Nutrition rehabilitation of children with severe acute malnutrition: Revisiting studies undertaken by the National Institute of Nutrition

Severe acute malnutrition (SAM) in children under five years is an important public health problem due to associated high mortality and long-term health consequences. Research on the dietary causes of SAM, especially the role and relative importance of dietary protein, in the aetiology of oedematous malnutrition, has led to considerable debates and controversies. The present article revisits some of the debates in this field, where the researchers at the National Institute of Nutrition (NIN), Hyderabad, India, with their pioneering work, have contributed to the global literature on the various facets of the disease. Highlighting the importance of energy as a bigger problem than protein malnutrition is a noteworthy contribution of NIN's research. It is, however, important to examine the protein quality of the diets in light of the new information on the lysine requirements. The article argues that the currently dominating hypothesis of free radical theory requires a critical review of the supporting evidence. Over the past few decades, the research has focused on low-cost diets using locally available foods. The article also argues that solutions based on local foods, being acceptable and sustainable, need to be strengthened for their effective delivery through the existing nutrition programmes. Recent evidence shows that the use of ready-to-use therapeutic foods (RUTF) with high micronutrient density may be linked with higher mortality possibly due to the high iron content, which could be counterproductive. There are several unaddressed concerns regarding the potential long-term impact of consumption of RUTF in children with SAM. More evidence and a cautious approach are, therefore, needed before implementing these solutions.

A Study on Comparison between WHO Protocol and Locally Adapted Dietary Protocol in the Management of Nutritional Marasmus At Hospitals in Bangladesh

Objectives: To compare the efficacy of locally adapted DMCHdietary protocol with the WHO protocol for the management ofnutritional marasmus in Bangladesh.Materials & Methods: A Hospital based Randomizedcontrolled Trial (RCT) was conducted on Marasmic children(06-59 years) with weight for height/length ≤ 3SD of themedian WHO references (n=62). Children treated with eitherWHO protocol (group-1, n=31) or DMCH protocol (Group-2,n=31). Clinical improvement, rate of weight gain, time taken toachieve target weight gain, return of appetite, return of smileand total cost of treatment were evaluated in both groups.Results: In DMCH group the time taken to achieve targetweight was 13.43 days which was around one day less thanthat of WHO group (14.33 days) and rate of weight gain washigher by around 2.6 gm/kg/day. Child receiving DMCHregimen took on average 3.47 days to return to smile the timewas 4.47 in WHO group (P< 0.01). Most importantly dailytreatment cost was higher by around 17 taka per day in WHOgroup. Neither of the group experienced any serious adverseeffect or fatality.Conclusion: Peanut based DMCH dietary regimen can beused effectively in the treatment of nutritional marasmus(without oedema) in the facility.

Development and reliability and validity tests of Elderly Frailty Assessment Scale / 中华护理杂志

Objective To develop the Elderly Frailty Assessment Scale and test its reliability and validity.Methods The primary item pool was formulated through literature review,compounding existing instruments measuring elderly frailty and group meeting.The items were selected by expert consultation.Totally 420 elderly adults were selected to test the reliability and validity and SPSS 20.0 was used to analyze data.Results The Elderly Frailty Assessment Scale consisted of 35 items;the exploratory factor analysis identified four principal factors which explained 72.685％ of the total variance.The item content validity index ranged from 0.824 to 1,and the scale content validity index was 0.932.The Cronbach's α coefficient of the scale was 0.952 and test-retest reliability was 0.937.Conclusion The Elderly Frailty Assessment Scale is reliable and valid,which can be used to evaluate elderly frailty.

