Aceptabilidad de un atole fortificado con 21 micronutrientes e impacto en la salud y nutrición de niños menores de 6 años de edad en la ciudad de guatemala / Acceptability of a 21 micronutrient-fortified atole and its impact on health and nutrition in children under 6 years of age from guatemala city

Con el objetivo de reducir la desnutrición crónica de niños que asisten 6 jardines infantiles en la Ciudad de Guatemala, se utilizó una bebida a base de soya y maíz como vehículo para el aporte de 21 micronutrientes con niveles elevados de hierro (12mg) y zinc (9mg) y se ofreció a 747 niños entre los 6 meses y 6 años. Se realizó seguimiento antropométrico cada 3m, Hb cada 6m y se registró el número de episodios de enfermedad diarreica aguda e infección respiratoria aguda a lo largo de la intervención. Un ANOVA longitudinal de medidas repetidas demostró que la media de la Hb mejoró de manera significativa a los 6 y 12m de recibir la bebida fortificada (11,26, 11,64, y 11,89g/dL, respectivamente), p<0,01; la prevalencia de anemia disminuyó 44,2% después de 12m, p<0,01; la media del puntaje z de talla para la edad también mejoró, -1,25 (0m) y -1,07 (12m), p<0.01; la prevalencia de retardo del crecimiento disminuyó 25% a los 12m. Se observó una disminución significativa en la prevalencia de infección respiratoria aguda y no se observaron cambios en la prevalencia de diarrea. Un estudio de aceptabilidad demostró que los niños consumen más del 98% del producto. Los resultados sugieren que la intervención con el atole fortificado mejora el estado nutricional y de salud de los niños. El producto es aceptado por los niños y el personal de los jardines infantiles(AU)

With the aim to reduce chronic undernutrition in children that attended 6 Guatemala City daycare centers, a corn and soy-based beverage was used as a vehicle to provide 21 micronutrients and high concentrations of iron (12mg) and zinc (9 mg) and was provided to747 children aged 6 to 72 months. Children were followed for anthropometry every 3m, hemoglobin every 6m, and episodes of acute diarrhea and respiratory tract infections were registered throughout the intervention. A longitudinal Repeated Measures ANOVA demonstrated that mean hemoglobin significantly improved at 6 and 12m of receiving the beverage (11.26, 11.64, and 11.89g/dL, respectively), p<0.01; the prevalence of anemia decreased by 44.2% after 12m, p<0.01; mean height-for-age z score improved from -1.25 (0m) to -1.07 (12m), p<0.01; the prevalence of stunting decreased by 25% after 12m. A significant decrease in the prevalence of acute respiratory infection was observed. No changes were observed in the prevalence of diarrhea. Moreover, an acceptability study showed that children consumed more than 98% of the atole. These results suggest that this nutrition intervention with the fortified atole improves the health and nutritional status of children. The product is widely accepted by the children and staff at the nurseries(AU)

Impact of malnutrition on cardiac autonomic modulation in children / Impacto da desnutrição na modulação autonômica cardíaca em crianças

Abstract Objective: To compare the autonomic behavior between malnourished children and a control group using analysis of heart rate variability (HRV). Method: Data were analyzed from 70 children who were divided into two groups: malnourished and eutrophic, according to the Z-score nutritional status for height and age. For analysis of HRV indices, heart rate was recorded beat to beat with the child in the supine position for 20 min. The analysis of these indices was performed using linear methods, analyzed in the time and frequency domains. Student's t-test for unpaired data and the Mann-Whitney test were used to compare variables between groups, with a significance level of 5%. Results: A reduction in systolic and diastolic blood pressure and an increase in heart rate were found in malnourished children compared to eutrophic children. The HRV indices suggested that malnourished children present reductions in both sympathetic and parasympathetic autonomic nervous system activity. The SDNN, rMSSD, NN50, pNN50, SD1, SD2, TINN, LF (ms2), and HF (ms2) indices were lower in malnourished children. Conclusion: Malnourished children present changes in cardiac autonomic modulation, characterized by reductions in both sympathetic and parasympathetic activity, as well as increased heart rate and decreased blood pressure.

