George G. Graham

Nutritional management of chronic diarrhea and malnutrition: Primary reliance on oral feeding

n The course of 61 infants admitted for treatment of chronic diarrhea and malnutrition was reviewed. 30 children had (M) marasmus, 18 (K) kwashiorkor, and 13 (MK) marasmic kwashiorkor. After initial rehydration, infants were managed with a predominantly oral nutrition regimen utilizing a formula based on whole protein (casein), vegetable oil, glucose, and sucrose. Intravenous fluids were required for 38 infants (62%) for a median duration of 6 days, principally for the delivery of antibiotics, although amino acids were added in many instances. Feedings were started at 25 kcal/kg/day and were increased 35 kcal/kg/day every other day until acceptable steady weight gain ensued, provided that stool ouput did not exceed 100-50 gm/day and stool character was improving. Infants with M and MK reached a maximum intake of 151 + or - 21 kcal/dg/day after 5 weeks of treatment. Weight gain had been occurring for 2 weeks prior to this time. Infants with K were purposely not advanced past 75 kcal/kg/day until edema had cleared; a maximum intake of 135 + or - 16 kcal/kg/day was reached at 5 weeks. Mean initial serum albumin concentration in these infants with K was 1.8 + or - 0.3 gm/day and required 20 + or - 13 and 53 + or - 24 days to exceed 2.0 and 3.6 gm/dl, respectively. 14 of the 61 infants were moribund on arrival and died within the first 3 days; the remaining 8 died of overwhelming infection (6 generalized and 2 pneumonia). Data suggest that once infection is controlled, infants with chronic diarrhea and malnutrition can usually be effectively managed by enteral feeding without resorting to parenteral alimentation.n

The High Cost of Being Poor

Longitudinal anthropometric and socioeconomic assessment was made of 127 families of children admitted to the British American Hospital in Lima, Peru, with malnutrition in 1961 to 1971. In 1972, those recruited during 1961 to 1966 had higher incomes and were more likely to have running water and electricity than those recruited later, who were more likely to be using candles or kerosene and to buy water in cylinders, at a unit cost 16.7 times higher. Mean mid parental heights were equal, but the children from families with water and electricity services were taller for their age. Expenditures for illumination were similar, whether for electricity or for candles or kerosene, but the cost of water by volume was very much higher in families without running water. When expenditure was expressed as percentage of income or as the amount of working time to pay for water, the differences were even greater: 2.6% to 2.7% vs 0.4% to 0.7% and 423 to 445 vs 71 to 129 minutes/month.

Adrenal function in normal infants and in marasmus and kwashiorkor: Plasma aldosterone concentration and aldosterone secretion rate

In normal infants 2.1 to 3.2 months of age and in those 4.8 to 10.6 months of age, plasma aldosterone concentrations were, respectively, 88±42 and 61±43 ng. per 100 ml. (S.D.) and the aldosterone secretion rates were 75±21 and 70±36 μg per 24 hours. Older infants, 12.5 to 18.5 months of age, had plasma aldosterone levels of 17±7 ng. per 100 ml. and aldosterone secretion of 73±43 μg per 24 hours. The plasma aldosterone concentrations of the two younger groups were significantly higher than that of the 12.5-to 18.5-month-old children (p

Thyroid hormonal studies in normal and severely malnourished infants and small children

Thyroid hormone levels have been determined in nutritionally normal infants and in infants with marasmus or marasmic kwashiorkor. In the normal subjects, serum thyroxine is higher during the first year of life than at birth or after one year. Free thyroxine is higher at 2 to 3 months of age than later. TBG falls slightly but not significantly with age. Elevated TSH of cord serum falls to normal adult levels by 2 to 3 months. Despite normal TBG, serum thyroxine may be decreased in marasmus and during recovery; free thyroxine may be high to low initially and normal or low during recovery; serum TSH is low or normal at both times. In kwashiorkor, low initial TBG accounts for low thyroxine, but free thyroxine is normal or elevated; TSH is normal. During recovery, TBG returns to normal but thyroxine only partially so, and free thyroxine falls as does TSH. TBPA does not change significantly with age or nutritional state.

Adrenal function in normal infants and in marasmus and kwashiorkor. Cortisol secretion, diurnal variation of plasma cortisol, and urinary excretion of 17-hydroxycorticoids, free corticoids, and cortisol.

