Full Recovery means more than Nutritional recovery

Protein Energy Malnutrition decreases cellular immunity yet immune recovery has rarely been investigated during nutritional rehabilitation. In a recent study, 110 malnourished children from low income families of Cochabamba (Bolivia) with a mean age of 16.9 months were hospitalised for 2 months in the Centre for Immune and Nutritional Rehabilitation (CRIN), of the German Urquidi Materno-Infantil Hospital. They received a special four-step diet. Nutritional status was determined by daily clinical examination and weekly anthropometric measurements. Immune status was assessed by weekly ultrasonography of the thymus gland. The thymus gland demonstrates certain pathological changes in response to immune deficiency secondary to malnutrition.

Findings
The classical criterion for discharge from nutritional rehabilitation units in Bolivia (90% of median reference weight for height) was reached after the first month, whereas a 2-month period was required for complete recovery of immunity. The children belonged to a poor population group with high exposure to disease. In this type of environment discharge based only on nutritional status after one month of treatment could explain the frequent relapses noted at the CRIN because the children were still immuno-depressed.

It was also noted that MUAC only reached normal values after the second month at the centre. There was a much better correlation between MUAC and thymic recovery than between weight for height and thymic recovery. The study concluded that to prevent frequent relapses and to reduce the high case-fatality rates observed in many rehabilitation centres, practitioners should consider immune recovery as part of the management of severe malnutrition. For example, immunostimulating factors like zinc should be used to reduce the time required for immune recovery. A previous study showed that physiological doses of zinc supplement during the 2 month CRIN hospitalisation significantly reduced the immune recovery period. As a result, anthropometric and immune recoveries coincided so that the children could be discharged after only one month of hospitalisation to face a pathogenic environment with confidence.

Reference:
Immune Recovery of Malnourished Children Takes Longer than Nutritional Recovery: Implications for Treatment and Discharge (Oct 1998): Chevalier. R, et al, Journal of Tropical Paediatrics, Vol 44, pp 304-307.