- Email: [email protected]
Some Causes of Malnutrition in Infancy
Medical Clinics oj North America September, 1937. Baltimore Number
CLINIC OF DR. C. LORING JOSLIN FROM THE DEPARTMENT OF PEDIATRICS, UNIVERSITY OF MARYLAND MEDICAL SCHOOL SOME CAUSES OF MALNUTRITION IN INFANCY
THIS presentation will offer some concepts concerning the possible causes of an infant failing to make a progressive or normal gain in weight during the first year of life. Cases illustrating the more frequent causes of malnutrition in infancy with results of treatment will be presented. No attempt will be made to discuss malnutrition in the preschool or older child. Malnutrition is all too common in pediatric practice. In the dispensary patient, it is frequently a result of the present economic distress because the parents have been unable to purchase sufficient food for normal growth and health. In private practice, the undernourished child frequently presents himself, not as an economic problem, but as a diagnostic and therapeutic difficulty. Malnutrition in the private patient who has freedom from economic stress may be due to one of many causes, or to a combination of several. The etiology is not always clear and may require rather lengthy clinical and laboratory studies before it is apparent. The average medical student does not see as many cases of extreme malnutrition (marasmus) today as were seen twenty years ago. This is due to simplified methods of infant feeding and a better knowledge of underlying conditions. The student is likewise taught that the growth and development of the infant are his direct responsibilities. He soon recognizes that the baby ordinarily will gain if the mother follows the physician's directions and if the child does not present any congenital abnormality. If the baby does not gain on an adequate diet, then there is an error in judgment as regards the particular infant in question. Uncomplicated malnutrition is regrettable beI275
C. LORING JOSLIN
cause it is a preventable disorder easily controlled by modifying the diet to suit the digestive characteristics of the individual infant. When other factors enter into the picture, an undernourished infant may well represent a difficult problem. A good general outline of the causes of malnutrition is a modification of one offered by W right, as follows:
i
FAILURE TO GAIN WEIGHT
Anatomical, e. g., amyotonia congenita. . 1 Congenital heart disease. C . ongemta D f ' bId I t I. Constitutional e ectJve cer.e ra eve opmen . Various other congenital anomalies. or organic · 11 . I n fectlon. ...
Ill. Food. . . . . . . .
1
A' d cqUlre
i
l
{Intracranial hemorrhage. Physiological, e. g., endocrine disorders.
1 e. g., otitis media, mastoiditis, pyelitis, tuberParentera { CUlOSIS, ' syph'l' 1 IS.
i
Enteral
Quantity Q l' ua Ity
e. g., diarrheal diseases.
Insufficient calories or too many calories. { Incorrect formula-fat, protein, carbohydrate, salts, iron, vitamins, etc.
IV E . {Home. . ~nvlronment. Outside.
Congenital Anomalies.-A myotonia congenita is among the organic causes of congenital origin. It is rare, but, when it does occur, demands accurate diagnosis because upon this depends prognosis. The disease is thought by some to be a muscular dystrophy, of the Werdnig-Hoffmann type, while others call attention to transitional forms, which possibly connect it with spinal muscular atrophy. The exact etiology is unknown. The chief symptoms concern the muscles, those of the lower extremities being so weak the infant is unable to move its legs. The upper extremities are usually moved, but feebly so; the intercostal muscles are usually involved, while the diaphragm and muscle~ supplied by the cranial nerves escape. The reflexes are diminished or absent. Various degrees of amyotonia occur, depending on the stage at which the disease is first seen. It either remains stationary or progresses very slowly and the child usually dies of intercurrent iI1fection. Treatment is of no avail. The following case illustrates this condition:
SOME CAUSES O.F MALNUTRITION IN INFANCY
1277
6/14/28. (A.w.) Age: four months. Complaint: Failure to grow and develop. Family History: One child living and well. One infant was recorded to have died as a result of "wasting disease" at six weeks of age. Past History: Natural birth. Birth weight: 7 pounds. Present Illness: Weak and feeble since birth. Weak cry. Has not gained since birth. Stools normal. No vomiting. Feedings: breast-fed for several weeks. Has also been fed modified cow's milk and condensed milk. Physical Examination: Lack of development of muscles of entire body, especially of lower extremities (flaccid paralysis) . Muscles soft, flabby and general atonic condition. Knee jerks present. No impairment of sensation. Feeble respiratory movements. Amyotonia congenita. Diagnosis:
Congenital heart disease, in which there is cyanosis, with clubbing of the fingers and toes, is likely to be accompanied by a general malnutrition. The physical examination along with these symptoms should enable the physician to make the diagnosis and to account for the malnutrition on this basis. It is well to remember that frequently congenital anomalies are multiple and others should be searched for. Congenital cerebral developmental defects are also among the causative factors of malnutrition in infancy. These children may apparently do well for a while and then cease to develop normally. In other cases the infant is retarded from the beginning. The disorders may be classified as congenital cerebral diplegias, paraplegias, or hemiplegias. They result in the birth palsies, of which the spastic diplegias are most common. These children rarely are able to stand, walk or talk; their extremities are held spastic and the lower extremities are usually crossed. They are mentally retarded and show little signs of intelligence. As feeding problems they are discouraging since they take little interest in food, especially solid food, so that feedings must be forced upon them. The prognosis at best is poor in these cases and they usually succumb to intercurrent infections. Clinically they are' likely to be confused with the picture of intracranial hemorrhage. The differential diagnosis depends largely upon an examination of the spinal fluid, which shows evidence of either fresh bleeding or old bleeding, in the event of hemorrhage, and the absence
C. LORING JOSLIN
