Indian Pediatrics 1999; 36:139-143

C.R. Banapurmath, S.M. Prasad, Shobha Banapurmath and Nirmala Kesaree

From the Nutrition Rehabilitation Center, Department of Pediatrics, J.J.M. Medical College, Davangere 577 004, Karnataka, India.

Reprint requests: Dr. C.R. Banapurmath, Professor of Pediatrics, 390, 8th Main, P.J. Extension, Davangere 577002, Karnataka, India.

Manuscript received: November 27, 1996; Initial review completed: January 20, 1997;
Revision accepted:. October 7, 1998.

Objective: To evaluate the nutritional profile of survivors of severe protein energy malnutrition on follow-up at 1-3 years and 5-7 years. Design: Prospective and Cross-sectional point prevalence. Methods: Group I comprised 50 severely malnourished children discharged 5-7 years from nutritional rehabilitation center and Group II comprised 50 children discharged 1-3 years ago. The nutritional status of these 100 children was compared to the nutritional status of 35 siblings who had not suffered from severe malnutrition in their earlier life (Group III). Results: All the malnourished children showed significant improvement in weightfor age. More children in Group I had better height for age compared to Group II (p >0.05). Analysis of weight for height showed that study children had better nutritional status than their siblings who had not suffered from significant malnutrition. Conclusion: Significant improvement in nutritional status occurs with nutritional rehabilitation. However, improvement. in height for age is more difficult to obtain. Interestingly, rehabilitated malnourished children on follow up had better nutritional status as compared to their siblings. .

Key words: Nutrition rehabilitation center, Protein energy malnutrition.

Protein energy malnutrition (PEM) is a major health problem in developing countries. The World Health Organization (WHO) defines "PEM as a range of pathological condition arising from co-incident lack, in varying proportion of proteins and calories occurring most frequently in infants and young children and commonly associated with infection"(1).

Rapid "catch up!" growth leading to clinical recovery, namely, achievement of expected weight for height occurs within 6-8 weeks with suitable dietary regimen(2). Follow up of children with severe PEM is essential because mortality rate of 10-30% has been reported after discharge from hospital(3). The present study was aimed to assess the physical growth at foI1ow up after 3-7 years in children who suffered from severe PEM and were treated in nutritional rehabilitation center and to compare it with their own siblings who had not suffered from significant PEM.

Subjects and Methods

One hundred children with severe PEM (lAP classification) admitted, treated and discharged from the Nutrition Rehabilitation Center (NRC), were re-examined 3-7 years later and their nutritional status was assessed. Out of the 100 children who were discharged, 50 children who were discharged 7 years ago were Included in Group I and another 50 children who were discharged 3 years ago comprised Group II. A third group, consisting of 35 siblings of these children who were not admitted to the NRC and who had not suffered from significant protein energy malnutrition, was also studied for comparison. Nutritional Anthropometry was done !is detailed earlier(4).

Weight: Children at follow up were ,weighed with minimal clothing on a platform beam balance with an accuracy of 50 grams. The child was made to stand on the center of the platform without touching anything else.

Height: As !ill the children at follow-up were more than four years of age, vertical measurement marked on the wall was used to the accuracy of 0.5 cm. After removing the footwear, the child was made to stand on the flat floor by the scale with feet parallel and with heels, buttocks, shoulders and back of head touching the upright wall. The bead was held comfortably erect, with the lower border of the orbit in the same horizontal plane as the external auditory meatus. The A wooden plane was placed against the scale horizontally, pressing the hair and making contact with the top of the head.

Results

Nutritional categorization of the 100 children suffering from PEM according to the lAP classification(5) on admission to NRC is depicted in Table I. The mean ages of the various groups was 10.2 years for Group I, 6.5 years for Gropp II and 7.3 years for Group III. At follow up, in Group I, 44% attained normal weights, 32% had Grade I PEM, 22% had Grade II PEM and only 2% had Grade III PEM. In group II, at follow up, 52% attained normal weight for age, 26% had Grade I, 14% had Grade II and 8% had Grade III PEM. No one in either groups had Grade IV PEM. Table , I also compares the study groups with their own siblings, grown up in the same socio-economic conditions. As against 44% of Group I and 52% of Group II, only 20% of their siblings had normal weight for age.

Table II shows the distribution of height for age according to NCHS standards. Majority of the children in either study groups were stunted, this being more marked in Group II, thereby suggesting that recovery of height for age takes longer time in rehabilitated children.
 

