.001, respectively) compared to Group C as a reference. Marasmus type and kwashiorkor type malnutrition are associated with distinct profiles and high mortality, and marasmic-kwashiorkor type malnutrition has the poorest prognosis.

Dermatological changes in a prospective cohort of acutely ill, hospitalised Malawian children, stratified according to nutritional status.

RATIONALE: Since the first documentation of skin changes in malnutrition in the early 18th century, various hair and skin changes have been reported in severely malnourished children globally. We aimed to describe the frequency and types of skin conditions in children admitted with acute illness to Queen Elizabeth Central Hospital, Blantyre, Malawi across a spectrum of nutritional status and validate an existing skin assessment tool. METHODS: Children between 1 week and 23 months of age with acute illness were enrolled and stratified by anthropometry. Standardised photographs were taken, and three dermatologists assessed skin changes and scored each child according to the SCORDoK tool. RESULTS: Among 103 children, median age of 12 months, 31 (30%) had severe wasting, 11 (11%) kwashiorkor (nutritional oedema), 20 (19%) had moderate wasting, 41 (40%) had no nutritional wasting and 18 (17%) a positive HIV antibody test. Six (5.8%) of the included patients died. 51 (50%) of children presented with at least one skin change. Pigmentary changes were the most common, observed in 35 (34%), with hair loss and bullae, erosions and desquamation the second most prevalent skin condition. Common diagnoses were congenital dermal melanocytosis, diaper dermatitis, eczema and postinflammatory hyperpigmentation. Severe skin changes like flaky paint dermatosis were rarely identified. Inter-rater variability calculations showed only fair agreement (overall Fleiss' kappa 0.25) while intrarater variability had a fair-moderate agreement (Cohen's kappa score of 0.47-0.58). DISCUSSION: Skin changes in hospitalised children with an acute illness and stratified according to nutritional status were not as prevalent as historically reported. Dermatological assessment by means of the SKORDoK tool using photographs is less reliable than expected.

Under-five protein energy malnutrition admitted at the University of Nigeria Teaching Hospital, Enugu: a 10 year retrospective review.

OBJECTIVE: To determine the prevalence, risk factors, co-morbidities and case fatality rates of Protein Energy Malnutrition (PEM) admissions at the paediatric ward of the University of Nigeria Teaching Hospital Enugu, South-east Nigeria over a 10 year period. DESIGN: A retrospective study using case Notes, admission and mortality registers retrieved from the Hospital's Medical Records Department. SUBJECTS: All children aged 0 to 59 months admitted into the hospital on account of PEM between 1996 and 2005. RESULTS: A total of 212 children with PEM were admitted during the period under review comprising of 127 (59.9%) males and 85 (40.1%) females. The most common age groups with PEM were 6 to 12 months (55.7%) and 13 to 24 months (36.8%). Marasmus (34.9%) was the most common form of PEM noted in this review. Diarrhea and malaria were the most common associated co-morbidities. Majority (64.9%) of the patients were from the lower socio-economic class. The overall case fatality rate was 40.1% which was slightly higher among males (50.9%). Mortality in those with marasmic-kwashiokor and in the unclassified group was 53.3% and 54.5% respectively. CONCLUSION: Most of the admissions and case fatality were noted in those aged 6 to 24 months which coincides with the weaning period. Marasmic-kwashiokor is associated with higher case fatality rate than other forms of PEM. We suggest strengthening of the infant feeding practices by promoting exclusive breastfeeding for the first six months of life, followed by appropriate weaning with continued breast feeding. Under-five children should be screened for PEM at the community level for early diagnosis and prompt management as a way of reducing the high mortality associated with admitted severe cases.

Risk of Chronic Disease after an Episode of Marasmus, Kwashiorkor or Mixed-Type Severe Acute Malnutrition in the Democratic Republic of Congo: The Lwiro Follow-Up Study.

