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)

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 percent of the sample were found to have additional illnesses at enrolment. 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 (AU)

The Kingston Project. II. the efects 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 weght 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 percent of the children treated with metronidazole failed to respond to community-based intervention and were admitted to hospital, compared with 19 percent for the other groups (P<0.05). These findings support targetted high-energy supplementation for the rehabilitation of moderately malnourished children receiving health clinics care, and suggest further that such programs should include antibiotic treatment directed at SBBO (AU)

The Kingston Project: VII. The point prevalence of helminths and parasites, and morbidity in malnourished children failing ambulatory treatment with a high energy supplement and a course of metronidazole - abstract

In a prospective study, 163 moderately malnourished children, living in the slums of Kingston, were followed up for one year. The anthropometric measurements in weight and length in those children receiving a High Energy Supplement (HES), and in wasting in those receiving, additionally, a course of metronidazole (MET) have been previously reported. The point prevalence as assessed by positive stool tests for helminths and parasites of the children treated with metronidazole, and if deemed necessary with mebendazole, increased significantly over the period of one year concurrent with improvement of their nutritional status (chi-2 = 13.57; p < .001). A significant increase was observed in both the supplemented and unsupplemented group (chi-2 = 3.98; p < .05 and chi-2 = 5.31; p < .05 respectively). Children receiving health care (HC) only, or health care and a high energy supplement (HC/HES) failed more than twice (17 per cent) as often the community-based management as those receiving additional metronidazole (HC/MET and HC/HES/MET) (8 per cent). Admissions to hospital for full nutritional and clinical recovery in the HC/HES group were mostly for enteric infections and septicaemia, while children in the MET groups were admitted for respiratory tract infections leading to anorexia. Malnourished children, managed in the community, are less likely to be admitted for failure if a course of metronidazole and mebendazole is given combined with their rehabilitation, using HES. This treatment reduces social and nutritional costs to the child, as well as costs to the public health service (AU)

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

Moderate and severly malnourished children referred from public health clinics in Kingston, Jamaica, to a metabolic ward were treated at home for 6 months using community health services. 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 (AU)

Helminths and nutritional status in Jamaica toddlers - abstract

Malnutrition, ascariasis and trichuriasis are prevalent and co-exist among the poor. However, the nature of the relationship between nutritional status and helminthiasis remains unclear. We therefore compared the prevalence and intensity of infection with Trichuris trichuria and Ascaris lumbricoides in 11 to 25-month-old children in two groups from the same slum communities in Kingston, Jamaica. One group comprised 66 malnourished children (<90 percent weight-for-age) and the other 55 well-nourished children (<90 percent weight-for-age). Both groups of children had similar mean ages, comprised similar proportions of boys and girls and had similar socio-economic status. Duplicate faecal specimens were examined twice, using the Kato thick Smear technique. Infected children were treated with mebendazole (Janssen, Pharmaceuticals). Helminths occurred with similar prevalence among the well-nourished (38 percent) and the malnourished (44 percent) children. However, the prevalence was highest in the mildly wasted children (57 percent, n=30) and least in the moderately/severely wasted children (15 percent, p<0.05). Similar patterns were observed for both Ascaris and Trichuris. In both groups, the presence of helminths was positively associated with age (Xý = 10.7, p<0.05), acess to water (Xý = 9.1, p<0.05)and geophagia(Xý = 4.2, p<0.05). These results show that nutritional status alters the host-parasite relationship. Perhaps mild malnutrition increases whereas more severe malnutrition decreases susceptibility to helminths, as Bundy and Golden (Parasitolgy, 1987) have suggested (AU)