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Nutritional ILL health among Malay children in the ipoh district of Perak, Malaya A case described of severe malnutrition with enlarged liver
339 'I"RANSACTIONS OF THE ROYAL SOCIETY OF TROPICAL MEDICINE AND HYGIENE.
Vol. 44. No. 3. December, 1950.
NUTRITIONAL ILL HEALTH AMONG MALAY CHILDREN IN THE IPOH DISTRICT OF PERAK, MALAYA* A CASE DESCRIBED OF SEVERE M A L N U T R I T I O N E N L A R G E D LIVER.
WITtt
BY
FLORENCE ADAM THOMSON, Medical Officer, Malaya.
Records of a small series (1,703) of Malay children in the Ipoh district of Perak have been collected during the past 9 months. The area covered is about 500 square miles and is mainly rural in character although the nearness of Ipoh, a large town, the capital of the State of Perak (population, 1947: Chinese, 115,089 ; Malay, 15,078 ; Malaysians, 1,354 ; Indian, 21,867 ; others, 2,674) has influenced these rural Malays to a great extent. Apart from rice, they rarely grow their own food and much prefer an occasional trip on the bus to town where they buy mainly Chinese grown vegetables, salt fish, sugar and tins of sweetened condensed milk. Meat is rarely eaten, and as nearly all Malays are Mohammedan, pork, the most easily available meat, both domestic and wild, never. Malays are not milk drinkers, and although buffaloes and goats are sometimes kept, the milk in the case of the buffalo is very rarely used, and goats' milk not at all. Careful questioning of mothers both at the town clinic and at the clinics held in the rural areas has revealed these dietetic habits, and as BURGESS(1948) has already noted, diets are grossly deficient in protein, minerals, vitamins and, * Published by kind permission of Dr. R. B. MACGREoOR,C.M.G., Director of Medical Services, Federation of Malaya.
NUTRYrIONAL ILL HEALTH IN I~[ALAY CHILDREN
340
usually as well, total calories are low. Malay custom demands that after confinement mother and child shall remain inside the house for 44 days. Houses are dark and the mother as a rule must lie beside a log fire which is kept burning night and day. She is not permitted to drink cold water and her diet is restricted, no vegetables nor fruit being allowed. This unhealthy existence must interfere with the flow of an adequate supply of good quality breast milk. (In 243 antenatal Malay women, 145 showed a haemoglobin 60 per cent. or under (Talqvist), i.e., 59.7 per cent. were anaemic.) Artificial feeding is becoming more fashionable and indeed, although the baby may at frequent intervals be given the breast to suck, the main " meals " consist of sweetened condensed milk (given in the strength of 1 drachm to a cup--say 3½ oz. of water) and rice. Signs of nutritional ill health : ante-natal patients at Ipoh and Batu Gajah.
TABLE I.
243 Malays.
666 Chinese.
416 Indians.
Eyes Pigmentation ...'~ Vascnlarization . . . j Xerosis (including~ 128 = 52.7 per cent. crinkling and l Bitot spots) ...J
397 = 59.7 per cent.
270=
64.9 per cent.
Lips Cheilosis Dryness . . . . . . Tongue Glossitis . . . . . .
...) f
18 = 2'7 per cent.
8 = 1.9 per cent.
22=
9.5 p e r cent.
62=
25.5 p e r cent.
205=
30.9 per cent.
126 = 30-2 per cent.
...). f
1 0 2 = 4 2 . 0 per cent.
217=
32.7 per cent.
115 = 27.6 per cent.
iii)
243=
662 = 99.8 per cent.
416 = 100 p e r cent.
143 = 21.5 per cent.
1 8 2 = 4 3 . 7 per cent.
38.4 per cent.
271 = 65.1 per cent.
-~
Oeo ra a.1 mentation
GUNs Gingivitis Bleeding . . . . . . Teeth
Caries ... Hypoplasia Pigmentation
1O0 p e r cent.
Skin
Dry Mosaic
...... ......
Anaemia 60 per cent. or below . . . . . .
"~ f
50=20.6
per cent.
1 4 , 5 = 5 9 . 7 per cent.
