Social cost effectiveness of 2 systems of treatment of malnourished children, in Chile

Two approaches in the care of malnourished children were evaluated in order to ascertain both their medical and economical effectiveness. One was a group of 745 children under an ambulatory nutritional rehabilitation program that included health care, supplementary foods and nutrition education; a second group of 420 children attended Day Care Centers (8 hours a day and five days per week) where they received a balanced diet, psychomotor stimulation according to age, and health care. The evolution of nutritional status was followed up and plotted against the NCHS/WHO weight-for-height tables. The rate of recovery was unsatisfactory; below 50% in mild cases of malnutrition, and even less in the more severe cases. The average length of time for attaining normality was longer for moderate malnutrition and for the ambulatory program. When the calculation included a correction for the probability of recovery for each system, the advantage of the Day Care Centers became even more evident: the mean length of time for recovery was 33.2% less than the ambulatory program. The social cost per child, per day, was substantially lower in the ambulatory program. The integral calculus of social cost per child, per day, and the corrected mean time for recovery provided the social cost-effectiveness of nutritional recovery. This figure was clearly adventageous for the ambulatory program for all ages and degrees of malnutrition, exception made for moderately malnourished children below two years of age. In this case, the Day Care Centers appeared to be the most effective therapeutic alternative. This type of analysis is a contribution to the evaluation of medico-social programs for the recuperation of malnutrition. The advantage lies in the fact that it allows an optimization in the allocation of resources, when the previous step is the choice of best therapeutic alternative based upon the patient's age and nutritional status.     

Energy protein intake during nutritional recovery and nutritional status achieved

Thirty years ago malnourished Chilean children were recovered by CONIN; they were fed ad libitum and this may have favoured the appearance of overweight-obesity (SP/OB). The objective of this study was to evaluate the relationship between energy-calorie intake during nutritional recovery and the appearance of overweight-obesity (SP/OB). The design was a retrospective, analytical study of the universe formed by the 168 clinical records found, of children below 2 years of age, recovered by CONIN between 1977 and 1982. Nutritional status was assessed using the Sempé criteria (applied in the period evaluated) and those of WHO, (currently in use), on admission, after 4 month treatment and on discharge. By Sempé criteria, malnutrition on admission was classified 25% severe, 63% moderate and 12% mild; instead, using WHO standards these figures were 14.9%, 29.2% y 38.1%, respectively; the remaining children were well nourished. On discharge, there was no SP/OB by W/A (Sempé), but by W/H (WHO) 6% and 13.8% were SP/OB after 3 months and on discharge, respectively. Food intake, administered ad libitum, reached a mean of 148 kcals/ kg/d and 4 g prot/kg/d. SP/OB children had greater daily weight gain (30.3 vs 19.2 g/d) than the non-obese children and greater daily weight gain than the mean for age and sex (19.7 vs 8.2 g/dia). The prescribed feeding reached values considered high by currently used criteria; actual intake, administered ad-libitum, was significantly lower and was associated with 13.8% of children with overweight-obesity at the time of discharge.     

Anemia and deficiency of vitamin A in children evaluated in a nutritional attention center from Caracas

In order to determine the prevalence of anemia and the deficiency of vitamin A in children under 10 years, the concentration of hemoglobin, transferrin saturation, serum iron and the nutritional state of vitamin A were studied between 1999 and 2000, in 124 children with moderate malnutrition and 98 healthy children who attend triage consultation in the Centro de Atención Nutricional Infantil Antímano (CANIA, Caracas) by means of plasma retinol test (high performance liquid chromatography), relative dose response test (RDR) and conjunctival impression cytology (CIC). The dietary intake was analyzed by 24 hour recall. The Student t and Chi-square test were used for the statistical analysis of the data. The prevalence of vitamin A deficiency was approximately 10% in malnourished and healthy children, the CIC test discriminated a proportion of vitamin A deficient children superior to 25% and RDR test detected a significantly smaller percentage of deficiency in healthy children (p < 0.05). The prevalence of anemia was significantly higher in malnourished (34.2%) than in healthy children (19.2%). In children under 2 years the percentage of anemia reached 75.8% in undernourished children and 50% in healthy children. The consumption of macronutrients and micronutrients was inadequate; more than 40% undernourished children had caloric and macronutrients intake adequacy below 85%, whereas this level of adequacy in healthy children was around 30%. These results indicate there were problems of moderate anemia and moderate vitamin A deficiency in the studied infantile population, without significant differences between moderate undernourished and healthy children.     

