Guillermo López de Romaña

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

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.

Milk consumption and hydration status of exclusively breast-fed infants in a warm climate

To assess the hydration status of 40 exclusively breast-fed Peruvian infants, their milk intake and urinary volume and concentration were measured during 8-hour daytime observations. Maximum home temperatures ranged between 26 degrees and 33 degrees C; environmental relative humidity ranged between 49% and 96%. The infants consumed between 105 and 528 gm milk during the observation period; the standardized intakes ranged between 4.0 and 12.1 gm/kg body weight per hour (mean +/- SD 7.5 +/- 1.7 gm). The infants voided between 0.9 and 6.3 ml urine per kilogram of body weight per hour (mean +/- SD 3.4 +/- 1.3 ml). The maximum urinary specific gravity in each infant ranged between 1.003 and 1.017. We conclude that healthy infants can maintain adequate hydration status while exclusively breast-fed under these environmental conditions.

The relationship between infants' preceding appetite, illness, and growth performance and mothers' subsequent feeding practice decisions

Data from a longitudinal study of 153 low-income Peruvian infants were used to examine (i) whether infant characteristics such as appetite, illness and past growth performance are related to subsequent changes in their feeding practices (e.g. addition of non-human milks, solid foods, weaning), and (ii) whether this relationship depends on maternal characteristics such as feeding exposure and experience (MFEE). With one exception, infants were breastfed from birth. Feeding practices during the first month of life were related to practices throughout infancy. Most mothers changed their practices once (61%) or twice (34%) from birth to 6 months. Low weight gains from 1 to 2 (P < 0.003) and 2 to 3 (P < 0.04) months were identified as significant predictors of feeding changes during the following months, using logistic regression models that also adjusted for MFEE, infant gender, previous practice, and previous practice change. The interaction between past weight gain and MFEE (objective ii) was not statistically significant in the logistic regression models. However, when analyzed separately, the relationships between low weight gains and subsequent feeding changes were observed for high but not low MFEE mothers. The prevalences of anorexia and infection (diarrhea, respiratory, and/or fever), and poor length gain during the previous month were not related to subsequent changes in feeding practices. These results suggest that poor growth influences feeding practices from 2 to 4 months, when exclusive breastfeeding is recommended.

Health and growth of infants and young children in Huáscar, Perú

Rural to urban migration has increased greatly over the last several decades in Latin America. New migrants usually live in peri‐urban communities that lack basic services, including potable water, sewerage or electricity. Residents of one such community near Lima, Peru, were found to have a high rate of infant and childhood mortality; half of childhood deaths were associated with diarrhea. Surviving children had a high rate of diarrhea with a peak incidence in 12 to 23‐month‐old children, Young children had mean weights and lengths at birth that were nearly identical to North American newborns (NCHS population), and growth during the first few months was similar to the reference population. However, relative growth faltering was observed after the first four months of life suggesting that environmental factors, either nutrition or infectious diseases, were interfering with potential growth. After this preliminary study, longitudinal investigations of the feeding practices, dietary intake and diarrheal di...

Transient steatorrhea following episodes of mild diarrhea in early infancy.

Fecal fat excretion was studied after a mild episode of diarrhea in eight infants for whom adequate control data were available. Mean age of onset of diarrhea was 28 days. Duration of the episode, defined as the number of days until the infant was again feeding and libitum, averaged 5.1 days. Balance studies were carried out 3 to 13 days later. Mean fecal fat excretion rose from a prediarrhea value of 2.9 +/- 1.4 gm/day to 8.7 +/- 3.1 gm/day following diarrhea (P less than 0.001). Restudy of five infants one month later showed persistent steatorrhea in one. Mild transient steatorrhea may follow mild diarrhea in infancy and should be considered in infants who are slow to gain weight subsequent to an episode of diarrhea.

