Influence of nutritional status on child mortality in rural Zaire.

Although the association between nutritional status and mortality risk is obvious for extreme malnutrition, the issue is not so clear for mild to moderate undernutrition. We have investigated this association in children of 0-5 years in the rural area of Bwamanda, Zaire, where an integrated development project, with good medical facilities, has operated for 20 years. A random cluster sample of 5167 children was taken; newborn infants and immigrants were included at six quarterly survey rounds from October, 1989, until February, 1991. All surveys included clinical and anthropometric assessment of nutritional status. Deaths were recorded up to April, 1992; there were 246 deaths. Marasmus, kwashiorkor, and other causes of death were defined by the verbal autopsy method and checked against medical records kept at the central hospital and the peripheral dispensaries. As expected, we found an increased risk of death in severe malnutrition. When deaths directly attributed to marasmus or kwashiorkor were excluded, mild to moderate stunting or wasting were not associated with higher mortality in the short term (within 3 months of the previous study round) or in the long term (from 3-30 months after study entry). The commonest causes of death were malaria and anaemia. Extreme marasmus and kwashiorkor caused 16% of deaths, and are important causes of death even in this favoured area with an integrated development project. Nutritional interventions should be targeted more selectively so that children with moderate malnutrition can be protected from progression to marasmus or kwashiorkor.

Screening for marasmus: a discriminant analysis as a guide to choose the anthropometric variables.

In a cross-sectional study, children 0-6 yr of age from eight different population groups in Africa and Asia were examined. Clinical assessment defined 8750 children as being well nourished and 194 as having marasmus. Height, weight, arm circumference (AC), and triceps skinfold thickness were measured; the latter two measurements and the clinical assessment were done by the same observer. Based on data from normal children, local growth curves were computed for each group. Each child's growth was expressed in standard deviation scores (SDS) of his own group. On the basis of the results of a discriminant analysis, all variables were ranked by their decreasing power to discriminate between normal and marasmic children. For 83% of the children one measurement (AC/age) is sufficient to classify them definitely; for the others several variables are needed. This strategy yields an overall sensitivity of 80%, a specificity of 97%, and a positive predictive value of 38%.

PIP: The definition of a malnourished child is commonly based on anthropometric measurements. In order to define an optimal selection procedure, this study uses a discriminant analysis to choose the most appropriate anthropometric variables for distinguishing clinically defined marasmic children from clinically normal children. This selection procedure would be a better alternative for routine practice in health clinics than the commonly used procedures of weight for age or weight for height. In a cross-sectional study, children 0-6 years of age from 8 different population groups in Africa and Asia were examined. Clinical assessment defined 8750 children as being well nourished and 194 as having marasmus. Height, weight, arm circumference, and triceps skinfold thickness were measured; the latter 2 measurements and the clinical assessment were done by the same observer. Based on data from normal children, local growth curves were computed for each group. Each child's growth expressed in standard deviation scores of his own group. On the basis of the results of a discriminant analysis, all variables were ranked by their decreasing power to discriminate between normal and marasmic children. For 83% of the children 1 measurement (arm circumference/age) is sufficient to classify them definitely; for the others, several variables are needed. This strategy yields an overall sensitivity of 80%, a specificity of 97%, and a positive predictive value of 38%. Developing countries, where scarcity of resources is a daily reality, need uniformly efficient selection procedures in order to tackle their very common problem: marasmus. Using the clinical definition of marasmus as a substitute for morbidity and mortality, the proposed selection procedure is able to select children at risk with high sensitivity and a very low number of false positives.

Local versus universal growth standards: the effect of using NCHS as universal reference.

Lack of local references has brought many fieldworkers to use the NCHS reference or other Western standards to assess the nutritional status of children in different developing countries. Cross-sectional data from 6631 children between 0 and 6 years of age, without signs of protein-energy malnutrition, were collected by the same observer in four different geographical areas in Africa and Asia. For each of the four geographical areas, local growth curves were drawn and compared with the NCHS reference. The local curves shows clear heterogeneity, and the values at different ages are not a constant proportion of the NCHS. These observations are in favour of using local standards in the nutritional screening of children in order to develop efficient and effective nutritional programmes.

Nutritional anthropometry in children from 0 to 6 years of age in different geographical areas.

Anthropometric data of 12,769 clinically normal children 0-6 years of age from 12 different geographical areas in Africa and Asia are presented. Height, weight, arm circumference and triceps skinfold thickness were measured and presented for age. Derived variables, as muscle circumference, muscle area and muscle proportion-for-age were computed. Weight, arm circumference and muscle area-for-height were calculated. Comparison of these 12 cross-sectional growth patterns shows important differences between groups. The observed differences show that height-for-age, weight-for-age, arm circumference-for-age and weight-for-height are not sufficient to describe adequately and to interpret the variations in nutritional status.

Arm muscle and fat in the evaluation of nutritional status. A study of African pre-school children in three different environments.

Anthropometric variables were collected in 10230 clinically healthy children under 5 years of age. The children belong to three African tribes living in different environments. The conventional anthropometric methods of screening children nutritionally at risk were used and their validity is scrutinised. It is shown that, to assess nutritional condition, arm muscle area and arm fat area add essential information to data on weight-for-age, weight-for-height and arm circumference-for-age. It is suggested that the choice of anthropometric methods and standards must be adapted to the ecological situation.