Serum zinc in Brazilian children of families of low income

Serum zinc was measured in 103 Brazilian children from low income families, 3 months to 6 years of age, with the purpose of characterizing their zinc nutritional status. Serum albumin was determined in some of the children studied. They were grouped in three categories according to the adequacy of height for age and weight for height indices related to the growth curves determined for Brazilian children. There were 30 normal, 18 acutely malnourished and five chronically malnourished children. This criteria was complemented by the Gomez criteria. Thirty healthy adults of both sexes served as a reference group for the analytical procedures. In the adults, serum zinc was 107.5 +/- 14.5 micrograms/dl, similar to values observed by other investigators, and significantly higher than in all of the children studied. Serum zinc of normal children was 98.3 +/- 15.7 micrograms/dl. It decreased with the degree of malnutrition, being significant for second degree acutely malnourished (87.8 +/- 9.2 micrograms/dl; p less than 0.05) and chronically malnourished children (68.7 +/- 8.9 micrograms/dl; p less than 0.001). Serum zinc and albumin correlated significantly (r = 0.51; n = 37; p less than 0.01), particularly in the severely malnourished children (r = 0.63; n = 8; p less than 0.05).     

Nutritional status of Guatemalan preschool children hospitalized for acute respiratory infections

Nutritional status (weight-for-age, length-for-age, and weight-for-length) was determined in 678 children aged 0-59 months, admitted to the San Juan de Dios General Hospital in Guatemala City with signs and symptoms of acute respiratory infections. Five hundred and fifty seven (82.2%) cases were bronchopneumoniae; 62 (9.1%) were pneumoniae, and 43 (6.3%) were bronchiolitis. Five hundred and seventy (82.6%) children lived in the urban zones of the capital city and 118 (17.4%) in the municipalities of the Department of Guatemala. Deficit in weight-for-age was found in 188 (27.8%) cases, while 176 (25.9%) showed a deficiency in length-for-age. In terms of weight-for-length, 84 (12.4%) were below -2.00 standard deviations of the reference curve. The children from out of the city showed the highest proportions of malnutrition. Monitoring of nutritional status of hospitalized children with infectious diseases can provide valuable information, not only for their management, but also for parental health education.     

Assessment of the nutritional impact of the complementary feeding program of Panama in children under five years old

To evaluate the nutritional impact of the Complementary Feeding Program of Panama in children under 5 years old. A retrospective cohort of children beneficiaries of the program was studied and compared with others of the same age and districts not involved in this intervention. Weight for age (W-A), height for age (H-A), and weight for height (W-H) was calculated in each control and the nutritional status determined according to Ministry of Health norms. Every beneficiary received six pounds/month of a food supplement containing cereals, legumes, calcium, iron and vitamin A (350 Kcal and 12 g of protein by 100 grams). Most of the children enter into the program in their second year of life with an average W-A and W-H of -1.5 +/- 1.2 and -0.6 +/- 0.9 respectively; both indicators were declining before the intervention (-0.6 +/- 1.2 y -0.3 +/- 1.3 respectively, p < 0.01). In 9 months of intervention an average change in W-A of 0.0 +/- 1.1 and H-A of - 0.1 +/- 1.1 was observed (NS). Weight gain was higher in children with lower W-A, in families with less children or mother with better education level (p < 0.05). In 35% of malnourished children and 24% of children at risk nutritional status improved during the intervention. Children with higher nutritional deficit at the beginning of the program have significantly better nutritional improvement (p < 0.001), encouraging the importance on focusing this program in malnourished children.     

