Long-stay versus short-stay hospital treatment of children suffering from severe protein-energy malnutrition

OBJECTIVE: To contrast early discharge versus attempted full nutritional rehabilitation in hospital of children suffering from severe protein-energy malnutrition (PEM). DESIGN: Field experiment, two-way analysis of variance with one between group (short- versus long-stay) and one repeated measures factor (admission, then 12, 18, 24, 30 and 36 months post-admission). Covariates introduced. SETTING: Primary health care, Kingston, Jamaica. SUBJECTS: n = 81; mean age 11 months; 79 contribute longitudinal data; 44 every measurement. INTERVENTIONS: When concurrent illnesses had been treated and normal feeding re-established (weight gain 5 g/kg.day-1), subjects were randomly allocated to short-stay (SS) or long-stay (LS) group. LS retained in hospital for full nutritional rehabilitation mean 40 days. SS discharged immediately (mean 18 days) for standard Health Service care at home for 6 months plus high-energy supplement (3.31 MJ with 20.6 g protein daily) for first 3 months. After discharge LS received 6 months home care, but without supplementation. RESULTS: Significant advantages for LS group on NCHS weight & length for age at discharge, and at 12, 18, 24 and for length also 30 months (P< 0.05 tp P < 0.001). Weight advantage peaked at 12 and 18 months, length later at 18 and 24 months. CONCLUSIONS: Contrary to earlier reports, full nutritional rehabilitation can be achieved in hospital for children suffering from PEM. Although in the long-term both groups move towards expected levels in their home community, a significant advantage maintained for 2 years is developmentally advantageous during the critical time after weaning. SPONSORSHIP: Fully funded by Ministry of Development Cooperation, the Netherlands, with cooperation of Ministry of Health, Kingston, Jamaica (AU)

Serum inorganic phosphate in protein-energy malnutrition

We retrieved a series of measurements made 35 years ago of the concentration of inorganic phosphate (P) in the serum from 56 cases of severe protein-energy malnutrition at the Tropical Metabolism Research Unit, Jamaica. There is no record of whether or not the cases were randomly selected. The samples were obtained within 4 days of admission and except in 3 cases there was no follow-up. The average age was 12 months. The children have been classified retrospectively from the notes as marasmus (11 cases), kwashiorkor (22 cases) and marasmic kwashiokor (23 cases). In all 11 children died (fatality rate 20 percent), eight of them from the group with marasmic kwashiorkor. Weight-for-age, length-for-age and weight-for-length have been calculated as Z-scores. Nearly all serum phosphate concentrations were low (mean 1.41 mmol.1-1, SD 0.444, range 0.50-2.45) compared with the normal value at this age of about 2 mmol.1-1. The serum P was significantly less depressed in the marasmic children (P=0.042), but there was no relation between serum P and any of the anthropometric measurements, nor with outcome (death or survival). There was, however, a significant relationship with the degree of oedema. Death was related to age - the children who died were younger (mean difference 3.8 months; P=0.01; 95 percent confidence interval 0.23-6.43). It took about 3 weeks of feeding a milk-based diet for serum phosphate to reach normal levels. There have been few previous measurements of serum P in malnutrition. We agree with previous authors that the low serum values are evidence of phosphate depletion and suggest that phosphate might be added to the electrolyte solutions used in the early stages of recovery. However, reports of adverse effects indicate that this should be done with great care (AU)

Malnutrition of children in developing countries: what can we do?

This informal paper is a personal account of the development of my work on malnourished children, starting with clinical studies in Jamaica and the challenge of an unacceptably high mortality rate; moving on to the problem of how to define less severe malnutrition in the community; and ending with some reflections on the enormously difficult question of prevention and the contribution that richer countries such as the UK could make (AU)

Nutrition and protein turnover in man

The composition and homoeostasis of the body are maintained by the integrated action of all the tissues and organs. Therefore, although it is of interest to look at the component parts separately, each part has to be fitted functionally into a greater over-all framework. Whole-body protein turnover represents the integration of one fundamental activity of living organisms. Each individual protein has its own turnover rate, responding in a particular way to any change in metabolism. The turnover in the whole body is the resultant of these activities and in this sense has been likened to basal metabolic rate. The measurement of protein turnover in man has wide application, not only to the normal metabolic changes taking place during growth but also to disorders of metabolism in many clinical conditions. Although the standard nitrogen balance technique gives valuable information on net changes, it cannot indicate either the intensity of nitrogen metabolism or the mechanism by which changes are brought about. Nitrogen balance is the resultant of differences between synthesis and breakdown, which may change in the same or opposite directions in any given clinical state.(AU)

Protein turnover in man measured with 15N: comparison of end products and dose regimes