Resumo Objetivo: Avaliar a modulação autonômica cardíaca de crianças desnutridas por meio da variabilidade da frequência cardíaca (VFC). Método: Foram analisadas 70 crianças com média de 3,71 anos, que foram distribuídas em dois grupos, de acordo com o estado nutricional: desnutridas (n = 35) e eutróficas (n = 35), seguindo o escore Z, para estatura e idade. Para análise dos índices da VFC, a frequência cardíaca foi captada batimento a batimento com as crianças em decúbito dorsal por 20 minutos. A análise desses índices foi feita por meio de métodos lineares, analisados nos domínios do tempo e da frequência. Teste t de Student para dados não pareados e teste de Mann-Whitney foram aplicados para comparar as variáveis entre os grupos, com nível de significância de 5%. Resultados: Redução da pressão arterial sistólica e diastólica e aumento na frequência cardíaca foram encontrados nas crianças desnutridas quando comparada com as eutróficas. Os índices da VFC sugerem que crianças desnutridas apresentam uma redução da modulação simpática e parassimpática do sistema nervoso autônomo. Os índices SDNN, rMSSD, NN50, pNN50, SD1, SD2, TINN, BF e AF em ms2 foram menores nas crianças desnutridas. Conclusão: Crianças desnutridas apresentam modificações na modulação autonômica cardíaca caracterizadas por depressão no componente simpático e no parassimpático, bem como aumento na frequência cardíaca e diminuição da pressão arterial.

Nutritional evaluation of children with chronic cholestatic disease / Avaliação nutricional de crianças com colestase crônica

Abstract Objective: To evaluate the nutritional status of children with persistent cholestasis and to compare the anthropometric indices between children with and without liver cirrhosis and children with and without jaundice. Methods: Children with persistent cholestasis, i.e. increased direct bilirrubin or changes in the canalicular enzyme gamma-glutamyl transferase (GGT), were included. The anthropometric measures were weight (W), height or length (H), arm circumference (AC), triceps skinfold thickness (TST), arm muscle circumference (AMC), and body mass index (BMI). Results: Ninety-one children with cholestasis, with current median age of 12 months, were evaluated. W/age (A) and H/A indices below −2 Z-scores were observed in 33% and 30.8% of patients, respectively. Concerning the W/H index and BMI, only 12% and 16% of patients, respectively, were below −2 Z-scores. Regarding AC, 43.8% of 89 evaluated patients had some depletion. Observing the TST, 64% of patients had depletion, and 71.1% of the 45 evaluated patients had some degree of depletion regarding the ACM index. Conclusion: Evaluation using weight in patients with chronic liver diseases may overestimate the nutritional status due to visceromegaly, subclinical edema, or ascites. Indices that correlate weight and height, such as W/H and BMI, may also not show depletion because of the chronic condition in which there are depletion of both weight and height. TST, AC, and ACM are parameters that better estimate nutritional status and should be part of the management of patients with liver diseases and cholestasis.

Resumo Objetivo: Avaliar a situação nutricional de crianças com colestase persistente e comparar os índices antropométricos entre crianças com e sem cirrose hepática e crianças com e sem icterícia. Métodos: Foram incluídas crianças com colestase persistente, ou seja, aumento da bilirrubina direta ou alterações na enzima canalicular, gamaglutamiltransferase (GGT). As medidas antropométricas foram peso, estatura ou altura, circunferência do braço (CB), espessura da prega cutânea do tríceps (TST), circunferência muscular do braço (CMB) e índice de massa corporal (IMC). Resultados: Foram avaliadas 91 crianças com colestase, com idade média de 12 meses; 33% e 30,8% dos pacientes apresentaram índices P/I e A/I com escore Z abaixo de –2, respectivamente. Com relação ao índice P/A e IMC, somente 12% e 16% dos pacientes, respectivamente, apresentaram escore Z abaixo de –2. Com relação à CB, 43,8% de 89 pacientes avaliados apresentaram alguma depleção. Observando a TST, 64% dos pacientes que apresentaram depleção, 71,1% dos 45 pacientes avaliados apresentaram algum grau de depleção com relação ao índice de CMB. Conclusão: A avaliação do peso em pacientes com doenças hepáticas crônicas poderá superestimar a situação nutricional devido a visceromegalia, edema subclínico ou ascite. Os índices que correlacionam peso e altura, como P/A e IMC, também podem não mostrar depleção devido à doença crônica em que há depleção tanto do peso quanto da altura. A TST, BC e CMB são parâmetros que estimam melhor a situação nutricional e devem fazer parte de gestão de pacientes com doenças hepáticas e colestase.

