A study of the age of onset, diet and the importance of infection in the pattern of severe protein-energy malnutrition in Ibadan, Nigeria

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Abstract
1. Fifty unselected consecutive cases of protein-energy malnutrition (PEM) presenting at the General Out-patient Clinic of the University College Hospital, Ibadan were classified as marasmus (twenty), kwashiorkor (nineteen) marasmic-kwashiorkor (seven) and undernutrition (four) according to the Wellcome Classification of PEM (Lancet, 1970; Waterlow, 1972).2. The mean age of the children with marasmus (22.4 months) and of the children with kwashiorkor (25.4 months) were not significantly different. The children with marasmickwashiorkor (27.8 months) were significantly older than the children with marasmus.3. The deficits in weight- and length-for-age were similar to values previously reported (Waterlow, 1972) even though the children with marasmus tended to be older and the children with kwashiorkor younger than has been reported. Values obtained for the deficit in length-for-age suggested that the children with marasmus had been undernourished from birth whereas the children with kwashiorkor had apparently grown normally until they were 10 months old. It is possible that the history of growth in the first year of life influences the final form of PEM in these two groups of children.4. Forty-nine of the fifty children had been breast-fed for at least 9 months and nine children had been breast-fed for 2 years. Of the twenty children with marasmus nine were still receiving some breast milk. The diets fed to weaned children with marasmus and to children with kwashiorkor were identical and consisted solely of a maize-starch gruel with no supplementation of protein or vitamins. The similarity in the dietary histories of the two main groups of children suggests some uncertainty concerning a specific role for protein deficiency in the development of kwashiorkor.5. All the children had had similar infections. The most common of these were measles (morbilli) (40% of all cases) and gastrointestinal infections. However the children with marasmus had a history of chronic diarrhoea whereas the children with kwashiorkor had had more acute diarrhoea.6. The similar dietary histories but dissimilar histories of infection given by the mothers of the children with marasmus as opposed to those with kwashiorkor suggest that recurrent diarrhoea was at least partially responsible for the chronic undernutrition in the group of children with marasmus. Furthermore although the weaning diets were inadequate the final deterioration in nutritional status was precipitated by gastroenteritis, often following measles.