Weight reduction after severe brain injury: a challenge during the rehabilitation course.

BACKGROUND: There is a paucity of studies, which have described malnutrition in patients with acquired brain injury (ABI) across etiology. This study describes weight change, malnutrition, and potential associations in patients with ABI at a subacute inpatient rehabilitation hospital. METHOD: This is a descriptive cohort study. Ninety-eight patients were admitted in a 3-month period, of whom n = 76 met inclusion criteria. The Malnutrition Universal Screening Tool was used for categorizing patients according to risk of malnutrition. RESULTS: Patients had experienced weight loss of 5.59% ± 5.89% (p < .001) at admission at the rehabilitation hospital, and patients with traumatic brain injury had experienced a greater weight loss than patients with stroke (p < .01). Thirty percent of patients were at high risk for malnutrition, and 52% of these patients received enteral or parenteral nutrition at admission at the rehabilitation hospital. No association was found between risk of malnutrition and severity of injury, complications, functional outcome, or length of stay. CONCLUSION: RESULTS underline the importance that nurses, especially in acute care, adhere to clinical guidelines to minimize weight loss. Special attention should be on patients with traumatic brain injury. Weight gain in the following course of rehabilitation may facilitate positive rehabilitation outcomes.

Programmatic response to malnutrition in India, room for more than one elephant.

Programming platforms need to recognize the diversity of malnutrition epidemiology in India and choose appropriate implementation designs. With severe chronic malnutrition as the dominant epidemiologic entity, the net needs to be cast wide, focusing on food security, health care, agriculture, water and sanitation, livelihoods and womens empowerment. Community-based malnutrition treatment and prevention programs need to collaborate to complement treatment with socioeconomic and preventive interventions. Expansion of nutrition rehabilitation centers should be limited to areas/districts with high wasting. Pediatric services with nested nutrition services (including counseling) requires urgent strengthening. Continuum of Care is a weak link and requires strengthening to make both hospital and community-based models meaningful.

Dietary supplementation with aromatic amino acids increases protein synthesis in children with severe acute malnutrition.

Although 2 earlier studies reported that aromatic amino acid (AAA) supplementation of children with severe acute malnutrition (SAM) improved whole-body protein anabolism during the early postadmission (maintenance) phase of rehabilitation, it is not known whether this positive effect was maintained during the catch-up growth and recovery phases of treatment. This study aimed to determine whether supplementation with an AAA cocktail (330 mg · kg(-1) · d(-1)) vs. isonitrogenous Ala would improve measures of protein kinetics in 22 children, aged 4-31 mo, during the catch-up growth and recovery phases of treatment for SAM. Protein kinetics were assessed by measuring leucine, phenylalanine, and urea kinetics with the use of standard stable isotope tracer methods in the fed state. Supplementation started at the end of the maintenance period when the children were clinically/metabolically stable and continued up to full nutritional recovery. Three experiments were performed: at the end of maintenance (at ∼13 d postadmission), at mid-catch-up growth (at ∼23 d post- admission when the children had replenished 50% of their weight deficit), and at recovery (at ∼48 d postadmission when they had achieved at least 90% weight for length). Children in the AAA group had significantly faster protein synthesis compared with those in the Ala group at mid-catch-up growth (101 ± 10 vs. 72 ± 7 µmol phenylalanine · kg(-1) · h(-1); P < 0.05) and better protein balance at mid-catch-up growth (49 ± 5 vs. 30 ± 2 µmol phenylalanine · kg(-1) · h(-1); P < 0.05) and at recovery (37 ± 8 vs. 11 ± 3 µmol phenylalanine · kg(-1) · h(-1); P < 0.05). We conclude that dietary supplementation with AAA accelerates net protein synthesis in children during nutritional rehabilitation for SAM.

Can nutrition rehabilitation centers address severe malnutrition in India?