of blood and its products in the palsies. In the later months, the tape measure may give evidence of cerebral disorder and occasionally a microcephalic is diagnosed by this simple method. It is important to diagnose the condition, because it is our experience that the mothers of these children are frequently unaware of the nature of the disorder and go from physician to physician in an attempt to rear a normal child, without realizing that their child will never be normal. Acquired Defects.-Intracranial hemorrhage has not only recently been recognized as the most frequent cause of death in the newly born, but it may be the cause of an infant failing to gain normally. One of the more common symptoms in the less severe cases o{ intracranial hemorrhage, is failure to nurse properly and to make a satisfactory weight gain. Fortunately, when there is only moderate intracranial bleeding at birth, the condition clears up spontaneously and the infant will make a normal gain. Frequently, though, this is not the case and it is later observed that the infant is underweight and is not developing normally. Vomiting may result from increased intracranial pressure as a result of intracranial hemorrhage at birth and thus interfere with the nutrition of the child. Vomiting is not a common nor a characteristic symptom of intracranial hemorrhage, but occasionally occurs. The symptoms one is usually able to elicit, suggesting intracranial hemorrhage as a cause of failure to progress normally, are rigidity of neck muscles (intermittent), adductor spasm of lower extremities, spasticity of upper and lower extremities, and attacks of cyanosis. The following case illustrates the influence intracranial hemorrhage may have upon the weight gain of an infant. 2/18/34. (L.J .N;) Age: two months. Complaint: Not gaining. Vomiting. Family History: Negative. Past History: Low forceps delivery. Birth weight, 8 pounds 8 ounces. Formula: modified cow's milk. Present Illness:' Has not gairied since birth. Vomiting since four weeks of age. Change of formulas has no effect upon weight gain or vomiting. Physical Examination: Slight rigidity of neck and spasticity of extremities, especially marked if infant is excited or cries. Adductor spasm of lower extremities. Marked malnutrition.
SOME CAUSES OF MALNUTRITION IN INFANCY
I279
Intracranial hemorrhage at birth. Vomiting and malnutrition, secondary to increased intracranial pressure, resulting from hemorrhage. Lumbar punctures.
Diagnosis: Treatment:
Figure 69 shows graphically the weight gain of this infant before and after institution of treatment. Endocrines.-The endocrines play an important part in the growth and development of the infant. In most cases, an endocrine imbalance is clinically manifested by a faulty growth. 13 lbo.
12 lb ••
11 lb ••
~I~:I::-J:::I='::_=I-'( --·:-1 , - =-----1--1:1=1__ Vi
:~:ii-i~::,=,-I=I=I=,-=I~I~I= - i ,11-
-1--1-
1 1
,
10 lb ••
9 lb ••
, , 1_. 'I ::·-1-'-'1··'1· i~-I-'-F"i~ i-(-:='1 =r 1 -I---=Vi-=-JI·
, I I I
,-
--- -. -I--T-
..
- - j - - --
-I·
!1_~U~=-I_I_iL,_-,_.I -T-~I~i-'-- r/1-1:- i--I· .,
. i _.
i~--
'_'.1
1
:
,-
!I': 'I
,i
1,1
8 lb •• Month.
1
2
3
4
Fig. 69. Note.-Infant gained immediately after first lumbar puncture, which was repeated until pressure symptoms disappeared.
Perhaps the most classical example of this is seen in the cretin, who represents an infant with a deficient secretion or absence of thyroid hormone. These children are short, have coarse features, dry skin, broad nose, frequently a protruding tongue, and show a general lack of development both mentally and physically. The important differential diagnosis is between the cretin and the mongolian idiot. In clear-cut cases there is little difficulty encountered, whereas in others a very careful examination may be necessary. The roentgenographic studies
1280
C. LORING JOSLIN
of the centers of ossification along with growth age and mental age are of great value in orienting oneself as to the status of the child. It is important to remember that large doses· of thyroid extract are sometimes necessary to achieve the best results, doses which may bring about a state of temporary hyperthyroidism. The pituitary is intimately connected with the various types of dwarfs. Disorders of the pineal gland and the thymus gland are not clear as yet. A diagnostic difficulty is frequently encountered where there is a pluriglandular dysfunction. Parenteral Infections.-These are frequent causes of an infant not making the normal gain in weight. Some children are much more susceptible to recurring infections than others, and with each recurring infection the child is retarded in its nutritional gain, until a very definite state of malnutrition exists. Otitis media is one of the most frequent of the parenteral ipJections interfering with nutrition, not infrequently causing a diarrhea with weight loss. Mastoiditis, secondary to otitis media, sometimes interferes with nutrition. It is not the usual mastoiditis to which I wish to call attention, but the so-called "hidden mastoiditis," in which there may be no local symptoms, such as swelling or tenderness over the mastoid. Otoscopic examination of the ear likewise does not reveal any appreciable involvement of the tympanic membrane, the diagnosis being based upon the clinical picture as a whole. These cases fortunately are not frequent, but do occur. The onset is usually suddel1, with a diarrhea, which persists in spite of all forms of treatment. The infant becomes rapidly dehydrated, toxic, loses weight until it is merely skin and bones. Death always follows unless the correct diagnosis is made and the mastoid is opened and drained. The condition is illustrated by the following case: 10/20/31. (C.T.) Age: five months. Complaint: Diarrhea, loss of weight. Family History: Negative. Past History: Negative. Developed normally until four months of age. Present Illness: At four months infant developed diarrhea, which has persisted until the present. During the past three weeks the infant has been treated in the hospital and
SOME CAUSES OF MALNUTRITION IN IN.FANCY
1201
the diarrhea has become progressively worse in spite of all treatment, averaging from 10 to 15 stools per day. There was a weight loss of several pounds before entering hospital and this loss of weight has continued. Physical Examination: Extreme malnutrition, dehydration and toxicity. No local evidence of mastoid involvement. Tympanic membrane of right ear shows slight congestion around the circumference; the drum is otherwise negative. Stool cultures, blood, etc., negative. Diagnosis: Mastoiditis. Diarrhea and malnutrition secondary to a hidden mastoid infection.
