Severe Undernutrition Research Articles

Noninvasive ventilation during percutaneous gastrostomy placement in Duchenne muscular dystrophy

Noninvasive positive pressure ventilation (NPPV) is used for respiratory support in a number of diseases causing acute or chronic respiratory failure. We describe a novel use of NPPV to provide respiratory support during sedation for percutaneous placement of a gastrostomy tube in a patient with Duchenne muscular dystrophy (DMD). The patient had severe respiratory insufficiency, progressive dysphagia, and undernutrition. In addition to the case in this report, we have used NPPV to provide respiratory support to DMD patients during five other gastrointestinal endoscopies without complication. The technique is highly labor intensive and requires physicians and respiratory therapists familiar with NPPV. The primary risk associated with this technique is lack of definitive airway protection during the procedure, which must be balanced against the risks of intubation in an anesthetized patient with neuromuscular disease. The potential benefit to selected patients is substantial, such as initiation of gastrostomy tube feeding in our patient, with subsequent improvement in his quality of life and nutritional status.

Noninvasive ventilation during percutaneous gastrostomy placement in Duchenne muscular dystrophy

Noninvasive positive pressure ventilation (NPPV) is used for respiratory support in a number of diseases causing acute or chronic respiratory failure. We describe a novel use of NPPV to provide respiratory support during sedation for percutaneous placement of a gastrostomy tube in a patient with Duchenne muscular dystrophy (DMD). The patient had severe respiratory insufficiency, progressive dysphagia, and undernutrition. In addition to the case in this report, we have used NPPV to provide respiratory support to DMD patients during five other gastrointestinal endoscopies without complication. The technique is highly labor intensive and requires physicians and respiratory therapists familiar with NPPV. The primary risk associated with this technique is lack of definitive airway protection during the procedure, which must be balanced against the risks of intubation in an anesthetized patient with neuromuscular disease. The potential benefit to selected patients is substantial, such as initiation of gastrostomy tube feeding in our patient, with subsequent improvement in his quality of life and nutritional status. Pediatr. Pulmonol. 1997; 23:468–471. © 1997 Wiley-Liss, Inc.

Absence of desensitization by hexarelin to subsequent GH releasing hormone-mediated GH secretion in patients with anorexia nervosa.

Both the basal levels and the neuroregulation of GH secretion are perturbed in patients with anorexia nervosa. It is unknown if these alterations are due to severe undernutrition or if they reflect basic neurotransmitter alterations of the patient's neural pathways. On the other hand, prior administration of the GH secretagogue hexarelin in normal subjects blocks the GH-releasing capability of GH releasing hormone (GHRH) administered 2 hours later. In the present work a sequential test was performed using the administration of hexarelin as first stimulus followed 120 minutes later by GHRH. The two aims of the study were: (a) to evaluate the interaction of GHRH and hexarelin, and (b) to further understand the alterations in GH neuroregulation in patients with anorexia nervosa. The GH stimuli used were hexarelin (1 micrograms/kg i.v.), a GH stimulus whose main action is hypothalamic, followed 120 minutes later by GHRH (1 micrograms/kg i.v.) as a pituitary stimulus. Each woman was tested once. Thirty-two woman matched for age participated in the study: six normal-weight women as controls, 14 women with anorexia nervosa, seven women with secondary amenorrhoea due to voluntary weight loss for aesthetic reasons, and five normal-weight women after 72 hours of a controlled hypocaloric diet (800 cal/day). Plasma GH levels were measured by time-resolved fluoroimmunosasay, each value shown is the mean +/- SE in mU/l. The administration of hexarelin to the normal-weight women induced a clear-cut GH secretion (expressed as mean +/- SE of GH peak in mU/l of 77.5 +/- 21.8, but blocked the GH-releasing capability of GHRH administered 120 minutes later (6.6 +/- 2.8, P < 0.05). In contrast, the women with anorexia nervosa showed a normal GH response after the two stimuli: hexarelin 64.8 +/- 9.2. GHRH 71.1 +/- 14.2. The absence of heterologous desensitization was specific to anorexia nervosa, because the women with amenorrhoea due to voluntary weight loss but with a normal energy intake showed a pattern similar to the controls (GH after hexarelin 60.3 +/- 9.5 and to GHRH 120 minutes later 6.2 +/- 1.0 (P < 0.05)). Similarly, the women after the short-term hypocaloric diet showed a hexarelin-mediated GH secretion of 99.6 +/- 17.8, which blunted the subsequent administration of GHRH (GH mean peak of 9.9 +/- 2.9, P < 0.05 vs hexarelin). In the normal subjects, the administration of hexarelin induced clear-cut GH secretion, but inhibited the action of GHRH when administered 120 min later, while this heterologous desensitization was not observed in the patients with anorexia nervosa. This sequentially delayed test may be of some value in the clinical setting for assessing the status of patients with anorexia nervosa.

