Brief Reports

Umesh Kapil
Monica Tandon
Priyali Pathak
Deepika Nayar

From the Department of Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110 029, India.

Revision accepted: January 6, 1999

In India, severe protein energy malnutrition (PEM) is one of the important factors associated with high infant and child mortality rate in India. Malnutrition predisposes to infection, which in turn aggravates malnutrition. This vicious cycle thus proves fatal to a child. To break this cycle, direct intervention in the form of supplementary nutrition (SN) is provided through ICDS scheme to malnourished children for improving their nutritional status. Therapeutic nutrition is given to children who are suffering from severe forms of mal-nutrition.

As per guidelines of ICDS package of services, supplementary nutrition worth 300 Kcal and 8 g to 10 g of protein is distributed to moderately malnourished children. Severely malnourished children receive double supplementary nutrition worth 600 Kcal and 18-20 g of protein(1).

Data regarding the status of receipt of consumption of SN by severely malnourished children in ICDS scheme is lacking. The present study was, therefore undertaken to evaluate the nutrient intake and consumption pattern of SN by severely malnourished children.

Subjects and Methods

The study was conducted in two urban ICDS projects of Rajasthan. All the districts in Rajasthan were enlisted and two districts (Alwar and Bharatpur) were selected by using multistage random sampling procedure. At the time of study, 5 and 9 ICDS projects were operational at Alwar and Bharatpur, respectively. From each district, one project was selected, which was operational for more than five years. Therefore, in each project, 25 angan-wadi centers (AWCs) were selected for the detailed study. All the child beneficiaries in a total of 50 anganwadi centers were included for the detailed study.

The nutritional status of all the children in 6 months to 6 year age group in 50 AWCs was assessed by weight for age criteria as per the Indian Academy of Pediatrics Classification. Weight recording was done by using SECA electronic weighing scale to the nearest 100 g. Age of children was assessed from the secondary records of AWC. Local event calendar was utilized, whenever the age of the child was not available. One hundred and thirty children were found to be severely malnourished in the study area.

All mothers (of severely malnourished children) were interviewed in detail to assess the nutrient intake by undertaking domicilliary visits. The nutrient intake of child was assessed by utilizing the 24 hour dietary recall methodology(2). Nutrient intake was calculated using the database derived from Indian food composition tables(3). The recommended dietary allowances (RDA) suggested by the Indian Council of Medical Research (ICMR) for 0-6 year children were used to assess the adequacy of nutrient intake of the subjects(4).

Data on receipt and consumption of supplementary nutrition by SMN children was collected by observation method at the AWC. Home visits were also made and mothers were specifically asked about the actual receipt and consumption of supplementary nutrition by their child. Information regarding the venue of consumption of supplementary nutrition was also collected.

In the ICDS projects studied, "Ready to Eat" SN was provided to children, i.e., corn soya flour and soya oil supplied by Cooperative of American Relief Everywhere (CARE). This supplement was, at times, further cooked as mathari, namakpara or paratha by anganwadi workers to improve palatability and facilitate higher consumption.

Results

The 50 AWCs catered to 5543 families having a population of 40,672. The study population had 1623 children. About 56.8% children were male and 43.2% were female. It was observed that 35.2%, 26.1%, 6.5% and 1.5% of children belonged to Grades I, II, III and IV malnutrition, respectively. Thirty per cent children were found to be normally nourished.

The nutrient intake assessment of severely malnourished children revealed that the mean calorie intake in 6-11 months age group was 626 Kcal, which was 26% less than the recommended dietary allowances for this age group. In 12-35 months age group children, the mean calorie and protein intake was 717 Kcal and 22 g, respectively. The calorie deficit for this age group was 42.2%. Similarly, in 36-71 months age group the deficit in calorie intake was 50.4% (Table I).

SN was received by 84.6% severely malnourished children. Of those receiving supplementary nutrition, 45.4% received single and 39.2% received double ration of SN (Table II). About, 15.4% severely malnourished children did not receive any supplementary nutrition possibly because it was not acceptable to them.

Discussion   

The calorie intake of severely malnourished children was found to be low and in- sufficient in all the three age groups, inspite of registration for delivery of supplementary nutrition. In comparison to RDAs, the diet was deficient in calories but no protein deficiency was observed except in the age group of 36-71 months.

Results further revealed that distribution of double supplementary nutrition to severely malnourished children was not according to the guidelines. Almost 46% severely malnourished children who should receive double SN were still provided the single ration of SN. Even after receipt of SN, only few children were consuming 100% of supplementary nutrition.