Figure 70 shows weight record of this case while in the hospital. Pyelitis is another cause of malnutrition, especially in the female infant, although it may occur in the male as well. These infants are handicapped in their development, they are frequently anemic in appearance and fail to gain because of an active infection in the kidney. Recognition of the cause of the failure to gain depends on completeness of urinary studies. Frequently the diagnosis is missed because only one urinary specimen has been examined, and that at a time when the patient is not eliminating pus in the urine. Anomalies of the genito-urinary tract are often a source of chronic infection and result in malnutrition. These may be so well masked that only necropsy discloses them, as for example in the case of aberrant ureter with infection. Tuberculosis as such is not a common cause of malnutrition in infancy. Here diagnosis does not depend upon physical examination alone, but on tuberculin tests and x-ray findings. The diagnosis should be made when the infant is still well nourished, rather than later, when a state of malnutrition exists, if treatment is going to be effective. Syphilis is another cause of faulty development and failure to grow properly. These cases are pathetic when the condition is marked at birth. The picture is a familiar one and I should only like to call attention to the importance of treating the mother during pregnancy, thus giving prophylactic treatment rather than curative. Attention is also called to the fact that a negative Wassermann during the first few months of life does not rule out congenital lues. VOL. 21-8r
C. LORING JOSLIN
Enteral Infections.-The diarrheal diseases, while still a problem during the summer months, are not the frequent causes UNIVERSITY' HOSPITAL WEIGHT CHART NAME
WARD
r.. r.
C
No.
75077
CAYD ..
MONTH
DAY'N
HO.PITAL
AGIlIN MONTHS AMOUNT
0""000
.... o."
o. ,.
·
··:1 7
z
..JL..fj~
...." "o. o•
·., ··, · , 71
.1LL••~ o.
..o.." O•
· - ·· 7
' .ia...J..••~
WIlIGHT
2.
..o."
"
IN !EVIIN 14 !"OUND., 13
·
··· · 7
o~
astoidotomy
Fig. 70. Note.-There was a loss in weight of 2 pounds after admission to the hospital, which occurred before the mastoid was drained. Following the mastoidectomy the diarrhea immediately ceased, the weight loss was checked, the infant gained slowly for a time and then made an uninterrupted progress to normal weight and health.
of extreme malnutrition as in the past. During the past ,tw(5 years we have been able to carry seventy-five per cent of
SOME CAUSES OF MALNUTRITION IN INFANCY
1283
. .our cases .of diarrhea and dysentery thrDugh their illness with.out any IDSS in weight, and when the average .of all cases has
been taken, there has been a slight gain in weight during the attack .of diarrhea. This is quite a cDntrast tD the IDSS .of weight we fDrmerly saw. Many infants fail to make their normal gain in weight during infancy because of recurring attacks .of diarrhea. These repeated attacks may be due t6 intolerance tD SDme .one ingredient .of the diet, such as t.oD much fat, or carbohydrate, or tD tDO large a quantity per feeding. Recurring parenteral infectiDns may prDduce the same· clinical picture. Of the enteral infectiDns dysentery is the most CDmmon, and nDt infrequently occurs unrecognized, because of the absence .of macrDscDpic blDod in the stDols. In the preventiDn of weight IDSS from diarrheal diseases, the addition to the diet .of the fully ripe banana, or the dehydrated banana powder has prDved mDst effective. Typhoid fever likewise is nD longer the prDducer of such a state of extreme malnutritiDn as we used tD see because of imprDved methDds .of feeding these cases. Quantity .of F.o.od.-The quantity of fDOd fed tD an infant has an .obviDUS effect on his general state of well-being. If he is not getting sufficient calDries tD supply his maintenance requirements along with his grDwth requirements, he will not gain. Likewise many infants wiIl not gain if given tDO much fDDd. There has been a strong tendency during recent years tD allow the child to decide fDr himself the question of how much food he should have. This may be a satisfactory method for s.ome infants, but for others it is not a safe guide. Many an infant who is getting to.o much fDDd, having colic, and crying frequently will take eagerly an increase in the formula, when what the infant needs is less food. According to my experience, the greatest difficulty the' physician has today is in estimating the total ealoric requirement of the individual infant. Before the introduction of simplified infant feeding (whole milk modifications) one would see many infants failing to gain because .of the quality of the food-but now this has changed, and many infants are seen failing to make an optimum gain because the total calDric intake is not properly adjusted to the individual infant. Those infants failing t.o gain because of too much f.ood may have recurring attacks of
C. LORING JOSLlN
diarrhea and vomiting, or the infant may be simply refusing part of its feedings. It is well to remember, that there is a maximal point at which an infant will gain, a minimal point, and an optimal point. Many infants are seen suffering from a moderate degree of malnutrition, because such infants are having to subsist on the maximal or minimal number of calories and are not receiving the optimal number upon which they would gain best. The following case will illustrate the importance of the total caloric intake in relation to the infant's weight gain .
14 lb ••
. i-
. H-I-· hrati I~!=+ 1-1-1-; !- 1-
I
~I-
12 lba. 10 lba.
!)I- 1·_·1- -~I--I-
i-~
-
-1--_.
1..- .
IZ
.
·-~-~-i.·-I7'--I----I-
. ±I--~I-r ~I-
..
I-~+~
=r=
+
I- I-- . ...... I:-I-I~I -
\.-1-
..