Scientific basis for the content of routine antenatal care. II. Power to eliminate or alleviate adverse newborn outcomes; some special conditions and examinations.

There is uncertainty concerning antenatal care as a tool to eliminate or alleviate adverse outcomes in the newborn. We identified congenital conditions, intrauterine infections, intrauterine growth retardation, preterm birth and some specific infectious diseases in the mother with a view to prophylactic and other interventions. The value of some special diagnostic tools is also under discussion. Review of recent literature, especially randomized controlled trials and systematic reviews. Genetic abnormalities cannot be prevented after conception, but many of them, and a number of acquired conditions, can be discovered by ultrasonographic and biochemical diagnostics. The advisability of screening must be determined locally for each condition, based on prevalence, treatment options and the legal requirements for abortion. Smoking, excessive alcohol intake, and severe undernutrition cause fetal growth retardation. Interventions to reduce maternal smoking have had limited success. Protein-energy supplementation only modestly affects birthweight. Routine measurement of uterine height is a good predictor of severe growth retardation and in rural settings of perinatal death. Preterm birth has been linked to ascending infection and subsequent rupture of the membranes. Attempts to eradicate local infections have shown some benefit but results are not convincing yet. Cervical cerclage and betamimetic drugs have little, if any, effect. Claims for reduction of physical strain (standing > 5 hours) at work should be supported. Tuberculosis in the mother should be discovered and treated. Malaria prophylaxis during pregnancy will protect the mother and possibly benefit the fetus. Adequate tetanus immunization of all mothers is a high priority intervention in developing countries. In HIV-positive mothers, Zidovudine ante- and perinatally will lower perinatal HIV-transmission significantly. Risk scoring may help identify some women for referral to higher level of care. Routine ultrasonography does not improve the outcome of pregnancy in terms of live births and morbidity, but may influence mortality through discovery and abortion of fetuses with major malformations. One vaginal examination during pregnancy is recommended but no repeat procedure unless medically indicated.

Effects of the intrauterine environment on childhood growth.

The intrauterine environment plays a critical role in childhood growth. Infants exposed to acute malnutrition in early pregnancy are more likely to be obese in later life. Similarly, children exposed to hyperglycemia in utero are also more likely to develop insulin intolerance and obesity during childhood. The mechanisms underlying these changes are not understood. However, animal experiments suggest that severe overnutrition or undernutrition during pregnancy may affect hypothalamic development, or pancreatic beta-cell development. The effects of cigarette smoking on childhood growth can best be explained by the increased risk of intrauterine growth retardation. In contrast, alcohol ingestion during pregnancy leads to a syndromic decrease in childhood head circumference, stature, and weight. The effects of cocaine are most likely multifactorial, since cocaine ingestion tends to covary with tobacco use, alcohol use, opiate use, and low socioeconomic status. The most striking effects of the intrauterine environment on childhood growth are seen in children with intrauterine growth retardation. These children remain significantly lighter and shorter than their peers. Efforts to reverse intrauterine growth retardation have been disappointing, and at times risky. However, caloric supplementation in undernourished populations may be of significant benefit. The use of growth hormone promises to reduce some of the height deficits in children with intrauterine growth retardation. However, to date there is no evidence suggesting changes in final height in children with intrauterine growth retardation who receive growth hormone.

A model of intrauterine growth retardation caused by chronic maternal undernutrition in the rat: effects on the somatotrophic axis and postnatal growth.

