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)

Coagulase-negative staphylococcal bacteraemia in severely malnourished Jamaican children - abstract

Immunosuppression increases the susceptibility to infection and changes the inflammatory response in children with severe protein-energy malnutrition. In this five-year prospective study, bacteraemia was documented in 16 percent of 336 severely malnourished children (2-34 months of age), who were hospitalized consecutively in the Tropical Metabolism Research Unit, UWI, Kingston, Jamaica. The fifty-three children had 60 episodes of noscomial and community-acquired bacteraemia with 69 blood isolates. Community-acquired bacteraemia accounted for 72 percent (43/60) of bacteraemic episodes. Thirty-five per cent (24/69) of the strains were coagulase-negative staphylococci, 19 percent (13/69) were Staphylococcus aureus and 11 percent (8/69) were Streptococcus Group D. Seventeen episodes of coagulase-negative staphylococcal bacteraemia were acquired in the community, and seven were nosocomial. These patients were more likely to have pneumonic consolidation than children with all other bacteraemias combined (p<0.02, Fisher Exact Test). The bacteraemia-related case fatality rate was 8 percent (5/60). Polymicrobial and gram-negative septicaemia were independent positive predictive factors for mortality when compared with single-agent and gram-positive sepsis (p<0.02). This 71 percent (49/69) prevalence of gram-positive organisms suggests a change in the epidemiology from the predominant gram-negative aetiologies described in previous reports (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)

Coagulase-negative staphylococcal bacteremia in severely malnourished Jamaican children

Immunosupression increases the susceptibility to infection and changes the inflammatory response in children with severe protein-energy malnutrition. In this 5-year prospective study bacteremia was documented in 16 percent of the 336 severely malnourished children, 2 to 34 months of age, who were hospitalized consecutively in the Tropical Metabolism Research Unit, Kingston, Jamaica. The 53 children had 60 episodes of nosocomial and community-acquired bacteremia with 69 blood isolates. Community-acquired bacteremia accounted for 72 percent (43 of 60) of bactermic episodes. Thirty-five percent (24 of 69) of the strains were coagulase-negative staphylococci, 19 percent (13 of 69) were Staphylococcus aureus and 11 percent (8 of 69) were Streptococcus Group D. Seventeen episodes of coagulase negative staphylococcal bacteremia were acquired in the community and 7 nosocominal. These patients were more likely to have pneumonic consolidation than children with all other bacteremias combined (p < 0.02, Fisher's exact test). The bacteremia-related case fatality rate was 8 percent (5 of 60). Polymicrobial and Gram-negative septicemia were independent positive predictive factors for mortality when compared with single-agent and Gram-positive sepsis (P < 0.02). This 71 percent (49 of 69) prevalence of Gram-positive organism suggests a change in the epidemiology from the predominant Gram-negative etiologies (76 percent) described in previous reports (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: VIII. Intrahousehold distribution of a therapeutic dietary supplement targeted at malnourished children in the community - abstract

The fate of a dietary supplement, high energy supplement (HES), was studied in 16 households of moderately malnourished children (7-32 months-of-age) attending a nutrition clinic in the slums of Kingston. Two methods were used in the study: observation of the consumption of the HES and a urine collection from all household members (on three occasions) to analyse the presence of D-Xylose, a tracer mixed in the HES. Households were observed during eight (8) four-hour periods by community health workers. The results showed that 60 percent of both adults and non-index children had positive urine results for xylose. However, adults were observed less often than the non-index children to consume the supplement (23 percent and 50 percent respectively). More children of large households (more than 6 members) consumed HES than those from small households. Both methods showed that sharing occurred during dietary supplementation. High energy supplements used in rehabilitation of malnourished children in this study are frequently shared by house-hold members; hence the index child will not receive sufficient nutrients required for full catch-up growth. This experience has led the public health service to focus more on fortifying existing menus in the households of malnourished children (AU)

Acute respiratory infections in ambulatory malnourished children: a serological study - abstract

