The electroencephalogram in kwashiorkor

THE ELECTROENCEPHALOGRAM

IN KWASHIORKOR 1

G. K. NELSON, B.A. ( H o n s . ) National Institute ~or Personnel Research, 1ohannesburg, South Africa

(Received for publication: May 27, 1958) ment at B a r a g w a n a t h H o s p i t a l Johannesburg, and 21 at the Unit of the IJ~ fantile Malnutrition Group of the British Medical Research Council, and at 2¢[ulago ltospital, the latter two in K a m p a l a , Uganda. There were 19 males and 14 females. The mean age on admission was 20.70 (s.d. 8.69) months and the age range 8 to 44 months. Twelve children were anaemic ( H b < 60 per cent) on admission to hospital, and 4 became anaemic later. Of the 33 cases, 26 recov.~red, 5 were removed f r o m hospital by their parents before recovery was complete, and 2 died. In addition to these 33 patients there were 14 cases f r o m whom single E E G s w,:,re recorded on admission to hospital. The a g , range was 11 to 59 months, mean 20.64 (s.d. ll.74). The first control group comprised 11 African children (mainly surgical ~.ases) f r o m B a r a g w a n a t h Hospital, f r o m eaoh of whom at least 2 serial E E G s were obtained. These children were selected as controls 1,ecause they were not suffering f r o m a debilitating disease, their nutritional status and ment.fl state were both satisfactory, and their envi"onment was similar to that of the kwashiorkor patients. The age range was 3 to 51 months, mean 31.0 (s.d. 17.1). The second control group c , m p r i s e d 27 A f r i c a n children f r o m whom single E E G s were obtained. There were 23 normal children and 4 convalescent surgical p~l:ients. The age range was 2 to 49 months, re(an 12.9 (s.d. 10.9). There were thus 47 kwashiorkor patients and 38 control subjects in all.

The possibility of E E G disturbance in kwashiorkor (infantile protein malnutrition) was suggested b y the p r o f o u n d a p a t h y and irritability encountered in the disease (Clark 1951; Geber and Dean 1956). Evidence of organic b r a i n damage in kwashiorkor is as yet confined to post-mortem findings consistent with cerebral oedema (Trowell et al. 1954). I n 10 cases S a r r o u y et al. (1953) found greatly diminished voltage and f r e q u e n c y of brain potentials, lack of response to photic stimulation, and lack of change with the onset of sleep; in particular, the " c h a r a c t e r i s t i c fast activity of s l e e p " did not appear. These features were held to i m p l y a decrease in cortical metabolic activity, and showed a tendency to disappear d u r i n g recovery, although often persisting for up to three months afterwards. Their final disappearance was claimed to be the best criterion of complete recovery. Engel (1956) found grossly abnormal E E G s in 7 f a t a l cases of kwashiorkor, due to the presence of excessive slow activity. The E E G was mildly to m o d e r a t e l y abnormal in 16 cases which recovered. I n the latter group, the E E G abnormalities d i s a p p e a r e d during recovery, this t r e n d being p a r t i c u l a r l y r a p i d in a f u r t h e r 2 cases of mild kwashiorkor. Engel concluded t h a t the function of the cerebral cortex was i m p a i r e d in the disease and that, although the E E G abnormalities appeared to have no prognostic value, the possibility of p e r m a n e n t brain damage was raised. MATERIAL The clinical subjects were 33 young African children s u f f e r i n g f r o m moderate to severe kwashiorkor. Twelve were undergoing treat-

METItOD

1Thls investigation w~s financed by the South African Council for Scientific and Industrial Research, nnd bv a grant from the Mental Health Section of the Worhl Health Organization, Geneva.