Madhya Pradesh has made remarkable progress in facility based management of severe acute malnutrition, and has developed a model that is being replicated in many states. India has uniquely high prevalence of both stunting and wasting, implying that both severe acute malnutrition and severe chronic malnutrition co-exist. This study sought to explore design issues of nutritional rehabilitation centers in order to inform its effectiveness in settings where the prevalence of chronic poverty and malnutrition is high. Our analysis attributes the limited success (marked by poor cure rates and high non-responder rates) to high prevalence of chronic malnutrition, particularly in nutritional rehabilitation centers located in pheripheral areas. There is a failure to recognize severe chronic malnutrition as an epidemiological entity and gear wide-ranging programmatic and social interventions.

Evaluation of a nutrition rehabilitation protocol in hospitalized adolescents with restrictive eating disorders.

PURPOSE: Nutritional rehabilitation is an essential part of inpatient treatment for adolescents with restrictive eating disorders (ED). The purpose of this study was to examine weight gain, prevalence of refeeding syndrome, and nutritional composition of the diet in hospitalized adolescents with anorexia nervosa (AN) and eating disorder not otherwise specified (EDNOS), restrictive type, on a structured nutrition rehabilitation protocol (NRP). METHODS: An evidence-based NRP was implemented on the inpatient eating disorders unit at the Hospital for Sick Children in June 2011. Adolescents 12-18 years of age with AN or EDNOS, an ideal body weight (IBW) of 70% or greater, no clinical or metabolic signs of refeeding syndrome, and on their first admission were assigned to the NRP. A retrospective chart review between June 2011 and June 2012 was completed. A repeated measures analysis was used to determine the mean rate of weight gain. Mean cumulative % change in body mass index (BMI) was plotted against days to assess daily weight trajectory. RESULTS: Twenty-nine patients, mean age of 14.7 (SD ± 1.5) years, were included in the study. A total of 3.5% developed hypophosphatemia on day 1. Mean weight gain was .24 kg/day (p < .0001) and 1.7 kg/week. An increase in mean cumulative % change in BMI was observed from days 2-14. Actual caloric intake was 98%-113% of the prescribed intake. Macronutrient distribution was within acceptable limits based on dietary reference intakes. CONCLUSIONS: The NRP is considered effective, efficient, and safe. Further research is needed to explore the effectiveness and safety of NRPs in other populations.

Improving protein and vitamin D status of obese patients participating in physical rehabilitation.

PURPOSE: Sarcopenia and vitamin D deficiency increase risk of disability outcomes associated with a million hip and knee replacements annually. The purpose of the present study was to identify protein and vitamin D inadequacy in arthroplasty patients, and observe the effect of supplementation on metabolic markers on protein and vitamin D status. METHODS: One hundred and eighty obese arthroplasty patients admitted for inpatient rehabilitation, positive for protein and vitamin D insufficiency, received supplemental protein and vitamin D. RESULTS AND CONCLUSION: Following supplementation, normalization of protein and vitamin D status was achieved. Nutrient supplementation during physical rehabilitation provided an efficient and effective means to reverse nutrient deficiency in an obese, orthopedic population. CLINICAL RELEVANCE: Inpatient physical rehabilitation is an opportune environment for nurses to provide education and intervention of nutrient supplementation, which may lessen consequences of sarcopenic obesity and related frailty disorders.

Infant malnutrition is associated with persisting attention deficits in middle adulthood.

Infantile malnutrition is known to be associated with cognitive and behavioral impairment during childhood and adolescence. Data pertaining to longer-term effects on behavioral outcomes in adulthood are limited. In this study, we report associations between infantile malnutrition and attention problems in adults at midlife. Attention problems were assessed by the Conners Adult ADHD Rating Scales (CAARS) and the Conners Continuous Performance Test (CPT) in 145 Barbadian adults (aged 37-43 y) who had been followed longitudinally since childhood. Previously malnourished participants (n = 80) had experienced moderate to severe protein-energy malnutrition in the first year of life and were successfully rehabilitated thereafter. They were compared with healthy adults (n = 65) who were former classmates of the index cases and who had been matched for age, sex, and handedness in childhood. Multiple regression analyses showed persisting effects of childhood malnutrition on both the CAARS and the CPT, independent of effects of household standard of living assessed in childhood. The malnutrition effect on the CAARS ratings was independent of IQ, whereas this effect was attenuated for the CPT after adjustment for IQ. Teacher-reported attention problems in childhood predicted attention problems in adulthood, indicating continuity over the life span. Infantile malnutrition may have long-term effects on attentional processes nearly 40 y after the episode, even with excellent long-term nutritional rehabilitation and independent of socioeconomic conditions in childhood and adolescence. This finding has major public health implications for populations exposed to early childhood malnutrition.