Fifteen million children under five years of age die each year. Ninety-six per cent of them in "The Third World", and the majority die of acute respiratory infection (ARIs) and/or malnutrition. We therefore studied the aetiological agents of acute respiratory infections occurring in an ambulatory population of 83 malnourished Jamaican-born children, aged 6 to 32 months, using serological methods for the diagnosis. In 60 per cent (38/63) of symptomatic children and in 25 per cent (5/20) of those without reported disease, the following micro-organisms were observed: para influenza viruses in 15 children, influenza viruses in 12, adeno viruses in 10, respiratory syncitial viruses in 7 and Mycoplasma pnuemoniae in 7 children. The prevalence of the viral ARIs increased with the severity of malnutrition. This probably reflects the T-cell immunodeficiency which accompanies protein-energy malnutrition (AU)

Acute respiratory infections in ambulatory malnourished children: a serological study

We studied the aetiological agents of acute respiratory infections occuring in an ambulatory population of 83 malnourished Jamaican-born children aged 6 to 32 months using serological methods for diagnosis. In 60 percent (38/63) of symptomatic children and in 25 percent (5/20) those without reported disease the following microorganisms were observed: parainfluenza viruses in 15 children, influenza viruses in 12, adenovirus in 10, respiratory syncitial virus in 7 and Mycoplasma pneumoniae in 7 children. The prevalence of the viral infections apparently increased with the severity of malnutrition. (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)

Nosocomial and community acquired infections in malnourished Jamaican children - abstract

Infection is a contributing or initiating factor in children with inadequate food intake who develop malnutrition, and malnutrition by virtue of immunosuppression leads to further episodes of infection. In this prospective study, 206 community acquired and 73 nosocomial infections occurring in 50 hospitalised severely malnourished children were investigated. This represented an average of 5.6 episodes of infection per child. Predominant community acquired infections in the 50 children included gastroenteritis (68 percent), otitis media (60 percent), rhinopharyngitis (60 percent), oral candidiasis (46 percent), skin infections (40 percent), pneumonia (28 percent), bacteraemia (24 percent), and bacteriuria (18 percent). The most frequent nosocomial infections were rhinopharyngitis (34 percent), lower respiratory tract infections (24 percent) and septicaemia (18 percent). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen and Klebsiella sp. were recovered from the majority of urines. Coagulase Negative Staphylococcus was the most frequent aetiological agent of bacteraemia, 12 of the 13 episodes were associated with fever +/- leucocytosis and in six episodes this organism was recovered from two or more blood culture sets. The lack of clinical signs and symptoms, and the atypical presentation in some of the infected malnourished children were attributed to impairment of the acute inflammatory response. Nasal, throat and axillary swabs taken on admission revealed significant colonisation with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Two of the four deaths were attributed to infection. The role of Cryptosporidium, an enteric pathogen which is prevalent in immunocompromised hosts, was further investigated. Cryptosporidium was isolated from the stools of 19.5 percent (15/77) malnourished children compared to 2.4 percent (10/436) well-nourished children, who were more likely to present with fever, vomiting, prolonged diarrhoea and dehydration. Community acquired non-bacterial respiratory tract infections were further investigated from paired sera in 83 moderately malnourished children. In 60 percent of the children with a history of respiratory tract disease and 25 percent of those without reported disease, a specific non-bacterial infection was diagnosed. Multiple aetiological agents were identified in 6 of the 42 chidren with respiratory disease. The most common micro-organisms observed were: Para-influenza 1,2 or 3 (in 15 children), Influenza H1N1, H2N3 or "B" in 12, Adenovirus in 10, Respiratory Syncitial Virus in 7 and Mycoplasma Pneumoniae in 6 children. These three studies report a high prevalence of common and unusual infections, especially Cryptosporidium enteritis and Coagulase Negative Staphylococcus bacteraemia, occurring in these immunocompromised children. Diagnosis of infection requires a high index of suspicion and a comprehensive screening system (AU)

