Stress and incidence of bleeding in children and adolescents with hemophilia.

OBJECTIVE: To examine the relationship of stress and incidence of bleeding in boys with hemophilia. STUDY DESIGN: We conducted a 6-month longitudinal study of 97 subjects (ages 4 to 16 years) from six hemophilia centers. Diaries recorded bleeding episodes (including site and history of previous trauma) and both child and parent daily stress. Parent and child stressful life event measures were obtained monthly. Socioeconomic data and clotting factor level were determined at enrollment. Logistic regression models examined the influence of recent stress on likelihood of bleeding on each day, controlling for factor level and socioeconomic data. We also determined associations of aggregated previous month's events with bleeding likelihood in the succeeding month. RESULTS: Fifty-eight percent of study participants had severe hemophilia. The sample population averaged nine bleeding episodes per 6 months; of these; two thirds of bleeding incidents occurred into joints and 44% after injury. Factor level strongly predicted bleeding incidence (p < 0.0001). Increased parent stress was associated with increased bleeding in general (odds ratio = 1.37, p < 0.003) and with injury (odds ratio = 1.65, p < 0.001), but not bleeding into joints. Similar findings followed parent reports of positive life events. Increased parent negative life events in 1 month were associated with increased bleeding in the succeeding month (p < 0.05). CONCLUSION: Short- and long-term parental stress may lead to increased bleeding incidence in hemophilia, although factor level much more strongly predicts bleeding.

The nutritional value of oat flour for very young children.

Whole groat flour was consumed by nine infants and young children as 22.5, 45, or 67% of total diet energy (one half of 6.4%, all of 6.4%, or all of 9.6% protein energy). Isonitrogenous and isoenergetic casein control diets were given. Apparent absorption of oat nitrogen (N) was consistently around 75% of intake (casein, 87%), but absorptions of oat energy, carbohydrate, and fat, as percentages of intake, decreased disproportionately as oat flour intake was doubled and then tripled. Apparent retentions were 39 +/- 5% of mixed oat-casein protein intake in the 22.5% diet, the preceding and following casein controls being 38 +/- 8% (NS) and 44.4% (p less than 0.05) of the intakes; 32 +/- 6% from oats in the 45% diet, controls 38 +/- 5 and 46 +/- 5% (both p less than 0.05), and 33 +/- 11% from oats in the 67% diet, controls, 36 +/- 9% (NS). Fasting plasma free total essential amino acid (TEAA) levels of children consuming 45% oats were low (562 +/- 119 mumol of TEAA/L) and did not change significantly after meals. Fasting molar proportions of individual essentials (millimoles of EAA per mole of TEAA) were similar to those from milk protein diets and did not vary significantly 3 and 4 h after feeding, suggesting that no individual amino acid, but rather protein digestibility, was first limiting to N retention. Oats are a satisfactory source of energy, protein, and fat for very young children and many infants.

Protein quality and oil digestibility of Lupinus mutabilis: metabolic studies in children.

The nutritional quality of lupins (Lupinus mutabilis) for infants and children was evaluated in two sets of balance studies. In the first the digestibility and protein quality of diets based on lupin flour, with and without methionine supplementation, were compared with those of a control diet consisting of casein, sucrose and vegetable oil. Apparent nitrogen absorption from lupin flour (81.8 and 84.3% of intake) was slightly but significantly less than that during casein control periods (87.2 and 86.8% of intake, P less than 0.05 and less than 0.001). Apparent nitrogen retention from unsupplemented lupin (15.6 +/- 5.8% of intake) was significantly less than that from casein in the corresponding control periods (29.8 +/- 4.9%, P less than 0.001); a small but significant (P less than 0.05) increase in nitrogen retention was observed during the control period following the lupin diet when compared with that preceding it. Methionine supplementation of lupin produced a marked improvement in apparent nitrogen retention (to 22.2 +/- 6.9%, P less than 0.05). In the second set of studies the digestibility of lupin oil was compared with that of a blend of soybean and cottonseed oils (50:50). Excretion of fecal fat (9.8 +/- 3.0% of intake) and fecal energy (6.7 +/- 1.2% of intake) with the diet containing lupin oil were similar to those observed with the control diet. Both the protein quality and oil digestibility of Lupinus mutabilis are very similar to those from soybeans processed in a similar manner. For certain countries the lupin could be a valuable source of protein and edible oil for human consumption.

Plasma free amino acids in children consuming lupin protein with and without methionine supplementation.