255=
FLORENCE ADAM THOSISON
341
The idea is general that papaya, eggs and fish if given to a child will result in worms. The partially weaned child's solid food therefore consists frequently of nothing but small quantities of rice. A mother will bring her child to the clinic complaining that it has " no appetite "--on questioning this is found to mean that rice has been refused. Even if the Malay baby is fortunate enough to be breast-fed at all, these factors tend to give it a bad start in life, and nutritional ill health is evident from a few months old. In Tables I, IIa, IIb nutritional defects in different races are recorded; diets are all imbalanced with excess carbohydrate and low protein; Chinese, Malay and Indian diets are as a rule low in total calories as well. The Fijian diet differs in that imbalance is there, but total calories are usually adequate and besides, their way of life is a more healthy one. Table I shows a comparison of Malay, Indian and Chinese ante-natal patients in Ipoh and Batu Gajah, Malaya. Although the dietetic habits of Indians and Chinese differ from that of the Malay and are not considered in detail here, figures are given to show that the incidence of nutritional ill health is high in all three races. TABLE IIA. Malnutrition in children in Fiji and Malaya. Comparison of factors resulting in signs of malnutrition of different severity.
Fijians, Viti Levu, Fiji. 1. Anaemia in mothers unusual. 2. Prolonged breast feeding (for 2 to 3 years). 8. Artificial feeding rare. 4. Supplements to breast feeds rare.
Perak Malays and Chinese, Malaya.
Anaemia in mothers usual. Prolonged breast feeding (for 2 to 3 years). Artificial feeding common (sweetened condensed milk 1 drm. to cup of water). Supplements to breast feeds common (rice, rice flour, etc.).
5. Diet in addition to breast given, say, from 9 months onwards. (a) White bread. (b) Tea with sugar and without milk. (c) Occasional root vegetables (sweet potato, dalo--taro--). (d) Coconut milk and cream. (e) Fruits in season (especially guava). 6. Houses dark but children play, dance and sing outside. Bathing clone outside. 7. No malaria. 8. H o o k w o r m and ascaris infestation common.
Diet in addition to breast given almost from birth. (a) Rice and rice flour. (b) S w e e t e n e d condensed milk (strength as above). (c) From 1 year onwards occasional small quantities of vegetables, salt fish, fruit, coconut cream.
Houses dark. Children inside many hours each day. Bathing inside house. Malaria common. H o o k w o r m and ascaris infestation common.
342
NUTRITIONAL ILL HEALTH IN MALAY CHILDREN
T a b l e I I a compares some factors affecting children in two parts of the Colonial Empire. I t is interesting to find that, as one might expect f r o m this Table, the Malay child's health is poorer on the whole than the Fijian's, signs of nutritional ill health occur m o r e frequently, are more severe and a p p e a r at an earlier age. T a b l e I I b shows that the different signs of nutritional ill health are present in a greater proportion of Malay children t h a n of Fijian children. It is puzzling to observe several differences in the two colonies--follicular hyperkeratosis is more frequently f o u n d in Fiji although night blindness and keratomalacia were not seen. I n Perak Malays the reverse is the case. I t is also difficult to account for the absence in Fiji of the typical picture of s e v e r e malnutrition with skin changes and enlarged liver. (Cases m a y yet be found in Fiji, but during 2 years' observation there only one case was seen - - a n I n d i a n - - r e s e m b l i n g the classical picture. T h i s child showed skin changes but had no enlargement of the liver and responded to a generous diet with riboflavine supplement.) A n u m b e r of severe cases have been seen in the I p o h area and are at present being investigated. T h a t they are similar in character to the " sugar babies " (PLATT, 1946) of the West Indies and the malignant malnutrition (TROWELL, 1949) or kwashiorkor (WILLIAMS, 1940) of Africa, seems very certain. T h e signs in the I p o h district differ somewhat f r o m WATERLOW'S (1948) description. Below one of these cases is described. I t is unfortunate that a full faecal fat analysis was not done and that the plasma protein level was not obtained, nor was a b r o m sulphalein clearance test done. NOTES OF A CASE OF SEVEREMALNUTRITIONWITH ENLAllGED LIVER. Latifah. Age 2 years--female--Malay; weight 9 lb. 24.vi.49. Brought to the Centre with a history of 15 days' vomiting and diarrhoea; stools loose, sometimes green, sometimes yellow. Feeding was breast and the usual rice with a little salt fish--no fruit and very small quantities of vegetables. (Special food is not prepared for the children who take a little of that cooked for the adults.) Admitted to hospital.