Prevalence of child malnutrition at a university hospital using the World Health Organization criteria and bioelectrical impedance data

Malnutrition constitutes a major public health concern worldwide and serves as an indicator of hospitalized patients’ prognosis. Although various methods with which to conduct nutritional assessments exist, large hospitals seldom employ them to diagnose malnutrition. The aim of this study was to understand the prevalence of child malnutrition at the University Hospital of the Ribeirão Preto Medical School, University of São, Brazil. A cross-sectional descriptive study was conducted to compare the nutritional status of 292 hospitalized children with that of a healthy control group (n=234). Information regarding patients’ weight, height, and bioelectrical impedance (i.e., bioelectrical impedance vector analysis) was obtained, and the phase angle was calculated. Using the World Health Organization (WHO) criteria, 35.27% of the patients presented with malnutrition; specifically, 16.10% had undernutrition and 19.17% were overweight. Classification according to the bioelectrical impedance results of nutritional status was more sensitive than the WHO criteria: of the 55.45% of patients with malnutrition, 51.25% exhibited undernutrition and 4.20% were overweight. After applying the WHO criteria in the unpaired control group (n=234), we observed that 100.00% of the subjects were eutrophic; however, 23.34% of the controls were malnourished according to impedance analysis. The phase angle was significantly lower in the hospitalized group than in the control group (P<0.05). Therefore, this study suggests that a protocol to obtain patients’ weight and height must be followed, and bioimpedance data must be examined upon hospital admission of all children.

Zinc y desnutrición / Zinc and undernutrition

Son cuatro los nutrientes en que su deficiencia es importante en niños: hierro, yodo, vitamina A y zinc. Más o menos se calcula que hay 2 billones de personas en el mundo con algún grado de déficit de zinc. Los pacientes que están en riesgo de presentar deficiencias de zinc son los recién nacidos con bajo peso al nacimiento, bien sea prematuros, desnutridos in útero o hijos de madres desnutridas, en los cuales sus depósitos están reducidos. A diferencia de otros oligoelementos o micronutrientes, determinar el estado de déficit no es fácil. Los niveles séricos de zinc, están influenciados por factores no dietarios como infección, estrés o actividad física extenuante; al igual que por el ciclo circadiano.

Four nutrient deficiency that is important in children, iron, iodine, vitamin A and zinc. More or less it is estimated that 2 billion people in the world with some degree of zinc deficiency. Patients who are at risk for zinc deficiency are infants with low birth weight, either premature or malnourished in utero, undernourished mothers, in which their deposits are reduced. Unlike other trace elements or micronutrients, determine the deficit is not easy. Serum levels of zinc are not influenced by dietary factors such as infection, stress or strenuous physical activity, as well as by the circadian cycle.

Efeitos da deficiência de cobre, zinco e magnésio sobre o sistema imune de crianças com desnutrição grave: [revisão] / Effects of copper, zinc and magnesium deficiency on the immune system of severely malnourished children: [review]

