The Kingston Project. II. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: anthropometry.

Malnourished children (mean age 1.2 years) referred from public health clinics to a paediatric metabolic ward in Kingston, Jamaica, were enrolled for treatment in a community-based health care project and were randomly allocated to one of two groups. The first group was treated at home with metronidazole and then for 6 months using the standard health care provided from local clinics by community health aides. The second group was given the same drug and home treatment, but in addition received a high energy supplement of 3.31 MJ daily for 3 months. We have previously shown a significant advantage in both weight and height gain for a group given the same supplement in contrast with standard health care controls (Heikens et al., 1989, Eur. J. Clin. Nutr. 43, 145-160), and in this study test the addition of a drug treatment aimed at reducing malabsorbtion due to a possible microbial overgrowth of the small bowel in malnourished children. This paper reports anthropometric findings showing significant benefits from both the drug and nutritional treatments. Greatest gains were by the group given both treatments, but the group given the antibiotic treatment, without energy supplementation, also made better growth recovery than did controls. Only 8% of the children treated with metronidazole failed to respond to community-based intervention and were admitted to hospital, compared with 19% for the other groups (P < 0.05). These findings support targetted high-energy supplementation for the rehabilitation of moderately malnourished children receiving health clinic care, and suggest further that such programs should include antibiotic treatment directed at SBBO.

PIP: In 1985-86 in Jamaica, a community-based health care project randomly allocated 81 3-36 month old malnourished children from the slums of metropolitan Kingston to either a group receiving home health care/clinic-based care and a 5-day course of a broad spectrum antibiotic, metronidazole (20 mg/kg/day), for 6 months or a group receiving these same interventions and a high energy supplement (HES) (790 kcal) containing 20.6 gm protein for 3 months to test the effect of these interventions on anthropometric measures of growth. The researchers also wanted to determine whether metronidazole would overcome malabsorption of nutrients due to small bowel bacterial overgrowth. Children of both groups benefited considerably from the interventions. For example, significant improvements in weight occurred almost immediately followed by improvements in length, resulting in a significant improvement in the body mass index (BMI) (p = .0001). Children receiving both HES and metronidazole made significantly greater gains than those who only received HES (weight, p = .02; length, p = .0002; and BMI, p = .0001). A significantly greater proportion of children did not respond to treatment and had to be hospitalized for infections, especially respiratory infections, in the HES only group than did those in the HES and metronidazole group (19% vs. 8%; p .05). None of the children receiving metronidazole died. Reduced morbidity, absence of case fatalities, and anthropometric improvements support the belief that home visits by community health aides in combination with clinic-based health services providing HES and antibiotic treatment to moderately malnourished children can indeed rehabilitate them.

The Kingston Project. III. The effects of high energy supplement and metronidazole on malnourished children rehabilitated in the community: morbidity and growth.

In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65% of the sample were found to have additional illnesses at enrollment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic, treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group.

PIP: In 1985-86 in Jamaica, a community-based health care project randomly allocated 163 malnourished children (mean age 1.2 years) from the slums of greater Kingston to 1 of 4 groups: group visited at home by community health aides within the existing health service (HC); group receiving HC and a high energy supplement (HES) (790 kcal); group receiving HC and a 5-day course of abroad spectrum antibiotic, metronidazole, for 3 months; or group receiving HC, HES, and metronidazole. The researchers wanted to examine morbidity and to relate morbidity to the various interventions and growth velocity. 65% of all the children at enrollment suffered from an illness in addition to malnutrition, especially upper respiratory tract infections (URTIs). URTIs continued to be the most frequent illness in all groups throughout the 6-month study. Children receiving HES had significantly more gastroenteric infections, but this was not the case for those receiving metronidazole. Children receiving just HC suffered from morbidity more frequently and were ill for longer durations than the children in the other 3 groups (at 0-3 months, 96.2% vs. 74.3-92.9%, p .04; at 4-6 months, 96.2% vs. 74.3-82.1%, p .06; and 4-7 days, 46.2% vs. 2.9-5.7%, p .0001). Significant covariates of weight velocity were fever (p .0001), mucoid diarrhea (p .0001), and dysentery (p .0003). These illnesses had the same effect on weight velocity, even though their prevalences were different between treatment groups. The effect of cold and cough on weight velocity approached significance (p .052 and P .094, respectively). These findings showed that some illnesses greatly slowed weight gain in malnourished children. They also indicated that antibiotic use reduced the risk of gastroenteric infections in malnourished children, these infections having the most detrimental effect on weight gain.

The Kingston project. I. Growth of malnourished children during rehabilitation in the community, given a high energy supplement.

Moderate and severely malnourished children referred from public health clinics in Kingston, Jamaica, to a metabolic ward were treated at home for 6 months using community health aides and standard health care similar to that offered by the local health service. A randomly selected subgroup of these children received in addition a daily high energy food supplement of 3.31 MJ for the first 3 months of the 6-month intervention period. Both groups received full nutritional and medical surveillance and care. The supplemented gained significantly more in weight than the unsupplemented children, but the advantage was lost once supplementation ceased. They also gained significantly more in length and this gain was maintained at the end of the intervention period. However, this increase in length, without continuing superior weight gain, left the supplemented children significantly more wasted than the unsupplemented, as measured by a body mass index (weight divided by height squared). These findings remained stable after interactions with morbidity measures had been taken into account. It is concluded that (1) high-energy supplementation assists rehabilitation of malnourished children brought to public health service clinics and treated in the community, and (2) supplementation should be continued until there is catch-up growth to within an acceptable distance from expected length for age.

Longitudinal study of growth and development of young Jamaican children recovering from severe protein-energy malnutrition.

The developmental level and nutritional status of a group of 17 children aged between six and 24 months who were admitted to hospital with severe protein-energy malnutrition were studied from admission to hospital until 36 months after returning home. They were compared with a group of 14 adequately nourished children of similar age who had been admitted to hospital for other reasons. Initially the malnourished group were markedly behind the controls in developmental level, and they failed to reduce their deficit in hospital. Over the following 36 months they showed a gradual improvement relative to the controls in developmental level, height and head circumference, but were still significantly behind at the end of the study. In contrast, they caught up in weight for height by one month after returning home. When length of stay in hospital, age at admission, birthweight, mother's IQ and home background measures were taken into account, the direction of the differences between the two groups and significance levels were unchanged.

Effect of long-term psychosocial stimulation on mental development of severely malnourished children.

The effect of adding psychosocial stimulation to the treatment of severely malnourished children was studied by comparing the developmental levels (DQs) of the children with those of two other groups of children--an adequately nourished group with diseases other than malnutrition and a second malnourished group who received standard hospital care only. The intervention children underwent structured play sessions daily in hospital and weekly for 6 months after discharge; mothers were also shown how to play with them. The non-intervention malnourished group showed a marked deficit in DQ compared with the adequately nourished group throughout the study period. The intervention group made significant improvements in DQ in hospital and continued to do so after discharge. By 6 months they were significantly ahead of the non-intervention malnourished group, and were no longer significantly behind the adequately nourished group.