Effect of the nutritional recovery on the concentration of Interleukin-2 in severely malnourished children

The severely malnourished child has dysfunction of the immune response that may increase the risk of morbidity or mortality due to infectious diseases, therefore, the purpose of this study was to demonstrate the effect of intensive nutritional support on the cellular and serum concentration of IL-2 and CD4+, as well as CD8+ T cells in children with severe protein energy malnutrition. A clinical assay was carried out in a tertiary care hospital. 10 severely malnourished children < 48 months of age who received formula without lactose via enteral feeding for two weeks and ad libitum for an additional two weeks were included. Cellular and serum concentrations of IL-2 and the subpopulation of CD4+ and CD8+ were obtained. A control group (n = 13) was included. A paired student t test for initial-final determinations and the Mann-Whitney Test for comparison with control group were used, and null hypothesis was rejected with a p value < 0.05. There was a noteworthy increase in the comparison between the initial vs. final percentage of the cellular expression of IL-2 (p < 0.001) and in the serum concentration of IL-2 (p = 0.001). Therefore, four weeks of nutritional recovery significantly restored the production of IL-2, independently of the nutrients involved in the process, although, the rate of restoration seems to depend on the severity of the children primary PEM.     

Treatment of severe malnourished children with WHO protocol: experience of a referral center in São Paulo, Brazil

Mortality rate, anthropometric development and nutritional therapy with the use of World Health Organization guidelines (WHO) were assessed. In a cross-sectional retrospective study 191 hospitalized malnourished children were assessed. To classify and evaluate nutritional rehabilitation Z-score was used: weight-for-age (ZW), height-for-age(ZH) and weight-for-height(ZWH). The children were divided in three groups (G): GI (primary malnutrition--30,9%), GII (secondary malnutrition--51,7%) and GIII (children who were admitted as GI but during internation had an identified chronic disease--12%). Nutritional therapy used was based on WHO guidelines, with slight modifications. The formulas chosen were all industrialized: lactose-free polymeric formula (PLF) for children with diarrhea, low lactose polymeric formula (PLL) for children without diarrhea and cow's milk hydrolysate (H) for sepsis or chronic diarrhea. In the rehabilitation phase, all the children used PLL formula. Statistical analysis: Student's, chi-square tests, simple linear regression. The median age and mortality rate were 10,3 months and 4,2%, respectively. The GI and GII children were older than GIII (11vs12vs7months,p=0,02) and had shorter length of stay (20vs22vs37days,p=0,010). Mortality risks in GIII were twice as frequent as in GI+GII. Pneumonia, diarrhea and poor weight gain were the main diagnosis at admission. Tubes were used more frequently in GII+GIII than GI (p=0,004). Parenteral nutrition was indicated in 5,7% of children, more often in GIII than GI+GII (p=0,037). Tolerance of the initial formula wasn't satisfactory in 20% of the children. An improvement of 87% ZWH, 74,1% ZW and 22% was observed. ZW in GI and ZWH in GIII were the indices that showed the most effective gain during hospital stay. The modified WHO guidelines were effective in the multiprofessional treatment of malnourished children, resulting in good nutritional rehabilitation with low mortality rates. A high percentage of children admitted as primary malnutrition who had a chronic disease diagnosed was observed. The late diagnosis may be responsible for the high length of stay, formula intolerance and mortality risk.     

Prevalence of sub-clinical vitamin A deficiency and malnutrition in slum children in Maraicabo - Venezuela

The present cross sectional study was carried out to estimate the prevalence of vitamin A deficiency among children by means of clinics and conjunctival impression cytology (CIC), and nutritional status by anthropometric indicators H//A, W//A, W//H. The study population included 157 children 2-6 y old, from urban and rural slums of Maracaibo, Venezuela, Conjunctival impression cytology was performed by ICEPO standard procedure. Z-score was applied to anthropometric data with reference values of NCHS-WHO. No evidence of clinical or ophthalmologic signs of vitamin A deficiency were detected. The prevalence of subclinical vitamin A deficiency, as detected by abnormal CIC, was 35.4%, being higher in rural children (48.3%). These prevalence values are higher than the criteria laid down by WHO/UNICEF to indicate a public health problem (> 20%). Mild or moderate protein-energy global malnutrition and stunting were detected in 36.1% and 44.6% of children, respectively. Abnormal CIC was indistinctly observed (approximately equal to 35%) as much in children with adequate nutrition as in malnourished ones. There was no significant difference in the distribution of the CIC results in relation to nutritional status. The findings indicate that CIC and Z-score of nutritional anthropometric data are useful to characterize the risk of vitamin A deficiency and of malnutrition in communities. Beside the implementation of an integral nutritional program which includes supplementation, food fortification and dietary diversification, improvement of socio-economic and sanitation conditions and also the educational level, with emphasis on nutritional and health education, are highly recommended.     