Whole-body protein synthesis was measured with [15N]glycine in malnourished and recovered infants and in obese patients. Comparisons were made: 1) between results obtained with single (S) and repeated (R) oral dosage of tracer; and 2) between urea and ammonia as end products. In the infants S and R gave similar values for the synthesis rate. With NH3 as end product were about two-thirds of those with urea. It is suggested that the cause of this result is that glycine contributes preferentially to the formation of urinary NH3 with NH3 as end product, a collection period of 12 h has been found to be suitable. With urea it is not possible to define an appropriate collection period. The combination of single dose of [15N] glycine with urinary NH3 as end product provides a simple method for measuring whole-body protein synthesis under clinical and field conditions. It can be repeated at short intervals and can give useful comparative information provided that conditions are carefully standardized. The reproducibility so far is ñ 13 percent. (AU)

Protein turnover, synthesis and breakdown before and after recovery from protein-energy malnutrition

Rates of total protein turnover, synthesis and breakdown were measured in five children before and after recovery from severe protein-energy malnutrition and while receiving 0.6 g of protein and 397 kj day 1 kg-1. These rates were calculated after giving doses of [15N] glycine every 2 h along with the feeds and measuring the rate of excretion of [15N] urea in urine. Malnourished children had significantly lower rates of protein turnover, synthesis and breakdown than after they had recovered. During recovery from protein-energy malnutrition, two children on a daily intake of 1.2 g of protein and 605 j/kg body weight, had rates of protein turnover, synthesis and breakdown that were twice as great as those found on admission and higher than after recovery. On the study diet the malnourished children maintained their weight while the recovered children lost weight; the apparent nitrogen balance was more positive in the malnourished children. In recovered children, the rate of protein synthesis was unchanged over a wide range of protein intake, whereas the rate of protein breakdown appeared to rise with a reduction in protein intake.(AU)

Total protein synthesis in elderly people: a comparison of results with [15N]glycine and [14C]leucine

Total body protein turnover was studied in six elderly patients. During the study they were fed by continuous infusion of a liquid formula through a nasogastric tube. L-[1-1+C] leucine and [15N]-glycine were infused at a constant rate for 30 h. The labelled glycine was infused into the intragastric line; the labelled leucine was given either by this route of intravenously. The specific radioactivity of free leucine in plasma and the rate of output of 14CO2 in expired air both reached a plateau at 10 h, and remained constant until the end of the infusion at 30 h. The 15N abundance in urinary urea and total N was very similar. In neither was a plateau reached by 30 h but in four out of the six patients the abundance in urinary NH4+ had attained a plateau by the end of the infusion. Flux rates and rates of protein synthesis were calculated in four ways: (A) from the specific radioactivity of plasma leucine at plateau; (B) from the proportion of dose excreted as 1+CO2 at plateau; (C) from the final rates of 15N excretion in urea or total urinary N; (D) from the final or plateau rates of 15N excretion in urinary NH4+. On average, the estimates of synthesis rate obtained by methods B and C agreed closely; those given by methods A and D were lower.(AU)

The in vivo measurement of protein synthesis

Methods of measuring in vivo protein synthesis are briefly reviewed. Methods involving incorporation of label into protein are more appropriate for mixed proteins. The major difficulty is the definition of the precursor for protein synthesis. The only data available on the effect of infection on protein synthesis are open to criticism on the grounds that the precursor pool was not sampled. (AU)

The relationship between dietary intake, weight change, nitrogen balance, and protein turnover in man

We have examined the relationships between protein turnover, protein synthesis, and protein breakdown and dietary intake, weight change, and nitrogen balance in children who were recovering and had recovered from severe protein-energy-malnutrition. Protein metabolism was measured by giving [15N]glycine and measuring the enrichment of urinary area. The levels of dietary protein did not affect protein metabolism. There were highly significant correlations between both protein flux and protein synthesis and the ad libitum dietary intake, nitrogen balance, and weight change. Over the range of dietary intake, 60 to 270 cal/kg per day, the protein synthesis rate increased 5-fold. Large changes in dietary intake resulted in small changes in protein breakdown, with breakdown being least on an inadequate intake. Changes in the rate of protein breakdown did not contribute to changes in nitrogen balance or body weight. (AU)

Protein turnover in patients before and after elective orthopaedic operations

Whole body protein turnover was measured in 11 patients before and after elective orthopaedic operations by giving 15N-glycine orally every 4 hours for 32 hours. The patients were maintained throughout on a constant protein intake. In two control subjects a comparison was made between intermittent dosage and continuous infusion of 15N-glycine for the estimation of total turnover. With intermittent dosage the 15N abundance in urinary urea reached a constant level after about 24 hours. Rates of total protein synthesis and breakdown were calculated from the 15N abundance at the plateau level. After surgery there was a moderate increase in urinary N output. The apparent N balance (intake - urinary N) was -0.25 ñ 1.31 g/d (mean ñ s.d.) before operation and =7.51 ñ 4.5g/d/ after operation. The rate of protein synthesis fell from 3.83 ñ 0.73g kg-1d-1 before operation to 2.94 ñ 0.83 g kg-1d-1 after operation. This difference is statistically significant (0.05 > p > 0.01). There was no significant change in the rate of protein breakdown. The possibility remains that a block in protein synthesis, probably mainly in muscle, may be partly responsible for the so-called 'catabolic' loss of nitrogen after injury, but this has not been proved. (AU)