Recording technique : E E G s ~w,re recorded by means of a 4-channel portable Ediswan electroencephalograph. In general, 11 electrodes in 7 different a r r a y s were employed,

[ra]

74

G.K. NELSON

giving transverse and longitudinal bipolar derivations from the frontal, parietal, occipital and temporal areas. Sedation was avoided because of the possible intrusion of fast activity into the EEG. However, the subjects frequently fell asleep d u r i n g the recording' session and occasionally even while the electrodes were being attached. I n the clinical group, the first E E G was obtained as soon as possible after admission to hospital, generally on the first or second day. Subsequent recordings were made at intervals of one week or more, depending on clinical progress. I n isolated cases, E E G s were taken at daily intervals. Each patient had a

nent was individually assessed : if present for up to 25 per cent of the total waking record, it was assigned a rating of 1, and ratings of 2-4 represented the presence of a component for 26-50 per cent, 51-75 per e ,nt and 76-100 per cent, respectively, of the ,raking record. The dominant E E G frequency was computed by taking the mean of all coml,onents with a rating" of 2 or higher. The following criteria were adopted for the purpos, of assessing EEG "improvement". (i) Disappearance of abnom~:ality, if any. (ii) Increase in dominant fre( ueney. (iii) Appearance of, or inerea.e in, response to photie stimulation.

TABLE I INCIDENCE OF ABNORMAL RECORDS IN 47 KWASHIORKOR PATIENFS ON ADMISSION TO HOSPITAL, AND 38 CONTROLS; WAKING AND SLEEPI~G EGGs Patients on admission State

Available records

No. abnormal

Waking

41

Sleeping

24

Sig. of difference

Controls -

Sig. of difference

No. abnormal

%

%

Available records

5

12

35

0

0

p ~ .02 (sig.)

10

42

13

1

8

p < .01 (sig.)

p ~ .02 (sig.)

minimum of 2 E E G s and several had 3 or more records, making a total of 94 E E G s from the 33 cases. Photie stimulation was incorporated where possible. Notes were kept throughout the recording of any psychological changes. I n the serial control group, E E G s were obtained at intervals of one week to 3 months. INTERPRETATION

( a ) Criteria of abnormality. I n the absence of E E G frequency norms for A f r i c a n children, records were only classified as abnormal if they contained focal discharges.

(b ) Criteria of EEG "improvement". To enable detailed comparison of serial records, each distinguishable frequency compo-

p ~ .05 (not sig.) (iv) Appearance of, or inereas,, in, fast activity, especially spindles, ,luring sleep.

(c) Assessment of mental stab. The following criteria were adopted in assessing improvement in mental state in the clinical group : (i) Alleviation of misery, a p , t h y and irritability. (ii) Increase in euphoria, ir~terest in toys, etc., and co-operation wi~h the tester. RESULTS

(a) EEG abnormalities. I n the clinical group, 9 of lhe 33 cases (27 per cent) had abnormal E E G s on admission to hospital. I n 4 of these the abnormalities were not present in the second EEG. As a rule E E G abnormalities were present during

THE ELECTROENCEPHALOGRAM IN KWASHIORKOR o n l y one p h a s e of t h e r e c o r d i n g (i.e. a w a k e , or a s l e e p ) a n d b o t h these p h a s e s w e r e n o t r e p r e s e n t e d in all the E E G s t a k e n , so t h a t d e f i n i t e e v i d e n c e of t h e d i s a p p e a r a n c e or p e r s i s t e n c e of foei was n o t a v a i l a b l e in 5 of the above 9 eases. S i x c h i l d r e n of these 9 h a d a t h i r d E E G , the r e c o r d r e m a i n i n g n o r m a l in ME I ; ~ S c / P

I

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75

n o r m a l i t y r e a p p e a r e d in a d i f f e r e n t s t a t e of consciousness. O n l y one of these p a t i e n t s was a n a e m i c on a d m i s s i o n . A l l b u t oJle r e c o v e r e d ; the l a t t e r d e v e l o p e d a n a e m i a at t h e t i m e of the 2nd E E G a n d d i e d 3 d a y s lat( ~.. F o u r cases h a d n o r m a l E E G s ,,n a(hnission b u t l a t e r r e c o r d s were a b n o r m a l . ()ne of these

