Young infant and Malnutrition

see also : Infant feeding in emergency (1997), Assessment Tool for Treatment of Severely Malnourished Children (1999), Infant Feeding In Emergencies (1999), Infant formula (1999), Making up formula feed (1999)

Young infant and Malnutrition Sophie Baquet 24.01.2000
Young infant and Malnutrition Michael Golden 26.01.2000
Re: Young infant and Malnutrition Buford Nichols 26.01.2000
Re: Young infant and Malnutrition Andre Renzaho 26.01.2000
Re: Young infant and Malnutrition aliou ayaba 26.01.2000
Re: Young infant and Malnutrition George Kent 26.01.2000
Re: Young infant and Malnutrition aliou ayaba 26.01.2000
Infantile Malnutrition David Morley 28.01.2000


From: sophie.baquetatmsf.be

Date: Mon, 24 Jan 2000 15:29:44 +0100

Subject: Young infant and Malnutrition :

 

Dear Ngonuts,

In the field practice, there are often confusion/difficulties in the diagnose of malnutrition in young infants (below 6 months),...

CC The treatment of severely malnourished infants < 6 months :

I will be very happy to receive any advices and comments or references on this topic. Thanks in advance.

Greetings

Sophie Baquet

 

Medecins Sans Frontières, Bruxelles


Date: Wed, 26 Jan 2000 18:26:04 +0000

From: Michael Golden <m.goldenatabdn.ac.uk>

Subject: Young infant and Malnutrition

 

Dear Ngonuts,

The issues raised by Sophie Baquet's questions about infant malnutrition are very important and not addressed elsewhere as far as we can find - we apologize therefor for giving a lengthy answer.

 

a) first

This is an important age group to consider. These infants have the highest mortality rate in Therapeutic Feeding Centres. Here is our data of case fatality rate in severely malnutrition by age group:

Age

dead/total

case fatality %

0-5

97/565

17.2

6-11

155/1288

12.0

12-17

142/1414

8.3

18-23

53/899

5.9

24-29

142/1778

8.0

30-35

73/900

8.1

36-47

77/1029

7.5

48-59

41/747

5.5

     

total

780/8620

9.0

Clearly, the figures for the children are not bad, but for infants, particularly young infants, we have a long way to go to improve the care that we give (in adolescents and adults the case fatality rate increases again - but that is another story - almost all the research that defines optimum care has been directed to the child). 21% of the patients are less than 12 months and 6.5% are less than 6 months - this is a significant part of the patient population and there exist no authoritative guidelines about how these patients should be managed.

 

b) second,

malnourished young infants have been totally neglected in the past for a number of reasons that should now be recognised and each addressed:

b1) Survey methods in emergencies hide the problem.

Most surveys have followed MSF guidelines and included only children whose mothers say they are over 6 months AND are found to be over 65 cm (although a few have used 60 cm which is advocated by WHO because there is often high prevalence of stunting). This has led to a systematic bias as all children of over 6 months, who are stunted, are deliberately excluded - and the wasted are much more likely to also be stunted. Thus, it "appears" as if all surveyed 6 month old children are of normal height with a low prevalence of wasting; although this is caused by the selection bias. It is then erroneously presumed that the younger ones (and less than 65cm) have remained normal until that age.

b2) The reliability of the standards are in question.

The NCHS standards are derived from US bottle-fed infants. Many studies have shown that healthy breast-fed children are lighter than these standards and therefore we may "expect" that healthy infants will fall below the NCHS standards. WHO is collecting data to address this problem at the moment, but, in the mean time, we have a real difficulty in the definition of "malnutrition" in this age group. Where malnutrition is seen using the present standards it is therefor often "discounted" as being an artefact (the high mortality rate being ascribed to "other factors"!).

b3) It has been thought (and expressed by earlier MSF staff) that the malnourished infant in the developing world is :

More recently, inappropriate complementary foods have been blamed (which is we believe a major factor). However, it is now assumed that if the already malnourished infants started to be exclusively breast fed their problems would evaporate and so all guidelines are exclusively directed to the mother to stop her giving complementary foods.

There was a time when UNHCR and donors raised queries when NGOs admitted malnourished infants to TFCs. With HIV and the problems of young orphans this policy has now reversed and agencies suggest that both malnourished infants and all those who do not have access to breast milk should be admitted first to a TFC (both positions seem inappropriate).

b4) It has been an article of faith by many groups that all children in whatever circumstances who are being breast-fed are perfectly nourished, that there has to be an alternative explanation for any child found not be well nourished when receiving breast milk. However, as it is so frequently found that breast-fed children are malnourished this has recently changed to "exclusive" breast feeding. At any rate, it is said that any guidelines that advocate using therapeutic feeding for the less than 6 month old infant would undermine the campaign for universal exclusive breast-feeding.