+
.. 1 I-I.-~ _I:: 1-_ ~ .~ .. I ,. I-I--H
-
6 lba. Io!ontbs
6 7 6 9 10 11 12 13 Fig. 71. N ote.-In the above chart it will be seen that the infant, although given various formulas and different types of foed, made little gain in weight for six months. When the total caloric intake was adjusted to meet the requirements of the infant, there was an immediate and continued weight gain.
1
2
:3
4
Ii
11/21/30. (L.H.B.) Age: six months. Complaint: Not gaining. Family History: Negative. Past History: Birth weight, 7 pounds 12 ounces. Feeding: breast two months, modified cow's milk, goat's milk, predigested milk, condensed milk, cow's milk. Present Illness: Has gained only 11 pounds in six months. Vomiting at irregular intervals. Constipated. Present formula: milk, 15 ounces; water, 15 ounces; sugar, 2 tablespoonfuls (42 calories per pound). Physical Examination: Negative, except for marked degree of undernutrition . . Diagnosis: Malnutrition, extreme. Feeding, regulation of.
SOME CAUSES OF MALNUTRITION IN INFANCY Treatment:
I285
Formula adjusted to caloric requirements of infant. Milk· increased to 18 ounces, sugar to 3 tablespoonfuls (57 calories per pound). No other change was made in the care and feeding of the infant. Formula later increased as baby gained.
Quality of Food.-Some infants may receive an adequate quantity of food for proper gain in weight, but have difficulty in gaining because the quality is not suitable. Premature babies present a special problem, inasmuch as such infants are born with sufficient reserves of iron and other accessory factors to take care of only the immediate needs. The rate of growth is relatively rapid and the premature infant quickly outstrips his reserves so that he is in danger of being undernourished unless the need for the accessories is met. The normal infant tends to grow at a rate commensurate with his natal reserves until the second month is reached. At this time growth has progressed to a point where the stores are not sufficient, and the child has what has been termed a physiologic anemia. Usually the child makes a physiologic adjustment to the situation, and after ,a variable period, depending on the individual, resumes normal growth. There are many factors entering itlto the maintenance of normal nutrition, and it would appear that our concept of normal nutrition is changing. Certainly it is clear that improved nutrition may be obtained for many infants and children, who are generally considered to be in a normal state of health, by the addition of certain vitamins and minerals to their regular diet. ' Various degrees of undernutrition, especially nutritional anemias, are produced by a deficiency in the diet, or a lack of balance of certain minerals, such as iron, calcium, phosphorus, and perhaps copper. It has been shown that a preponderance of one mineral may interfere with the utilization of another. From the biochemical standpoint, there are such problems as the secretions of the various ferments that aid in digestion. For example, the amount of hydrochloric acid secreted in the stomach may have an important part in the mechanism of digestion and nutrition. Our knowledge concerning the vitamins has been greatly increased during recent years, yet our information is still in-
c.
1286
LORING JOSLIN
complete. The clinical picture produced by a deficiency of vitamins C and D in the diet is a familiar one to all. The picture of an inadequate amount of vitamins A, Band G is not so clear, yet they are necessary vitamins, and perhaps more important than we have thought. This is shown graph~ It)
:1) ~
o hO/:' #.
f-
/ 80
/
/
/
70 0
V ("is Id.
i'-. .......
""'= ~
/ I'\.
"- I~
ru on
/
I'-...
I'\. r- / e
0
i'I
~
/
/
./
/
I
EG W
0 I
~
J
4-
Weeks
.5
/0
Fig. 72.-Effect of vitamin B complex upon growth of rats.
Note.-Vitamin B-free diet was fed for six weeks to· 2 rats. Rat 4 died;
rat 5 shows progressive loss of weight until vitamin B was added to the diet at six weeks, then follows a progressive gain in weight. It will be seen that without the vitamin B complex in the diet, the rats lose appetite and weight, and soon die. When the vitamin B complex is added to the diet, norma) nutrition is rapidly regained, as shown by this chart.
ically in Fig. 72, in which there is given the weight curve of two rats on a vitamin B-free diet for a period of six weeks, after which time the vitamin B complex is added to the diet in the form of a special cereal mixture. It is also interesting to note that improved nutrition may be ···obtained by including additional vitamin B and perhaps
SOME CAUSES OF MALNUTRITION IN INFANCY
1287
minerals in the regular diet of many infants. This is shown in Fig. 73, where a cereal! mixture rich in vitamin Band minerals was substituted for the regular cereal being given a group of infants.in an orphanage, no other change being made in the diet or routine care. The group receiving the cereal, enriched with vitamins and minerals, had an increased rate of gain in· weight an,d growth as compared to the control group. The individual tolerance of fat, protein, and carbohydrate should be considered in the feeding of infants who are not making normal progress. Carbohydrate intolerance is not frequent, and protein intolerance causes little trouble, except from an allergic standpoint, as in eczema. If this condition develops early in life the infant's nutrition and growth are temporarily interfered with. Fat intolerance is quite frequent;
22.13 24.14
eo
Fig. 73.
it may be recognized by vomiting, crying from colic, frequent stools, or constipation. The effect of fat intolerance upon nutrition is shown by the following case: 1/12/34. (R.D.G.) Age: five weeks. Complaint: Crying. Not gaining. Family History: Negative. Past History: Natural birth; birth weight, 9 pounds 9 ounces. Present Illness: Crying and has not gained since birth. Physical Examination: Negative, stools frequent and contain large number of fat curds. Diagnosis: Colic. Fat intolerance. Treatment: Fat-free milk.
The bacteriologic flora of the intestinal tract has recently received considerable attention and may at times have a re1
Cerevim.
c.