Hospital based nutrition rehabilitation of severely undernourished children using energy dense local foods.

OBJECTIVE: To examine the catch up growth in severely wasted children using energy dense local foods at a hospital based nutrition rehabilitation unit. DESIGN: Retrospective cohort. SETTING: In-patient ward at a tertiary care government pediatric hospital in Hyderabad. PATIENTS: Children with severe malnutrition (n=309) admitted to nutrition ward from January 2001 to December 2005. INTERVENTION: A diet based on energy dense local foods along with multivitamin-multimineral supplements. MAIN OUTCOME MEASURES: Catch up growth (g/kg/day) during each week of hospital stay. RESULTS: Mean age of the children was 25 months (range 2-60). Their baseline weight for height (WHZ) Z score was -4.1. Mean weight gain was moderate (5g/kg/day) and baseline WHZ score had a significant negative relationship to the weight gain. The prevalence of morbidities was high and the commonest morbidity was fever. Weight gain was higher by almost 40% in the absence of morbidities in any week. CONCLUSIONS: The diet based on local energy dense foods was found to be suitable for the nutrition rehabilitation of severely malnourished children though the rate of weight gain was moderate.

CD95 expression in white blood cells of malnourished infants during hospitalization and catch-up growth.

Malnutrition continues to be a major health burden in developing countries. Flow cytometric estimation of the apoptotic marker CD95 in peripheral neutrophils, lymphocytes and monocytes was done for 18 infants with non-oedematous protein energy malnutrition (PEM) and 12 oedematous ones, on hospital admission and after supervised nutritional rehabilitation, and compared with 12 matched controls. CD95 counts in the 3 types of white blood cells were significantly higher in PEM infants and showed improvement after nutritional rehabilitation yet not reaching the control values. Enhanced apoptosis in the leukocytes of peripheral blood of PEM patients may be a marker of increased infection and immune disturbances. This derangement reverses upon proper nutritional rehabilitation.

HIV prevalence and mortality among children undergoing treatment for severe acute malnutrition in sub-Saharan Africa: a systematic review and meta-analysis.

This systematic review and meta-analysis explored HIV prevalence and mortality in children undergoing treatment for severe acute malnutrition (SAM) in sub-Saharan Africa. It included all studies reporting on HIV infection within a sample of children with SAM where HIV status was assessed using a blood test and SAM was defined using the WHO, Gomez, Wellcome or Waterlow definitions. Children from 17 studies were included in the analysis (n=4891), of whom 29.2% were HIV-infected. HIV-infected children were significantly more likely to die than HIV-uninfected children (30.4% vs. 8.4%; P<0.001; relative risk=2.81, 95% CI 2.04-3.87). HIV-negative children treated within community-based therapeutic care (CTC) programmes had lower mortality (4.3%) than those treated within an inpatient nutrition rehabilitation unit (NRU) (15.1%). There was no significant difference in mortality for HIV-infected children with SAM treated in the CTC (30.0%) or NRU (31.3%) settings. HIV prevalence is high in children with SAM in sub-Saharan Africa, and HIV-infected children are at significantly increased risk of mortality. There is an urgent need to integrate HIV testing and treatment into care for children with SAM in regions of high HIV prevalence.

Sleep-wake cycle disturbances in protein-energy malnutrition: effect of nutritional rehabilitation.