Background: Long-term impact of different forms of severe acute malnutrition (SAM) in childhood on the emergence of noncommunicable diseases (NCDs) is poorly known. Aim: To explore the association between subtypes of SAM during childhood, NCDs, and cardiovascular risk factors (CVRFs) in young adults 11 to 30 years after post-SAM nutritional rehabilitation. Methods: In this follow-up study, we investigated 524 adults (mean age 22 years) treated for SAM during childhood in eastern Democratic Republic of the Congo (DRC) between 1988 and 2007. Among them, 142 had a history of marasmus, 175 of kwashiorkor, and 207 had mixed-form SAM. These participants were compared to 407 aged- and sex-matched control adults living in the same community without a history of SAM. Our outcomes of interest were cardiometabolic risk markers for NCDs. Logistic and linear regressions models were sued to estimate the association between subtype of SAM in childhood and risk of NCDs. Results: Compared to unexposed, former mixed-type SAM participants had a higher adjusted ORs of metabolic syndrome [2.68 (1.18; 8.07)], central obesity [1.89 (1.11; 3.21)] and low HDL-C (High-density lipoprotein cholesterol) [1.52 (1.08; 2.62)]. However, there was no difference between groups in terms of diabetes, high blood pressure, elevated LDL-C (low-density lipoprotein cholesterol) and hyper TG (hypertriglyceridemia) and overweightness. Former mixed-type SAM participants had higher mean fasting glucose [3.38 mg/dL (0.92; 7.7)], reduced muscle strength [−3.47 kg (−5.82; −1.11)] and smaller hip circumference [−2.27 cm (−4.24; −0.31)] compared to non-exposed. Regardless of subtypes, SAM-exposed participants had higher HbA1c than unexposed (p < 0.001). Those with a history of kwashiorkor had cardiometabolic and nutritional parameters almost superimposable to those of unexposed. Conclusion: The association between childhood SAM, prevalence of NCDs and their CVRFs in adulthood varies according to SAM subtypes, those with mixed form being most at risk. Multicenter studies on larger cohorts of older participants are needed to elucidate the impact of SAM subtypes on NCDs risk.

Dietary intake of sulfur amino acids and risk of kwashiorkor malnutrition in eastern Democratic Republic of the Congo.

BACKGROUND: Kwashiorkor is an often-fatal type of severe acute malnutrition affecting hundreds of thousands of children annually, but whose etiology is still unknown. Evidence suggests inadequate sulfur amino acid (SAA) status may explain many signs of the condition but studies evaluating dietary protein intake in relation to the genesis of kwashiorkor have been conflicting. We know of no studies of kwashiorkor that have measured dietary SAAs. OBJECTIVES: We aimed to determine whether children in a population previously determined to have high prevalence of kwashiorkor [high-prevalence population (HPP)] have lower dietary intakes of SAAs than children in a low-prevalence population (LPP). METHODS: A cross-sectional census survey design of 358 children compared 2 previously identified adjacent populations of children 36-59 mo old in North Kivu Province of the Democratic Republic of the Congo. Data collected included urinary thiocyanate (SCN), cyanogens in cassava-based food products, recent history of illness, and a 24-h quantitative diet recall for the child. RESULTS: The HPP and LPP had kwashiorkor prevalence of 4.5% and 1.7%, respectively. A total of 170 children from 141 households in the LPP and 169 children from 138 households in the HPP completed the study. A higher proportion of HPP children had measurable urinary SCN (44.8% compared with 29.4%, P < 0.01). LPP children were less likely to have been ill recently (26.8% compared with 13.6%, P < 0.01). Median [IQR] intake of SAAs was 32.4 [22.9-49.3] mg/kg for the LPP and 29.6 [18.1-44.3] mg/kg for the HPP (P < 0.05). Methionine was the first limiting amino acid in both populations, with the highest risk of inadequate intake found among HPP children (35.1% compared with 23.6%, P < 0.05). CONCLUSIONS: Children in a population with a higher prevalence of kwashiorkor have lower dietary intake of SAAs than children in a population with a lower prevalence. Trial interventions to reduce incidence of kwashiorkor should consider increasing SAA intake, paying particular attention to methionine.

Understanding the Mothers of Children with Spina Bifida and Hydrocephalus in Tanzania.