When I was writing the WHO manual on treatment of severe malnutrition I was specifically asked not to include guidelines for this age group because - "they should all be breast-feeding and then, as there will be no nutritional problem, we do not need to include them". It is not clear to us that making an explicit exception for the severely malnourished infant would have "diluted the message" : perhaps more lives were saved by this commission than died in silent neglect because no clear guidance was given.

There was also the problem of confusion of the therapeutic diets used specifically for treatment of severe malnutrition and infant formula. If they were both used in this age group there may have been the perception by some that we may be advocating "artificial feeding" for the less than 6 month old, and it would have been very difficult to restrict F100 to the treatment of severe malnutrition. Indeed, F100 is now being abused in this way by some who give it as a "take home product" for inappropriately diagnosed children - but that is also another story.

Now nutritionists are awakening to find that we have relatively large numbers of malnourished young infants and it is not clear how they should best be assessed and treated. Recently agencies have been several closed meetings to address some of the issues involved; I understand there will be a session at the forthcoming ACCSCN meeting in Washington on about infant malnutrition in emergency settings.

 

c) assessment.

c1) The infants that we admitted and experienced a 17.2% mortality rate, were admitted using the present NCHS standards with <70% WFH as the cut-off. If the new standards are revised downwards (so that "normal" infants are lighter than the present standards), then a lot of these infants would not have been admitted to the TFC. If we simply change the standards and definitions so that the would no-longer be classed malnourished I do not think that this would prevent their deaths (deaths which would then occur at home instead of in a TFC). It is not likely that the new standards, when they are generated at great effort, will help the problem of admission criteria. Plotting different cutoffs from the prognostic formula of Prudhon (6-59 month old children) shows that the lines of "Risk" cross the weight-for-height lines so that at the lower heights much less stringent criteria for admission for malnutrition should be used.

c2) In our opinion we should move away from cut-off points for admission based upon a fixed % or Z-score of the standards, and for the purposes of intervention should develop new cut off tables based directly upon assessed risk of death - this has now been done for the 6-59 month age group, but we have insufficient data at the moment to develop these criteria for infants.

c3) scales that are generally used in TFCs for older children are insufficiently precise for assessing infants -and scales that weigh to 10g are needed for both their assessment and, particularly, for management. It is thus almost impossible to correctly assess, monitor and treat infants with the weighing equipment currently in use.

 

d) Breast feeding

We have repeatedly tried "trials" of exclusive breast feeding in these wasted infants: they are almost always insufficiently strong to stimulate increased breast milk output, and these trials are aborted by the staff as they see an already emaciated infant going down hill. Indeed, this delay with further deterioration may be partly responsible for the high mortality, although this supposition is untested. In the past these infants have then been given the same therapeutic diet as the older children and managed according to the standard protocols. They frequently end up weaned, which is tragic.

Recently, we did a trial of "supplemented suckling" and carefully measured daily weight change and calculated breast-milk output. This is the same as the "nursing supplementer" used for relactation. But here we have a mother who is already breast feeding and a severely malnourished infant. The results exceeded all our expectations. The infants rapidly gained weight AND stimulated the breast more and more as they regained their strength - so that after about 10 days the supplemented suckling could be stopped and they continued to gain weight at an accelerated rate on breast-milk alone. The 468 surviving young infants we studied above gained weight at 17g/kg/d. The infants with supplemental suckling gained at 17.9 g/kg/d - the breast milk intake was 100ml/kg infant/d during the supplemental suckling period. After cessation breast milk output increased to 204ml/kg infant/d and the rate of weight gain, on exclusive breast feeding was 9.4g/kg/d.

This has since been introduced widely in ACF with success. The trial was to small to assess the effect that this had on mortality - these data are being collected by ACF. However, in terms of weight gain and breast-milk output the trial was sufficiently large to show that this has a major effect. The infants became strong enough and hungry enough to stimulate large quantities of breast milk.

The position with normally nourished infant who starts to falter is quite different from the already severely malnourished infant - the best way of dealing with the moderately malnourished infant is not at all clear - but there is certainly less risk from the underfeeding that inevitably occurs before breast milk flow is adequately stimulated.