Phototherapy promotes healing of cutaneous wounds in undernourished rats

BACKGROUND: Various studies have shown that phototherapy promotes the healing of cutaneous wounds. OBJECTIVE: To investigate the effect of phototherapy on healing of cutaneous wounds in nourished and undernourished rats. METHODS: Forty rats, 20 nourished plus 20 others rendered marasmus with undernourishment, were assigned to four equal groups: nourished sham, nourished Light Emitting Diode treated, undernourished sham and undernourished Light Emitting Diode treated. In the two treated groups, two 8-mm punch wounds made on the dorsum of each rat were irradiated three times per week with 3 J/cm2 sq cm of combined 660 and 890nm light; wounds in the other groups were not irradiated. Wounds were evaluated with digital photography and image analysis, either on day 7 or day 14, with biopsies obtained on day 14 for histological studies. RESULTS: Undernourishment retarded the mean healing rate of the undernourished sham wounds (p < 0.01), but not the undernourished Light emission diode treated wounds, which healed significantly faster (p < 0.001) and as fast as the two nourished groups. Histological analysis showed a smaller percentage of collagen in the undernourished sham group compared with the three other groups, thus confirming our photographic image analysis data. CONCLUSION: Phototherapy reverses the adverse healing effects of undernourishment. Similar beneficial effects may be achieved in patients with poor nutritional status. .

Fallas maternas: la historia del no cuidado en La dinámica relacional de madres con hijos con desnutrición tipo marasmo / Maternal failures: the story of no nursing in relational dynamics of mothers with children with marasmus type malnutrition

La desnutrición es un problema de salud pública y una causa reconocida de mortalidad y morbilidad a nivel mundial. En la Clínica Infantil Santa Ana de la ciudad de Medellín, para el año 2009, el 63% de los niños atendidos tenían este diagnóstico. El objetivo de esta investigación es identificar las epresentaciones acerca de la maternidad, construidas por las madres de niños con desnutrición tipo marasmo en la Clínica Infantil Santa Ana durante el periodo 2011 y 2012. Método: se utilizó un diseño cualitativo, con un enfoque fenomenológico- hermenéutico, haciendo uso de la historia de vida como estrategia metodológica. La técnica de generación de información fue la entrevista en profundidad. Participaron 7 madres entre 15 y 46 años de edad, quienes ingresaron a la Clínica Infantil Santa Ana de la ciudad de Medellín con su hijo, el cual tenía como diagnóstico desnutrición tipo marasmo. Resultados: las representaciones sobre la maternidad, halladas en los relatos construidos por madres de hijos con desnutrición tipo marasmo, dan lugar a la denominación de esta investigación como Fallas maternas: la historia del no cuidado; comprendidas estas como un vínculo con características específicas, que dan lugar a déficits en la relación madre/hijo. Conclusiones: el fenómeno de la desnutrición es un asunto complejo que va más allá del alimento. Las personas que se ocupan de la salud y del tema deben considerar los aspectos psicológicos que se hallan presentes en la desnutrición tipo marasmo.

Malnutrition is a public health problem, it is a cause of mortality and morbidity recognized worldwide and especially in countries like ours, and specifically marasmus type malnutrition generates high risk of death. The Santa Ana Children Hospital in Medellín, reported in 2009, that 63% of its patients had this diagnosis. The purpose of this research Project is to identify the representations of motherhood that mothers of children with a diagnosis of marasmus type malnutrition in this clinic between 2011 and 2012. The method used was a qualitative design under a hermeneutics phenomenological approach, using life stories as a methodological strategy. The data collection technique employed was the interview with the participation of 7 mothers between the age of 15 and 46, who came to the Santa Ana Hospital in the city of Medellin with a child who had the diagnosis of marasmus type malnutrition. The motherhood representations, found in the stories told by these mothers give support to the name of this research project which is Maternal failures: the story of no nursing, being the relation with the specific characteristics in deficits in the mother-child relationship. Conclusions: the malnutrition phenomenon is a complex isuue that goes beyond nourishment. Health personnel should consider the psychological aspects present in the marasmus type malnutrition. Conclusions: the phenomenon of malnutrition is a complex issue, goes beyond food. And people who are concerned with health and topic should consider the psychological aspects that are present in marasmus type malnutrition.