Oral iron absorption in infantile protein-energy malnutrition

The ability of infants with protein-energy malnutrition to absorb iron was assessed using the serum iron response to a dose of ferrous sulfate providing 3 mg elemental iron per kg body weight. Responses were grouped as flat (delta serum Fe less than 30 microgram/dl), intermediate (30 to 100 microgram/dl), and normal (greater the 100 microgram/dl). Of 25 consecutively admitted children studied, seven had a flat, five an intermediate, and 13 a normal curve (mean delta serum Fe: 10 microgram/dl, 66 microgram/dl, and 175 microgram/dl, respectively). There were no differences among the three groups in hematocrit, fasting serum iron or transferrin saturation, severity of malnutrition, or evidence of other malabsorption sufficient to explain these differences. Although hematocrits, fasting serum iron, and transferrin saturations did not change appreciably during nutritional rehabilitation, all children with initially abnormal responses subsequently had normal tests.

Effect of the level of dietary protein intake on fat absorption in children.

Summary: The quantity and quality of protein in the diet affect both nitrogen balance and energy utilization in man. One possible mechanism is by a direct effect on the process of fat digestion and absorption. The effect on fat absorption of feeding diets providing 0%, 6.4%, or 12.5% of energy as protein was assessed in nine children. Liquid diets were prepared by high speed blending of calcium caseinate, a soy-cottonseed oil blend (80:20), sucrose, water, vitamins, and a mineral mixture and fed by bottle five times per day. Diets varied in the amount of protein and were fed to maintain constant the intakes of fat and carbohydrate. All children began by consuming the diet providing 6.4% of energy as protein for a period of 6 days: 3 days of adaptation, 3 days of metabolic collection of urine and stool. Successive 3-day dietary periods and metabolic collections followed in one of two sequences: 12.5%, 0%, 6.4% energy as protein in five children; 0%, 12.5%, 6.4% energy as protein in four. Mean fat excretion during the two 6.4% periods did not differ significantly (initial 14.5 ± 6% of intake; final, 11.7 ± 5.0% of intake). Fat excretion was significantly greater during the period when no protein was consumed (23.9 ± 7.7% of intake) than during either the period in which protein provided 6.4% of energy (P < 0.01) or during that in which protein provided 12.5% of energy (10.0 ± 2.6% of intake, P < 0.001). The difference between the 6.4% and 12.5% periods did not attain significance (P = 0.10). Fecal fat expressed as a percentage of fecal dry weight was significantly greater during periods when the diet contained no protein than during periods in which protein provided either 6.4% (P < 0.05) or 12.5% (P < 0.01) of energy.Additional studies were carried out in a similar fashion in six children consuming diets in which protein provided 5%, 9.6%, and 15% of energy. All six possible dietary sequences were used. At these intakes fat excretion did not vary significantly with protein intake.Speculation: The low protein intake of children in much of the developing world may be detrimental to maximal fat absorption and consequently may increase their energy requirements.

TRANSIENT STEATORRHEA AFTER MILD DIARRHEA OF INFANCY

Chronic and recurrent diarrhea is a recognized antecedent of malabsorption and malnutrition. The relationship of transient mild diarrhea to subsequent malabsorption is unknown. Six normal term infants, for whom 6 d balance control data were available, developed diarrhea in hospital while consuming formula diets (116±22 KcalAg/d). Mean age of onset was 29 d (range 13-37). Treatment: dilute diet (2), Lytren (2), IV + Lytren (2). Full diet was tolerated and all infants clinically well in 3-9 d. Six-day restudy was carried out 7-13 d later while gaining weight on 145±13 KcalAg/d. Results (mean±S.D.) :Apparent N absorption and retention slightly lower and rate of wt gain slightly higher post-diarrhea, neither significantly so. Fecal fat in 9 similarly fed 33 d old infants without diarrhea: 3.3±1.1 g/d, 10.5±3.8% intake (P<0.001). Steatorrhea had resolved 4 wks later in the 2 infants restudied. Mild diarrhea may cause steatorrhea which persists several weeks after illness has clinically resolved. This could be the first step towards malnutrition-chronic diarrhea cycle in marginally fed infants.