While it is well established that severe maternal undernutrition during pregnancy causes intrauterine growth retardation (IUGR), there has been relatively little study of the endocrine consequences and postnatal development of growth-retarded offspring. We have developed a model in the rat of IUGR by nutritional restriction of the mother throughout gestation and have examined the effects of fetal growth retardation on the endocrine and metabolic status during the perinatal period. Timed matings were performed in Wistar rats and dams were randomly assigned to one of two dietary treatment groups. Food was available ad libitum throughout pregnancy to a control group (at libitum group) and a restricted group was fed 30% of the ad libitum intake (restricted fed group). After birth, food was available ad libitum in both groups and litter size was adjusted to eight pups per litter. Dams lost a significant amount of body weight throughout gestation due to undernutrition but were able to catch up to the ad libitum group by day 10 postnatally. Litter size was not affected by maternal undernutrition. Maternal plasma IGF-I levels were significantly reduced in the restricted fed group throughout gestation (P < 0.001) but were not different postnatally. Maternal plasma IGF-binding proteins (IGFBPs)-1, -2 and -3 were significantly (P < 0.05) increased in the restricted fed dams. The mean body weights of fetuses in late gestation from the restricted fed dams were significantly lower (P < 0.001) in comparison with fetuses from control dams. Placental weights were also significantly (P < 0.01) reduced in the restricted fed compared with control dams. Body weights were significantly lower in the offspring of restricted fed dams than control dams from birth (P < 0.01) until 90 days of age (P < 0.05). Nose-rump length was reduced in the fetuses of the restricted fed group at day 22 of gestation (P < 0.001) until weaning (P < 0.05). Plasma IGF-I levels were significantly reduced in the pups of restricted fed dams from day 22 of gestation (P < 0.01) until postnatal day 9 (P < 0.05) but were not significantly different at the later time-points. Plasma insulin levels were significantly reduced in the pups of restricted fed dams at birth (P < 0.05) but not at later time-points. Plasma IGFBP-1 and -2 levels were significantly increased in the offspring from restricted fed dams at day 22 of gestation, at birth and at day 9 postnatally (P < 0.05). 125I-Bovine GH specific binding to liver membranes was significantly lower (P < 0.05) in offspring from restricted fed dams at 21 days of age but not at 90 days of age. These data demonstrate that nutritional deprivation in the pregnant rat leads to IUGR and postnatal growth failure and to changes in allometric growth patterns and endocrine parameters of the somatotrophic axis postnatally.

Regulation of reproductive hormone secretion in primates by short-term changes in nutrition

In primates, as in nonprimates, it is well established that periods of chronic or severe undernutrition can lead to a suppression of reproductive hormone secretion. Recent studies in monkeys and humans indicate that reproductive hormone secretion begins to be suppressed with even very brief periods of undernutrition. Specifically, in male monkeys reproductive hormone secretion responds to missing a single meal, eating a single meal, and to a change in the timing of daily meal intake. These findings suggest that nutritional/metabolic signals that are linked to food intake are part of the normal physiological mechanism regulating the daily activity of the reproductive axis, rather than simply signals that influence the activity of the reproductive axis in pathological conditions of severe undernutrition. The nature of the metabolic cue(s) linking reproductive hormone secretion to subtle changes in the metabolic status of the body remains unknown, as does the route by which metabolic information reaches the central hypothalamic neurones governing reproductive hormone secretion. However, recent studies indicate that the metabolic cue transmitting information to the reproductive axis is dependent on calorie intake, but is not dependent on changes in body mass or composition, changes in intake of a specific nutrient, changes in plasma glucose or insulin concentrations, or signals emanating from the taste or smell of food or the physical process of food ingestion.

Regulation of reproductive hormone secretion in primates by short-term changes in nutrition.

In primates, as in nonprimates, it is well established that periods of chronic or severe undernutrition can lead to a suppression of reproductive hormone secretion. Recent studies in monkeys and humans indicate that reproductive hormone secretion begins to be suppressed with even very brief periods of undernutrition. Specifically, in male monkeys reproductive hormone secretion responds to missing a single meal, eating a single meal, and to a change in the timing of daily meal intake. These findings suggest that nutritional/metabolic signals that are linked to food intake are part of the normal physiological mechanism regulating the daily activity of the reproductive axis, rather than simply signals that influence the activity of the reproductive axis in pathological conditions of severe undernutrition. The nature of the metabolic cue(s) linking reproductive hormone secretion to subtle changes in the metabolic status of the body remains unknown, as does the route by which metabolic information reaches the central hypothalamic neurones governing reproductive hormone secretion. However, recent studies indicate that the metabolic cue transmitting information to the reproductive axis is dependent on calorie intake, but is not dependent on changes in body mass or composition, changes in intake of a specific nutrient, changes in plasma glucose or insulin concentrations, or signals emanating from the taste or smell of food or the physical process of food ingestion.