OBJECTIVE: To identify if there are cultural, medical, educational, economic, nutritional and geographic barriers to the prevention and treatment of spina bifida and hydrocephalus. METHODS: The mothers of infants with spina bifida and hydrocephalus admitted to Muhimbilli Orthopaedic Institute, Dar Es Salaam, Tanzania, between 2013 and 2014 were asked to complete a questionnaire. A total of 299 infants were identified: 65 with myelomeningoceles, 19 with encephaloceles, and 215 with isolated hydrocephalus. The questionnaire was completed by 294 of the mothers. RESULTS: There was a high variation in the geographic origin of the mothers. Approximately 85% traveled from outside of Dar Es Salaam. The mean age was 29 (15-45) years old with a parity of 3 (1-10). The rates of consanguinity, obesity, antiepileptic medication, HIV seropositivity, and family history were 2%, 13%, 0%, 2%, and 2%, respectively. A maize-based diet was found in 84%, and only 3% of woman took folic acid supplementation, despite 61% of mothers stating that they wished to conceive another baby. Unemployment was high (77%), a low level of education was common (76% not attended any school or obtaining a primary level only), and 20% were single mothers. Hospital only was the preferred method of treatment for 94% of the mothers, and 85% of the babies were born in a hospital. CONCLUSIONS: Our study highlights some of the cultural, educational, geographic, nutritional, and economic difficulties in the prevention and management of spina bifida and hydrocephalus in Tanzania.

Assessment of Myocardial Function in Kenyan Children With Severe, Acute Malnutrition: The Cardiac Physiology in Malnutrition (CAPMAL) Study.

Importance: Mortality among African children hospitalized with severe malnutrition remains high, with sudden, unexpected deaths leading to speculation about potential cardiac causes. Malnutrition is considered high risk for cardiac failure, but evidence is limited. Objective: To investigate the role of cardiovascular dysfunction in African children with severe, acute malnutrition (SAM). Design, Setting, and Participants: A prospective, matched case-control study, the Cardiac Physiology in Malnutrition (CAPMAL) study, of 88 children with SAM (exposed) vs 22 severity-matched patients without SAM (unexposed) was conducted between March 7, 2011, and February 20, 2012; data analysis was performed from October 1, 2012, to March 1, 2016. Exposures: Echocardiographic and electrocardiographic (ECG) recordings (including 7-day Holter monitoring) at admission, day 7, and day 28. Main Outcomes and Measures: Findings in children with (cases) and without (controls) SAM and in marasmus and kwashiorkor phenotypes were compared. Results: Eighty-eight children (52 with marasmus and 36 with kwashiorkor) of the 418 admitted with SAM and 22 severity-matched controls were studied. A total of 63 children (57%) were boys; median age at admission was 19 months (range, 12-39 months). On admission, abnormalities more common in cases vs controls included severe hypokalemia (potassium <2.5 mEq/L) (18 of 81 [22%] vs 0%), hypoalbuminemia (albumin level <3.4 g/dL) (66 of 88 [75%] vs 4 of 22 [18%]), and hypothyroidism (free thyroxine level <0.70 ng/dL or thyrotropin level >4.2 mU/L) (18 of 74 [24%] vs 1 of 21 [5%]) and were associated with typical electrocardiographic changes (T-wave inversion: odds ratio, 7.3; 95% CI, 1.9-28.0; P = .001), which corrected as potassium levels improved. Fourteen children with SAM (16%) but no controls died. Myocardial mass was lower in cases on admission but not by day 7. Results of the Tei Index, a measure of global cardiac function, were within the reference range and similar in cases (median, 0.37; interquartile range [IQR], 0.26-0.45) and controls (median, 0.36; IQR, 0.28-0.42). Echocardiography detected no evidence of cardiac failure among children with SAM, including those receiving intravenous fluids to correct hypovolemia. Cardiac dysfunction was generally associated with comorbidity and typical of hypovolemia, with low cardiac index (median, 4.9 L/min/m2; IQR, 3.9-6.1 L/min/m2), high systemic vascular resistance index (median, 1333 dyne seconds/cm5/m2; IQR, 1133-1752 dyne seconds/cm5/m2), and with few differences between the marasmus and kwashiorkor manifestations of malnutrition. Seven-day continuous ECG Holter monitoring during the high-risk initial refeeding period demonstrated self-limiting significant ventricular arrhythmias in 33 of 55 cases (60%) and 6 of 18 controls (33%) (P = .049); none were temporally related to adverse events, including fatalities. Conclusions and Relevance: There is little evidence that African children with SAM are at greater risk of cardiac dysfunction or clinically significant arrhythmias than those without SAM or that marasmus and kwashiorkor differed in cardiovascular profile. These findings should prompt a review of current guidelines.

Lost in Aggregation: The Geographic Distribution of Kwashiorkor in Eastern Democratic Republic of the Congo.