 

e) diet.

The formula that you quote is designed to simply emulate the crude energy and protein contents of breast milk from DSM, sugar and oil. It is inferior to generic infant formula for normally nourished infants who do not have a supply of breast milk available and should only be used in extremis when the pipeline for generic formula is broken. We should clearly differentiate the requirements of the normal infant from the requirements of a malnourished infant.

The Mineral & Vitamin mix (CMV) has been designed for specifically for the F100 diet at 1kcal/g and NOT for the formula that you give: addition of 3g of this CMV to the 50/75/25formula that you quote will give an excess some minerals which could be dangerous - the young infants would be getting a 30% excess over that coming from F100 diluted.

The two formula that you give :

will have respective renal solute loads (per 1000kcal) of 322 and 326 mOsm and osmolalities per liter of 320 and 417 mOsm/L. The 50/75/25 formula has thus a high osmolality and I would be concerned, in particular, that it would precipitate diarrhoea in these young malnourished infants.

At the moment we would use the same formula that is used for older malnourished children but diluted to give 70kcal/100ml instead of the normal 100kcal/100ml - this is because of the problems of osmolality and renal solute load/water intake in these young infants. Both formulae that you give are low iron formulae - iron nutrition in the malnourished infant of <6 months in the developing world has not been studied to my knowledge.

We would emphasise that there are insufficient experimental data from severely malnourished infants of this age group: we cannot assume that the results would be the same as with older children. We are mindful of the effect of cow's milk causing gastrointestinal bleeding in young infants (positive occult blood) which does not seem to occur in older children taking the same cow's milk. Perhaps the data and formula coming from feeding premature infants in developed country experience should guide us here. We think that there is a long way to go to optimize the diets for this age group. When supplemental suckling is not an option we would use F100 diluted.

 

f) the amount.

If the infants receive only 135 ml/kg/d of a diet giving 70kcal/100ml then the infants will not catch up in weight. This is the intake we used with supplemental suckling, but the infants were getting 100ml/kg breast milk as well! For those that are only getting the therapeutic diet then you will need to start at this level (phase one) and build up to much higher levels as the infants regain their appetites (transition phase and phase two).

 

Mike Golden and Yvonne Grellety

 

Prof. Michael H.N.Golden

Dept of Medicine and Therapeutics, Univ of Aberdeen, Foresterhill, AB9 2ZD. Scotland, (UK)

INTERNET m.goldenatabdn.ac.uk, Tel +44 (1224) 681 818 ext 52793/53014, Fax +44 (1224) 699 884, Tel(direct) +44 (1224) 663 123 527 93


Date: Wed, 26 Jan 2000 20:25:40 +0000

From: "Buford Nichols, M.D." <bnicholsatbcm.tmc.edu>

Subject: Re: Young infant and Malnutrition

 

Dear Ngonuts,

I have found the mid-arm to head circumference ratio of Donald McLauren of great clinical value, it is immediately available and the cut-off ratio of 0.3 as the lower limit of normal is practical and reproducible. The only caveat is the need to recognize intrinsic defects of head circumference such as hydrocephaly and anenchephaly. The arm ratio is valid in infants with pitting edema of dependent limbs and is valid in marasmic-kwashiorkor with edema. It has the great advantage of applicability in stunted children. It has been validated in premature infants.

 

Buford nichols, MD, Professor of Pediatrics

Baylor College of Medicine, Houston, TX, USA


Date: Wed, 26 Jan 2000 11:40:21 +1100 (EST)

From: Andre Masumbuko Nzunzu Renzaho <a.renzahoatpgrad.unimelb.edu.au>

Subject: Re: Young infant and Malnutrition

 

Dear Sophie,

From my 6 years' experience managing and supervising feeding centres, I would like to share some ideas with you.

Concerning your question about infants' feeding, here are some tips:

Firstly, I would like to correct your formula of DSM reconstituted milk: 50g of DSM, 75g Sugar, 25g oil should not be added to one litre of water, but rather water should be added to this premix to form reconstitute one litre of milk, that is:

This premix provides approximately 705 kcal and 18 g of protein. Knowing that the infant formula should provide 70 Kcal and 1.8 g of protein per 100ml, then the quantity of water to be add4ed is 850ml. The formula becomes:

50g DSM+ 75g Sugar + 25g OIL +850 ml of water (70kcal and 1.8g prot/100ml)

However, the daily energy and protein requirements for infants are approximately 105 kcal and 2.8 g protein/ kg bodyweight/day

Given that 100ml provide only 70 kcal and 1.8 g of protein, the infant daily requirements for energy and protein would be met by approximately 150ml/kg bodyweight/day. (Note: It is presumed that the DSM is fortified with Vit A, iron and other nutrients)

Breastfeeding should still be a priority unless the mother died or is critically ill.