Anthropometric and motor characteristics of Senegalese with different nutritional histories

The effects of Protein Energy Malnutrition (PEM) on the motor performance of 4.5-6.5-year-old Senegalese children were studied. Body dimensions included weight, lengths, circumferences, and four skinfolds. Motor performance tests included a 3-min endurance run, 4 x 10 m shuttle-run, distance throw, standing long jump and grip strength. The sample consisted of 147 children: 52 children who were hospitalized for severe undernutrition (severe UN group) during infancy but who had been nutritionally rehabilitated; 63 children who were never severely malnourished but who were chronically exposed to mild-to-moderate undernutrition up to the time of study (chronic UN group); and 32 well nourished children (well nourished group) from well-off households. After adjusting for sex and age, the well nourished group performed better than the severe UN and chronic UN groups. Principal components analysis resulted in two factors which explained 65% of the variance in anthropometry and motor performance. One was related to body size and the second to body composition. The three nutritional groups differed significantly in principal component scores for the two factors; chronic UN and severe UN children also differed for the second factor. Body composition, especially low fat mass appeared to be an important feature for motor performance in chronically undernourished children.

Nutritional issues in nursing home care.

The most common nutritional problems in nursing home residents are weight loss and concomitant protein energy undernutrition. Although the causes of weight loss in these patients can usually be treated, they are rarely identified in the nursing home. Depression and adverse drug effects are the most common causes of weight loss. We discuss the appropriate use of feeding tubes in the nursing home and the early use of enteral feeding to prevent the development of severe protein energy undernutrition. Vitamin deficiencies, especially folate and pyridoxine deficiencies, frequently develop in nursing home residents. Hip fractures are often associated with vitamin D deficiency. Trace mineral deficiencies (for example, zinc deficiency) can aggravate immune deficiency and slow wound healing. Inadequate fluid intake leads to dehydration, hypotension, and, in persons with diabetes mellitus, hyperosmolarity. Finally, food intake itself can cause postprandial hypotension (which in turn may precipitate falls), produce electrolyte shifts, and result in aspiration pneumonia. Physical activity programs are an important component of nursing home care that may have an effect on nutritional status, and simple, cost-effective programs may be as beneficial as high-technology programs. Careful attention to the nutritional intake of nursing home residents is both a clinical and a quality-of-life issue.

Infections during severe primary undernutrition and subsequent refeeding: paradoxical findings

Our earlier uncontrolled observations during primary famine and subsequent refeeding did not suggest that severe undernutrition inevitably increases vulnerability to infection. Some infections appeared suppressed by famine but reactivated by refeeding. To examine prospectively the occurrence of infections in a large cohort of primary famine victims before and during refeeding. From 1973 to 1993, 4382 famine victims aged 14 or more with an estimated weight loss greater than 25% were weighed and examined for infection before and after one, two, three and four weeks of refeeding. In 137, serum C-reactive protein was measured in an effort to detect latent asymptomatic infections before and after two weeks of refeeding. Refeeding diets included wheat, sorghum, millet, ghee and milk powder. Mean weight loss +/- SD was 28.7 +/- 2.3%. Before refeeding overt infections were found in 4.9%, an incidence rising to 29.1% at two weeks of refeeding and declining after four. Those developing infections gained more weight at two weeks, 4.6 3 +/- 0.81 kg, than those never infected, 3.94 +/- 0.76 (p = < 0.001 t test). C-reactive protein levels confirmed the presence of latent infections before refeeding. Severe undernutrition can suppress certain infections, mostly those due to intracellular pathogens and especially P. falciparum. Refeeding reactivates suppressed infection and can increase vulnerability to certain new infections especially of viral origin. Those gaining weight the most rapidly may be at greatest risk. Refeeding with foods alien to local culture could play a role in reactivating latent infections. Our findings may be limited to severe undernutrition and not apply to lesser forms or secondary undernutrition in hospital patients. These studies were done during charitable provision of medical care to famine victims.