OBJETIVO: Esclarecer as repercussões da deficiência de cobre, zinco e magnésio sobre o sistema imune de crianças desnutridas graves. FONTES DE DADOS: Foi realizada revisão bibliográfica mediante consulta às bases de dados Pubmed Medline, Lilacs e SciELO, selecionando-se publicações científicas recentes, da última década, e representativas do tema por meio dos descritores: desnutrição infantil, cobre, zinco, magnésio e sistema imune. SÍNTESE DE DADOS: Os micronutrientes são compostos orgânicos essenciais. Além de sua função regulatória, atuam de maneira decisiva na modulação da resposta imune. Sua deficiência pode ocorrer devido à ingestão inadequada ou associada a doenças específicas. Quando associada à desnutrição, a multideficiência de minerais pode acarretar disfunções imunológicas e aumento na suscetibilidade a infecções, afetando gravemente a eficácia de intervenções terapêuticas. Cobre, zinco e magnésio atuam como cofatores de enzimas responsáveis tanto por diversas atividades metabólicas como na resposta imune inata e adquirida, além do papel importante na maturação dos tecidos e células linfoides. Sua deficiência acarreta neutropenia e linfopenia, comprometendo a imunocompetência. CONCLUSÕES: As alterações ocasionadas pelos déficits séricos dos minerais cobre, zinco e magnésio comprometem o funcionamento do sistema imune, levando à imunossupressão. A reposição desses elementos no manejo da desnutrição grave, como preconizada pela Organização Mundial da Saúde, é essencial, uma vez que tais alterações podem ser reversíveis.

OBJECTIVE: To report the effects of the deficiency of copper, zinc and magnesium on the immune system of severely malnourished children. DATA SOURCE: A literature review was performed by consulting the databases Pubmed Medline, Lilacs and SciELO, using the descriptors: child malnutrition, copper, zinc, magnesium and immune system. Representative studies published during the last decade were chosen. DATA SYNTHESIS: Micronutrients are essential organic compounds. Besides their regulatory function, the minerals act on the modulation of the immune response. Their deficiency may be due to inadequate intake or associated with specific diseases. When combined with malnutrition, a multimineral deficiency can cause immune dysfunction and increased susceptibility to infections, altering the effectiveness of therapeutic interventions. Copper, zinc and magnesium act as co-factors of both enzymes responsible for several metabolic activities and associated to the innate and acquired immune response. These minerals also play an important role in the maturation of lymphoid tissues and cells. Their deficiency causes neutropenia and lymphopenia, decreasing the immunocompetence. CONCLUSIONS: Deficits of serum copper, zinc and magnesium affect the function of the immune system, leading to immunosuppression. The replacement of these elements in the management of severe malnutrition, as recommended by the World Health Organization, is essential, since such changes may be reversible.

Desnutrición mixta grave complicada: actualizacióndel tratamiento a propósito de un caso / Severe malnutrition complicated mixed: update the treatment of a case

La malnutrición afecta a más de 50 millones de niños de menos de 5 años en los países en desarrollo. Pese al tratamiento, la tasa de mortalidad llega al 50 % en algunos países. Hasta 1990, uno de cada cuatro niños con malnutrición grave fallecía durante el tratamiento. La tasa de letalidad no se modifi có durante los cinco últimos decenios (estudio de más de 60 países). Actualmente hay principios de tratamiento con fundamentos científi cos indiscutibles y la aplicación del protocolos recomendado por OMS - motivo de la presente actualización- reduce costos, letalidad hospitalaria, logra una rehabilitación integral y su aplicación ha originado una caída de la mortalidad a menos del 5% 1 .Se destaca la mortalidad asociada a desnutrición severa, aún pese al tratamiento y realizamos una actualización del tratamiento del desnutrido edematoso grave, presentando el caso de un niño de 1 año de edad, ingresado a la Unidad de Gastroenterología del Hospital del Niño de la Ciudad de La Paz, cuyo cuadro clínico tiene tres semanas de evolución con una enfermedad diarreica aguda (EDA), que se asocia a marcado compromiso del estado general y edema generalizado. El examen físico de ingreso clasifi ca al niño como desnutrido edematoso grave complicado y por su estado clínico crítico e inestabilidad hemodinámica, es transferido a la Unidad de Terapia Intensiva (UTI), donde pese al manejo especializado y oportuno, el niño fallece.