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:Fig. 1 INCREASE IN EEG FREQUENCY DURING :RECOVERY EROS/I KWASHIORN O:R Case 29: serial EEGs, female Ganda, 18 months, awake, kwashiorkor with anaemia. Clear increase in dominant frequency. Top tracing on admission, 2nd tracing 7 days later ~nd 3rd tracing after a further 7 (lays. Clinical recovery eomplete~ discharged 6 days after 3rd EEG. hTote: In the lowest sample there is a fault in the time-marker traee~ rendering eve]-,', other ' ~l)ip ' ' indistinct. one, b e i n g a g a i n a b n o r m a l in 3 a n d c o m p a r i s o n b e i n g i m p o s s i b l e in 2. T h u s t h e a b n o r m a l i t i e s p r e s e n t on a d m i s s i o n to h o s p i t a l d i s a p p e a r e d i n o n l y 2 p a t i e n t s o u t of 9 a n d d i s a p p e a r e d t e m p o r a r i l y in 3 cases. I n one case t h e ab-

eases was anaenfie on a d m i s s i o n a n d a n o t h e r h a d d e v e l o p e d a n a e m i a a t the t i m e of t h e l a s t EEG. All four recovered. There were 4 abnormal records amongst the 14 p a t i e n t s w i t h single E E (.~s. N o n e of

76

G.K. NELSON

these cases was anaemic at the time of the E E G and all recovered f r o m kwashiorkor. Thus, of a total of 47 kwashiorkor patients, 13 (28 per cent) had abnormal records on admission to hospital. All but one of these abnormalities were in the f o r m of focal disturbances at theta a n d / o r delta frequencies in the t e m p o r a l or post-temporal region. The

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abnormal record, in the f o r m of a delta focus in the left t e m p o r a l region. The incidence of a b n o r m a l i t y in waking and sleeping records for patient s and controls is summarized in table I. The, patients had significantly more abnormalities in both states, and also significantly ~ o r e abnormal records during sleep t h a n in th( ~waking state.

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Fig. 2 R E L A T I O N S H I P S OF AGE AND EEG FREQUENCY FOR K W A S H I O R K O R P A T I E N T S AND CONTROLS Dominant EEG freauency in relation to age for 38 kwashiorkor patients (10 with :~lmemia), 11 control children with serial EEGs and 24 controls with single EEGs. Changes in ~requency over short periods are indicated. The shaded area ~ndicates approximately the range of Lindsley's data for 132 normal American children (1939).

r e m a i n i n g a b n o r m a l i t y was a slow wave focus in the parietal area. Total incidence of abnormality, including abnormalities seen in subsequent records, was 36 per cent. I n the serial control group (n ~-~ 11) there were no a b n o r m a l E E G s . Only one of the 27 control subjects with single E E G s had an

(b ) Changes in domina~t freq ~e~zcg. There were 28 patients wit tL serial waking E E G s . The mean frequency c,f dominant activity on admission was 4.11 (.~.d. 1.18) c/sec., and at the time of the final E E G , 4.98 (s.d. 0.98) c/see., this difference being statistically significant (p < .01). Domillant frequency

THE ELECTROENCEPHALOGRAM IN KWASHIORKOR was accelerated in 21 cases, unchanged in 4, and decelerated in 3 cases. Nine of these patients had anaemia on admission. Those without anaemia had a lower mean frequency on admission, (3.95, s.d. 1.01 N E I~,~¢,#pIP - E / u

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before recovery was complete, and one deteriorated. Clinical improvement was accompanied by an increase in dominator frequency in 22 cases (e.g. fig. 1), by no elmnge in frequency in 3, and by a decrease :~ frequency

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Fig. 3 ~TI~4PROVED" RESPO~TSE TO P H O T I C S T I M U L A T I O N RECOVERY FROZ~ KWASHZORKOR

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Serial EEGs with photic stimulation from the same case as shown in figure 1. Progressive increase in response to stimulation at 7-9 f/sec. c/"sec.) and a higher mean frequency at the last E E G (5.00, s.d. 0.99 c/sec.) than did the anaemia group (4.44, s.d. 1.44 and 4.94, s.d. 0.96), but these differences were not statistically significant. Of all the above 28 cases, 23 recovered from kwashiorkor, 4 were removed from hospital

in three. I n the case which deteri~,rated, there was a decrease in frequency. F o r all 28 cases, there was a [:ighly significant negative correlation of m e ~ , dominant frequency on admission with change in frequency from the first to the last E E G (r .655, p <.001). This suggested that there was