Modelo de atención a la malnutrición crónica infantil en la región de Upper River, Gambia, según el marco Innovative Care for Chronic Conditions / Attention Model to chronic child malnutrition in the region of Upper River, Gambia, according to the Innovative framework Care for Chronic Conditions / Modelo de atenção à malnutrição crônica infantil na região de Upper River, Gâmbia, segundo o quadro Innovative Care for Chronic Conditions

La malnutrición es uno de los principales problemas de salud pública en la República de Gambia,con un 18 % de la población menor de cinco años afectada. El objetivo de este trabajo esofrecer una descripción y un análisis del conjunto de actores e instituciones y de sus políticase intervenciones involucradas en el abordaje de la malnutrición crónica infantil en la región deUpper River, Gambia. El mapa de atención a la malnutrición infantil se ha realizado a partirde una evaluación del modelo de atención vigente, siguiendo la herramienta Innovative Carefor Chronic Conditions Framework Situation Assessment de la Organización Mundial de laSalud, guiando el análisis por la experiencia profesional en este contexto del autor, y con elapoyo de la bibliografía consultada. Basado en los resultados, a modo de discusión se ofreceuna serie de intervenciones y estrategias de mejora del modelo en sus tres niveles de atencióna la malnutrición infantil...

Malnutrition is a major public health problem in the Republic of Gambia, with 18% of the populationunder five affected. The purpose of this paper is to provide a description and analysis of theset of actors and institutions, their policies and interventions involved in tackling child chronicmalnutrition in the region of Upper River, Gambia. The map of attention to child malnutritionhas been made from an assessment of the current care model, following the tool InnovativeCare for Chronic Conditions Framework Situation Assessment of the World Health Organization,guiding the analysis by professional experience in this context of the author, and with thesupport of the consulted bibliography. Based on the results, a series of interventions and strategiesfor improvement of the model in its three levels of care to child malnutrition is discussed...

A malnutrição é um dos principais problemas de saúde pública na República de Gâmbia, com um18 % da população menor de cinco anos afetada. O objetivo deste trabalho é oferecer descriçãoe análise do conjunto de atores e instituições e das suas políticas e intervenções envolvidasna abordagem da malnutrição crônica infantil na região de Upper River, Gâmbia. O mapa deatenção à malnutrição infantil realizou-se a partir de uma avaliação do modelo de atençãovigente, seguindo a ferramenta Innovative Care for Chronic Conditions Framework SituationAssessment da Organização Mundial da Saúde, guiando a análise pela experiência profissionalneste contexto do autor, e com apoio da bibliografia consultada. Baseado nos resultados, a modode discussão oferece-se uma série de intervenções e estratégias de melhoramento do modeloem seus três níveis de atenção à malnutrição infantil...

Dislipidemia en niños con desnutrición aguda. Turbo, Colombia / Dyslipidemia in children with acute malnutrition. Turbo, Colombia

Objetivo: comparar el perfil lipídico de niños menores de 5 años con desnutrición aguda con un grupo control. Metodología: estudio descriptivo, de corte transversal, en 43 niños, 26 con desnutrición aguda y 17 con adecuado peso para la talla (P/T). Entre los grupos de estudio se compararon las concentraciones séricas de CT, c-LDL, c-HDL y TG. Resultados: el grupo con desnutrición presentó una frecuencia significativamente mayor de c-HDL bajas comparados con controles (19 vs 7% respectivamente, p=0,036) y un riesgo 1,8 veces mayor de c-HDL bajas (OR=1,8; IC 0,960-3,280). Los TG fueron mayores en los desnutridos, pero sin diferencia significativa con los controles. Las concentraciones de CT, c-LDL y c-HDL disminuyeron significativamente a medida que aumentó el grado de desnutrición, mientras que los TG aumentaron pero no significativamente; en los niños con desnutrición grave el índice arterial TG/c-HDL fue significativamente mayor que en los moderados y en los controles. Los niños con kwashiorkor presentaron las concentraciones más bajas de CT, c-LDL y c-HDL, las más altas de TG y el mayor índice arterial. Conclusiones: los niños con desnutrición aguda grave, especialmente tipo kwashiorkor, presentan concentraciones más bajas de c-HDL y más altas de TG, con un índice arterial alto que los expone a desarrollar ateroesclerosis.