Anemias in preschool children: diagnosis, treatment and evaluation, Recife-PE, Brazil]

The diagnosis and the effects of treatment of anemia were assessed in children aged 6-71 months. A total of 1,161 preschool children from a health center of INAMPS (Instituto Nacional de Assistência Médica e Previdência Social) in Recife, Pernambuco, was studied. Hemoglobin was determined by the method described by Hainline. WHO criteria were used to identify anemia. According to their age, nutritional status and family income, the children were divided into groups, and those with anemia were treated with ferrous sulphate and an anti-helminthic (mebendazole). Anemia prevalence was substantially higher in children aged 2 years, and a statistically significant association (0.01 level) was found between anemia and nutritional status and family income. After treatment, hemoglobin values were normal in 40% of the anemic children; simultaneously, mean hemoglobin values increased from 9.11 to 10.3 g/dl which was statistically significant (p less than 0.001). This investigation is part of a collaborative study performed in four Brazilian states to offer "know-how" to a national program for combating iron deficiency anemia.     

Development of a methodology for the assessment of the nutritional status at the level of household units

The results of statistical analysis may be questionable when data measured by different units are compared. This is the case when nutritional status, which is quantitated individually, is compared with social variables (such as family income, patterns of education, housing, etc.), measured by households. In a nutritional anthropology study, the anthropometric measures of children have to be plotted against these social factors. Therefore, a method to evaluate the nutritional status of children at household level was devised; this procedure reduced the variables to one single unit. The "Analysis of Main Components" (ACP) was found satisfactory, using the family average of the following indexes: weight/height, weight/age and height/age. Also, two new indexes were created by giving a numerical value to the slightly modified Waterlow's classification. As a result, households were automatically divided into three groups: 1) households with well-nourished children, 2) households with children at risk of malnutrition, and 3) households with malnourished children. This was accomplished using the "ANADA" package created by PRIAD, University of Costa Rica, and a Burroughs B6920 computer. The method is useful for nutritional anthropology programs as well as for nutritional surveillance activities.     

Use of chickpea (Cicer arietinum L.) in non-dairy formulas. II. Nitrogen balance in children with lactose intolerance, fed with a formula based on chickpea and a commercial soybean product

The nutritive value of chick-pea and soy infant formulas was evaluated. Nitrogen balance was performed in 17 malnourished babies, seven of which were fed with the chick-pea formula, and 10 with the soy commercial formula (Sobee). The percentage of absorption, retention and biological value of the chick-pea formula were 72.4, 26.4 and 35.1, respectively and 69.6, 24.3 and 34.0 in the same order, with the soy formula. Since the nutritional quality of the chick-pea was not different to the commercial soy formula and the diarrhea was better controlled by the former, this formula could be recommended in the treatment of lactating babies with lactose intolerance.     

Infantile malnutrition: social cost of respiratory and digestive pathology

Information from the hospital records of 1,660 children under two years of age admitted to the Hospital Roberto del Río (Northern District of Santiago) during 1979, allowed carrying out an analysis of the effect of malnutrition upon the admission rate and length of stay for diarrhea and respiratory infections. The following indexes were calculated and related to nutritional status: a) Admission rate for the total population of children under two years of age from the Northern District of Santiago; b) frequency of associated and intercurrent pathology, and c) length of stay. The three indexes evidenced a clear relationship with nutritional status (P much less than 0.01), showing a progressive deterioration as the relationship weight/age became impaired. The admission rate for diarrhea was nine times higher, and the length of stay 16.9% higher (P less than 0.001) in children with mild malnutrition as compared with normal patients. For respiratory infections the rates were 2.4 and 24.7% higher (P less than 0.001) in malnourished patients than in normals. The excess of admission rate for diarrhea and respiratory pathology, conditioned by malnutrition in the Northern District of Santiago, was estimated as the cost equivalent to 10,609 extra days of stay, with an annual cost above US$300,000. The investment of such an amount of money in health promotion and protection activities would certainly increase its social cost-effectiveness.     