Plasma free amino acids were measured in the fasting state and 3 and 4 hours postprandially in children after 9 days consumption of diets in which lupin provided all of 6.4-6.7% protein kcal, either with supplementation of 2% (grams/gram protein) DL-methionine (L & Met, n = 9) or with an isonitrogenous amount of urea (L & U, n = 10). Fasting concentration of total amino acids (TAA) and of essential amino acids (TEAA) and the TEAA:TAA molar ratio did not differ between diets. Fasting Met concentration (15 +/- 4 mumol/liter) and the Met:TEAA ratio (0.021 +/- 0.005) were markedly depressed after 9 days of L & U. Supplementation with Met caused an expected increase of Met concentration (25 +/- 6 mumol/liter) and the Met:TEAA molar ratio (0.039 +/- 0.007) and a profound decrease of Thr concentration (119 +/- 28 to 77 +/- 22 mumol/liter) and Thr:TEAA (0.165 +/- 0.027 to 0.124 +/- 0.028). Postprandially after L ", Met and Met: TEAA did not change from their low fast ing values. After L rMet, Met and Met:TEAA increased significantly relative to fasting values. Threonine concentration increased but the Thr:TEAA ratio decreased significantly (0.124 +/- 0.028 to 0.111 +/- 0.027). These studies confirm Met as the first-limiting amino acid in lupin protein and suggest that Thr becomes limiting when Met is provided in adequate amounts.

[Digestibility and protein quality of quinua: comparative study of quinua (Chenopodium Quinoa) seed and flour in children]. / Digestibilidad y calidad proteínica de la quinua: estudio comparativo, en niños, entre semilla y harina de quinua.

Based on the hypothesis that the digestibility of quinua seed is the limiting factor in the utilization of nutrients from this staple, two quinua-based diets were prepared using quinua seeds and quinua flour. Theses diets were offered to children recovering from malnutrition. The digestibility and protein quality of the quinua diets were compared to those of a casein control diet by analyzing the children's metabolic balance. Results showed that digestibility of the quinua diets were compared to those of a casein control diet by analyzing the children's metabolic balance. Results showed that digestibility of the quinua seed is the limiting factor in the protein and energy utilization, and that milling improves significantly the digestibility of fat and carbohydrates. Findings also confirmed that the protein quality of quinua seeds is adequate for human consumption.

Determinants of growth among poor children: nutrient intake-achieved growth relationships.

Seven-day individual weighed dietary intakes and anthropometric measurements were determined in 123 children, 2 to 19 yr of age, from 26 poor families in Lima: each included one child who had been malnourished, six were adopting families. Heights and weights were converted to "ages" based on Boston reference data and local data, then to "quotients" as percentages of actual ages. Mineral and vitamin intakes were expressed as amounts per day and per 1000 kcal, calories and protein as percentages of FAO/WHO recommendations for age and height age and of modified recommendations based on size of Peruvian children. Regression analyses identified common sources of nutrients and greater dependence of intakes on body size than on age. Analysis of covariance for sex identified different nutrient-growth correlations. Polynomial regression analysis identified percentage protein from animal sources and percentage fat calories as having significant quadratic as well as linear correlations with achieved growth. In males, multiple regression analysis identified percentage protein from animal sources and beta-carotene intakes as strongly associated with achieved height and weight, and percentage fat calories as strongly associated with weight quotient/height quotient ratios. In females the correlations were not as strong, possibly because a significant percentage had reached the menarche some time before the survey and were probably no longer growing. Nevertheless, calorie intake, as a percentage of the recommendation for height age, was prominent in the regressions for height quotient and percentage fat calories in that for weight quotient. The very strong association of animal protein intake with male height, despite seemingly generous total protein intakes, is difficult to reconcile with current recommendations. The possible role of vitamin A (as beta-carotene) has potentially important implications for food policies.

Determinants of growth among poor children: relation of nutrient intakes to expenditure for food.

The growth status and the nutrient intakes of 123 children from 26 urban poor families in Peru were related to per capita expenditure for food. Children from six better off families were taller and heavier (p less than 0.001), with no difference in weight for height. They had significantly higher calorie and total protein intakes (as percentage of recommended) and higher intakes of animal protein, fat, calcium, carotene, riboflavin, and vitamin C. When macronutrient intakes were expressed as percentages of recommended calorie intakes, correcting for age and relative size, all of the increase in total protein intake was due to animal protein, vegetable protein remaining constant. Almost all of the increase in adequacy of total calories was due to increasing fat intakes, relatively much less to carbohydrate, and this only among the poor families. In this population, as more money becomes available to purchase food, there is an increase in animal protein and fat intakes, over an almost constant vegetable protein and carbohydrate intake. There is a simultaneous increase in consumption of fruits and vegetables, accounting for increases in the carotene and vitamin C intakes.

Determinants of growth among poor children: effect of expenditure for food on nutrient sources.