Objective: to compare the lipid profile between preschools with and without acute malnutrition. Methods: a cross sectional study was developed in 43 preschools; 26 with and 17 without acute malnutrition. Malnutrition was assessed by weight for height ratio (P/T). Among the study groups were compared serum levels of TC, c-LDL, c-HDL and TG. Results: malnourished group showed a significantly higher frequency of c-HDL levels classified as lower compared with controls (19 vs 7%, respectively, p = 0.036) and a 1.8 times higher risk to c-HDL levels classified as lower (OR = 1,8; CI 0,960-3,280). TG levels were higher in malnourished, but no significant difference with controls. TC, c-LDL, and c-HDL concentration sincreased significantly by increasing the acute malnutrition degree. TG increased but not significantly, in preschool with severe acute malnutrition arterial index TG/HDL-C was significantly higher thanin control group. The lowest concentrations of TC, LDL-C, and HDL-C were detected in preschool affected by kwashiorkor. The highest TG, and arterial index were detected in preschool affected by kwashiorkor. Conclusions: preschool affected by severe acute malnutrition, especially kwashiorkor, has lower HDL-C concentrations, higher TG, and a high index which exposed them to develop atherosclerosis.

La relación entre madre - hijo en la desnutrición tipo marasmo: una revisión temática / The relationship between mother-relationship children marasmus type malnutrition

El presente trabajo es un trabajo de reflexión que tiene como objetivo exponer la revisión de algunas construcciones y reflexiones teóricas sobre las características que se presentan en la dinámica relacional madre/hijo/alimento. En concordancia con esto, se presentan trabajos investigativos que existen sobre la relación entre la desnutrición y los aspectos psicológicos que la acompañan. El método. Para seleccionar la bibliografía se tomaron los siguientes criterios de búsqueda: trabajos publicados entre 2001 y 2011 y se utilizaron palabras-frases clave: (desnutrición), (marasmo), (desnutrición tipo marasmo y aspectos psicológicos) y (relación madre/hijo y desnutrición). Como medios de búsqueda se consultaron las bases de datos electrónicas Ebsco, MedLINE, PubMed, Scielo y Embase. Se priorizaron trabajos de investigaciones en los contextos nacional y local. Se consideraron solo aquellos trabajos que utilizaban explícitamente el concepto de desnutrición / marasmo / vínculo madre hijo. Además, se identificaron los autores más destacados en el tema y se realizó un intercambio con especialistas que trabajan en el tema. Los resultados muestran que hasta el momento no hay trabajos recientes relacionados con esta temática específica, excepto los del médico y psicoanalista René Spitz en 1945. Ante la ausencia de trabajos investigativos, y dada la particularidad del fenómeno de la desnutrición tipo marasmo, como un problema inaceptable que afecta la salud mental infantil, surge la urgencia de crear acciones investigativas que favorezcan la construcción de nuevos mecanismos de intervención para esta compleja realidad.

This reflection aims to describe some theoretical reflections about the features that appear in the mother / son / food relational dynamic. It presents the research projects that are so far on the relationship between malnutrition and psychological aspects that accompany it. The chosen method in order to select the literature used the following search criteria: papers published between 2001 and 2011. It was used word-phrases: (Malnutrition), (marasmus), (marasmus type malnutrition and psychological) and (mother / child relationship and malnutrition). As search facilities: Electronic databases (Ebsco, Medline, PubMed, SciELO, Embase). Priority was given to research work at national and local levels. Only those works which explicitly use the concept of malnutrition / stagnation / mother son bond were considerate. Also it was identified the most prominent authors in the field, and it was conducted exchanges with specialists on the field. Results show that so far there is no recent work related to this specific subject, except the work done by the doctor and psychoanalyst Rene Spitz in 1945. Conclusions: In this absence of research papers and given the particular phenomenon of marasmus type malnutrition, unacceptable as a problem that affects children's mental health; there is the urge to create investigative actions that favor the construction of new intervention mechanisms for this complex reality.

Modelos experimentais de desnutrição e sua influência no trofismo cutâneo / Experimental models of malnutrition and its effect on skin trophism