BACKGROUND: Kwashiorkor is a major classification of severe acute malnutrition whose etiology remains elusive. It is estimated to affect hundreds of thousands of children annually, but no accurate global prevalence figures are available. Little is known how prevalence varies within populations, an important undocumented aspect of kwashiorkor obscured by the aggregation of prevalence or incidence of the condition across large populations and geographic areas. OBJECTIVE: To estimate the prevalence of kwashiorkor in select neighboring villages of the eastern Democratic Republic of the Congo (DRC) and assess if prevalence can vary dramatically among neighboring villages. METHODS: An anthropometric census survey evaluated 1328 children aged 12 to 59 months within all 19 villages in one health area of eastern DRC, recording all cases of kwashiorkor, diagnosed by bipedal pitting edema. RESULTS: Village-level prevalence of kwashiorkor in the study area varied from 0% to 14.9%. Interviews with health services staff in the study area and across 2 provinces confirmed that current differences in prevalence reflect a long-term pattern and are a common feature of kwashiorkor throughout this region. CONCLUSIONS: Aggregation of kwashiorkor prevalence and incidence data across large populations or geographic regions poses several risks to understanding the epidemiology of kwashiorkor. If clustering of kwashiorkor is not taken into account, (1) nutritional crises in particular villages may go undetected; (2) the real effect of interventions may be underestimated; (3) interventions may be inappropriately targeted, leading to reduced coverage, efficacy, and cost-efficiency; and (4) important insights into the root causes of kwashiorkor may be lost.

What's new? Investigating risk factors for severe childhood malnutrition in a high HIV prevalence South African setting.

AIM: To identify risk factors for severe childhood malnutrition in a rural South African district with a high HIV/AIDS prevalence. DESIGN: Case-control study. SETTING: Bushbuckridge District, Limpopo Province, South Africa. PARTICIPANTS: 100 children with severe malnutrition (marasmus, kwashiorkor, and marasmic kwashiorkor) were compared with 200 better nourished (>-2 SD weight-for-age) controls, matched by age and village of residence. Bivariate and multivariate analyses were conducted on a variety of biological and social risk factors. RESULTS: HIV status was known only for a minority of cases (39%), of whom 87% were HIV positive, while 45% of controls were stunted. In multivariate analysis, risk factors for severe malnutrition included suspicion of HIV in the family (parents or children) (OR 217.7, 95% CI 22.7-2091.3), poor weaning practices (OR 3.0, 95% CI 2.0-4.6), parental death (OR 38.0, 95% CI 3.8-385.3), male sex (OR 2.7, 95% CI 1.2-6.0), and higher birth order (third child or higher) (OR 2.3, 95% CI 1.0-5.1). Protective factors included a diverse food intake (OR 0.53, 95% CI 0.41-0.67) and receipt of a state child support grant (OR 0.44, 95% CI 0.20-0.97). A borderline association existed for family wealth (OR 0.9 per unit, 95% CI 0.83-1.0), father smoking marijuana (OR 3.9, 95% CI 1.1-14.5), and history of a pulmonary tuberculosis contact (OR 3.2, 95% CI 0.9-11.0). CONCLUSIONS: Despite the increasing contribution of HIV to the development of severe malnutrition, traditional risk factors such as poor nutrition, parental disadvantage and illness, poverty, and social inequity remain important contributors to the prevalence of severe malnutrition. Interventions aiming to prevent and reduce severe childhood malnutrition in high HIV prevalence settings need to encompass the various dimensions of the disease: nutritional, economic, and social, and address the prevention and treatment of HIV/AIDS.

Therapeutic feeding at a rural hospital in Zimbabwe.

OBJECTIVE: The purpose of this audit was to review treatment outcomes of participants in the Cooperazione e sviluppo/Cooperation and Development (CESVI), Therapeutic Feeding Programme (TFP) (i.e., death vs cure vs absconded) and to make recommendations for improving this and other similar programmes. DESIGN: This study was a retrospective chart review. The charts of all patients admitted to the TFP from 1 January 2005 to 31 December 2005 were analyzed. SETTING: The Salvation Army Howard Hospital is a district hospital in rural Zimbabwe. The hospital provides both inpatient and outpatient paediatric care. SUBJECTS: 132 consecutive children were enrolled in the TFP in 2005. INTERVENTION: The objectives of the TFP included identification of children with severe malnutrition; treating complications associated with severe malnutrition and prescribing appropriate dietary treatment. MAIN OUTCOME MEASURES: The main outcome of interest was whether TFP participants died, were cured, or absconded. We assessed factors that may be associated with these outcomes such as age, gender, comorbidities and length of stay. RESULTS: Female children and children with marasmus were more likely to abscond from the programme than male children and children with kwashiorkor (p = 0.041, 0.039 respectively). The majority of children who died while in the programme did so within the first week of their admission. The majority of children who were cured while in the programme achieved this goal after two weeks of hospitalization (p < 0.0001). CONCLUSION: Given the contextual factors in rural African settings that could potentially impede the healthy growth and development of children, this review has produced programmatic recommendations and suggestions for future research directions.