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G.K. NELSON

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THE ELECTROENCEPIIALOGRAM IN KWASHIORKOR a g r e a t e r i n c r e m e n t i n f r e q u e n c y i n those cases with lower d o m i n a n t f r e q u e n c i e s on a d m i s s i o n to hospital. I n the serial " n o r m a l " g r o u p there was a n increase i n f r e q u e n c y i n 3 c h i l d r e n , no c h a n g e i n 6 a n d a decrease i n 2. The r e l a t i o n s h i p s b e t w e e n age a n d domi n a n t f r e q u e n c y for 37 k w a s h i o r k o r p a t i e n t s a n d 33 c o n t r o l A f r i c a n c h i l d r e n , c o m p a r e d

79

A t the f i n a l E E G o n l y ]1 (39 per c e n t ) of the 28 p a t i e n t s w i t h serial w a k i n g E E G s h a d f r e q u e n c i e s w i t h i n the n o r m a l r~lnge. T h r e e of these (27 p e r c e n t ) were anae~,dc. The rem a i n i n g 17 all h a d f r e q u e n c i e s bel, ~w the r a n g e a n d 6 (35 p e r c e n t ) of these wer,. anaemic. T h e r e were 33 controls with w:~king E E G s (11 w i t h serial r e c o r d s ) . O n l y 9 (27 p e r c e n t ) h a d f r e q u e n c i e s below the n o r m a l range. Of

TABLE I I SERIAL EEG CHANGES AND CLINICAL PROGRESS - - FIRST AND LAST E l.',Gs 33 KWASHIORKOR CASES EEG changes

Improved

Unchanged

Deteriorated

Clinical changes

All cases

Improved Unchanged Deteriorated

fil 1 2

7 1

14 --

1

1

Improved Unchanged Deteriorated

4 -1

----

4 --

Improved Unchanged Deteriorated

2 -2

--1

2 -1

33

10

23

TOTALS :

w i t h L i n d s l e y ' s (1939) d a t a for 132 n o r m a l A m e r i c a n c h i l d r e n , are s h o w n i n f i g u r e 2. S e r i a l c h a n g e s i n d o m i n a n t f r e q u e n c y are also indicated. O n a d m i s s i o n to h o s p i t a l o n l y 7 (18 p e r c e n t ) of the 38 k w a s h i o r k o r cases h a d d o m i n a n t E E G f r e q u e n c i e s w i t h i n the r a n g e of L i n d s l e y ' s n o r m a l cases. Of these 7, two (29 p e r c e n t ) were anaemic. The r e m a i n i n g 31 pat i e n t s all h a d f r e q u e n c i e s below this r a n g e , 8 (26 p e r c e n t ) of these b e i n g anaemic.

Anaemias

Nona,:~aemias

1

the r e m a i n d e r , 20 (61 p e r c e n t ) were w i t h i n the r a n g e a n d 4 (12 p e r c e n t ) above it.

( c) Response to photic stimulatio',!. Responses to photic s t i m u l a t i o n were normal i n both p a t i e n t s a n d controls. C h a n g e s i n response to photic s t i m u l a t i o n w(,re assessed i n 22 k w a s h i o r k o r p a t i e n t s . A n increase i n a m p l i t u d e , a m o u n t a n d r a n g e of r,'~ponses was shown i n ]5 cases (e.g. fig. 3), a decrease i n 2 a n d no c h a n g e i n 5. Of the 22 patients, 20

Fig. 4 INCREASE IN EEG FREQUENCY IN SLEEP D U R I N G R E C O V E R Y FROM K W A S H I O R K O R

Case 13: male Ganda aged 13 months, kwashiorkor. Serial EEGs recorded during sleep on the 1st, 3rd, 4th, 5th, 6th and 18th days after admission. Dominant frequency increases from 0.5 to 1 c/sec. (top sample) to 3-4 e/see. (last sample). Spindles of fast activity appear in the EEG on the 4th day and are clear the next day. There is a sharp wave focus in the right temporal region on the 4th, 5th and 6th days (underlined in the third sample, not apparent in the fourth). /Vote: The mechanical fault in the time-marker trace seen in figure 1 is also present in the first two samples in this figure.

80

G, K . N E L S O N

(d) Changes in the EEGs during sleep.

improved clinically and 2 deteriorated. Clinical i m p r o v e m e n t was accompanied by an imp r o v e d response in 15 cases, by no change in 4, and by a deterioration in response in one.