Nosocomial and community acquired infections in malnourished children

A total of 206 community-acquired and 73 nosocomial infections in 50 malnourished Jamaican children were studied prospectively. Predominantly community-acquired infections in the 50 children, included gastroenteritis (68 percent), otitis media (60 percent), rhinopharyngitis (60 percent), oral candidiasis (46 percent), skin infections (40 percent), pneumonia (28 percent), bacteraemia (24 percent) and bacteriuria (18 percent). The most frequent nosocomial infections were rhinopharyngitis (34 percent), lower respiratory tract infections (24 percent) and septicaemia (18 percent). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen, Staphylococcus epidermidis, the most frequent blood culture isolate and Klebsiella sp. were recovered from the majority of urines. The lack of clinical signs and symptoms and atypical clinical presentation in some infected malnourished children were attributed to impairment of the acute inflammatory response. Diagnosis of infection in these children required a high index of suspicion and a comprehensive screening system. Nasal throat and axial swabs taken on admission revealed significant colonization with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Four of the fifty children died and two of these deaths were attributed to infection. (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)

Community rehabilitation of malnourished children: effects of nutritional supplementation on morbidity - abstract

Fifty-one moderately and severely malnourished children were studied in the community. They were randomly allocated to receive either medical care and an energy dense dietary supplement for three mons and then medical care alone for a further three months (supplemented) or to receive medical care alone for the six months (unsupplemented). All children were seen at two-weekly intervals, alternately in their homes by community Health Aides and in the clinic by a paediatrician. At each visit, a morvidity questionnaire was administered to obtain the mother's history of the child's illness during the previous two weeks. Weight was measured every two weeks and height monthly. Clinical assessment was done montly. During the first 3 months, growth velocity was higher in the supplemented than the unsupplemented children (2.4 and 1.2 times normal growth rate). During the second 3 months, growth rate was equal in the two groups (1.1 times normal growth rate). The mean ñ SD number of days of respiratory illness and diarrhoea (3 or more loose stools daily) were as follows: FOLLOW-UP PERIOD: Respiratory infection: (1-3 MONTHS - Unsuppl. 22ñ17, Suppl. 23ñ12), (4-6 MONTHS - Unsuppl. 15ñ13, Suppl. 20ñ15); Diarrhoea: (1-3 MONTHS - Unsuppl. 6ñ9), (4-6 MONTHS: Unsuppl. 2ñ3, Suppl. 8ñ12): No. Of Children With > 7 Days: (1-3 MONTHS: Unsuppl. 8/25, Suppl. 18/26), (4-6 MONTHS: Unsuppl. 1/24, Suppl. 7/25). In the first three months, the supplement was not associated with any significant decrease or increase in morbidity from respiratory illness or diarrhoea. Although more of the children had diarrhoea lasting for over seven days, these latter children did not show a diminution in rate of weight gain. In the second three-month period, there were fewer days of both respiratory illness and of diarrhoea in the unsupplemented children than in the children who had been supplemented during the previous three months. There were fewer children who had diarrhoea for more than seven days in the three-month period amongst the unsupplemented than the previously supplemented. Their preliminary analysis shows that dietary supplementation with an energy dense formula does not lead to a reduction in morbidity in malnourished children. It is possible that the supplement is associated with an increased in incidence of diarrhoea following its cessation (AU)

Community rehabilitation of the Jamaican malnourished child: the effects of supplementary feeding on growth - abstract