I288
LORING JOSLIN
tarding effect upon nutrition. These cases are frequently diagnosed as chronic intestinal indigestion, and there may be a relationship with celiac disease. The part that the intestinal flora plays in some conditions is not as yet entirely clear, and needs further study. Environment.-The surroundings in which the baby is placed frequently have an important bearing upon its nutrition and general health. The nervous mother, for example,
14 lb ••
-!-
I-
II-f-
I-
-
f-l=i= ~
-I--
I-
,
I-
i-
-,-f--
r
1.3 lb ••
i--i-
r-
l- eI--
1=::::1=
r-
-
r- I-~
r 1--,- -,
I
I -I -
I
11+-
1-1--
12 lb •• 1---
l-
II lbl.
1:- -1=
1-110 lba.
I
I'-i-
i
r'
f
1 -
I
9 lb.
Weeu
I
H 1
2
34.6
1--1-
I
I
6
7
I-
8
\l
Fig. 74. Note.-There was a gain in weight as soon as fat-free milk was given infant, crying also immediately ceased.
usually leaves her mark upon the baby so that the infant is overexcitable, unable to relax, -and generally underweight. Needless to say, the environment outside of the home, as well as within, has an important bearing on the health of the child. Pure fresh air is a prime requisite in the life of ever); infant. When an infant is deprived of an adequate amount of sunshine its nutrition suffers. During the winter months it is frequently advantageous to compensate for this lack by 'exposure to the ultraviolet light. It is· important that a pains-
SOME CAUSES OF MALNUTRITION IN INFANCY
1289
taking investigation be made into the environmental factors in every case of failure to gain weight during infancy. Summary.-Little emphasis has been placed upon the treatment of undernutrition in infancy, but an attempt has been made to stress the importance of making a diagnosis as to the cause of the undernutrition. Without a correct diagnosis the treatment may not only be difficult, but may prove costly because the fundamental cause is untouched. Malnutrition in infancy (except in cases of congenital abnormalities) is a preventable condition and should be treated from a prophylactic, rather than from a curative standpoint.
CLINIC OF DR. C. LORING JOSLIN FROM THE DEPARTMENT OF PEDIATRICS, UNIVERSITY OF MARYLAND MEDICAL SCHOOL SOME CAUSES OF MALNUTRITION IN INFANCY
THIS presentation will offer some concepts concerning the possible causes of an infant failing to make a progressive or normal gain in weight during the first year of life. Cases illustrating the more frequent causes of malnutrition in infancy with results of treatment will be presented. No attempt will be made to discuss malnutrition in the preschool or older child. Malnutrition is all too common in pediatric practice. In the dispensary patient, it is frequently a result of the present economic distress because the parents have been unable to purchase sufficient food for normal growth and health. In private practice, the undernourished child frequently presents himself, not as an economic problem, but as a diagnostic and therapeutic difficulty. Malnutrition in the private patient who has freedom from economic stress may be due to one of many causes, or to a combination of several. The etiology is not always clear and may require rather lengthy clinical and laboratory studies before it is apparent. The average medical student does not see as many cases of extreme malnutrition (marasmus) today as were seen twenty years ago. This is due to simplified methods of infant feeding and a better knowledge of underlying conditions. The student is likewise taught that the growth and development of the infant are his direct responsibilities. He soon recognizes that the baby ordinarily will gain if the mother follows the physician's directions and if the child does not present any congenital abnormality. If the baby does not gain on an adequate diet, then there is an error in judgment as regards the particular infant in question. Uncomplicated malnutrition is regrettable beI275
C. LORING JOSLIN
cause it is a preventable disorder easily controlled by modifying the diet to suit the digestive characteristics of the individual infant. When other factors enter into the picture, an undernourished infant may well represent a difficult problem. A good general outline of the causes of malnutrition is a modification of one offered by W right, as follows:
i
FAILURE TO GAIN WEIGHT
Anatomical, e. g., amyotonia congenita. . 1 Congenital heart disease. C . ongemta D f ' bId I t I. Constitutional e ectJve cer.e ra eve opmen . Various other congenital anomalies. or organic · 11 . I n fectlon. ...
Ill. Food. . . . . . . .
1
A' d cqUlre
i
l
{Intracranial hemorrhage. Physiological, e. g., endocrine disorders.
1 e. g., otitis media, mastoiditis, pyelitis, tuberParentera { CUlOSIS, ' syph'l' 1 IS.
i
Enteral
Quantity Q l' ua Ity
e. g., diarrheal diseases.
Insufficient calories or too many calories. { Incorrect formula-fat, protein, carbohydrate, salts, iron, vitamins, etc.
IV E . {Home. . ~nvlronment. Outside.