Earlier research workers have reported the poor acceptance and consumption of supplementary nutrition by ICDS beneficiaries(5). However, Rao et al. had observed that therapeutic food was considered as the best recipe for young children in the nutrition component of ICDS scheme(6).

The consumption pattern of children receiving single and double SN is depicted in Tables III and IV.

Table I^__Mean Energy and Protein Intake of Severely Malnourished Children (n = 130).

Table II^__ Distribution of SMN Children According to the Receipt of Supplementary Nutrition on the Day of Survey.

Figures in parantheses denote percentages

Table III^__Consumption Pattern in Children Receiving Single SN.

Figures in parantheses denote percentages

The findings of the present study revealed that only 13 children out of 110 who received, did not consume supplementary nutrition. There is a need of emphasizing to anganwadi workers, that the guidelines for distribution and consumption of SN should be adhered to for management of severe malnutrition thorugh the ICDS scheme. Also more operational research is required in relation to consumption of supplementary nutrition by child beneficiaries for further improvement.

Table IV^__Consumption Pattern in Children Receiving Double SN.

Figures in parentheses denote percentages.

References

1. Tandon BN, Acharya SK, Kapil U, Bansal AK, Krishnamurthy KS. Central Technical Committee (CTC), ICDS Monitoring, Motivation, Continuing Education, Evaluation Research and Training System in ICDS. Department of Women and Child Development, Ministry of Human Resource Development, R.K. Puram, New Delhi, 1994; pp 57-59.

2. Thimmayamma BVS. A Handbook of Schedules and Guidelines in Socio-economic and Diet Surveys. National Institute of Nutrition, Hyderabad, 1987.

3. Gopalan C, Ramasastri BV. Nutritive Value of

Indian Foods. National Institute of Nutrition, Indian Council of Medical Research, Hyderabad 1993; p 156.

4. Nutrient Requirement and Recommended Dietary Allowances. National Institute of Nutrition, Indian Council of Medical Research, Hyderabad 1990; p 86.

5. Ghosh S. Integrated Child Development Services Programme: Need for reappraisal. Indian Pediatr 1997; 34: 911-918.

6. Rao H, Sharma KVR, Kumar S, Reddy CG, Rao NP. Acceptability trials with ready to eat foods in a rural area. Indian Pediatr 1992; 29: 1513-1518.

Sudhir Gupta

From the Departments of Pediatrics and Gastroenterology, Institute of Medical Sciences, Banaras Hindu University, Varanasi 221 005, India.

Revision accepted: March 1, 1999

Any diarrheal episode that begins acutely but is of unusually long duration (at least 14 days) in known as persistent diarrhea. Chronic diarrhea is a recurrent long lasting diarrhea due to mainly non infectious causes. The impact of chronic and persistent diarrhea is major in terms of malabsorption and malnutrition, susceptibility to other infections, specific nutrient deficiencies and mortality. Mortality is uncommon beyond early infancy but growth failure and chronic debilitation with its associated wide spectrum of problems are a major concern. Specific gastrointestinal histopathologi-cal changes have been described by various workers in patients of chronic and persistent diarrhea(1-4). This study was carried out to evaluate the various histopathological changes in the gastrointestinal tract of preschool children with diarrhea of more than 14 days duration.

Subjects and Methods

The present study was carried out on the patients attending the Pediatric OPD and those admitted in Children's Ward of Institute of Medical Sciences, Banaras Hindu University, Varanasi during the period July 1996 to March 1998. The study sample comprised of 148 children selected randomly, using simple randomization from amongst those fulfilling the following entry criteria: (a) Age £ 5 years but more than 1 year; and (b) Duration of diarrhea 15 days or more.

Most children were on follow up from the time their diarrhea was acute. Children between age group of 1 to 5 years having prolonged diarrhea were registered for endoscopic and etiological evaluation. Only those children with prolonged diarrhea were registered who were not receiving any antidiarrheal or lactose free diet for the preceeding five days lest this influence the observations. None of the study subjects were on gluten free diet. All the children were subjected to detailed anthropometric measurements using standard techniques. The

nutritional status of the children was assessed and categorized as described by Gomez et al. (5). Detailed stool examination was done. Stool samples were collected from all children at admission and processed for: (a) pH, reducing sugars; (b) Microscopy for cells, protozoa, ova, cysts and Cryptosporidium using modified Ziehl Neelsen stain; and (c) Bacterial detection.