The feasibility of rehabilitating malnourished children in the community, using the health service framework, was examined over a 6-month period. Eighty moderately and severely malnourished children, aged 3-36 months, were recruited from the Casualty Department, U.H.W.I., and Clinics in Kingston. The results of the first fifty to complete are reported. The children were randomly assigned to two treatment groups which provided medical care with and without a dietary supplement. The supplement, as prescribed, provided 750 Kcal/day for 3 months (55 percent of their energy requirements). At enrollment, both group had similar weight-for-age (WFA), height-for-age (HFA) and weight-for-height (WFH). At this point, mean WFA were 67 percent and 66 percent for supplemented and control groups respectively. By the end of the second month, the supplemented group was better nourished than their controls (p<0.05). The mean WFA were 73 percent and 69 percent respectively. By the end of the third month, the advantage of the supplemented group was more pronounced (p<0.01) with mean WFA of 74 percent and 69 percent respectively. This represented 8 percent WFA improvements in the supplemented as opposed to a 2 percent improvement in their controls. Mean weight gains of 1.22 and 0.84 Kg in supplemented and control groups were 2.0 and 1.3 times respectively, the normal rate for children of the same age. After three months, the supplemented group which had had three severely malnourished children at enrollment had none, while the control group which had had four still had two. Twice as many supplemented as opposed to control children had advanced to the mildly malnourished category. However, three months after the supplementation ceased (6 months), both groups were distributed similarly between the Gomez categories. Both interventions resulted in some catch-up growth. The regime of medical care plus supplementation proved more effective during the supplementation period. However, this advantage was not maintained when both groups received medical care only. Continous medical care and a onger supplementation period are needed for community rehabilitation of Jamaican malnourished children (AU)

Small bowel overgrowth in malnourished children as measured by the breadth hydrogen test - abstract

Overgrowth of the small intestine with bacteria has been implicated in the chronic diarrhoea associated with severe malnutrition. The hydrogen breath test has been introduced as a simple non-invasive technique to assess bacterial fermentation in the bowel. An increase in breath hydrogen in excess of 20 ppm within 60 minutes of the oral presentation of substrate is taken as evidence of small bowel overgrowth (SBO). The hydrogen breath test was used in 30 children admitted with severe protein energy malnutrition. Of the 19 children tested on admission and at intervals during recovery, 5 were positive on admission and a further 3 became positive at varying times after admission. Of these 8 with positive results, 5 were treated with metronidazole and all were negative on subsequent testing. Of the 3 children who were not treated one improved, but 2 had persistently positive breath hydrogen. Eleven (11) children had breath hydrogen measured at some time during recovery. In 6 the test was positive; all received metronidazole and became negative. In 2 children who had received metronidazole and were negative, the test became positive at a later date. Three children had a positive test with lactose specifically, one was treated with metronidazole and became negative. Therefore, of 30 children studied, 14 had a positive test at some time, which became negative in the 11 treated with metronidazole. We conclude that small bowel overgrowth as measured by the breath hydrogen test is a frequent accompaniment of severe malnutrition and responds to treatment with metronidazole (AU)

Infections in malnourished children - abstract

Specific nutrient deficiencies may increase susceptibility to and severity of infection. This is particularly evident in young children admitted to hospital with malnutrition. This prospective study documents the community and hospital-acquired infections in 47 malnourished children admitted to the University Hospital of the West Indies. The study group comprised 26 boys and 21 girls aged 5 to 23 months, of whom 28 had oedematous malnutrition. A total of 131 infections were diagnosed on admission with each child having at least one identifiable focus of infection. Thirty-two (68 percent) had gastroenteritis, 27 (57 percent) had otitis media and 25 (53 percent) presented with upper respiratory tract infections. Twelve children (25 percent) were bacteraemic and two of these had polymicrobial bacteraemia. Bladder aspirates were positive in 8 of 11 children with bacteruria and 6 of these yielded more than one organism. Ten children (21 percent) had giardiasis and there were individual cases of E. coli peritonitis, pneumococcal meningitis and tuberculous urinary tract infection. Twenty-nine children (62 percent) acquired hospital infections, including 12 upper and lower respiratory tract infections and 6 episodes of small bowel overgrowth. Hospital-acquired staphylococcal bacteraemia was diagnosed in 8 of 10 patients with positive blood cultures. Cytomegalovirus pneumonitis septicaemia and influenza A encephalitis with disseminated intravascular coagulation accounted for 2 of 3 deaths. In view of the high incidence of single and multiple infections in malnourished children, it was concluded that a comprehensive screening system should be used to identify and monitor infections in these patients. Malnourished children are often immunocompromised and may be prone to infections with unusual organisms. Therefore, every effort should be made to identify aetiological agents so that appropriate antimicrobial therapy may be administered (AU)