Congenital Anomalies.-A myotonia congenita is among the organic causes of congenital origin. It is rare, but, when it does occur, demands accurate diagnosis because upon this depends prognosis. The disease is thought by some to be a muscular dystrophy, of the Werdnig-Hoffmann type, while others call attention to transitional forms, which possibly connect it with spinal muscular atrophy. The exact etiology is unknown. The chief symptoms concern the muscles, those of the lower extremities being so weak the infant is unable to move its legs. The upper extremities are usually moved, but feebly so; the intercostal muscles are usually involved, while the diaphragm and muscle~ supplied by the cranial nerves escape. The reflexes are diminished or absent. Various degrees of amyotonia occur, depending on the stage at which the disease is first seen. It either remains stationary or progresses very slowly and the child usually dies of intercurrent iI1fection. Treatment is of no avail. The following case illustrates this condition:
SOME CAUSES O.F MALNUTRITION IN INFANCY
1277
6/14/28. (A.w.) Age: four months. Complaint: Failure to grow and develop. Family History: One child living and well. One infant was recorded to have died as a result of "wasting disease" at six weeks of age. Past History: Natural birth. Birth weight: 7 pounds. Present Illness: Weak and feeble since birth. Weak cry. Has not gained since birth. Stools normal. No vomiting. Feedings: breast-fed for several weeks. Has also been fed modified cow's milk and condensed milk. Physical Examination: Lack of development of muscles of entire body, especially of lower extremities (flaccid paralysis) . Muscles soft, flabby and general atonic condition. Knee jerks present. No impairment of sensation. Feeble respiratory movements. Amyotonia congenita. Diagnosis:
Congenital heart disease, in which there is cyanosis, with clubbing of the fingers and toes, is likely to be accompanied by a general malnutrition. The physical examination along with these symptoms should enable the physician to make the diagnosis and to account for the malnutrition on this basis. It is well to remember that frequently congenital anomalies are multiple and others should be searched for. Congenital cerebral developmental defects are also among the causative factors of malnutrition in infancy. These children may apparently do well for a while and then cease to develop normally. In other cases the infant is retarded from the beginning. The disorders may be classified as congenital cerebral diplegias, paraplegias, or hemiplegias. They result in the birth palsies, of which the spastic diplegias are most common. These children rarely are able to stand, walk or talk; their extremities are held spastic and the lower extremities are usually crossed. They are mentally retarded and show little signs of intelligence. As feeding problems they are discouraging since they take little interest in food, especially solid food, so that feedings must be forced upon them. The prognosis at best is poor in these cases and they usually succumb to intercurrent infections. Clinically they are' likely to be confused with the picture of intracranial hemorrhage. The differential diagnosis depends largely upon an examination of the spinal fluid, which shows evidence of either fresh bleeding or old bleeding, in the event of hemorrhage, and the absence
C. LORING JOSLIN
of blood and its products in the palsies. In the later months, the tape measure may give evidence of cerebral disorder and occasionally a microcephalic is diagnosed by this simple method. It is important to diagnose the condition, because it is our experience that the mothers of these children are frequently unaware of the nature of the disorder and go from physician to physician in an attempt to rear a normal child, without realizing that their child will never be normal. Acquired Defects.-Intracranial hemorrhage has not only recently been recognized as the most frequent cause of death in the newly born, but it may be the cause of an infant failing to gain normally. One of the more common symptoms in the less severe cases o{ intracranial hemorrhage, is failure to nurse properly and to make a satisfactory weight gain. Fortunately, when there is only moderate intracranial bleeding at birth, the condition clears up spontaneously and the infant will make a normal gain. Frequently, though, this is not the case and it is later observed that the infant is underweight and is not developing normally. Vomiting may result from increased intracranial pressure as a result of intracranial hemorrhage at birth and thus interfere with the nutrition of the child. Vomiting is not a common nor a characteristic symptom of intracranial hemorrhage, but occasionally occurs. The symptoms one is usually able to elicit, suggesting intracranial hemorrhage as a cause of failure to progress normally, are rigidity of neck muscles (intermittent), adductor spasm of lower extremities, spasticity of upper and lower extremities, and attacks of cyanosis. The following case illustrates the influence intracranial hemorrhage may have upon the weight gain of an infant. 2/18/34. (L.J .N;) Age: two months. Complaint: Not gaining. Vomiting. Family History: Negative. Past History: Low forceps delivery. Birth weight, 8 pounds 8 ounces. Formula: modified cow's milk. Present Illness:' Has not gairied since birth. Vomiting since four weeks of age. Change of formulas has no effect upon weight gain or vomiting. Physical Examination: Slight rigidity of neck and spasticity of extremities, especially marked if infant is excited or cries. Adductor spasm of lower extremities. Marked malnutrition.
SOME CAUSES OF MALNUTRITION IN INFANCY
I279
Intracranial hemorrhage at birth. Vomiting and malnutrition, secondary to increased intracranial pressure, resulting from hemorrhage. Lumbar punctures.
Diagnosis: Treatment:
Figure 69 shows graphically the weight gain of this infant before and after institution of treatment. Endocrines.-The endocrines play an important part in the growth and development of the infant. In most cases, an endocrine imbalance is clinically manifested by a faulty growth. 13 lbo.
12 lb ••
11 lb ••
~I~:I::-J:::I='::_=I-'( --·:-1 , - =-----1--1:1=1__ Vi
:~:ii-i~::,=,-I=I=I=,-=I~I~I= - i ,11-
-1--1-
1 1
,
10 lb ••
9 lb ••
, , 1_. 'I ::·-1-'-'1··'1· i~-I-'-F"i~ i-(-:='1 =r 1 -I---=Vi-=-JI·
, I I I
,-
--- -. -I--T-
..
- - j - - --
-I·
!1_~U~=-I_I_iL,_-,_.I -T-~I~i-'-- r/1-1:- i--I· .,
. i _.
i~--
'_'.1
1
:
,-
!I': 'I
,i
1,1
8 lb •• Month.
1
2
3
4
Fig. 69. Note.-Infant gained immediately after first lumbar puncture, which was repeated until pressure symptoms disappeared.