The effect of increasing expenditure on the nature and the amounts of foods consumed by children from an urban population was estimated by studying the diets of 111 children from 20 typically poor families and those of 12 children from six economically better off families who had a much more satisfactory growth status. Total calories and protein, fat, and carbohydrate calories were expressed as a fraction of each individual's estimated energy requirement, thus adjusting for sex, age, and size. No important sex differences were found. Calorie intake was 87.2 +/- 17.3% and 111.4 +/- 18.1% of requirement for the two groups, respectively. Differences were found between the groups in protein calories which were totally due to milk and meat. Differences in fat calories were due to milk, meat, and separated fats. There was no significant difference between groups in total carbohydrate calories, although there were shifts in its components with increasing expenditure. Regression analysis of calorie adequacies as a function of per capita expenditure for food, both in the poorer group and in the combined population, were performed and yielded highly significant (p less than 0.001) results. These were due to significant gradual increases in the consumption of milk, meat, separated fats, fruits and vegetables on top of an almost constant consumption of the staple cereals, roots and tubers.

Lactose malabsorption by premature infants: magnitude and clinical significance.

Sequential studies of breath hydrogen excretion in response to lactose feeding were carried out in 22 premature infants during the first seven weeks of life. Seventy-five percent of infants excreted H2 in breath during the first two weeks, 100% by the end of the third week. The peak H2 concentration and the five-hour mean breath H2 excretions were significantly related to lactose intake per day, lactose intake per feeding and postnatal age, though only lactose intake per day remained significant when all three variables were included in multiple regression analysis. Preprandial breath H2 concentration was inversely related to the frequency of feeding. Using the five-hour mean H2 excretion, it was estimated that 66% or more of ingested lactose entered the colon and was fermented. Throughout the studies stool patterns and rates of weight gain of the infants were normal. Premature infants normally malabsorb substantial amounts of lactose. The elevation of breath H2 in these infants apparently represents a successful adaptation of the colonic microflora to this physiologic malabsorption and should not be cause to modify the diet of an infant who is clinically well.

Nutritional management of chronic diarrhea and malnutrition: primary reliance on oral feeding.

PIP: The course of 61 infants admitted for treatment of chronic diarrhea and malnutrition was reviewed. 30 children had (M) marasmus, 18 (K) kwashiorkor, and 13 (MK) marasmic kwashiorkor. After initial rehydration, infants were managed with a predominantly oral nutrition regimen utilizing a formula based on whole protein (casein), vegetable oil, glucose, and sucrose. Intravenous fluids were required for 38 infants (62%) for a median duration of 6 days, principally for the delivery of antibiotics, although amino acids were added in many instances. Feedings were started at 25 kcal/kg/day and were increased 35 kcal/kg/day every other day until acceptable steady weight gain ensued, provided that stool ouput did not exceed 100-50 gm/day and stool character was improving. Infants with M and MK reached a maximum intake of 151 + or - 21 kcal/dg/day after 5 weeks of treatment. Weight gain had been occurring for 2 weeks prior to this time. Infants with K were purposely not advanced past 75 kcal/kg/day until edema had cleared; a maximum intake of 135 + or - 16 kcal/kg/day was reached at 5 weeks. Mean initial serum albumin concentration in these infants with K was 1.8 + or - 0.3 gm/day and required 20 + or - 13 and 53 + or - 24 days to exceed 2.0 and 3.6 gm/dl, respectively. 14 of the 61 infants were moribund on arrival and died within the first 3 days; the remaining 8 died of overwhelming infection (6 generalized and 2 pneumonia). Data suggest that once infection is controlled, infants with chronic diarrhea and malnutrition can usually be effectively managed by enteral feeding without resorting to parenteral alimentation.^ieng

Urban-rural differences in the growth of Peruvian children.

The growth characteristics of children from four villages in northern Peru were compared with those of poor urban children in the capital city, in whom short stature but generally satisfactory weight for height relationships after infancy had been demonstrated. Height for age and weight for age fell more rapidly during infancy in the rural than in the urban children of both sexes. Rural girls caught up with the urban girls in height during childhood but did not match them in weight until late adolescence. Their weight to height ratios were consistently lower after 1 year of age, most strikingly between 2 and 5 years of age, and did not approach or match those of the urban girls until adolescence. Rural boys did not catch up with the urban boys in height or weight (differences in height were not statistically significant between 6 and 10 years, however) and their ratios remained consistently lower until late adolescence, most strikingly in early childhood and during puberty. Such urban-rural and sex differences, if typical and current, might well call for very different remedial measures at different ages in each of the populations.

Effect of an episode of severe malnutrition and age on lactose absorption by recovered infants and children.

The degree of which the ability to absorb lactose can be regained after recovery from an acute episode of severe malnutrition is in doubt. Lactase activity was indirectly assessed by means of a standard lactose tolerance test (2 g lactose per kilogram of body weight) in 71 Peruvian Mestizo infants and children (age 5 to 55 months) who had suffered such an episode. All were studied just before discharge after several months of hospital rehabilitation, during which linear growth and weight gain had accelerated and signs of significant malabsorption of other nutrients had disappeared. Only 39% of the total group had a positive test (delta blood glucose greater than 25 mg/dl); there was a decreasing proportion of positive responders with increasing age. No difference in response attributable to type or severity of malnutrition was found. Comparison of the present data with previous data from children in the same community who had never been acutely malnourished suggests that acute malnutrition may hasten the permanent decline of lactase activity normally expected later in life.