FUNDAMENTOS: A pele, para exercer suas funções, necessita de níveis adequados de nutrientes. OBJETIVO: Analisar o trofismo cutâneo de ratos nutridos e desnutridos por meio de dois modelos de desnutrição. MÉTODOS: No Modelo Marasmo, utilizaram-se 60 ratos Wistar em controle dietético, dos quais 30 foram selecionados aleatoriamente para receber metade da dieta diária durante 60 dias. No Modelo Gelatina, empregaram-se 60 ratos, dos quais 30 receberam dieta associada a proteína de baixa qualidade (gelatina) durante 30 dias. Avaliou-se o estado nutricional dos animais por meio da massa corporal, dos sinais clínicos e da dosagem de albumina sérica. Após o período de desnutrição, fez-se a histologia da pele dos animais para análise da espessura da derme e epiderme com o software Leica Application Suite; nas lâminas coradas com tricrômio de Gomori, analisou-se a colagênese com o software ImageJ. RESULTADOS: A massa corporal dos animais desnutridos pelo marasmo e gelatina foi significativamente menor (p<0,0001 e p<0,0001) do que a dos grupos nutridos. Quanto à albumina sérica, não houve diferença entre os grupos nos dois modelos. Em relação à análise histológica da espessura da pele, os desnutridos apresentaram a derme significativamente menos espessa em comparação aos nutridos (p<0,0001 e p<0,0001). No que respeita à colagênese, os grupos desnutridos apresentaram menores percentuais de colágeno em relação aos nutridos (p<0,0005 e p<0,003). CONCLUSÕES: Os animais desnutridos pelos dois modelos apresentaram diminuição na espessura dérmica, confirmada histologicamente pelo menor percentual de colágeno, mostrando a influência negativa da desnutrição no trofismo cutâneo.

BACKGROUND: The skin requires adequate levels of nutrients to function properly. OBJECTIVE: To analyze skin trophism in well-nourished and undernourished rats using two models of malnutrition. METHODS: In the marasmus model, 60 Wistar rats were kept on a controlled diet, 30 being randomly selected to receive half the established diet for 60 days. In the gelatin model, 60 rats were used, 30 of which received a diet consisting of poor quality protein (gelatin) for 30 days. The nutritional status of the animals was evaluated according to body mass index, clinical signs and serum albumin measurement. After the period of malnutrition, histology was performed on the animals' skin to analyze the thickness of the dermis and epidermis using the Leica Application Suite software. Collagen was analyzed on slides stained with Gömöri trichrome using the ImageJ software program. RESULTS: The body mass index of the malnourished animals in the marasmus and gelatin groups was significantly lower than that of the well-nourished animals in the two groups (p<0.0001 in both models). With respect to serum albumin, there was no difference between the groups in either of the two models. In relation to the histological analysis of skin thickness, the dermis of the malnourished animals was significantly thinner compared to that of the well-nourished animals (p<0.0001 in both models). The percentage of collagen was lower in the malnourished animals compared to the well-nourished animals (p<0.0005 and p<0.003 in the marasmus and gelatin model, respectively). CONCLUSIONS: Skin thickness measurements were lower in the malnourished animals in both models, and this finding was histologically confirmed by the lower percentage of collagen, showing the negative effect of malnutrition on skin trophism.

Inflammatory response in Colombian children with severe protein-energymalnutrition before and after nutritional intervention / Respuesta inflamatoria en niños colombianos con desnutrición grave antes y después del tratamiento nutricional

Aim: To evaluate the changes in C-reactive protein and pro-inflammatory cytokines in severely malnourished children, before nutritional intervention and at the moment of restoring appetite. Methodology: To assess changes in inflammatory mediators, 20 severely malnourished children under 5 years of age, 10 with kwashiorkor and 10 with marasmus were studied. Hemoglobin, total serum proteins, albumin, ferritin, transferrin, ceruloplasmin, C-reactive protein and pro-inflammatory cytokines (IL-8, IL-1β, IL-6,IL-10,TNF-α, and IL-12p70) were determined.Results: Upon hospital admission, the mean values of C-reactive protein in kwashiorkor and marasmus patients (16.3±19.0 mg/l and 23.1±27.9 mg/l, respectively) indicated an inflammatory response process with no difference between both groups (p=1.0). Total protein, albumin, transferrin and ceruloplasmin in children with kwashiorkor were significantly lower than in marasmic children (p=0.003, p=0.007, p=0.035, p=0.007, respectively). All cytokines, except IL-12p70, showed significantly higher concentrations in kwashiorkor than in marasmic children. After the stabilization phase, concentrations of C-reactive protein decreased significantly in both groups and albumin increased to normal values, but cytokines remained high. Conclusion: These results show that malnourished children are able to synthesize C-reactive protein in response to an infectious process. Additionally, higher levels of pro-inflammatory cytokines and depletion of albumin in children with kwashiorkor suggest that these inflammatory mediators could be critical biomarkers during clinical phases of kwashiorkor.

