LSTM’s Seminar Series continued last week with a presentation entitled: Food for Thought: Childhood nutrition in low-income countries. It was delivered by LSTM’s Professor Stephen Allen along with Dr Melissa Gladstone from the University of Liverpool and Dr Isabella Swai from Muhimbili National Hospital in Tanzania. Dr. Swai’s visit to the UK was facilitated by RESULTS UK, a London based NGO working in advocacy to end poverty.
Professor Allen introduced the seminar by looking at the impressive global fall in the deaths of children under five years old of more than half in the last 40 years. However the progress in malnutrition in the same period has been less than impressive. Data shows that severe acute malnutrition (SAM) is most prominent in low-income countries, and undernutrition is thought to be an underlying contributor in up to 50% of all deaths in the under 5s.
Dr Isabella Swai talked about the challenges of managing SAM both in hospital and during follow up. She described the physical symptoms and then looked at a specific case study describing the treatment of a child of one year and 10 months. Management was according to WHO guidelines with three phases: the stabilisation, transition and rehabilitation phase.
Dr Swai then highlighted some of the challenges faced, such as the lack of early diagnosis, lack of capacity and the fact that there is no means of follow up at the patient’s own home. She described a number of steps for prevention, including exclusive breastfeeding for the first six months. In conclusion, said that the way forward should involve community nutrition rehabilitation centres, for screening, initial referral and management post discharge.
Dr Gladstone talked about SAM and the developing brain. She began by looking at the fact that over 200 million children under the age of five in the world are at extreme risk of impaired cognitive and social –emotional development, with most developmental delay being related to malnutrition. She explained the alteration of the structure of the brain with malnutrition both in terms of the size of the brain and a reduction in the number of synapses.
Dr Gladstone pointed out the uncertainly in the degree to which much of the damage to the brain caused by malnutrition can be reversed. However, it is clear that sensory stimulation and emotional support in children suffering from SAM is critical and is borne out in both animal studies and those involving children.
Professor Allen’s presentation focussed on enteropathy, asking the question: “is this the missing piece of the jigsaw in SAM?” He showed the group images of the normal mucosa of the gut, which is the body’s largest immune organ. Uncontrolled inflammation results in an enteropathy that breaks the healthy structures down resulting in impaired food digestion and nutrient absorption and probable increased sepsis through bacteria crossing the damaged mucosa.
He looked at the similarity in signs and symptoms between SAM and inflammatory conditions affecting the gut seen in high-income countries, such as coeliac disease, food sensitive enteropathy and Crohn’s disease. While all are responses to different antigens, the inflammation in the gut is similar and may respond to the same treatments. However, whilst the target of treatment of in high-income countries is to reduce gut inflammation through a hypoallergenic diet, the main approach in SAM is nutritional rehabilitation. He concluded by posing a question as to whether the failure to use the same approach results in poor outcomes in SAM and talked about his intention to carry out research into the effects of treating SAM using hypoallergenic food products, similar to those used in high-income settings.