Normal infants exhibited circadian rhythmicity of plasma F concentration. Infants from 2.1 to 3.2 months of age had CSR significantly higher than those of older infants. THF/THE urinary excretion ratios increased with age. The 17OHCS excretion was higher in the younger infants. Urinary excretions of free corticoids and cortisol were similar in all age groups. In marasmus, plasma F concentrations in the morning and evening were significantly elevated. Normal diurnal variation returned following therapy. CSR and 17OHCS excretions were not different from age controls, but were significantly lower than size controls, THF/THE ratios, urinary excretion of free corticoids and cortisol were normal. In marasmic kwashiorkor, plasma F concentrations were significantly elevated in the morning and evening. There was a suggestive decrease with therapy. CSR was low before and after treatment. THF/THE ratios, urinary 17OHCS excretion, and urinary free corticoids and cortisol were not significantly different from infants matched for size or patients with marasmus.

Detection of endotoxemia with the Limulus test: Preliminary studies in severely malnourished children†

Eighteen Peruvian children with protein-calorie malnutrition were studied to evaluate the usefulness of the limulus assay for endotoxin in detecting gram-negative sepsis. Nine of the children had at least one positive Limulus assay, and eight of this group had bacteriologic cultures indicative of gram-negative infection. Four of these nine children with positive Limulus assays died, whereas only one of the nine children with negative assays died. This preliminary study suggests the usefulness of the Limulus assay as an adjunct to bacteriologic cultures in the early detection of significant gram-negative infection in severely malnourished children.

Free catecholamine excretion in the urine in normal infants and in those with marasmus or kwashiorkor

Free catecholamine (epinephrine + norepinephrine) excretions of normal male infants 2.1-3.2, 4.5-10.6, and 12.5-18.5 months of age, respectively, and of infants and children with marasmus or marasmic kwashiorkor were measured on three consecutive days after admission and after partial rehabilitation. In normal infants, particularly the older ones, the first days excretion was higher than that of the next two days, probably in response to the stress of the procedures. There was an increase with age, but on a surface area basis, the differences were not significant, the three age groups excreting 15.1 plus or minus 10.2, 23.8 plus or minus 20.9, and 24.7 plus or minus 14.3 mug/m-2/day, respectively. Excretions of marasmic infants on admission were not significantly different from those of the control children. Higher mean values were due to elevated excretions of infants with severe infection. After partial rehabilitation, excretions were similar to those of control subjects. In children with marasmic kwashiorkor excretions were no different from those of control infants, except in severely infected children. Admission values revealed more day-to-day variation than recovery values or than those of normal and marasmic infants, in whom subject to subject variation was more marked.

Detection of endotoxemia with the Liniulus test: preliminary studies in severely malnourished children.

Eighteen Peruvian children with protein-calorie malnutrition were studied to evaluate the usefulness of the limulus assay for endotoxin in detecting gram-negative sepsis. Nine of the children had at least one positive Limulus assay, and eight of this group had bacteriologic cultures indicative of gram-negative infection. Four of these nine children with positive Limulus assays died, whereas only one of the nine children with negative assays died. This preliminary study suggests the usefulness of the Limulus assay as an adjunct to bacteriologic cultures in the early detection of significant gram-negative infection in severely malnourished children.

Absorption and retention from an iso-osmolal casein hydrolysate infant formula

Abstract Pregestimil ® , the control formula, and Nutramigen ® , a casein hydrolysate formula, further modified to reduce osmolality from 443 to 300 m0sm/kg water, were well accepted and tolerated while supporting adequate growth and maintaining normal serum albumin levels in six recovering malnourished infants. Stool characteristics were similar in both groups. An apparent nitrogen absorption of 88±4% of intake was observed for both products with apparent nitrogen retention rates of 39±8 and 43±6% for the control and test products, respectively. Mean fat absorptions exceeded 93% of intake for both products and carbohydrate absorption was practically complete as confirmed by the absence of significant peaks in the breath hydrogen determinations. Dry stool weights and fecal excretions of energy, fat and carbohydrate were modestly but significantly higher with reformulated Nutramigen ® than with Pregestimil ® , however, no clinical effects were noted in this infant population.