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0 n l y 4 cases had sleeping records on both the first and final occasions, 3 of these showing no change and one deterioration in the

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Fig. 5 EEG CONCOMITANTS OF AFFECTIVE CHANGE Case 47: m a l e G a n d a , 22 m o n t h s , k w a s h i o r k o r ; awake w i t h eyes open. I n i t i a l l y rh 3thins f r o m 6-8 e/see, are p r e d o m i n a n t . W i t h i n c r e a s i n g distress, t h e t a a n d slower r h y t h m % g r e a t e r on t h e l e f t side, become d o m i n a n t . T h e s e slow w a v e s are s o m e t i m e s co-existent w i t h "alpha" r h y t h m s a n d hence r e p r e s e n t i n t r u s i o n of a n e w component.

The p a t i e n t who deteriorated clinically had a deteriorated response. I n the serial normal group, 3 showed improved responses, 6 were unchanged, and in 2 cases no assessment could be made.

pattern. These patients all improved clinically. One f u r t h e r case ( f i ~ 4) showed an improved sleeping E E G p a t t e r n during recovery, but did not sleep on th(~ final occasion. Spindle activity was seen in ] 5 (63 per cent)

THE ELECTROENCEPHALOGRAM

of the patients on admission (n = 24) and 16 (84 per cent) of the controls (n = 19), this difference being insignificant. (e) E E G " i m p r o v e m e n t " . Of the 33 kwashiorkor patients with serial EEGs, the final records were " i m p r o v e d " in 24 cases, " d e t e r i o r a t e d " in 4 and " u n c h a n g e d " in 5 cases. The relationship between these assessments and clinical changes is shown in table II. In 27 clinically improved cases, 21 had " i m p r o v e d " E E G s 4 had " u n c h a n g e d " and 2 " d e t e r i o r a t e d " records. Only one case of the 5 which deteriorated clinically during the E E G series failed to recover, this being the patient who died of anaemia, mentioned earlier. The only other fatal ease was recovering from kwashiorkor at the time of the last E E G , but contracted pneumonia 9 days later, dying within 24 hours of diagnosis, probably due to penicillin allergy. CHANGES IN MENTAL STATE Assessment of mental change was possible in 24 cases. I n 14 (58 per cent) there was improvement, 12 with concomitant E E G " i m p r o v e m e n t " and 2 with no E E G change. In 9 patients (38 per cent) there was no marked change in mental state, 6 of these showing E E G " i m p r o v e m e n t " , the remainder showing no E E G change. Deterioration in mental state occurred in one patient (a fatal case) and was accompanied by E E G "deterioration". In addition to these general relationships, transient affective changes were often accompanied by augmentation of theta and slower rhythms. A typical instance in which these E E G changes accompanied increasing distress is illustrated in figure 5. DISCUSSION

The high incidence of focal abnormalities in the temporal lobe in this group of kwashiorkor patients is striking and has not been previously reported in the disease. There is an a p p a r e n t l y significant relationship between the abnormalities in these patients and their level of consciousness, the incidence of foci being" g'reater in sleep than during the waking state. [t is possible that these foci represent

IN KWASHIORKOR

81

the localization to this area of some feature such as cortical oedema (cf. Walter ]937) or that the temporal lobe is peculiarly vulnerable to the gross physiological disturbances in kwashiorkor. Strauss et al. (1955~ suggested that focal slow activity in the t~,mporal region appears sooner and often in greater degree than abnormality elsewhere in the presence of disease in almost any part of the cerebral hemisphere. However, Corbin and Bickford (1956) suggested that the clinical significance of focal abnormalities in young children is much lower than in adul:~, owing to the relatively high incidence of such foci in normal children. The present study does not corroborate this contention, since ,,nly one of 38 normal children had a focal abnormality. An unequivocal finding is that the alleviation of the physical and mental symptoms of kwashiorkor is usually aecompa~ded by an " i m p r o v e m e n t " in the E E G , imp~ying acceleration of dominant frequency, and an increased responsiveness to photic stim~dation. In regard to the frequency of the EE(} in particular, changes occur during recovery from the disease which are greater than tho~e normally to be expected as a result of maturation over short intervals, and clearly in exc,.ss of those found in control subjects. F u r t h e r m o r e the majority of the patients had a dor~inant E E G frequency below the range of Lind,[cy's group and of the controls, even at the last E E G . These findings raise the possibility that kwashiorkor exerts an impeding' e~'feet on the development of brain rhythms i~ childhood and that recovery from the diset~e is paralleled by a partial removal of this ,,ffeet. This supports the hypothesis of Gallais et al. (1951b) and ~[undy-Castle et al. 1953) that the high incidence of E E G abnormalities in a group of normal West African Negro adults (Gallais et al. 1951 a and b) mighl be at least partially the result of endemic dis(~tses such as kwashiorkor. There appear to be a number- of specific factors which might be responsil,le for the present findings : Engel (1956) sn_,'R'ested that anoxie effects on the brain res~dting from anaemia in kwashiorkor might be ~'eflected in the E E G . In the present study no significant