On examination.
A severely wasted, weakly child. Teeth showed hypoplasia, discoloration and destruction of enamel, upper incisors stumps only. Tongue : glossitis red and sore at margins. Hair : scanty and brittle. Face : pigmented, especially cheeks. Skin : mosaic--general distribution, but especially on the back. Abdomen : spleen not felt. Liver : two fingerbreadths below the costal margin. Laboratory notes.
Blood : malaria negative. Kahn negative. Haemoglobin (Talqvist) : 55 per cent. Stool : Ascaris + . Total faecal fat : 38.72 per cent. of dried faeces. 15.vii.49. Weight 9 lb. 5 oz. ; general condition still poor (Photograph 1.) On a generous mixed diet and taking about ¼ pint milk daily. Vitamin supplements given daily. Ascariasis treated. 25.vii.49. Weight 11 lb. Taking food well, with about 1 pint milk. 15.viii.49. Weight 12 lb. 8 oz. (Photograph 2). Skin normal, hair growing. Can walk with help, Liver still enlarged (one fingerbreadth).
FLORENCE ADAM THOMSON
15.vii.49.
W e i g h t 9 lb. 5 oz.
Age 2 years.
19.ix.49.
15.viii.49.
W e i g h t 13 lb. 14 oz.
343
W e i g h t 12 lb. 8 oz.
345
FLORENCE ADAM THOMSON
TABLE I I m
Signs of nutritional ill health : Fiji and Malay children compared. 2,515 Fijians (school age).
1,703 Malays (pre-school age)
M i n o r defects only
417 ~ 24.5 per cent.
Eyes Pigmentation Vascularization Xerosis (includes spots . . . .
......... ......... crinkling, Bitot . . . . . . . .
L~s Cheilosis Dryness
......... .........
::7)
14 :
0.5 per cent.
51 =
2.9 per cent.
4 :
0.1 per cent.
159 =
9.3 per cent.
To~kue Glossitis . . . . . . . . . . . . "~ Geographical pigmentation ...f
Gums Gingivitis . . . . . . . . . . . . Bleeding . . . . . . . . . . . .
-~ f
801 = 31.8 per cent.
617 = 36.2 per cent.
1,081 = 42.9 p e r cent.
1,18l = 69"3 per cent.
Teeth .
.
I-Iypoplasia Pigmentation Sk/n
Dryness
.
.
.
.
.
.
.
...... ......
.........
:::;
Mozaic ......... Follicular hyperkeratosis ... Sores . . . . . . . . . . . . _J M u s c l e tone poor
. . . . . . . . .
E n l a r g e d spleen
. . . . . . . . .
784 = 31-2 per cent.
397 ~ 15.8 per cent. Nil
864 = 50.7 p e r cent. (Follicular hyperkeratosis only 6 cases) 764 :
44.8 per cent.
190 = 14'0 p e r cent.