With respect to admission and discharge criteria, the clinical indicators are better than anthropometric measures for infants less than 6 months (problem of accuracy in measurement). Therefore, factors to look for would include wet nappies, dehydration, infant clinically wasted, appetite, nutritional status of the mother- effect on breast-milk production and so on. Other colleagues may want to take this discussion further to complement my ideas.

 

Andre Renzaho

Department of General Practice and Public Health, The University of Melbourne, Australia


Date: Wed, 26 Jan 2000 13:36:43 -0800 (PST)

From: aliou ayaba <ayabaatu.washington.edu>

Subject: Re: Young infant and Malnutrition

 

Dear ngonuters,

I notice a very important issue here.Why were malnourished kids nelected in the past? and I believe it will be the same for longtime eventhough many organizations claim to work on the issue.As I've thought about it I realise that management of malnutrition is not cost-effective, it draws ressources from others sectors of healthcare. The problem should be targeted on the top: healthcare accessibility, water supplies, food policy etc.. I just return from a survey in Africa among previouisly malnourished kids.The result: most of them died or become malnourished again.....

 

Aliou AYABA MD, MPH candidate..

.......................................................................

Believing that we existe is the source of our shame and much more
ridiculous we keep asking in this world " Why this? Why that? ... J.N

.......................................................................


From: kent <kentathawaii.edu>

Subject: Re: Young infant and Malnutrition

Date: Wed, 26 Jan 2000 11:57:58 -1000

 

aliou ayaba wrote:

> I notice a very important issue here.Why were malnourished kids nelected
> in the past? and I believe it will be the same for longtime eventhough
> many organizations claim to work on the issue.As I've thought about it I
> realise that management of malnutrition is not cost-effective, it draws
> ressources from others sectors of healthcare.

This depends on what you mean by "effective". Surely the management of malnutrition is highly cost effective for the purpose of saving lives, or for minimizing "Disability Adjusted Life Years", when compared with other health interventions.

The priorities of health care providers are likely to be very different from those of top government officials. The management of malnutrition must compete not only with other sectors of health care, but also with all other sectors. In government budgets, health competes against armaments and monuments and salaries and everything else. The sad and simple truth is that most governments appear to give low priority to the saving of children's lives.

Aloha, George

 

George Kent, Professor and Chair

Department of Political Science, University of Hawai'i

Honolulu, Hawai'i 96822-2281, U.S.A.

Phone: 1 (808) 956-7536, Fax: 1 (808) 956-6877, Email: kentathawaii.edu, Website: http://www2.hawaii.edu/~kent


Date: Wed, 26 Jan 2000 21:08:06 -0800 (PST)

From: aliou ayaba <ayabaatu.washington.edu>

Subject: Re: Young infant and Malnutrition

 

Thank for your feedback! I'm thinking from a policy maker point of view.A healthcare provider does not have any priority: all patients have the same right , the only priority is technical when we care for life threatned patient before the others.My perspective is that the issue of malnutrition cannot be mastered only by focusing on severe malnutrition, something has to be done in the population.Unfortunately both sides are not usually held.

 

Aliou AYABA MD, MPH candidate.

.......................................................................

Believing that we existe is the source of our shame and much more
ridiculous we keep asking in this world " Why this? Why that? ... J.N

.......................................................................


Date: Fri, 28 Jan 2000 18:18:40 +0000

From: David Morley <Davidatmorleydc.demon.co.uk>

Subject: Infantile Malnutrition.

 

Dear Michael, I found the high fatality rate in young infants disturbing.

The mid a upper arm circumference head ratio interesting.

TALC has produced an accurate circumference insertion tape using methods devised by Dr Fred Zerfas. We would like these evaluated if any Ngonutters would like a sample if they send and e-mail with a postal address to TALC <talcukatbtinternet.com> I will see they get one.

David

 

David Morley,Emeritus Professor of Tropical Child Health, University of London.

Davidatmorleydc.demon.co.uk

Tel: & Fax. 44 (0) 1582 712199.

Preferred Address; 51 Eastmoor Park, Harpenden, AL5 1BN. UK.