8~,

G.K. NELSON

difference was f o u n d between the mean dominant f r e q u e n c y of the anaemia and nonanaemia groups, either on admission or at the last E E G , and only one of the 9 patients with abnormal E E G ' s on admission to hospitaL had anaemia at the time. F u r t h e r m o r e , the E E G consistently " i m p r o v e d " in 3 out of 4 patients who developed anaemia during treatment, " d e t e r i o r a t i n g " in only one child, who died of anaemia. One f u r t h e r case had E E G " i m p r o v e m e n t " , in spite of increasing anaemia, u p to his removal f r o m hospital. I t therefore a p p e a r s t h a t anaemia is not a critical factor. There a p p e a r s to be no relationship between the r e t a r d a t i o n of E E G frequency in kwashiorkor and basal metabolic rate. A decrease in alpha f r e q u e n c y in adults accompanies lowering of the B M R (Lindslcy and Rubinstein 1939), but the B M R in kwashiorkor is p r o b a b l y raised except in v e r y severe cases (Dean 1957). The dysphoria, irritability and reduced motility of children with kwashiorkor m a y contribute to the E E G changes. The tendency of the mental state of kwashiorkor patients to improve with clinical recovery is no doubt reinforced by greater relaxation following on increasing f a m i l i a r i t y with the E E G recording situation. Since the r h y t h m s of childhood often respond in a similar w a y to the alpha r h y t h m s of the adult, this tendency would lead to an increase of faster rhythms, due to a u g m e n t a t i o n of a l p h a or alpha-like activity. l~urthermore, slow waves were often augmented during periods of acute distress. Similar findings have been reported in children and adults ( H o a g l a n d et al. ]938; Hill 1950; Walter 1950; Mundy-Castle 1951, 1957; Klackenberg and Melin 1953). The E E G changes d u r i n g recovery f r o m kwashiorkor m a y therefore be influenced by such psychological factors. The results of this investigation differ in two main respects f r o m those of previous studies: (a) the high incidence of temporal lobe abnormalities; and (b) the presence of fast activity in sleep d u r i n g the acute phase of the disease.

SUMMARY 1. Serial E E G s were recorded f r o m 33 young," A f r i c a n kwashiorkor patients, 10 of whom were anaemic. Serial E E G s were also obtained f r o m 11 control child~'en and single recordings f r o m a f u r t h e r 14 k',vashiorkor patients and 27 controls. 2. A b n o r m a l (focal) recor, ts were found in 36 per cent of the kwashiork,+r patients, all except one in the f o r m of distt~+banees in the t e m p o r a l region, hIost of th~ abnormalities were seen in sleep records. 3. D u r i n g recovery there was usually a marked increase in dominant ] : E G frequency and in response to photic sti,tlulation. The dominant frequencies of the k~ ash]orkor children were mostly below the ra ~'e for normal A m e r i c a n children of the same ~ge, even after clinical recovery. No comparat~le serial E E G changes occurred in the eont~+,)ls, arid dominant frequencies were simib~, to those of normal American children. 4. The changes in domin~.nt fre(tuency during recovery might reflecl an impeding effect of kwashiorkor on the ,tevelopment of brain r h y t h m s in childhood. This effect m a y persist into adulthood. 5. Neither anaemia nor BM R a p p e a r to be responsible for the E E G chut~ges, whereas psychological factors m a y be , f significance.