T h e s e series of children are not exactly comparable as figures for pre-school age Fijians alone are not available. T h e r e is h o ~ e v e r considerable overlap as there are m a n y 5- to 6-year olds in each group. A comparison of Table IIB Malay children, with Table I Malay adults, shows a deterioration in health in the older age group. Fijians on the other hand, as a rule, improve in health once the dangerous weaning stage is past,
346
NUTRITIONAL ILL HEALTH IN MALAY CHILDREN
28.viii.49. Weight 13 lb. 4 oz. Liver still enlarged ; general condition very much improved. Under-cooked liver and marmite added as supplement to diet. 11.ix.49. Weight 14 lb. 8 oz. An attack of malaria treated with quinine set the child back slightly. 19.ixAg. Weight 13 lb, 14 oz. (Photograph 3). Liver not palpable. Hair and skin normal. Mouth normal. General condition very good. Discharged from hospital. 19.xii.49. After 3 months living lmder home conditions with a return to a diet of rice, salt fish and very small quantities of vegetables the general condition had much deteriorated. Weight 14 lb., liver just palpable. Child covered with scabies and sores. Fat analysis of stool : total fat 7.4 per cent. of dried faeces. Soap ......... 0"8 . . . . Free fatty acid ...... 1.7 . . . . Neutral fat . . . . . . . . . 2.8 ,, ,, Although the child is once again a malnourished child, steatorrhoea and gross enlargement of the liver have not as yet reappeared. As many observers have noted, the fatty enlarged liver, at least in the early stages, is a reversible condition. 5.i.50. Weight 15 lb. General condition much improved. (Supplied with milk weekly from the Centre--buys liver once a week) but liver palpable. Parotid enlargement noted for the first time. This is of interest as it is considered a sign that improvement in pancreatic function is taking place (DAVIES, 1942). T h e other cases seen (Malay, Chinese and Tamil) could not be followed up. Some deaths have occurred, improvement in others less severe. T h r e e fairly severe cases have been treated satisfactoriIy at home (two Chinese and one M a l a y ) - - a sensible m o t h e r giving extra milk and about 2 oz. liver daily. T h a t these cases responded to a good diet with supplementary milk is in agreement with the findings of WATERLOW in the West Indies, but it seems that addition of liver as well brings about a still more rapid improvement. T h e child's liver in each case became reduced to normal and the general condition greatly improved within a period of 2 to 3 weeks. ~UMMARY. Factors affecting the incidence of signs of nutritional ill h e a h h in different groups in Malaya and Fiji are considered. A case is described of severe malnutrition with enlarged liver ; improvement in health in this case took place on a generous diet with milk supplement, still further improvement after the addition of liver. Partial relapse occurred with the withdrawal of milk and liver supplements. A n u m b e r of similar cases are being investigated. i
REFERENCES. BuRoEss, R. C. (1948), Me&ft. Malaya, 2, 239~ DAVIES, J. N . P . (1948). Lancet, 1, 317. PLATT, B. S, 0946).- Trans. R. Soc. trop.: Med. Hyg., 40, 379,. THOMSON, F . A . (1949). Ibid., 42, 487. TROWELL, H. C. (1949). Ibid., 42, 417. WATERLOW, F. C. (1948). Fatty liver disease in infants in the British West Indies. Medical Research Council Special Report No. 263. London : H.M.S.O. WILLIAMS,C. (1940). Trans. R. Soc. trop. Med. Hyg., 84, 85.
Vol. 44. No. 3. December, 1950.
NUTRITIONAL ILL HEALTH AMONG MALAY CHILDREN IN THE IPOH DISTRICT OF PERAK, MALAYA* A CASE DESCRIBED OF SEVERE M A L N U T R I T I O N E N L A R G E D LIVER.
WITtt
BY
FLORENCE ADAM THOMSON, Medical Officer, Malaya.
Records of a small series (1,703) of Malay children in the Ipoh district of Perak have been collected during the past 9 months. The area covered is about 500 square miles and is mainly rural in character although the nearness of Ipoh, a large town, the capital of the State of Perak (population, 1947: Chinese, 115,089 ; Malay, 15,078 ; Malaysians, 1,354 ; Indian, 21,867 ; others, 2,674) has influenced these rural Malays to a great extent. Apart from rice, they rarely grow their own food and much prefer an occasional trip on the bus to town where they buy mainly Chinese grown vegetables, salt fish, sugar and tins of sweetened condensed milk. Meat is rarely eaten, and as nearly all Malays are Mohammedan, pork, the most easily available meat, both domestic and wild, never. Malays are not milk drinkers, and although buffaloes and goats are sometimes kept, the milk in the case of the buffalo is very rarely used, and goats' milk not at all. Careful questioning of mothers both at the town clinic and at the clinics held in the rural areas has revealed these dietetic habits, and as BURGESS(1948) has already noted, diets are grossly deficient in protein, minerals, vitamins and, * Published by kind permission of Dr. R. B. MACGREoOR,C.M.G., Director of Medical Services, Federation of Malaya.