Growth standards for poor urban children in nutrition studies.

In order to estimate the importance of a variety of environmental and dietary factors as determinants of growth in a group of 123 poor Peruvian urban children between 2 and 19 years old, we found it necessary to express anthropometric measurements in units that were not age- or sex-dependent. Height quotient and weight quotient for each child were calculated from height and weight ages derived from the 50th percentile of the Boston reference data for the appropriate sex. Only 5% of the children had heights above the Boston 50th percentile (height quotient greater than 100) and 18% had weights above the 50th percentile (weight quotient greater than 100), but 88% had weights that were appropriate or excessive for height (weight/height quotient greater than or equal to 1.00). Some CATch-up" gains in relative height and weight were apparent in preschool children but more impressive gains in both linear and ponderal growth, relative to the Boston data, were evident between 8 and 13.5 years in girls and 10 and 17 years in boys. When the same quotients were calculated for a much larger sample from the same socioceonomic level it seemed likely that this last peak was due to earlier puberty and sexual maturation, and that quotients derived from the Boston data would have different meanings at different ages, making them inappropriate for further statistical analysis. New quotients for the study population, derived from the larger Peruvian group, did not have sex- or age-dependent trends. Racial and regional differences in patterns of growth must be taken into account in the interpretation of anthropometric and nutritional data.

Oral iron absorption in infantile protein-energy malnutrition.

The ability of infants with protein-energy malnutrition to absorb iron was assessed using the serum iron response to a dose of ferrous sulfate providing 3 mg elemental iron per kg body weight. Responses were grouped as flat (delta serum Fe less than 30 microgram/dl), intermediate (30 to 100 microgram/dl), and normal (greater the 100 microgram/dl). Of 25 consecutively admitted children studied, seven had a flat, five an intermediate, and 13 a normal curve (mean delta serum Fe: 10 microgram/dl, 66 microgram/dl, and 175 microgram/dl, respectively). There were no differences among the three groups in hematocrit, fasting serum iron or transferrin saturation, severity of malnutrition, or evidence of other malabsorption sufficient to explain these differences. Although hematocrits, fasting serum iron, and transferrin saturations did not change appreciably during nutritional rehabilitation, all children with initially abnormal responses subsequently had normal tests.

Transient steatorrhea following episodes of mild diarrhea in early infancy.

Fecal fat excretion was studied after a mild episode of diarrhea in eight infants for whom adequate control data were available. Mean age of onset of diarrhea was 28 days. Duration of the episode, defined as the number of days until the infant was again feeding and libitum, averaged 5.1 days. Balance studies were carried out 3 to 13 days later. Mean fecal fat excretion rose from a prediarrhea value of 2.9 +/- 1.4 gm/day to 8.7 +/- 3.1 gm/day following diarrhea (P less than 0.001). Restudy of five infants one month later showed persistent steatorrhea in one. Mild transient steatorrhea may follow mild diarrhea in infancy and should be considered in infants who are slow to gain weight subsequent to an episode of diarrhea.

Postprandial glucose, insulin, free fatty acid and growth hormone responses in children consuming all the day's protein in one meal.

BLOOD GLUCOSE, INSULIN (IRI), growth hormone, and plasma free fatty acids (FFA) were determined in six children consuming a diet of uneven distribution of protein relative to energy (study period). Preprandial and postprandial samples surrounding the 8 AM protein-free feeding and the 3 PM feeding containing all the day's protein were compared with values obtained in the same children similarly sampled while consuming an isonitrogenous isoenergetic diet of even protein distribution (control period). After the 8 AM feeding during the study period there was a mean maximal rise of blood glucose at 30 min of 51 mg/dl compared with a rise of 16 mg/dl during the control period. Glucose remained significantly elevated above fasting values at 120 min during the study but not the control period. IRI response after the 8 AM feeding was significantly greater and suppression of FFA was more marked during the study than during the control period. Glucose concentration 30 min after the 3 PM feeding was significantly lower during the study period than during the control period. A peak value occurred at 60 min during the study period which was equal to the 30 min peak control value. Despite the slower elevation of blood glucose during the study period, IRI rose at 30 min, possibly related to a larger influx of amino acids from the protein-containing meal. FFA rose at 30 and 60 min and were then suppressed by the slowly rising blood glucose. Growth hormone after both meals while consuming both diets was variable but considered normal. The qualitative changes in glucose-IRI-FFA responses were for the most part attributable to differences in the test meals and suggested little long-term adaptation to the uneven protein distribution diet.