Risk factors for development of dehydration in young children with acute watery diarrhoea: a case‐control study

In a case-control study to understand the risk factors for development of life-threatening dehydration, a total of 379 children comprising 243 cases (moderate or severe dehydration) and 136 controls (non or mild dehydration) up to 2 years of age suffering from acute watery diarrhoea were studied. By univariate analysis, the presence of vibrios in stool, withdrawal of breast feeding during diarrhoea, not giving fluids, including oral rehydration solution (ORS), during diarrhoea, frequent purging ( > 8/day), vomiting ( > 2/day) and undernutrition were identified as risk factors. However, by multivariate analysis after controlling for confounders, withdrawal of breast feeding during diarrhoea (odds ratio (OR) = 6.8, p < 0.00001) and not giving ORS during diarrhoea (OR = 2.1, p < 0.006) were identified as significant risk factors. The confounding variables which also contributed significantly to increasing the risk were age ( < or = 12 months; OR = 2.7, p = 0.001), frequent purging ( > 8/day; OR = 4.1, p < 0.00001), vomiting ( > 2/day; OR = 2.4, p = 0.001) and severe undernutrition (%median < or = 60 weight-for-age of Indian Academy of Paediatrics classification; OR = 3.1, p = 0.001). We feel that these findings will be useful for Global and National Diarrhoeal Diseases Control Programmes for formulating intervention strategies for preventing death due to diarrhoeal dehydration.

Lungworm and stomach worm infection in relation to body fat reserves and blood composition in wild boar (sus scrofa)

Lung and stomach nematode burden was estimated in 8 juvenile and 12 adult wild boar (Sus scrofa), shot in The Royal Forestry 'Het Loo' between January 1988 and April 1989, in order to study whether body fat reserves or blood composition (i.e., nutritional status) is correlated with the parasite burden. Only bone marrow fat, the last fat reserve to be mobilized, showed a slight negative correlation with the stomach worm burden. Serum urea concentration, an indicator of severe undernutrition, was weakly correlated with the stomach worm burden in juvenile boars. These results suggest a relatively small impact of these parasites on animals with a lowered nutritional status. The burden of lungworms or stomach worms did not provide reliable information about the body condition of wild boar.

Body composition of Colombian women

Measurements of anthropometry and total body water (TBW) were made in 99 women 19-44 y of age living in socioeconomically deprived circumstances in Cali, Colombia. TBW was measured by dilution of deuterium oxide. An empirical equation for estimating lean body mass (LBM) was derived and applied satisfactorily to an independent study group. Comparisons were also made with body-composition values obtained by the Durnin and Womersley equations and an equation derived from rural women living in Guatemala. Neither set of equations was suitable for use with the Colombian subjects because both significantly overestimated LBM and therefore underestimated body fat. Lower values of standing height in older women suggest that they may have been subjected to more severe undernutrition during their growth than the younger subjects. When compared with a group of US women, Colombian subjects were less physically fit and had greater subcutaneous-fat deposits, which were distributed over the trunk and limbs, whereas body mass indexes and waist-hip ratios were not significantly different.

Morphology and cellularity of brain and visceral organs of severely undernourished baby pigs are restored after eight weeks of refeeding

Our objective was to assess the response of specific organs and tissues to dietary rehabilitation following severe calorie undernutrition. Pigs were weaned at 4 d of age, with 1/2 (C; n=4) given free access to a nutritionally adequate diet throughout the experiment (87d), and 1/2 (R; n=4) fed an adequate diet at 4% of body weight daily for 31 d, then given free access to an adequate diet for 8 wk. Growth rates of C and R pigs were similar during the 8-wk refeeding period; C pigs were approximately 9 kg heavier than R pigs at d 87. Body length, absolute organ weights, total body K, and total body lean mass were also reduced in R pigs. However, relative weights of small intestine, large intestine, cerebellum, and cerebrum were significantly greater in R than in C pigs. Protein and DNA concentration, content, and the protein/DNA ratio in liver, small intestine and cerebrum were not significantly different between C and R pigs. Our results suggest that a 4–5 wk period of severe undernutrition in neonatal pigs not malnourished prenatally or during the first 4 d postnatal, and in the absence of concomitant infections and diarrhea, does not produce permanent adverse effects on functional development.