Influence of malnutrition upon all-cause mortality among children in Swaziland.

OBJECTIVE: To analyze the effect of the type of malnutrition, sex, age and the presence of edema upon all-cause mortality in children under 5 years of age. MATERIAL AND METHODS: A cross-sectional study was conducted during 2010 and 2011 in Swaziland. Sex, age, weight and height were taken to classify nutritional status according to the 2006 WHO growth standards: stunting (low height for age), wasting (low weight for height or low body mass index for age) and underweight (low weight for age). The sample (309 boys and 244 girls under 5 years of age) was analyzed by sex and age groups (under and equal/over 12 months). The association between variables was evaluated using the χ2 test. Cox regression analysis (HR, 95% CI) was used to assess the likelihood of mortality. RESULTS: The mortality risk in malnourished children under one year of age was lower among females and increased in the presence of severe edema. Wasting combined with underweight increased the mortality risk in children under 12 months of age 5-fold, versus 11-fold in older children. The combination of stunting, wasting and underweight was closely associated to mortality. Stunting alone (not combined with wasting) did not significantly increase the mortality risk. CONCLUSIONS: Sex, severe edema and wasting are predictors of mortality in malnourished children. Regardless of these factors, children with deficiencies referred to weight for height and weight for age present a greater mortality risk in comparison with children who present stunting only.

The effect of family structure on a sample of malnourished urban Nigerian children.

This study focused on the role of family structure in 458 malnourished children under five years of age clinically diagnosed with protein-energy malnutrition (PEM), kwashiorkor, and marasmus. The majority of these children were of higher birth order (3rd child and higher): 63.2% based on the mother's parity and 56.4% based on the father's parity. More than half (54.8%) of the malnourished children's mothers were the first wives of their respective husbands. About 43.9% of the children's fathers were urban danfo (public minibus transport) drivers. Half (51.5%) of the mothers who claimed to be single opted into single status and were mostly from polygamous households, but 87.6% of the children were from polygamous families, of which 18.6% of the mothers had divorced. Only 27.7% of the children lived with both parents; 40.4% lived with their grandparents, and 37.8% were the financial responsibility of their grandparents. We observed an association between children treated for malnutrition and father's occupation, parents' marital status, mothers' seniority among other wives, and source of financial responsibility for the children.

Prevalence of aflatoxins in blood and urine of Egyptian infants with protein-energy malnutrition.

The aim of the present work was to study the presence of aflatoxins in blood and urine of infants with protein-energy malnutrition (PEM). The study was conducted on 60 infants, 30 with kwashiorkor and 30 with marasmus, with 10 age-matched healthy infants studied as a control group. Complete blood count, liver function tests, and determination of the level of aflatoxins (B1, B2, G1, G2, M1, M2, G2a, B3, GM1, P, and aflatoxicol R0) in blood and urine were carried out in all studied infants. Serum aflatoxins were detected in more infants with kwashiorkor (80%) than in those with marasmus (46.7%). The mean serum levels of total aflatoxins, AFB1, AFG1, and AFB2a, were significantly higher in infants with kwashiorkor (p <.001). Aflatoxin B1 (AFB1) was the most commonly detected type. The prevalence of aflatoxin excretion in the urine of infants with kwashiorkor was 80%, a higher value than that in infants with marasmus (46.7%). The mean urinary concentration of total aflatoxins followed the same pattern of distribution (p < .052). There were no significant differences between groups in the mean urinary concentrations of AFB1, AFG1, AFB2a, AFM1, and AFG2a. Aflatoxins were not detected in any of the serum or urine samples of the control group. Aflatoxins are highly prevalent in this study population and show a high degree of correlation with severe PEM.

Bacterial isolates in severely malnourished children at Kenyatta National Hospital, Nairobi.