Perhaps the most classical example of this is seen in the cretin, who represents an infant with a deficient secretion or absence of thyroid hormone. These children are short, have coarse features, dry skin, broad nose, frequently a protruding tongue, and show a general lack of development both mentally and physically. The important differential diagnosis is between the cretin and the mongolian idiot. In clear-cut cases there is little difficulty encountered, whereas in others a very careful examination may be necessary. The roentgenographic studies
1280
C. LORING JOSLIN
of the centers of ossification along with growth age and mental age are of great value in orienting oneself as to the status of the child. It is important to remember that large doses· of thyroid extract are sometimes necessary to achieve the best results, doses which may bring about a state of temporary hyperthyroidism. The pituitary is intimately connected with the various types of dwarfs. Disorders of the pineal gland and the thymus gland are not clear as yet. A diagnostic difficulty is frequently encountered where there is a pluriglandular dysfunction. Parenteral Infections.-These are frequent causes of an infant not making the normal gain in weight. Some children are much more susceptible to recurring infections than others, and with each recurring infection the child is retarded in its nutritional gain, until a very definite state of malnutrition exists. Otitis media is one of the most frequent of the parenteral ipJections interfering with nutrition, not infrequently causing a diarrhea with weight loss. Mastoiditis, secondary to otitis media, sometimes interferes with nutrition. It is not the usual mastoiditis to which I wish to call attention, but the so-called "hidden mastoiditis," in which there may be no local symptoms, such as swelling or tenderness over the mastoid. Otoscopic examination of the ear likewise does not reveal any appreciable involvement of the tympanic membrane, the diagnosis being based upon the clinical picture as a whole. These cases fortunately are not frequent, but do occur. The onset is usually suddel1, with a diarrhea, which persists in spite of all forms of treatment. The infant becomes rapidly dehydrated, toxic, loses weight until it is merely skin and bones. Death always follows unless the correct diagnosis is made and the mastoid is opened and drained. The condition is illustrated by the following case: 10/20/31. (C.T.) Age: five months. Complaint: Diarrhea, loss of weight. Family History: Negative. Past History: Negative. Developed normally until four months of age. Present Illness: At four months infant developed diarrhea, which has persisted until the present. During the past three weeks the infant has been treated in the hospital and
SOME CAUSES OF MALNUTRITION IN IN.FANCY
1201
the diarrhea has become progressively worse in spite of all treatment, averaging from 10 to 15 stools per day. There was a weight loss of several pounds before entering hospital and this loss of weight has continued. Physical Examination: Extreme malnutrition, dehydration and toxicity. No local evidence of mastoid involvement. Tympanic membrane of right ear shows slight congestion around the circumference; the drum is otherwise negative. Stool cultures, blood, etc., negative. Diagnosis: Mastoiditis. Diarrhea and malnutrition secondary to a hidden mastoid infection.
Figure 70 shows weight record of this case while in the hospital. Pyelitis is another cause of malnutrition, especially in the female infant, although it may occur in the male as well. These infants are handicapped in their development, they are frequently anemic in appearance and fail to gain because of an active infection in the kidney. Recognition of the cause of the failure to gain depends on completeness of urinary studies. Frequently the diagnosis is missed because only one urinary specimen has been examined, and that at a time when the patient is not eliminating pus in the urine. Anomalies of the genito-urinary tract are often a source of chronic infection and result in malnutrition. These may be so well masked that only necropsy discloses them, as for example in the case of aberrant ureter with infection. Tuberculosis as such is not a common cause of malnutrition in infancy. Here diagnosis does not depend upon physical examination alone, but on tuberculin tests and x-ray findings. The diagnosis should be made when the infant is still well nourished, rather than later, when a state of malnutrition exists, if treatment is going to be effective. Syphilis is another cause of faulty development and failure to grow properly. These cases are pathetic when the condition is marked at birth. The picture is a familiar one and I should only like to call attention to the importance of treating the mother during pregnancy, thus giving prophylactic treatment rather than curative. Attention is also called to the fact that a negative Wassermann during the first few months of life does not rule out congenital lues. VOL. 21-8r
C. LORING JOSLIN
Enteral Infections.-The diarrheal diseases, while still a problem during the summer months, are not the frequent causes UNIVERSITY' HOSPITAL WEIGHT CHART NAME
WARD
r.. r.
C
No.
75077
CAYD ..
MONTH
DAY'N
HO.PITAL
AGIlIN MONTHS AMOUNT
0""000
.... o."
o. ,.
·
··:1 7
z
..JL..fj~
...." "o. o•
·., ··, · , 71
.1LL••~ o.
..o.." O•
· - ·· 7
' .ia...J..••~
WIlIGHT
2.
..o."
"
IN !EVIIN 14 !"OUND., 13
·
··· · 7
o~
astoidotomy
Fig. 70. Note.-There was a loss in weight of 2 pounds after admission to the hospital, which occurred before the mastoid was drained. Following the mastoidectomy the diarrhea immediately ceased, the weight loss was checked, the infant gained slowly for a time and then made an uninterrupted progress to normal weight and health.
of extreme malnutrition as in the past. During the past ,tw(5 years we have been able to carry seventy-five per cent of
SOME CAUSES OF MALNUTRITION IN INFANCY
1283
. .our cases .of diarrhea and dysentery thrDugh their illness with.out any IDSS in weight, and when the average .of all cases has
been taken, there has been a slight gain in weight during the attack .of diarrhea. This is quite a cDntrast tD the IDSS .of weight we fDrmerly saw. Many infants fail to make their normal gain in weight during infancy because of recurring attacks .of diarrhea. These repeated attacks may be due t6 intolerance tD SDme .one ingredient .of the diet, such as t.oD much fat, or carbohydrate, or tD tDO large a quantity per feeding. Recurring parenteral infectiDns may prDduce the same· clinical picture. Of the enteral infectiDns dysentery is the most CDmmon, and nDt infrequently occurs unrecognized, because of the absence .of macrDscDpic blDod in the stDols. In the preventiDn of weight IDSS from diarrheal diseases, the addition to the diet .of the fully ripe banana, or the dehydrated banana powder has prDved mDst effective. Typhoid fever likewise is nD longer the prDducer of such a state of extreme malnutritiDn as we used tD see because of imprDved methDds .of feeding these cases. Quantity .of F.o.od.-The quantity of fDOd fed tD an infant has an .obviDUS effect on his general state of well-being. If he is not getting sufficient calDries tD supply his maintenance requirements along with his grDwth requirements, he will not gain. Likewise many infants wiIl not gain if given tDO much fDDd. There has been a strong tendency during recent years tD allow the child to decide fDr himself the question of how much food he should have. This may be a satisfactory method for s.ome infants, but for others it is not a safe guide. Many an infant who is getting to.o much fDDd, having colic, and crying frequently will take eagerly an increase in the formula, when what the infant needs is less food. According to my experience, the greatest difficulty the' physician has today is in estimating the total ealoric requirement of the individual infant. Before the introduction of simplified infant feeding (whole milk modifications) one would see many infants failing to gain because .of the quality of the food-but now this has changed, and many infants are seen failing to make an optimum gain because the total calDric intake is not properly adjusted to the individual infant. Those infants failing t.o gain because of too much f.ood may have recurring attacks of
C. LORING JOSLlN
diarrhea and vomiting, or the infant may be simply refusing part of its feedings. It is well to remember, that there is a maximal point at which an infant will gain, a minimal point, and an optimal point. Many infants are seen suffering from a moderate degree of malnutrition, because such infants are having to subsist on the maximal or minimal number of calories and are not receiving the optimal number upon which they would gain best. The following case will illustrate the importance of the total caloric intake in relation to the infant's weight gain .