TABLE I

Distribution of Study Groups and Siblings According to lAP Classification
 

Category	Normal	Grade I	Grade II	Grade III	Grade IV
Group I at admission	0	0	3	30	17
(n=50)
At follow up	22	16	11	1	0
Group U at admission	0	0	5	25	20
(n=50)
At follow lip	26	13	7	4	0
Group 1lI siblings'	7	13	13	2	0
(n=35)
'At follow up

 

Table II
 Height for Age at Follow-up According to NCHS Reference

Category		<5th centile	5-25th centile	25-75 centile
Group I	Boys	23 (79.3)	4 (13.8)	2 (69)
(n=50)	Girls	11 (55.0)	8 (35)	2 (100)
Group II	Boys	29 (96.7)	1 (3.3)	-
(n=50)	Girls	12 (60.0)	6 (30)	2 (10)
Group III	Boys	12 (57.1)	6 (28.6)	3 (4.3)
Siblings (n=50)	Girls	9 (69.2)	4 (23.1)	1 (7.7)

Figures in parentheses indicate percentages.

TABLE III
Distribution of Study Groups and Siblings at Follow-up According to Weight for Height by NCHS Reference.
 

Category	Sex	<5th centile	5th-25th centile	25th-75th centile	75th-90th centile
Group I	Boys	8	7	12	2
	(n = 29)	(27.5)	(24.1)	(41.3)	(6.8)
	Girls	5	5	10	I
	(n-21)	(23.8)	(23.8)	(47.6)	(4.7)
Group II	Boys	5	7	16	2
	(n = 30)	(16.6)	(23.3)	(53.3)	(6.6)
	Girls	3	4	II	2
	(n= 20)	(15)	(20)	(55)	(10)
Siblings	Boys	10	5	5	I
	(n = 21)	(47.6)	(23.8)	(23.8)	(4.7)
	Girls	5	5	4	-
	(n=14)	(35.7)	(35.7)	(28.5)

Figures in parentheses indicate percentages.

When weight for height was computed according to NCHS standards (Table Ill), 27.5% of boys and 23.8% of girls were below the 5th centile in Group I and 16.6% of boys and 15% girls Were below 5th centile in Group II whereas among the siblings in Group III, 47.6% of boys and 35.7% of girls were below the 5th centile, indicating that more children from follow up groups enjoyed better nutritional status then their siblings.

Discussion

Nutritional rehabilitation is essential for children who suffer from PEM. Long term adverse effects of PEM on physical growth are likely to occur in these children From the present study, when weight for age was com- pared, it was evident that the nutritional status of these children at follow up had improved. All the children who had suffered from severe grades of malnutrition in earlier life had better nutritional status 3 years later as well as 7 years later. These children had better nutritional status than their siblings who came from the same socio-economic background. This interesting phenomenon that successfully treated malnourished children tend to outgrow their siblings was also observed by earlier workers(6). This is quite likely because children who were discharged from NRC, are considered by their parents as weak children who need more food, resulting in improved allocation of food. Another study noted that the siblings who remained at home grew to essentially the same stature as children who had been rehabilitated after an aet al.(8) conducted a study on 116 rehabilitated Kwashiorkar patients in south Africa and their sibling controls. They found no difference in growth between cases and control.

When. children in study Groups I and II were compared with their siblings using weight for height, a significant number of children were above 5th percentile, again signifying that the children in the study group were enjoying a better nutritional status than their siblings. Weight for height is a good indicator of current nutritional status of al1Y child since it is age independent and also in- dependent of genetic difference in absolute body sizes(9).

It is believed that children who suffer from severe malnutrition in early life, are likely to have compromised growth in later life( 1 0, 11). It has been suggested that among children who survive an episode of malnutrition, approximately 39% remain stunted and probably fail to reach their potential adult stature(l2). Stunting following severe malnutrition probably reflects continued poor dietary intake rather than due to a limited episode of severe malnutrition(7). Studies on long. term effects on growth have also shown that children are shorter than local control and much shorter than American young men(l3). Another study has shown that marasmic children are more stunted than Kwashiorkar patients(l4). Severe calorie deficiency in early life possibly results in stunted growth(15). Though low cost outreach NRC's are effective in improving nutritional status and bringing down mortality(l6), a more recent study which has contrasted early discharge versus discharge following full nutritional rehabilitation has shown that there is significant growth advantage in the latter( 17), thereby suggesting that children who are well rehabilitated grow better.

Another recent study( 18) among school age children has shown that those children having regular contact with their families had better nutritional status than their peers having no such contact. Areport(l9) has shown that severely. malnourished children who were more stimulated and followed up 14 years later showed better psychosocial development.

In conclusion, the present study suggests that severely malnourished children, when rehabilitated, continue to remain short, though they do attain normal weight for height. However, the ultimate effect on height can be derived only after continued follow-up into adolescence and adulthood.

Acknowledgement

We thank all the members of Davangere Pediatric Research Foundation for their help.