Successful prediction of immediate effects of undernutrition throughout the brain growth spurt on capillarity and synapse-to-neuron ratio of cerebral cortex in rats

Based on the hypothesis that undernutrition depresses the growth rate of all processes in brain contemporaneous with it to the same extent (Peeling & Smart, 1994), specific predictions were made regarding the effect of undernutrition on two quite different facets of anatomical development within visual cortex. It was predicted that severe undernutrition during the suckling period would leave capillarity unaffected, but would result in a deficit in synapse-to-neuron ratio of similar magnitude to that in brain weight. At birth rat pups were fostered and either well fed to 30 days or undernourished to the same age by underfeeding their foster mothers. Rats were killed at 30 days by perfusion with glutaraldehyde. Visual cortex was dissected out for quantitative histological study. The number of capillary profiles per unit area of section and the area of each profile were assessed with an image analysis system. Quantitative characteristics of the neuron and synapse populations were estimated by light and electron microscopy respectively. Undernutrition resulted in a 21% deficit in brain weight, and a 22% deficit in the number of synapses per neuron. Capillarity, expressed as the fraction of section area occupied by capillary lumen, appeared completely indifferent to nutrition. However, fewer capillary profiles were found per unit area of section in growth-restricted samples, and the profiles which were present were, on average, larger. Neuron density was elevated by 19% in the undernourished group. These findings are in good agreement with the hypothesis.

Effects of severe undernutrition on body weight and fat tissue changes in dry Lacaune ewes

Effects of severe undernutrition on body weight and fat tissue changes in dry Lacaune ewes

Effects of severe undernutrition on body weight and fat tissue changes in dry Lacaune ewes

Effects of severe undernutrition on body weight and fat tissue changes in dry Lacaune ewes

Malnutrition in institutionalized elderly: how and why?

To determine the prevalence of undernutrition and overnutrition in long-term care elderly patients and the functional, behavioral, environmental, nutritional, and medical variables associated with this prevalence. Cross-sectional, observational. Long-term care hospital in Canada. Two hundred elderly patients (n = 166 male), average age 78.5 years. Assessment of nutritional status and presence of specific behavioral, medical, environmental, and functional characteristics known to impact on nutritional status. Nutritional status was determined by weight, % weight loss, BMI, skinfolds, arm circumference, area measurements, and % body fat. Multiple regression analyses were performed to identify the factors associated specifically with undernutrition and overnutrition in this population. Severe undernutrition was present in 18% (n = 36) and severe overnutrition in 10% (n = 20). Mild/moderate undernutrition was present in 27.5% (n = 55) and mild/moderate overnutrition in 18% (n = 36). Overnutrition was positively associated with primary diagnosis and number of medications and negatively associated with poor appetite, number of feeding impairments, protein intake, and mental state. Undernutrition was positively associated with dysphagia, slow eating, low protein intake, poor appetite, presence of a feeding tube, and age and negatively associated with primary diagnosis. Undernutrition exists at a level that is high (45.5%) but not unusual for this type of institutional setting. Behavioral, environmental, and disease-related factors greatly influence nutritional status. Undernutrition appears to be affected by nutritional factors more than overnutrition. Efforts should be directed toward influencing some of these factors to decrease undernutrition in the institutionalized elderly.

Recognition of pneumonia by primary health care workers in Swaziland with a simple clinical algorithm

In developing countries primary health care workers are being trained to manage and treat acute respiratory infections with a protocol developed by the WHO. We tested the ability of nurses and nursing assistants in Swaziland to recognise the signs and symptoms of pneumonia; with the results of a paediatrician's examination as "gold standard", sensitivities and specificities were calculated. Danger signs of stridor and abnormal sleepiness were poorly recognised (sensitivity 0—50%) by the health care workers, as was audible wheeze. Severe undernutrition, tachypnoea, and chest wall indrawing were well recognised. Overall, the recognition of pneumonia was good (sensitivity 71—83%, specificity 84—85%). These findings highlight topics for emphasis in training.