Malnutrition affects more than 5 million children under 5 years of age in developing countries. In spite of treatment, the mortality rate reaches 50% in some countries. Until 1990, one out of each of four children with severe malnutrition died during treatment .The rate of lethality did not change during the last fi ve decades (studies from over 60 countries). At the present, there exist principles of treatment with indisputable scientifi c bases, and the application of the protocol recommended by WHO - reason for the present actualization - reduces costs, lethality in the hospital, reaches a complete rehabilitation, and its application has originated a fall in mortality to less than 5%.We present the case of a one year-old little boy, admitted to the Gastroenterology Unit of the Children’s Hospital in La Paz whose condition had an evolution of three weeks with an acute diarrheic disease (EDA), associated to a very poor overall state and generalized oedema. The physical exam upon admission, classifi ed the child as mixed undernourished, and due to his critical condition and hemodynamic instability he was transferred to the Intensive Care Unit (UTI), where in spite of the specialized and appropriate treatment, the child died. We publish this case in order to point out the mortality associated withsevere malnutrition in spite of the treatment in the UTI, and we present an actualization of the treatment.

Hierro, infección y nutrición

El hierro cumple un papel esencial en el organismo como componente de moléculas encargadas del transporte y almacenamiento de oxígeno, sistemas de transferencia de electrones y diversas enzimas. La relación entre infección y utilización de hierro ha sido estudiada en los últimos años, en esta revisión se analizan los tópicos de más controversia al respecto: 1) la deficiencia crónica de hierro aumenta en el huésped la susceptibilidad a infección; 2) la deficiencia de hierro para su supervivencia, lo que se llama "inmunidad nutricional"; y 3) cuál es el comportamiento del hierro en el paciente críticamente enfermo.

Growth, behavior, development and intelligence in rural children between 1-3 years of life.

In a rural cohort of 625 children registered from 1981 to 1983 in 10 villages of K.V. Block, Varanasi, 196 children were assessed for physical growth, development, intelligence and concept development between 1 and 3 years of age. Home environment was also assessed using Caldwell Home inventory. These rural children remained below 3rd centile of NCHS standard for weight, height, skull and mid-arm circumferences throughout the study. Malnourished children scored poorly in all the areas of development, i.e., motor, adaptive, language and personal social, 9% in Grade I and 16.6% children in Grade II + III had IQ less than 79 (inferior). Concept for color shape and size was poorly developed in malnourished children. Maternal involvement and stimulation was strongly associated with better behavior development and intelligence. Multiple regression analysis showed that the effect of home environment on development and intelligence was of a higher magnitude as compared to status and family variables and nutritional status during 1-3 years of age.

Inter-relationship between dental, skeletal and chronological ages in well-nourished and mal-nourished children.

Dental casts, wrist roentgenograms and full mouth radiographs of teeth of 80 mal-nourished and 40 well-nourished children were evaluated and compared for correlation of dental, skeletal and chronological ages. The findings revealed (1) very high correlation between dental and skeletal ages (r = 0.9584); (2) high correlation of chronological age with dental and skeletal ages (r = 0.8635 and r = 0.8716); (3) out of all the three correlations considered, dental and skeletal ages had the maximum correlation; (4) malnutrition had a significant adverse effect on the skeletal and dental ages. Greater the severity of malnutrition, more pronounced was its effect on the dental and skeletal ages; and (5) no evidence of severity of malocclusion with retarded skeletal and dental ages.

Estado nutricional en ninos de 0 a 5 anos de edad en los consultorios 2 y 8 del Policonsultorio Munaypata de la ciudad de La Paz / Nutritional status of children (0-5 years of age) in the Munaypata clinic of the city of La Paz

Se efectuo el estudio del estado nutricional en ninos de 0 a 5 anos de edad en los consultorios 2 y 8 del Policonsultorio de Munaypata en los meses de abril a mayo de 1985, estableciendose que la malnutricion cronica fue la prevalente y que el grupo etareo mas vulnerable era el preescolar, edad en la que el nino deja de recibir el seno materno, quedando expuesto a regimenes alimentarios deficientes, especialmente en proteinas. Los resultados obtenidos en el presente estudio, son concordantes con los obtenidos por el INAN en 1981, donde se compreuba el problema nutricional mas grave es el de la desnutricion cronica, causado por un consumo deficitario y sostenido de alimentos.