R~SUM];~ 1. On a enregistr6 ~ plusi(.urs reprises et d ' u n e fa~on syst6matique l'6h~etroenc6phalog r a m m e de 33 jeunes maladc,~ afrieains attcints de kwashiorkor (malnulrition prot6inique infantile), et dont 10 p~:6sentaient de ]'an6mie. I1 y avait en plus 1 l enfants avec des 61cctroenc6phalogrammes de contr61e et des enregistrements uniques (,nt 6t6 obtenus ehez 14 malades atteints de l
THE ELECTROENCEPHALOGRAM

3. Comme rhgle g6n6rale p e n d a n t le r6tablissement il y avait une augmentation marqu6e de la fr6quenee 61eetroene6phalographique dominante et de la r6ponse fi la stimulation lumineuse. D ' h a b i t u d e les fr6quenees dotalnantes des enfants atteints de kwashiorkor 6talent plus basses flue les fr6quenees dotalnantes 6leetroene6phalographiques des enfants am6rieains du m&ne groupe d'age, mSme aprbs la gu6risou elinique eompl6te. Darts le groupe de eontr/~le, ees perturbations 61eetroene6phalographiques ne se pr6sentaient pas, e t l e s fr6quenees dominantes 6taient du m~me ordre que ehez les enfants am6rieains normaux. 4. Le ehantz'ement de la fr6quenee dominante pendant le r6tablissement pourrait indiqner m~e influenee du kwashiorkor sup le d6veloppement des rythmes e6r6braux de l'enlance. Cet effet pourrait persister plus tap& 5. Ni l'an6mie ui les alt6rations du m6tabolisme basal semblent ~tre responsable pour ]es anormalit6s 6leetroene6phaloo'raphiques, tandis que des faeteurs psyehologiftues pourraient avoir mm sio.nifieation. ZUSAMMENFASSUNG 1. E E G - U n t e r s u e h u n g e n wurden serienweise bei 33 jungen afrikanisehen Patienten durehgeffihrt, web, he an Kwashiorkor (infantile Proteinunterern~ihrung) litteR. 10 dieser Patienten waren anihniseh. Serienweise E E O - U n t e r s u e h u n g e n wurden ebenfalls bei 11 Kindern als Kontrolle ausgefiihrt und Einzel-EEG-Untersuehnngen wurden aufgenommen bei 14 Patienten mit Kwashiorkor und bei 27 Kontollsubjekteu. 2. Abnorme Kurvenbilder mit herdfSrmigen Veriinderungen wurden in 36 Prozent der Kwashiorkor-Patienten gefunden. Die StSrungen im Hirnstrombild ersehienen alle, abgesehen yon einem einzelnen Pall, in der Temporalregion. Die abnormen Ver:,inderungen wurden am hfiufigsten in Sehlaf-EEOs beobaehtet. 3. Wiihrend der Heilung ereio'nete sieh im allgemeinen eine deutliehe Zunahme der dominanten E E G - F r e q u e n z e n und eine Verbesserung der Antworten auf intermittierende Liehtreize. Die dominanten Frequenzen bei K i n d e r n mit Kwashiorkor lagen im allge-

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KWASHIORKOR

83

meinen unterhalb der Werte, w,qehe ffir normale amerikanisehe Kinder derselben Alterstufe ermittelt worden waren. Dies galt sogar naeh Eintreteu kliniseher He:brag. Keine derartigen EEG-Ver:~inderunge~ wurden in den serienweisen EEO-Unters~,'hungen der Kontrollsubjekte g'efunden, und ,lie dominantell Pre,'tuenzen waren fihnlieh denjenigen, welehe f/it normale amerikansehe Kinder besehrieben worden waren. 4. Vergnderungen in der dm~linanten Freqnenz wiihrend des Heilproz,,sses seheint maglieherweise der Ausdruek ei~ es verzSgernden Einflusses der K w a s h i o r k o ' E r k r a n k u n g auf die normale Entwiekhmg' der Gehirnr h y t h m e n im Kindesalter zu -,,in. Es ist mSglieh, class diesee verzSgePnd,, E f f e k t bis ins Erwaehsenenalter anh/ilt. 5. Weder die An:,imie noeh ,tie Veriblderung'en des Orundmnsatzes seh~inen verantwortlieh zu spin file die EEG-V¢ ,'Sndernngen. Es ist jedoeh mSglich, dass 1,,yehologisehe Faktoren Pine gewisse Bedeutun;, haben. The author wishes to thank the f,,Jlowing: Dr. R. F. A. Dean, ~edieal Research Co,~leil, Kampala, Uganda; Dr. E. KMm and I)r. S. \Va: burn, of Bnragwanath Hospital, Jo|mnnesburg, for t!k,',facilities they placed at the author's disposal, and I~,. A. C. Mund>Castle, National Institute for Persom,4 Research, for adviee and eritieism. REFERENCES CLARK, M. Kwashiorkor. E. A f t . ~m,L J., 1951, 28: 229-236, CORBIN, ]t. P. F. and BICKEORD, R. G Studies of the eleetroeneephalogram of nornml hildren: a comparison of visual and automatie ~requeney analysis. EEG Clin. Ne~lrophysiol., 1955, 7: 15-28. DEAN,R. F. A. Personal eommunieati ,,, 195"/. ENGEL,R. Abnormal brain wave part, rns in kwashiorkor. EEG Clin. Ne~trophysiol., 1956, 8: 489-500. GALLAIS, P, MILETTO, G., CORRIOL, .[. et BERT, J. Introduction ~t l'6tude d'EEG ].hyslologique du noir d'Afrique. Mdd. Trop., 1951a, 11: 128-146. GALLAIS, P., BERT, J., CORRIOL~J. et I\[II~ETTO~ G. Les

