products to treat severe malnutrition
This discussion was initiated by a contribution to the discussion on "Type I and type II deficiencies" : see here
|milk and soy based diet||André Briend||04.05.2000|
|Soya-based products to treat severe malnutrition||Benjamin Torun||04.05.2000|
Date: Thu, 04 May 2000 10:19:54 +0200
From: "Andre' Briend" <briendaatcnam.fr>
Subject: milk and soy based diet
There have been frequent attempts to replace milk-based diets by blended food (with soy) based diets or local foods in treatment of severe malnutrition in order to cut down the cost. For the severely malnourished children, as far as I know, this often seems to lead to higher mortality and lower weight gain. Please have a look at the paper below by Brewster et al who monitored mortality in a tfc while donor agencies attempted to replace milk by blended flours to save money (??). There is also an interesting paper by the late JP Beau in Cote dIvoire who replaced a diet prepared from locally available food by a simple dried skimmed milk oil and sugar diet (without even added minerals). You can see from the abstract below that there was an impressive drop in treatment failure, at least in HIV - children.
Please note too that a milk based diet is not so expensive, at least in comparison to other costs involved in the treatment of severe malnutrition.
A recent study from Bangladesh showed that a milk based diet represented only 4% of total hospital treatment of a severely malnourished child (Ashworth A, Khanum S, Health Policy Planning 1997; 12 (2) 115-21).
Admittedly, this proportion may vary in different settings, but this paper nevertheless suggests that you cannot save much on hospital cost by droping milk from the child's diet.
Reports of successful rehabilitation of malnourished children without milk usually relate to moderately malnourished children... or often do not use a comparison group to evaluate their success. As pointed out by Mike, soy based feeds have a high phytate content and little absorbable phosphorus and other minerals. Admittedly, you can remove part of this phytate by enzymatic action, which is what is done in some soy based infant formulas.
These formulas also use soluble soy proteins, which I guess must have a lower phytate content, and are quite different from cheap soy based blended flours. As far as I know, these soy-based infant formulas are as expensive, if not more expensive, than milk based equivalent.
These remarks do not apply to moderately malnourished children who should be fed with cheapest locally available foods with a combined nutritional composition good enough to support cacth up growth at a reasonable rate.
Brewster DR, Manary MJ, Menzies IS, Henry RL, Oloughlin EV. Comparison of milk and maize based diets in kwashiorkor. Arch Dis Child 1997;76(3):242-8.
DR Brewster, Flinders Univ & Maternal & Child Hlth, Royal Darwin Hosp, POB 41326, Casuarina, Nt 0811, Australia The dual sugar test of intestinal permeability is a reliable non-invasive way of assessing the response of the small intestinal mucosa to nutritional rehabilitation. Aim-To compare a local mix of maize-soya-egg to the standard milk diet in the treatment of kwashiorkor. Design-The diets were alternated three monthly in the sequence milk-maize-milk. There were a total of 533 kwashiorkor admissions of at least five days during the study who received either milk or maize.
Intestinal permeability was assessed at weekly intervals by the lactulose-rhamnose test in 100 kwashiorkor cases, including 55 on milk and 45 on the maize diet. Results-Permeability ratios (95% confidence interval) on the milk diet improved by a mean of 6.4 (1.7 to 11.1) compared with -6.8 (-16.8 to 5.0) in the maize group. The improved permeability on milk occurred despite more diarrhoea, which constituted 34.8% of hospital days (29.8 to 39.8) compared with 24.3% (17.8 to 30.8) in the maize group. Case fatality rates for all 533 kwashiorkor admissions were 13.6% v 20.9%, respectively, giving a relative risk of death in the maize group of 1.54 (1.04 to 2.28). The maize group also had more clinical sepsis (60% v 31%) and less weight gain (2.9 v 4.4 g/kg/day) than the milk group.
Implications-Milk is superior to a local maize based diet in the treatment of kwashiorkor in terms of mortality, weight gain, clinical sepsis, and improvement in intestinal permeability.
Beau JP, Imboua Coulibaly L, Du Lou AD. [The effect of nutritional management on the mortality of malnourished children, uninfected and infected with the human immunodeficiency virus]. Sante 1999;9(3):163-7.
Weight loss is a major complication in children infected with HIV. Very few studies have focused on the nutritional management of malnourished HIV-positive children, particularly in developing countries, although there have been some studies in adults. Therefore, the aim of this retrospective study was to evaluate, as a function of HIV status, the effect of a nutritional rehabilitation program on the mortality of malnourished children in an Ivory Coast nursery. We studied 193 malnourished children over the age of 15 months from January 1 1994 to December 31 1996; 41 % of these children (80 of 193) were HIV-positive. The nutritional rehabilitation program was introduced in 1995. It had a beneficial effect in HIV-negative children because the setback rate (the number of deaths and transfers x 1,000/ the number of child-months at risk) decreased significantly over the three years of the study (1994: 130; 1995: 113; 1996: 26; p < 0.05). The rate in HIV-positive children did fall slightly, but this decrease was not statistically significant. These results demonstrate the difficulties involved in the nutritional management of malnourished HIV-positive children. However, recent studies have suggested that nutritional rehabilitation (by mouth) combined with total vitamin and mineral supplementation may be more effective. Given the frequency of malnutrition in HIV-positive children, clinical studies aimed at improving the nutritional management of these children should be a priority in developing countries.
André Briend, MD, PhD
CNAM - ISTNA, 5 rue du Vertbois
75003 Paris, France
tel : 33-1-53 01 80, 36 fax : 33-1-53 01 80 05
Date: Thu, 04 May 2000 15:25:23 +0100
From: "Dr. Benjamin Torun" <btorunatincap.org.gt>
Subject: Soya-based products to treat severe malnutrition
I don't think one must be so radical as to recommend either one single treatment regimen or none at all. The key is to understand the physiopathology of severe malnutrition and the principles for its treatment.
I agree with Mike that soya-based diets, and by extension all vegetable-based diets, have limitations related to their phytate content, lower protein digestibility compared with animal protein sources, in some instances poor protein quality, and micronutrient contents and bioavailability. Thus, I would not recommend them as the first choice to treat severely malnourished children. However, neither would I ban their use.
In the absence of F75/F100 or other adequately formulated diet based on a high quality animal protein source, appropriate energy and protein concentrations, and supplemented with adequate amounts of vitamins and minerals, diets based on soya or on adequately formulated vegetable mixtures can save lives and allow nutritional recovery. INCAP has positive experiences with such vegetable mixtures.
Certainly the use of soya-based porridge with high protein and energy concentrations, high osmolality, etc, can have serious consequences and even cause the death of a severely malnourished child during the early stage ot treatment. But if it is diluted to bring it down to appropriate concentrations and osmolality, and supplemented with electrolytes and micronutrients to meet the therapeutic requirements of a severely malnourished child, I believe it can be used to treat such children, although I would not advocate its use except when a better diet is not available.
Benjamin Torun, MD, PhD
Head, Human Nutrition and Chronic Diseases Institute of Nutrition of Central America and Panama
INCAP -- Calzada Roosevelt, Zona 11, Apartado Postal 1188
Guatemala, 01901 Guatemala
Tel (+ 502) 471-9913, 472-3762, Fax (+ 502) 473-6529
e-mail: btorunatincap.org.gt, Web site: http://www.incap.org.gt