OBJECTIVES: To identify bacterial isolates and determine antibiotic sensitivity pattern in children with severe Protein Energy Malnutrition (PEM) presenting at the Paediatric Filter Clinic (PFC) of Kenyatta National Hospital (KNH). DESIGN: Hospital based cross-sectional survey. SETTING: Paediatric Filter Clinic of Kenyatta National Hospital (KNH), a tertiary level teaching institution for the University of Nairobi, Kenya. SUBJECTS: Children between two and sixty months presenting at the hospital outpatient filter clinic with severe malnutrition. RESULTS: Ninety-one children, forty six female and forty five males, were recruited for the study. Of these, sixty had Marasmus, twenty Kwashiorkor and eleven Marasmic-Kwashiorkor. HIV serology was positive in 43% of study subjects. There were 30 bacterial isolates from 26 subjects. Ten bacterial isolates were gram positive and twenty gram negative. Isolation rates did not vary by HIV serological status. Twenty one out of the 30 isolates were from blood culture. About 1/3 of the gram positive isolates were coagulase negative staphylococci, largely resistant to commonly used antibiotics such as Erythromycin, Ampicillin, Cotrimoxazole, Chloramphenicol and even Oxacillin. More than half demonstrated resistance to commonly used oral antibiotics while 80% of all gram positive and negative isolates were sensitive to Ciprofloxacin. Aminoglycosides, Gentamicin and Amikacin, and third generation Cephalosporins, Ceftriaxone and Ceftazidime, were found to be effective against most gram-negative isolates. CONCLUSION: Nearly a third (28.9%) of children admitted with severe malnutrition at KNH have concomitant severe bacterial infections; primarily manifesting as bacteraemia. Gram-negative agents are responsible for most severe bacterial infections in children admitted at the KNH, regardless of their HIV serological status. Whenever possible, blood culture should be included in the initial septic screening of severely malnourished children at KNH. In the absence of culture and sensitivity information, ciprofloxacin should be considered among the first line options in the empirical treatment of severe bacterial infections among these children. Clinical trials to further evaluate in-vivo effectiveness of various single or combination antibiotics are recommended.

Kwashiorkor in North America.

The controversy regarding the relative importance of protein vs energy deficiency in the genesis of kwashiorkor has not been resolved by studies of protein-energy malnutrition (PEM) in developing countries. Cases of edematous PEM (n = 29) in North America on the other hand provide clear indications that protein deficiency is an essential prerequisite for the development of kwashiorkor and marasmic kwashiorkor. Energy intakes may vary from low to high and the main source of energy may be carbohydrate or fat. These findings are in keeping with experimental evidence that a low ratio of protein to energy disrupts the usual hypometabolic response to dietary deficiency and leads to hypoalbuminemia and consequent edema. Protein supplements should be a part of programs aimed at preventing kwashiorkor.

Protein and calorie malnutrition among preschool Navajo Indian children, a follow-up.

A follow-up study was conducted on the infant and child-feeding programs to determine the prevalence of protein and calorie malnutrition among preschool Navajo Indian children. These programs were introduced on the reservation in 1968. The numbers of patients admitted to the Public Health Service Indian Hospital, in Tuba City, Arizona, with deficits in weight for their chronological ages, marasmus, and kwashiorkor were compared during two 5-year-periods, 1963 to 1967 and 1969 to 1973. The results show an 18% reduction in the total number of patients under 5 years of age admitted to the hospital and a 39% reduction in the number of patients admitted with deficits in weight for their chronological ages. Marasmus has practically disappeared, with only two cases described since the end of fiscal 1969. The number of cases of kwashiorkor has also decreased by 50%, mainly in the last 4 years. The height and weight data on 1,462 Head Start children from all over the reservation were measured in September 1973, and these measurements were compared with data obtained in September 1967. While they still show a significant deviation from the Boston growth curves, there is a definite improvement from 1967 to 1973. This improvement was especially noticeable in height. Thirty percent of the girls and 30% of the boys fell below the 3rd percentile for Boston in 1967. In 1973, these figures were 11% and 16%, respectively. In the case of the girls in 1973, the numbers below the 3rd percentile are significantly smaller for younger girls than for the older girls, suggesting that the growth retardation occurred in the first 2 years of life, and that the older children had not received the full benefit of the free infant formula feeding programs. This trend, however, was not present in boys. It is concluded that the infant and child feeding programs have contributed to improved growth among Navajo preschool children. At the same time, concern is expressed that these feeding programs will be replaced by a Food Stamp Program and that the gains made will be reversed. Concern is also expressed for the regressive effects of inflation and rising food prices and the effects they will have on the nutritional status of the Navajo people.