Endoscopic examination was carried out using fibre-optic pediatric endoscope for visualization of upper gastrointestinal tract and biopsy was obtained from the third part of duodenum. Sigmoidoscopic biopsy was also carried out simultaneously. Sections were fixed in buffered formalin, blocks made in paraffin and stained with hemotoxylin eosin. All biopsies were assessed by the same pathologist.

Results

A total of 162 preschool children were enrolled into the study, of which 14 (8.6%) were dropped out due to non-availability of consent for endoscopic study by the parents. The sex composition of the study material was 70.2% boys and 29.8% girls. Symptomatology revealed that 34.4% of children in age group 1-2 years had stools mixed with blood and mucus. The corresponding percentages in age groups 2-3, 3-4 and 4-5 years were 20.4%, 21% and 24.1%, respectively. Similarly abdominal distention was noticed in 28.1%, 13.6%, 23.2% and 13.7% of children in age groups 1-2, 2-3, 3-4 and 4-5 years, respectively. All children had diarrheal stools. Of the total 148 children, who were a part of the study only 37.2% had normal nutritional status whereas grades II and III malnutrition was evident in 18.9% and 15.5%, respectively. Isolation of parasites was possible only in 23.6% of patients out of which 12% had Giardia in their stools. Only 42.6% of the

study population had lactose intolerance the frequency being the highest in children in age group 1-2 years (81.2%). Isolation of organisms was possible in only 23.0% of the patients. Out of the organisms E. coli was isolated in 71.4%, Salmonella in 20% and Aeromonas in 8.6%.

Endoscopic findings: Gross appearance of the duodenal mucosa did not reveal any specific change except for evidences of mucosal edema, nodularity, hyperemia and very rarely thinning in few of the patients. Histopathological observations revealed that majority of children (52.7%) had villous atrophy with duodenal mononuclear infiltration. Similarly chronic or non-specific duodenitis was observed in 20.9% of cases. Non-specific colitis was apparent in 15.5% of cases, 8.6% of whom presented clinically with blood and mucus in stools. Only 10.8% of children who participated in the study and had chronic diarrhea demonstrated normal histopathology of the GIT. Abnormal gross appearance on endoscopy did not have a statistically significant correlation with abnormal histological findings. In none of the patients both duodenal and colonic inflammation was evident simultaneously.

The duration of diarrhea, age of patients and gastrointestinal changes were correlated (Table I). No significant or consistent pattern was observed except for a higher frequency of histopathologic abnormality seen in younger study subjects and with increasing duration of diarrhea. Villous atrophy with mononuclear cell infiltration was seen in majority of the study subjects aged 1-2 years. None of the duodenal biopsy specimens revealed cysts or trophozoites of Giardia. A normal histo- pathology was seen in older subjects and in those with a shorter duration of diarrheal episode (though statistically not significant). Histological changes were also correlated with

nutritional status (Table II). No significance association was documented.

Discussion

Our observations on 148 children suffering from chronic diarrhea between the ages of 1 and 5 years were by and large in conformity with those reported by other workers. Most of the symptoms were much more marked in children in the age group of 1-2 years. Other workers(1) have also suggested that children having chronic diarrhea present with symptoms like upper abdominal cramps, vomiting and abdominal distention. Symptomatology is useful in determining the origin of damage in GIT. Small intestinal pathology has been associated with large volume of diarrhea and may lead to malabsorption of specific nutrients.Large bowel pathology leads to small volume of diarrhea and is likely to present with gross blood and mucus in stools along with symptoms of fecal urgency and tenesmus(2,3).

Secondary lactose intolerance was seen in 42.6% of cases. The cause of underlying mucosal injury could not be established in most of the patients and in only a small number of patients (11.1%) associated enteric pathogens could be isolated. Isolation of organism was possible only in 23.0% of all cases. E. coli was the predominant organism, further serotyping was not done. Salmonella which was isolated in 20% cases is a known cause of dysentery like illness with mucosal invasion in small and large bowel(4). Aeromonas sp. was isolated in 8.6% of all positive cultures. Other workers(6) have also reported a significant association of Aeromonas with childhood diarrheas. Giardia which is an important cause of malabsorption and protracted diarrhea was isolated in stools of 12% of all positive cases.