A standard sleep questionnaire was given to the parents of 26 infants with protein-energy malnutrition who underwent polysomnographic evaluation. These investigations were repeated approximately 2 months after enrolment in a nutritional rehabilitation programme based on World Health Organization guidelines. Anthropometric values and serum serotonin levels were also measured. After nutritional rehabilitation there was a significantly higher percentage of non-rapid eye movement (REM) sleep; 2nd REM time, and latency times for sleep and REM sleep increased. Percentages of REM sleep and serum serotonin levels decreased significantly. Protein-energy malnutrition seems to affect the sleep-wake cycle; disturbed serotonin levels may be among the factors responsible.

Cognitive functions in protein-energy malnutrition: in relation to long chain-polyunsaturated fatty acids.

Aiming to find out a correlation between plasma LC-PUFA levels and neurodevelopmental status of malnourished infants, the present study was conducted on 42 infants suffering from PEM, with a mean age of 11.28 +/- 4.59 months. They were divided clinically into edematous and non-edematous groups. Fifteen age and sex matched well nourished apparently healthy infants were chosen to serve as controls. All patients were subjected to a 3-phase workup, while controls were subjected only to phase 1. Phase I: includes clinical assessment, laboratory investigations including plasma LC-PUFA levels and Neurodevelopmental assessment. In Phase II: An interventional program of 8 weeks duration; where all patients were receiving an initial supportive treatment followed by nutritional rehabilitation according to WHO guidelines, 1999 as well as developmental stimulation. According to the formula supplied to patients, they were randomly divided into either PUFA supplemented (+ve group) or nonBsupplemented (-ve group). In Phase III: All patients were re-assessed clinically and neurodevelopmentaly as well as re-evaluation for plasma LC-PUFA levels. The study revealed that, the mean plasma AA and DHA levels as well as the mean MDI and PDI scores of BSID-II were significantly lower in PEM patients compared to those levels after nutritional rehabilitation and to controls. Moreover, the mean MDI score was significantly lower in edematous subgroup compared to non-edematous one. Meanwhile, the mean rate of change in plasma DHA level was significantly higher in edematous subgroup compared to non-edematous one. However, there was no significant difference in the mean of rate of change in AA level or MDI and PDI scores between the 2 subgroups. Further, the mean rate of change in plasma AA and DHA levels as well as MDI score were significantly higher in PUFA +ve patients compared to PUFA Bve ones after nutritional rehabilitation. Finally, the study showed significant positive correlations between plasma AA and DHA levels and both MDI and PDI scores. From the course of this study we concluded that malnourished infants had impaired neurodevelopmental functions that could be related to the poor status of plasma LC-PUF. Thus, we recommend early intervention including nutritional rehabilitation and LC-PUFA supplementation as well as stimulation program, so as to have a better effect on future cognitive abilities of these infants.

T-lymphocyte subsets and thymic size in malnourished infants in Egypt: a hospital-based study.

Thymus size was assessed ultrasonographically and correlated to the percentage of CD4 and CD8 T-lymphocytes in peripheral blood in 32 infants with protein-energy malnutrition (PEM) and compared with 14 healthy control infants. The study revealed thymus atrophy in patients with PEM, especially the oedematous type, accompanied by changes in the peripheral lymphocyte subsets. These changes were reversible after nutritional rehabilitation. However, they may affect the immune status of PEM patients and may require a longer duration of nutrition rehabilitation than required for recovery of anthropometric measures. We recommend proper assessment of the immune functions of PEM patients during nutritional rehabilitation until full recovery.

Pancreatic size in protein energy malnutrition: a predictor of nutritional recovery.

