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OBJECTIVE: To contrast early discharge versus attempted full nutritional rehabilitation in hospital of children suffering from severe protein-energy malnutrition (PEM). DESIGN: Field experiment, two-way analysis of variance with one between group (short- versus long-stay) and one repeated measures factor (admission, then 12, 18, 24, 30 and 36 months post-admission). Covariates introduced. SETTING: Primary health care, Kingston, Jamaica. SUBJECTS: n = 81; mean age 11 months; 79 contribute longitudinal data; 44 every measurement. INTERVENTIONS: When concurrent illnesses had been treated and normal feeding re-established (weight gain 5 g/kg.day-1), subjects were randomly allocated to short-stay (SS) or long-stay (LS) group. LS retained in hospital for full nutritional rehabilitation mean 40 days. SS discharged immediately (mean 18 days) for standard Health Service care at home for 6 months plus high-energy supplement (3.31 MJ with 20.6 g protein daily) for first 3 months. After discharge LS received 6 months home care, but without supplementation. RESULTS: Significant advantages for LS group on NCHS weight & length for age at discharge, and at 12, 18, 24 and for length also 30 months (P< 0.05 tp P < 0.001). Weight advantage peaked at 12 and 18 months, length later at 18 and 24 months. CONCLUSIONS: Contrary to earlier reports, full nutritional rehabilitation can be achieved in hospital for children suffering from PEM. Although in the long-term both groups move towards expected levels in their home community, a significant advantage maintained for 2 years is developmentally advantageous during the critical time after weaning. SPONSORSHIP: Fully funded by Ministry of Development Cooperation, the Netherlands, with cooperation of Ministry of Health, Kingston, Jamaica (AU)

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In the Kingston Project malnourished children referred from public health clinics to a metabolic ward were treated at home using community health aides within the existing health service. We have previously provided anthropometric results showing significantly greater gains in weight and length for groups given a high energy supplement (3.31 MJ daily) for 3 months during treatment, and greatest gains for a group treated with metronidazole at the beginning of supplementation [Heikens et al., Eur. J. Clin. Nutr. 43, 145-160 (1989); 47, 160-173 (1993)]. We now present findings on morbidity and relate these to the separate interventions and to growth velocities. Although referral was solely on nutritional criteria, 65 percent of the sample were found to have additional illnesses at enrolment. During the study period (6 months) upper respiratory tract infections (URTI) were the commonest illness in all groups; there were significantly more gastroenteric infections in the group given the supplement, but not the antibiotic treatment; the children who received only the standard health service care were ill more often and for longer periods than children in the other groups. Diarrhoea, fever and dysentery prevalences were all found to relate significantly to weight velocity, and although prevalences differed between treatment groups, the detrimental effect on velocity was similar whichever the group (AU)

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Malnourished children (mean age 1.2 years) referred from public health clinics to a paediatric metabolic ward in Kingston, Jamaica, were enrolled for treatment in a community-based health care project and were randomly allocated to one of two groups. The first group was treated at home with metronidazole and then for 6 months using the standard health care provided from local clinics by community health aides. The second group was given the same drug and home treatment, but in addition received a high energy supplement of 3.31 MJ daily for 3 months. We have previously shown a significant advantage in both weght and height gain for a group given the same supplement in contrast with standard health care controls (Heikens et al., 1989, Eur. J. Clin. Nutr. 43, 145-160), and in this study test the addition of a drug treatment aimed at reducing malabsorbtion due to a possible microbial overgrowth of the small bowel in malnourished children. This paper reports anthropometric findings showing significant benefits from both the drug and nutritional treatments. Greatest gains were by the group given both treatments, but the group given the antibiotic treatment, without energy supplementation, also made better growth recovery than did controls. Only 8 percent of the children treated with metronidazole failed to respond to community-based intervention and were admitted to hospital, compared with 19 percent for the other groups (P<0.05). These findings support targetted high-energy supplementation for the rehabilitation of moderately malnourished children receiving health clinics care, and suggest further that such programs should include antibiotic treatment directed at SBBO (AU)

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Moderate and severly malnourished children referred from public health clinics in Kingston, Jamaica, to a metabolic ward were treated at home for 6 months using community health services. A randomly selected subgroup of these children received in addition a daily high energy food supplement of 3.31 MJ for the first 3 months of the 6-month intervention period. Both groups received full nutritional and medical surveillance and care. The supplemented gained significantly more in weight than the unsupplemented children, but the advantage was lost once supplementation ceased. They also gained significantly more in length and this gain was maintained at the end of the intervention period. However, this increase in length, without continuing superior weight gain, left the supplemented children significantly more wasted than the unsupplemented, as measured by a body mass index (weight divided by height squared). These findings remained stable after interactions with morbidity measures had been taken into account. It is concluded that (1) high-energy supplementation assists rehabilitation of malnourished children brought to public health service clinics and treated in the community, and (2) supplementation should be continued until there is catch-up growth to within an acceptable distance from expected length for age (AU)