Several researchers have endorsed the utility of proximal small intestinal biopsy in demonstration of diffuse abnormalities and establishing the underlying cause thereby influencing the management and its outcome(7-9). Thomas et al.(10) carried out proximal small intestinal mucosal biopsy in 414 children presenting with chronic diarrhea. Enteropathy was observed in 44% of children, found to be more frequent in those aged less than 6 months and less frequent in children more than 5 years of age. The observations of our study with regards to the significant histopathological changes being more common in younger subjects and with increasing duration of diarrheal episode are in conformity with this study(10). Histopathological abnormalities were seen in 89.4% of the study subjects which is higher than what has been reported in the western literature(10,11). But similar figures have also been reported in an Indian study of chronic diarrhea in children less than 2 years of age(12) where villous atrophy was noticed in 97.5% of children. We do not have an explanation for such high values, but the high incidence of post enteritis enteropathy or parasitic infestations in our country could explain this disparity. It has been conclusively established earlier(10,11) that these agents may lead to significant histopathological changes in the GIT. The cause of chronic diarrhea in 10.8% cases with normal histology could not be identified. These patients may have had a mild carbo- hydrate intolerance or infection which we had failed to identify. These cases were investigated for carbohydrate intolerance, presence of enteropathogenic organisms and milk protein allergy without any positive outcome. None of the patients could be diagnosed as gluten induced enteropathy as repeat biopsies on gluten free diet were not obtained as a part of the study protocol. All patients with enteric pathogens or parasites were treated with specific antibiotics and drugs as and when required. Patients with secondary lactose intolerance responded to withdrawal of lactose from diet, in most of the patients diarrhea settled by 3-4 days. Dehydration was managed by ORS and IV fluids if required. Protein energy malnourished patients were nutritionally rehabilitated before discharge. The study subjects were not followed up and repeat endoscopy and biopsy was not done due to poor patient compliance and inherent cost factors.

In conclusion, majority of the hospitalized children with chronic or persistent diarrhea had histopathological evidence of gastrointestinal mucosal injury. Etiological factors were identified in only 89.2% of patients. Lactose intolerance was the major finding followed by isolation of various enteric pathogens. In contrast to the various Western studies, the degree of enteropathy appears to be more in Indian children with chronic or persistent diarrhea.

Table I^__Endoscopic Findings in Relation to Age and Duration of Diarrhea.

The Differences were not statistically significant. 

Table II^__Correlation Between the Nutritional Status and Histopathological Findings.

Figures in parentheses indicate the percentages.

References

1. Baldassano RN, Liacouras CA. Chronic diarrhea: A practical approach for pediatrician. Pediatr Clin N Am 1991; 38: 667-694.

2. Mehta DI, Lebenthal E, Blecker U. Chronic diarrhea: Cause, presentations and management. Indian J Pediatr 1996; 63: 459-471.

3. Burke V, Gracey M. Bacterial diarrheas. In: Diarrhea Ed. Gracey H. Boca Raton, CRC Press, 1991; pp 48-50.

4. Robbins, Brown RM. Enterotoxin and disease. South Afr J Sci 1980; 76: 352-358.

5. Gomez F, Ramos-Galvan R, Fren KSS, Cravioto JM, Chavez R, Vasquez J.

6. Challipalli M, Yess BT, Cunningham DG, Chopra AK, Houston CW. Aeromonas associated diarrhea in children. Pediatr Infect Dis 1988; 7: 693-698.

7. Lebenthal E. Prolonged small intestinal mucosal injury as a primary cause of intractable diarrhea in infancy. In: Chronic Diarrhoea in Children. Ed. Lebenthal E. New York, Raven Press, 1984; pp 5-29.

8. Phillips AD, Jenkins P, Raffat F, Walkar Smith JA. Congenital microvillous atrophy. Arch Dis Child 1985; 60: 135-140.

9. Unsworth DJ, Walkar Smith JA. Auto immu

nity in diarrheal diseases. J Pediatr Gastroenterol Nutr 1985; 4: 375-380.

10. Thomas AG, Phillips AD, Walker Smith JA. The value of proximal small intestinal biopsy in differential diagnosis of chronic diarrhea. Arch Dis Child 1992; 67: 741-744.

11. Hjelt K, Paerregaard A, Krasilnikoff A. Giardiasis causing chronic diarrhea in sub-urban Copenhagen: Incidence, physical growth, clinical symptoms and small intestinal abnormality. Acta Pediatr 1992; 81: 881-886.

12. Khoshoo V, Bhan MK. Associated factors of protracted diarrhea. Indian Pediatr 1990; 27: 559-569.