Objetivo: Evaluar los cambios en la concentración de proteína C reactiva y citocinas pro-inflamatorias en niños con desnutrición aguda grave antes del tratamiento nutricional y al recuperar el apetito. Metodología: Se evaluó en 20 niños menores de 5 años con desnutrición aguda grave, 10 con marasmo y 10 con kwashiorkor, el cambio en la respuesta inflamatoria mediante la concentración de ferritina, transferrina, proteínas totales, albúmina, ceruloplasmina, proteína C reactiva y citocinas pro-inflamatorias (IL-8, IL-1β, IL-6,IL-10,TNF-α y IL-12p70).Resultados: Al momento de la admisión, la concentración promedio de proteína C reactiva en niños con kwashiorkor y marasmo (16.3±19.0 mg/l y 23.1±27.9 mg/l, respectivamente) indicaron un proceso inflamatorio activo en ambos grupos (p=1.0). Las proteínas totales, la albúmina, la transferrina y la ceruloplasmina fueron significativamente menores en niños con kwashiorkor que en niños con marasmo (p=0.003, p=0.007, p=0.035, p=0.007, respectivamente). Todas las citocinas, excepto la IL-12p70, mostraron una concentración significativamente mayor en niños con kwashiorkor que en marasmáticos. Después de la fase de estabilización la concentración de proteína C reactiva disminuyó de manera significativa en ambos grupos y la albúmina aumentó a concentraciones normales, pero las citocinas permanecieron altas. Conclusión: Estos resultados muestran que los niños desnutridos graves son capaces de sintetizar proteínas de fase aguda como la proteína C reactiva en respuesta a un proceso infeccioso. Adicionalmente, las mayores concentraciones de citocinas pro-inflamatorias y la mayor depleción de albúmina ocurrida en niños con kwashiorkor sugieren que esos mediadores inflamatorios pueden ser biomarcadores críticos durante las fases clínicas del kwashiorkor.

Marasmus and Kwashiorkor by Nutritional Ignorance Related to Vegetarian Diet and Infants with Atopic Dermatitis in South Korea

Infants and children with food related Atopic Dermatitis (AD) need extra dietary efforts to maintain optimal nutrition due to food restriction to prevent allergy reactions. However, nutrition ignorance and food faddism make patients even more confused and practice desirable diet more difficult. The objective of this study was to report the AD patients' malnutrition cases in Korea. We report on 2 cases of severe nutritional deficiency caused by consuming macrobiotic diets which avoid processed foods and most animal foods, i.e. one of vegetarian diet. Case 1, a 12-month-old male child, was admitted with severe marasmus. Because of a history of AD, he was started on mixed grain porridge at 3 months without any breast milk or formula feeding. His caloric intake was 66% and protein intake was 69% of the recommended dietary allowance. Patient's height and weight was under 3th percentile. On admission the patient was unable to crawl or roll over. Case 2, a 9-month-old AD female patient, was diagnosed with kwashiorkor and rickets. She was also started on mixed grain porridge at 100 days due to AD. Her caloric intake has been satisfied recommended dietary allowance until 7 months, however, she conducted sauna bath therapy and reduced both energy and protein intake at 8 months. The amount of protein intake for case 2 was higher than recommended dietary allowance, but, sauna therapy and severe AD with intakes of low guality protein may increase patient's protein requirement resulting in kwashiorkor. Case 2 patient's height and weight was on 3th percentile. Both cases showed low intake of calcium, iron, zinc, vitamin A, vitamin E and especially very low intake of vitamin B12 and vitamin D. Allergy tests for certain foods had not done prior to admission for both cases. They followed the dietary advise operated by macrobiotic diet internet site. In conclusion, AD infants' parents and caregivers should contact a pediatrician trained as a specialist in allergy for accurate diagnosis. For infant patients, breast or formula feeding including hypoallergenic formula should be continued until their one year of age. When certain foods need to be restricted or to follow special diets such as vegetarian diet, consultation with pediatrician and dietitian is needed.