NUTRYrIONAL ILL HEALTH IN I~[ALAY CHILDREN
340
usually as well, total calories are low. Malay custom demands that after confinement mother and child shall remain inside the house for 44 days. Houses are dark and the mother as a rule must lie beside a log fire which is kept burning night and day. She is not permitted to drink cold water and her diet is restricted, no vegetables nor fruit being allowed. This unhealthy existence must interfere with the flow of an adequate supply of good quality breast milk. (In 243 antenatal Malay women, 145 showed a haemoglobin 60 per cent. or under (Talqvist), i.e., 59.7 per cent. were anaemic.) Artificial feeding is becoming more fashionable and indeed, although the baby may at frequent intervals be given the breast to suck, the main " meals " consist of sweetened condensed milk (given in the strength of 1 drachm to a cup--say 3½ oz. of water) and rice. Signs of nutritional ill health : ante-natal patients at Ipoh and Batu Gajah.
TABLE I.
243 Malays.
666 Chinese.
416 Indians.
Eyes Pigmentation ...'~ Vascnlarization . . . j Xerosis (including~ 128 = 52.7 per cent. crinkling and l Bitot spots) ...J
397 = 59.7 per cent.
270=
64.9 per cent.
Lips Cheilosis Dryness . . . . . . Tongue Glossitis . . . . . .
...) f
18 = 2'7 per cent.
8 = 1.9 per cent.
22=
9.5 p e r cent.
62=
25.5 p e r cent.
205=
30.9 per cent.
126 = 30-2 per cent.
...). f
1 0 2 = 4 2 . 0 per cent.
217=
32.7 per cent.
115 = 27.6 per cent.
iii)
243=
662 = 99.8 per cent.
416 = 100 p e r cent.
143 = 21.5 per cent.
1 8 2 = 4 3 . 7 per cent.
38.4 per cent.
271 = 65.1 per cent.
-~
Oeo ra a.1 mentation
GUNs Gingivitis Bleeding . . . . . . Teeth
Caries ... Hypoplasia Pigmentation
1O0 p e r cent.
Skin
Dry Mosaic
...... ......
Anaemia 60 per cent. or below . . . . . .
"~ f
50=20.6
per cent.
1 4 , 5 = 5 9 . 7 per cent.
255=
FLORENCE ADAM THOSISON
341
The idea is general that papaya, eggs and fish if given to a child will result in worms. The partially weaned child's solid food therefore consists frequently of nothing but small quantities of rice. A mother will bring her child to the clinic complaining that it has " no appetite "--on questioning this is found to mean that rice has been refused. Even if the Malay baby is fortunate enough to be breast-fed at all, these factors tend to give it a bad start in life, and nutritional ill health is evident from a few months old. In Tables I, IIa, IIb nutritional defects in different races are recorded; diets are all imbalanced with excess carbohydrate and low protein; Chinese, Malay and Indian diets are as a rule low in total calories as well. The Fijian diet differs in that imbalance is there, but total calories are usually adequate and besides, their way of life is a more healthy one. Table I shows a comparison of Malay, Indian and Chinese ante-natal patients in Ipoh and Batu Gajah, Malaya. Although the dietetic habits of Indians and Chinese differ from that of the Malay and are not considered in detail here, figures are given to show that the incidence of nutritional ill health is high in all three races. TABLE IIA. Malnutrition in children in Fiji and Malaya. Comparison of factors resulting in signs of malnutrition of different severity.
Fijians, Viti Levu, Fiji. 1. Anaemia in mothers unusual. 2. Prolonged breast feeding (for 2 to 3 years). 8. Artificial feeding rare. 4. Supplements to breast feeds rare.
Perak Malays and Chinese, Malaya.
Anaemia in mothers usual. Prolonged breast feeding (for 2 to 3 years). Artificial feeding common (sweetened condensed milk 1 drm. to cup of water). Supplements to breast feeds common (rice, rice flour, etc.).
5. Diet in addition to breast given, say, from 9 months onwards. (a) White bread. (b) Tea with sugar and without milk. (c) Occasional root vegetables (sweet potato, dalo--taro--). (d) Coconut milk and cream. (e) Fruits in season (especially guava). 6. Houses dark but children play, dance and sing outside. Bathing clone outside. 7. No malaria. 8. H o o k w o r m and ascaris infestation common.
Diet in addition to breast given almost from birth. (a) Rice and rice flour. (b) S w e e t e n e d condensed milk (strength as above). (c) From 1 year onwards occasional small quantities of vegetables, salt fish, fruit, coconut cream.
Houses dark. Children inside many hours each day. Bathing inside house. Malaria common. H o o k w o r m and ascaris infestation common.