BACKGROUND: Pancreatic exocrine dysfunction has been frequently recorded in protein energy malnutrition (PEM) because the pancreas requires optimal nutrition for enzyme synthesis. This pancreatic enzyme insufficiency may play a role in the continuation of PEM. OBJECTIVE: This study was designed to assess the pancreatic head size and exocrine pancreatic functions, namely serum amylase and lipase, in PEM and its subtypes and correlate any defect present with the various clinical and laboratory data of the PEM patients with special emphasis on the effect of nutritional rehabilitation. PATIENTS AND METHODS: A total of 33 cases of PEM; 15 marasmus, 10 kwashiorkor (KWO) and eight marasmic kwashiorkor (MKWO) were recruited from Ain Shams University children's hospital, together with 12 matched controls. The mean age of patients was 11.87 +/- 7.8 months and that of the controls was 14.83 +/- 7.7 months. Detailed history taking and thorough clinical examination with special emphasis on anthropometric measurements were taken for each studied infant as well as laboratory investigations which included; complete blood count, liver and kidney functions and serum amylase and lipase. Ultrasonographic assessment of pancreatic head size was performed for the cases and controls. Nutritional rehabilitation program was carried out for 3-6 months followed by reassessment of the cases. RESULTS: The pancreatic head size values were significantly lower in all subtypes of PEM (1.52 +/- 0.6, 2.73 +/- 0.12 and 3.00 +/- 0.54 cm(3) in the marasmus, KWO and MKWO respectively) compared to the controls (5.13 +/- 2.33 cm(3)). The serum amylase and lipase were also significantly lower in all subgroups of PEM when compared to the controls with significant improvement following nutritional rehabilitation coupled by a significant increase in pancreatic head size too. No significant differences were recorded when we compared the subgroups together except for a significant higher rate of change in serum amylase in edematous patients compared to nonedematous ones. The length of nutritional rehabilitation period, age of the patient, weight and serum albumin were the most determinant factors for pancreatic head size as evident from the multiple regression analysis study. CONCLUSION: The potentially correctable exocrine pancreatic insufficiency in cases of PEM should be carefully thought of when planning the nutritional rehabilitation program for such patients as it could be responsible for the serious continued morbidity issues that they face. We thus recommend that estimation of pancreatic head size and exocrine function should be included in the evaluation of PEM patients and they could also be used as a prognostic parameter. SPONSORSHIP: The patients enrolled were among those admitted and managed freely in the children's Hospital Faculty of Medicine Ain Shams University, including the use of the ultrasound apparatus, while the kits have been purchased by authors who contributed in financing the study.

Integrated medical-psychiatric treatment of the "crisis phase" in severe protein-energy malnutrition secondary to major eating disorders.

C.A., a 23-year old male was admitted in the clinical nutrition medical ward for severe, complicated protein-energy malnutrition (PEM) [body mass index (BMI) 11.08 kg/m2; body weight kg 35.81 due to major eating disorders. C.A.'s personality was narcissistic, with a rigid psychic structure. During hospitalitation (lasted 72 days) two acute episodes (a possibly self-inflicted damage and a persecution feeling) occurred that we consider as part of the "crisis phase", the period in which the patient's restrictive behaviour is no longer able to keep his personality equilibrium stable. The patient was treated by an integrated medical and psychiatric approach, including periods of never forced parenteral nutrition, nutritional and intensive psychoterapeutic interventions. For a short period the patient received also a pharmacological support (aloperidol orally). Treatment was successful and the patient was discharged completely autonomous and followed up on an outpatient basis. After about one year follow-up he is still in good clinical condition and in sufficient psychological equilibrium.

Ultrasonographic gastric emptying in protein energy malnutrition: effect of type of meal and nutritional recovery.

OBJECTIVE AND DESIGN: The earlier reports of disturbed gastric motility in protein energy malnutrition (PEM) point out to its possible contribution in the difficulties faced during nutritional rehabilitation. This study was thus designed to assess the ultrasonographic gastric emptying time (GET) using 20 ml/kg body weight of both liquid and semisolid meals, in 27 patients suffering from PEM as well as in 15 healthy matching infants to delineate any defect present, its degree in different types of PEM and the effect of nutritional rehabilitation. PATIENTS: The patients were recruited from the in-patient department of Children's Hospital, Ain Shams University, Cairo, Egypt. They were divided into three groups: 10 marasmic infants, 10 marasmic kwashiorkor (marasmic KWO) and seven kwashiorkor (KWO) cases. Ultrasonographic GET assessment was carried out within 72 h of admission and 30+/-7 days after nutritional rehabilitation. RESULTS: The gastric half-emptying time T(1/2) of both liquid and semisolid meals was markedly prolonged in patients with marasmus and marasmic KWO. It was more delayed for the semisolid than the liquid meals. This delay was reversible after nutritional rehabilitation of the patients, indicating that it was secondary to the malnourished status. On the other hand, T(1/2) of both liquid and semisolid meals showed no statistically significant delay in the KWO group and nutritional rehabilitation added no further to the results. CONCLUSION: PEM, especially marasmus and marasmic KWO, causes a delay in GET, which is reversible on nutritional recovery. This must be considered during nutritional rehabilitation of such patients to decrease the duration of their hospitalization and thus decrease the morbidity in PEM.