rythmes des heirs d'Afrique (Et ~de des 100 premiers trae6s de sujets normaux'l. EEG Clin. Neurophysiol., 1951b, 3: 110. GEBER, 5I. and DEA:¢, R. :E. A. The psyehologieal changes accompanying kwashi(.rkar. Courricr, 1956, 6 : 3.

HILL, D. Psychiatry. In Electroe~wepl.,,lography (Eds. Hill, D. and Parr, G.), London, MacDon:fld~ 1950. HOAGLAND, H., CAMERON, D. E. an, l RUBIN, M. A.

Emotion in man as tested by the. delta index of the electroencephalogram. J. Gcv. Psychol., 1938, 19: 227-245.

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G . K . NELSON

L1NDSLEY, D. B. and RUBINSTEm, B. B. Relationship between brain potentials and some other physiological variables. Proe. Soc. Exp. Biol. Med., 1937, 35: 558-560. KLACKENBERG, C-. and MELIN, K. A. Aspects on the electroencephalograms in a group of children with behaviour disorders. Arch. Int. Stu. Neur., 1953, 2: 1-6. LINDSLEY, D. B. A longitudinal study of the occipital alpha rhythm in normal children; frequency and amplitude standards. J. Genet. Psychol., 1939, 55 : 197-213. MUNDY-CASTLE, A. C. Theta and beta rhythm in the electroencephalograms of normal adults. EEG Clin. Neurophysiol., 1951, 3: 477-486. MUNDY-CASTLE, A. C. The electroencephalogram and mental activity. E E G Clin. Neurophysiol., 1957, 9: 643-655. MUNDY-CASTLE,A. C., McKIEVER~B. L. and PRINSLOO~ T. A comparative study of the eleetroencephalo-

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~ELSON, O. ~ .

grams of normal Africans and Europeans of Southern Africa. E E G Clin. N,~rophysiol., 1953, 5 : 533-543. SARROUY~ CI=I.~ SAINT-~EAN et CL ~USSE. L'dlectroenc6phalogramme au eours de b dystrophic nutritionnelle ced6mateuse. Algdrie Mdd., 1953, 57: 584-587. STRAUSS, H.~ OSTOW~~., GI~EENSTEIN, a. and LEWYN~ S. Temporal slowing as a s(,Hrce of error in electroencephalographic localiza~.on. J. Mr. Sinai Hosp., 1955, 22: 306-315. TROWELL, H. C., DAVIES, J. N. P. a~,l DEAN, R. F. A. Kwashiorkor. London, Edward Arnold, 1954. WALTER, W. G. The electroencepha?, gram in cases of cerebral tumor. Proc. Roy. So,' Med., 1937, 30: 579-598. WALTER, W. G. Normal rhythms - - : ~eir development, distribution and significance. In Electroenceph. alography. (Eds. Hill, D. and : 'arr, G.), London, MacDonald, 1950.

The electroencephalogram in kwashiorkor.

EEG Clin. Neurophysiol., 1959, i i : (" ,N