Muscle and fat indicators in boys of the upper socioeconomic strata of Caracas

A sample of 271 boys, aged four, eight and 12 years, belonging to the upper socioeconomic strata of Caracas, was studied in order to test the sensibility and specificity of arm muscle and fat indicators, as evaluators of the muscle and fat tissues development, as well as of the nutritional status. Weight, height, arm circumference and triceps skinfold were measured following standardized techniques; muscle and fat areas were calculated from arm circumference and skinfold measurements. For statistical analysis, results were compared with North American reference standards, and correlation and regression analyses were performed. Nutritional assessment was performed using weight-for-age, height-for-age and weight-for-height, arm circumference and skinfold, plus the two derived areas. Malnourished children were identified using WHO guidelines in height and weight. Prevalences were compared and the sensibility, specificity and predictive values were studied. Malnourished children were analyzed individually. Arm circumference was the best predictor of nutritional status and triceps skinfold the worst predictor; muscle and fat areas were moderate predictors. On the average, four-year olds were smaller, lighter and much leaner than the reference, and eight and 12-year olds were taller, heavier and more muscular than the reference. Low fat was most prevalent in four-year olds, while high muscle increased with age and was highest at age 12, consistent with pubertal development. Obesity was most prevalent in eight-year olds. Twenty-eight per cent of the 50 children identified as malnourished in weight and height according to WHO, were normal in muscle and fat, and 66% of the 100 identified as malnourished in muscle and fat were normal according to WHO guidelines. Furthermore, 24% of children classified as overweight by weight-for-height were not obese but high in muscle. It is concluded that muscle and fat areas reflect muscle and fat components but are poor indicators of malnutrition, expressed in terms of weight and height. On the other hand, weight and height do not measure body composition. Weight-for-height should be used in combination with muscle and fat areas. National reference standards are needed and cut-off points should be revised, in order to maximize the efficiency and predictive values of these indicators.     

Study protocol: Cost-effectiveness of transmural nutritional support in malnourished elderly patients in comparison with usual care

Background  

Malnutrition is a common consequence of disease in older patients. Both in hospital setting and in community setting oral nutritional support has proven to be effective. However, cost-effectiveness studies are scarce. Therefore, the aim of our study is to investigate the effectiveness and cost-effectiveness of transmural nutritional support in malnourished elderly patients, starting at hospital admission until three months after discharge.     

High prevalence of undernutrition in Spanish elders admitted to a general hospital and associated factors

The objective of the study was to evaluate the nutritional status of the hospitalised elderly patients using the Mini Nutritional Assessment (MNA) and nutritional classic parameters, to estimate the prevalence of undernutrition among them and to value the correlation of undernutrition with epidemiological characteristics of the sample for determine the highest risk's group among the malnourished patients. A cross sectional survey was done among a sample of 200 elderly patients admitted to the USP San Carlos Hospital (Murcia, Spain) during a period of 3 months. Patients answered a questionnaire including demographic data and the MNA clinical tool. Lymphocyte concentration and albumin and transferrin serum levels were also collected. Statistical analyses were performed with the Student t and chi 2 tests. For the MNA, the Spearman's coefficient was employed. Mean age of the 200 patients was 80.72 SD 7.43 years. Mean weight was 63.41 SD 19.57 kg and mean height was 160.93 SD 8.36 cm, with a mean Body Mass Index of 24.27 SD 7.31. The serum values of albumin and transferrin and total lymphocytes in blood were 3.09 SD 0.5 g/l, 1.69 SD 0.37 mg/dl and 1412 mm3 respectively. Average score of the MNA was 15.9 SD 6.21 and, according to this scale, 50% (n=100) of the patients were malnourished. Correlation analyses resulted in significant association (p < 0.001) between values of undernutrition in the MNA and measurements under normality of the biochemical and immunological parameters. The patients who presents chronic diseases, advanced physical or mental deterioration and minor self-sufficiency are either malnourished or at high risk of being. The individualized nutritional evaluation must be performed routinely when the patient is admitted to the hospital for detect and treat early signs of malnutrition.     