Nutritional status of preschool Senegalese children: long-term effects of early severe malnutrition.

The prevalence of malnutrition remains high in many developing countries. However, data relating to the long-term effects of severe malnutrition, specifically, serum levels of biochemical indicators of nutritional status, are still scarce in the literature. Hence the present study aimed to investigate the nutritional, biological and growth status of Senegalese preschool children previously hospitalised for severe malnutrition. The study involved twenty-four 7-year-old children who had suffered from marasmus 5 years earlier, twenty-four siblings living in the same household, and nineteen age-matched children living in the centre of Dakar. The siblings were of similar age to the post-marasmic children. Anthropometry, serum biochemical indicators of nutritional status, growth factors, and haematological and mineral parameters were measured. The prevalence of stunting and wasting was the same in the post-marasmic children as in the siblings. Body-fat and fat-free-mass (FFM) deficits in both groups were corroborated by abnormally low concentrations of transthyretin, osteocalcin, insulin-like growth factor (IGF)-1, and insulin-like growth factor-binding protein (IGFBP)-3. FFM was positively and significantly correlated with concentrations of IGF-1 and IGFBP-3. In the post-marasmic children, height for age was also correlated with IGF-1. Of the post-marasmic children, 53 % had Fe-deficiency anaemia, as did 35 % of the siblings and 29 % of the controls. No significant associations were found between the serum concentrations of Ca, Cu, K, Mg, Na, P, Se, Zn and growth retardation. At 5 years after nutritional rehabilitation, the post-marasmic children remained stunted with nutritional indices significantly lower than the control children. However, these children were doing as well as their siblings except for minor infections.

Comparison of the efficacy of a solid ready-to-use food and a liquid, milk-based diet for the rehabilitation of severely malnourished children: a randomized trial.

BACKGROUND: The World Health Organization recommends a liquid, milk-based diet (F100) during the rehabilitation phase of the treatment of severe malnutrition. A dry, solid, ready-to-use food (RTUF) that can be eaten without adding water has been proposed to eliminate the risk of bacterial contamination from added water. The efficacies of RTUF and F100 have not been compared. OBJECTIVE: The objective was to compare the efficacy of RTUF and F100 in promoting weight gain in malnourished children. DESIGN: In an open-labeled, randomized trial, 70 severely malnourished Senegalese children aged 6-36 mo were randomly allocated to receive 3 meals containing either F100 (n = 35) or RTUF (n = 35) in addition to the local diet. The data from 30 children in each group were analyzed. RESULTS: The mean (+/- SD) daily energy intake in the RTUF group was 808 +/- 280 (95% CI: 703.8, 912.9) kJ x kg body wt(-1) x d(-1), and that in the F100 group was 573 +/- 201 (95% CI: 497.9, 648.7) kJ. kg body wt(-1) x d(-1) (P < 0.001). The average weight gains in the RTUF and F100 groups were 15.6 (95% CI: 13.4, 17.8) and 10.1 (95% CI: 8.7, 11.4) g x kg body wt(-1) x d(-1), respectively (P < 0.001). The difference in weight gain was greater in the most wasted children (P < 0.05). The average duration of rehabilitation was 17.3 (95% CI: 15.6, 19.0) d in the F100 group and was 13.4 (95% CI: 12.1, 14.7) d in the RTUF group (P < 0.001). CONCLUSIONS: This study indicated that RTUF can be used efficiently for the rehabilitation of severely malnourished children.