342
NUTRITIONAL ILL HEALTH IN MALAY CHILDREN
T a b l e I I a compares some factors affecting children in two parts of the Colonial Empire. I t is interesting to find that, as one might expect f r o m this Table, the Malay child's health is poorer on the whole than the Fijian's, signs of nutritional ill health occur m o r e frequently, are more severe and a p p e a r at an earlier age. T a b l e I I b shows that the different signs of nutritional ill health are present in a greater proportion of Malay children t h a n of Fijian children. It is puzzling to observe several differences in the two colonies--follicular hyperkeratosis is more frequently f o u n d in Fiji although night blindness and keratomalacia were not seen. I n Perak Malays the reverse is the case. I t is also difficult to account for the absence in Fiji of the typical picture of s e v e r e malnutrition with skin changes and enlarged liver. (Cases m a y yet be found in Fiji, but during 2 years' observation there only one case was seen - - a n I n d i a n - - r e s e m b l i n g the classical picture. T h i s child showed skin changes but had no enlargement of the liver and responded to a generous diet with riboflavine supplement.) A n u m b e r of severe cases have been seen in the I p o h area and are at present being investigated. T h a t they are similar in character to the " sugar babies " (PLATT, 1946) of the West Indies and the malignant malnutrition (TROWELL, 1949) or kwashiorkor (WILLIAMS, 1940) of Africa, seems very certain. T h e signs in the I p o h district differ somewhat f r o m WATERLOW'S (1948) description. Below one of these cases is described. I t is unfortunate that a full faecal fat analysis was not done and that the plasma protein level was not obtained, nor was a b r o m sulphalein clearance test done. NOTES OF A CASE OF SEVEREMALNUTRITIONWITH ENLAllGED LIVER. Latifah. Age 2 years--female--Malay; weight 9 lb. 24.vi.49. Brought to the Centre with a history of 15 days' vomiting and diarrhoea; stools loose, sometimes green, sometimes yellow. Feeding was breast and the usual rice with a little salt fish--no fruit and very small quantities of vegetables. (Special food is not prepared for the children who take a little of that cooked for the adults.) Admitted to hospital.
On examination.
A severely wasted, weakly child. Teeth showed hypoplasia, discoloration and destruction of enamel, upper incisors stumps only. Tongue : glossitis red and sore at margins. Hair : scanty and brittle. Face : pigmented, especially cheeks. Skin : mosaic--general distribution, but especially on the back. Abdomen : spleen not felt. Liver : two fingerbreadths below the costal margin. Laboratory notes.
Blood : malaria negative. Kahn negative. Haemoglobin (Talqvist) : 55 per cent. Stool : Ascaris + . Total faecal fat : 38.72 per cent. of dried faeces. 15.vii.49. Weight 9 lb. 5 oz. ; general condition still poor (Photograph 1.) On a generous mixed diet and taking about ¼ pint milk daily. Vitamin supplements given daily. Ascariasis treated. 25.vii.49. Weight 11 lb. Taking food well, with about 1 pint milk. 15.viii.49. Weight 12 lb. 8 oz. (Photograph 2). Skin normal, hair growing. Can walk with help, Liver still enlarged (one fingerbreadth).
FLORENCE ADAM THOMSON
15.vii.49.
W e i g h t 9 lb. 5 oz.
Age 2 years.
19.ix.49.
15.viii.49.
W e i g h t 13 lb. 14 oz.
343
W e i g h t 12 lb. 8 oz.
345
FLORENCE ADAM THOMSON
TABLE I I m
Signs of nutritional ill health : Fiji and Malay children compared. 2,515 Fijians (school age).
1,703 Malays (pre-school age)
M i n o r defects only
417 ~ 24.5 per cent.
Eyes Pigmentation Vascularization Xerosis (includes spots . . . .
......... ......... crinkling, Bitot . . . . . . . .
L~s Cheilosis Dryness
......... .........
::7)
14 :
0.5 per cent.
51 =
2.9 per cent.
4 :
0.1 per cent.
159 =
9.3 per cent.
To~kue Glossitis . . . . . . . . . . . . "~ Geographical pigmentation ...f
Gums Gingivitis . . . . . . . . . . . . Bleeding . . . . . . . . . . . .