吸附百白破乙肝(CHO)四联疫苗接种反应及血清学效果观察

目的　考察百日咳、白喉、破伤风、乙肝四联疫苗的接种反应及血清学效果。方法　选择足月分娩、母亲乙肝表面抗原阴性、身体健康的新生儿为接种对象。一期观察 6 0例 ,随机分为 3组 ,第 1组按 2、4、6月龄接种四联疫苗 ;第 2组按 3、4、5月龄接种四联疫苗 ;第 3组按 3、4、5月龄接种三联疫苗。二期观察 35 0人 ,随机分为3组 ,第 1组按 2、4、6月龄接种四联疫苗 ,118人 ;第 2组按 2、4、6月龄左臂接种乙肝疫苗 ,右臂接种三联疫苗 ,114人 ;第 3组按 0、1、6月龄接种乙肝疫苗 ,3、4、5月龄接种三联疫苗 ,118人。结果　一期观察 1组、2组和 3组体温弱反应分别为 5 0 %、10 %和 2 0 % ,无中强反应和局部反应。二期观察试验组体温弱反应为 4 2 4 % ,中反应 1 6 9% ,无强反应。局部弱反应为 0 85 % ,无中、强反应。血清学检测百日咳、白喉、破伤风、乙肝阳转率均大于 90 %。结论　吸附四联疫苗具有较好的安全性 ,采用 2、4、6月龄接种程序可有效诱导产生百日咳、白喉、破伤风、乙肝的保护性抗体反应     

Nutritional anthropometry and dietary intake of children from the Las Cuevas region of the Dominican Republic

A nutritional survey was conducted in the "Las Cuevas" watershed located in the southwestern region of the Dominican Republic to assess the nutritional status of preschool children. Height, weight, mid-arm circumference and triceps skinfold measurements were taken of 280 children between 6 to 54 months of age. Dietary recall was elicited from mothers or care givers. Results compared with the National Center for Health Statistics reference data indicate that these children: 1) experience growth failure and poor nutritional status as indicated by low weight for age; 2) suffer chronic malnutrition as revealed by low height for age and reduced muscle mass of the mid-arm; and 3) have appropriate weight for height measurements. A food frequency survey revealed that these children consume a diet high in carbohydrates and low in animal protein. Breast feeding is a common practice although cow's milk was introduced early in 25% of the sample. The mean age at weaning is 12 months. The results indicate that these children experience the greatest growth deficits in the second year of life and that these deficits are indicative of chronic undernutrition rather than acute food shortage or recent disease episodes. This study was carried out to establish baseline data for a resource management project initiated by the Secretariat of Agriculture of the Dominican Republic.     

Maternal beliefs, feeding practices and nutritional status in Afro-Colombian infants

This study describes maternal practices and beliefs on children feeding and their relationship with nutritional status of Afro-Colombian children aged 6 to 18 months. We combined ethnographic and epidemiological data. We collected information using a food frequency questionnaire. Nine focus groups and 5 deep interviews to mothers of children less than 2 years of age were performed. Our data showed a prevalence of wasting of 2.6% (< -2 SD weight-for-length) and prevalence of stunting of 9.8% (< -2 SD height-for-age). These practices are characterized by a universal onset of breastfeeding, that lasted 10 months in average, and an early introduction of complementary food (mean: 3 months). Breastfeeding is a cultural norm. Weaning is related to new pregnancy, to low milk production and to negative effects of breast process on mothers' health. Early complementary feeding and bottle-feeding are highly valued due to their positive effect on nutritional status and adaptation of children to adult-type diets. The introduction of complementary food after 4 months, the quality of the first food introduced and the diversity of complementary food predicted better nutritional status (p < 0.05). We conclude that nutritional illiteracy and mothers' erroneous beliefs result in 50% of the mothers having inadequate feeding practices. We suggest focused interventions on those beliefs limiting good practices.