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Children who suffer from severe malnutrition in early childhood have lower levels of school achievement and intelligence quotients, and more behavioural problems than their peers or siblings for many years. Few studies have attempted intervention, and these have been short-term and had only transient benefits. We previously reported a programme of two years intervention, which had marked benefits. We now report the childrens' progress over a third year of intervention and three years following its cessation. The development of 16 children , who were in hospital with severe malnutrition and participated in a home visiting programme of psychosocial stimulation, was compared with that of two other groups who were also in hospital but received standard medical care only; another severely malnourished group (n=18) and an adequately nourished one (n = 20). All groups were assessed regularly on the Griffiths Mental Development Scales and then the Stanford Binet tests. Both malnourished groups were markedly behind the adequately nourished group on admission to hospital and the non-intervened group showed little signs of catching up. The intervened group caught up to the adequately nourished group in two years and showed no further improvement in the third year of intervention. Over the following three years, they showed a decline in three of the five Griffiths subscales. They, however, retained a marked advantage over the non-intervened malnourished group on the Standard Binet test to the end of follow-up, showing no further decline in the last year. Both malnourished groups failed to catch up to the adequately nourished group in height. It was concluded that relatively simple intervention can benefit the development of severely malnourished children (AU)

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The development of 16 children who were hospitalized for severe malnutrition and participated in a home-visiting program of psychosocial stimulation was compared with that of two other groups who were also hospitalized but received standard medical care only: severely malnourished group (n = 18) and an adequately nourished one (n = 20). All groups were assessed regularly on the Griffiths Mental Development Scales and the Stanford-Binet test. Both groups of malnourished children were markedly behind the adequately nourished group on admission to the hospital and the group that received no intervention showed little sign of catching up. The intervention group caught up to the adequately nourished group in 2 years. This report covers the third year of home-visiting and the 3 years following its cessation. The intervention group showed a decline in three of the five Griffiths subscales. However, they retained a marked advantage over the nonintervention group of malnourished children on the Stanford-Binet test until the end of follow-up, showing no further decline in the last year. For height, both malnourished groups failed to catch up to the adequately nourished group. It was concluded that a relatively simple intervention can benefit the development of severely malnourished children. (AU)

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The effect of adding psychosocial stimulation to the treatment of severly malnourished children was studied. The study period covered children from the time they left the hospital to 24 months later. The children's developmental levels (DQs) were compared with those of two other groups who were in the hospital - an adequately nourished group with diseases other than malnutrition, and a severely malnourished group who received standard hospital care only. The children receiving intervention had structured play sessions in the hospital and were visited weekly for 2 years after returning home. During the visits paraprofessionals showed mothers how to continue structured play with their children. The malnourished children who did not receive intervention showed a marked deficit in developmental level compared with that of control children throughout the study. The control children showed a decline in developmental level with age, which is characteristic of disadvantaged children. The children receiving intervention showed marked improvements and by 24 months were ahead of the children who did not receive intervention in every subscales. Both groups of malnourished children remained behind the control children in nutritional status and locomotor development. (AU)

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The developmental level and nutritional status of a group of 17 children aged between six and 24 months who were admitted to hospital with severe protein-energy malnutrition were studied from admission to hospital until 36 months after returning home. They were compared with a group of 14 adequately nourished children of similar age who had been admitted to hospital for other reasons. Initially the malnourished group were markedly behind the controls in developmental level, and they fail to reduce their deficit in hospital. Over the following 36 months they showed a gradual improvement relative to the controls in developmental level, height and head circumference, but were still significantly behind at the end of the study. In contrast, they caught up in weight for height by one momth after returning home. When length of stay in hospital, age at admission, birthweight, mother's IQ and home background measures were taken into account, the direction of the differences between the two groups and significance levels were unchanged. (AU)

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The effect of adding psychosocial stimulation to the treatment of severly malnourished children was studied by comparing the developmental levels (DQs) of the children with those of two other groups of children - an adequately nourished group with diseases other than malnutrition and a second malnourished group who received standard hospital care only. The intervention children underwent structural play sessions daily in hospital and weekly for 6 months after discharge; mothers were also shown how to play with them. The non-intervention malnourished group showed a marked deficit in DQ compared with the adequately nourished group throughout the study period. The intervention group made significant improvements in DQ in hospital and continued to do so after discharge. By 6 months they were significantly behind the adequately nourished group. (AU)

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A longitudinal study of the mental development of seventeen children admitted to hospital with severe protein energy malnutrition (PEM) was commenced in 1975. They were compared with fourteen adequately nourished children hospitalized for other reasons. Throughout the three years after leaving hospital all children had regular developmental assessments on the Griffiths Mental Development Scales, and anthropomentric measurements. When they left hospital the developmental level (DQ) of the malnourished group was markedly behind that of the comparisons. During the following three years the deficit was reduced, but the malnourished group remained significantly behind. (Malnourished mean = 86.1, SD = 11.8: comparison mean = 99.7, SD = 8.2, p<01). The malnourished group was significantly behind the comparisons in each subscale of the Griffiths test. Since leaving hospital the malnourished children had reduced their deficit in "performance" and "hand and eye' subscales but not in "locomotor" or "hearing and speech" subscales. All children were given the School Achievement Test (SAT) and Peabody Picture Vocabulary Test (PPVT) between one and six months after their 36-month test. These tests have been modified for Jamaica and are used to assess children's progress in Basic School. In both tests the malnourished children were behind the well nourished. (PPVT mean: comparison = 27.5, SD = 10.9, malnourished = 19.7, SD = 9.4; p<0.5 SAT mean: comparison = 34.3, SD = 19.0, malnourished = 26.8, SD = 10.6, p<.05). The malnourished children caught up to the comparison in percentage expected weight for age, but remained significantly more stunted, with smaller head circumferences and lighter. It was concluded that Jamaican children who suffer from severe PEM in early childhood have a persistent lag in mental development and retarded physical growth for several years. It is apparent that more comprehensive care is required to ensure full rehabilitation (AU)

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