-~ f
801 = 31.8 per cent.
617 = 36.2 per cent.
1,081 = 42.9 p e r cent.
1,18l = 69"3 per cent.
Teeth .
.
I-Iypoplasia Pigmentation Sk/n
Dryness
.
.
.
.
.
.
.
...... ......
.........
:::;
Mozaic ......... Follicular hyperkeratosis ... Sores . . . . . . . . . . . . _J M u s c l e tone poor
. . . . . . . . .
E n l a r g e d spleen
. . . . . . . . .
784 = 31-2 per cent.
397 ~ 15.8 per cent. Nil
864 = 50.7 p e r cent. (Follicular hyperkeratosis only 6 cases) 764 :
44.8 per cent.
190 = 14'0 p e r cent.
T h e s e series of children are not exactly comparable as figures for pre-school age Fijians alone are not available. T h e r e is h o ~ e v e r considerable overlap as there are m a n y 5- to 6-year olds in each group. A comparison of Table IIB Malay children, with Table I Malay adults, shows a deterioration in health in the older age group. Fijians on the other hand, as a rule, improve in health once the dangerous weaning stage is past,
346
NUTRITIONAL ILL HEALTH IN MALAY CHILDREN
28.viii.49. Weight 13 lb. 4 oz. Liver still enlarged ; general condition very much improved. Under-cooked liver and marmite added as supplement to diet. 11.ix.49. Weight 14 lb. 8 oz. An attack of malaria treated with quinine set the child back slightly. 19.ixAg. Weight 13 lb, 14 oz. (Photograph 3). Liver not palpable. Hair and skin normal. Mouth normal. General condition very good. Discharged from hospital. 19.xii.49. After 3 months living lmder home conditions with a return to a diet of rice, salt fish and very small quantities of vegetables the general condition had much deteriorated. Weight 14 lb., liver just palpable. Child covered with scabies and sores. Fat analysis of stool : total fat 7.4 per cent. of dried faeces. Soap ......... 0"8 . . . . Free fatty acid ...... 1.7 . . . . Neutral fat . . . . . . . . . 2.8 ,, ,, Although the child is once again a malnourished child, steatorrhoea and gross enlargement of the liver have not as yet reappeared. As many observers have noted, the fatty enlarged liver, at least in the early stages, is a reversible condition. 5.i.50. Weight 15 lb. General condition much improved. (Supplied with milk weekly from the Centre--buys liver once a week) but liver palpable. Parotid enlargement noted for the first time. This is of interest as it is considered a sign that improvement in pancreatic function is taking place (DAVIES, 1942). T h e other cases seen (Malay, Chinese and Tamil) could not be followed up. Some deaths have occurred, improvement in others less severe. T h r e e fairly severe cases have been treated satisfactoriIy at home (two Chinese and one M a l a y ) - - a sensible m o t h e r giving extra milk and about 2 oz. liver daily. T h a t these cases responded to a good diet with supplementary milk is in agreement with the findings of WATERLOW in the West Indies, but it seems that addition of liver as well brings about a still more rapid improvement. T h e child's liver in each case became reduced to normal and the general condition greatly improved within a period of 2 to 3 weeks. ~UMMARY. Factors affecting the incidence of signs of nutritional ill h e a h h in different groups in Malaya and Fiji are considered. A case is described of severe malnutrition with enlarged liver ; improvement in health in this case took place on a generous diet with milk supplement, still further improvement after the addition of liver. Partial relapse occurred with the withdrawal of milk and liver supplements. A n u m b e r of similar cases are being investigated. i
REFERENCES. BuRoEss, R. C. (1948), Me&ft. Malaya, 2, 239~ DAVIES, J. N . P . (1948). Lancet, 1, 317. PLATT, B. S, 0946).- Trans. R. Soc. trop.: Med. Hyg., 40, 379,. THOMSON, F . A . (1949). Ibid., 42, 487. TROWELL, H. C. (1949). Ibid., 42, 417. WATERLOW, F. C. (1948). Fatty liver disease in infants in the British West Indies. Medical Research Council Special Report No. 263. London : H.M.S.O. WILLIAMS,C. (1940). Trans. R. Soc. trop. Med. Hyg., 84, 85.