14 lb ••
. i-
. H-I-· hrati I~!=+ 1-1-1-; !- 1-
I
~I-
12 lba. 10 lba.
!)I- 1·_·1- -~I--I-
i-~
-
-1--_.
1..- .
IZ
.
·-~-~-i.·-I7'--I----I-
. ±I--~I-r ~I-
..
I-~+~
=r=
+
I- I-- . ...... I:-I-I~I -
\.-1-
..
+
.. 1 I-I.-~ _I:: 1-_ ~ .~ .. I ,. I-I--H
-
6 lba. Io!ontbs
6 7 6 9 10 11 12 13 Fig. 71. N ote.-In the above chart it will be seen that the infant, although given various formulas and different types of foed, made little gain in weight for six months. When the total caloric intake was adjusted to meet the requirements of the infant, there was an immediate and continued weight gain.
1
2
:3
4
Ii
11/21/30. (L.H.B.) Age: six months. Complaint: Not gaining. Family History: Negative. Past History: Birth weight, 7 pounds 12 ounces. Feeding: breast two months, modified cow's milk, goat's milk, predigested milk, condensed milk, cow's milk. Present Illness: Has gained only 11 pounds in six months. Vomiting at irregular intervals. Constipated. Present formula: milk, 15 ounces; water, 15 ounces; sugar, 2 tablespoonfuls (42 calories per pound). Physical Examination: Negative, except for marked degree of undernutrition . . Diagnosis: Malnutrition, extreme. Feeding, regulation of.
SOME CAUSES OF MALNUTRITION IN INFANCY Treatment:
I285
Formula adjusted to caloric requirements of infant. Milk· increased to 18 ounces, sugar to 3 tablespoonfuls (57 calories per pound). No other change was made in the care and feeding of the infant. Formula later increased as baby gained.
Quality of Food.-Some infants may receive an adequate quantity of food for proper gain in weight, but have difficulty in gaining because the quality is not suitable. Premature babies present a special problem, inasmuch as such infants are born with sufficient reserves of iron and other accessory factors to take care of only the immediate needs. The rate of growth is relatively rapid and the premature infant quickly outstrips his reserves so that he is in danger of being undernourished unless the need for the accessories is met. The normal infant tends to grow at a rate commensurate with his natal reserves until the second month is reached. At this time growth has progressed to a point where the stores are not sufficient, and the child has what has been termed a physiologic anemia. Usually the child makes a physiologic adjustment to the situation, and after ,a variable period, depending on the individual, resumes normal growth. There are many factors entering itlto the maintenance of normal nutrition, and it would appear that our concept of normal nutrition is changing. Certainly it is clear that improved nutrition may be obtained for many infants and children, who are generally considered to be in a normal state of health, by the addition of certain vitamins and minerals to their regular diet. ' Various degrees of undernutrition, especially nutritional anemias, are produced by a deficiency in the diet, or a lack of balance of certain minerals, such as iron, calcium, phosphorus, and perhaps copper. It has been shown that a preponderance of one mineral may interfere with the utilization of another. From the biochemical standpoint, there are such problems as the secretions of the various ferments that aid in digestion. For example, the amount of hydrochloric acid secreted in the stomach may have an important part in the mechanism of digestion and nutrition. Our knowledge concerning the vitamins has been greatly increased during recent years, yet our information is still in-
c.
1286
LORING JOSLIN
complete. The clinical picture produced by a deficiency of vitamins C and D in the diet is a familiar one to all. The picture of an inadequate amount of vitamins A, Band G is not so clear, yet they are necessary vitamins, and perhaps more important than we have thought. This is shown graph~ It)
:1) ~
o hO/:' #.
f-
/ 80
/
/
/
70 0
V ("is Id.
i'-. .......
""'= ~
/ I'\.
"- I~
ru on
/
I'-...
I'\. r- / e
0
i'I
~
/
/
./
/
I
EG W
0 I
~
J
4-
Weeks
.5
/0
Fig. 72.-Effect of vitamin B complex upon growth of rats.
Note.-Vitamin B-free diet was fed for six weeks to· 2 rats. Rat 4 died;
rat 5 shows progressive loss of weight until vitamin B was added to the diet at six weeks, then follows a progressive gain in weight. It will be seen that without the vitamin B complex in the diet, the rats lose appetite and weight, and soon die. When the vitamin B complex is added to the diet, norma) nutrition is rapidly regained, as shown by this chart.
ically in Fig. 72, in which there is given the weight curve of two rats on a vitamin B-free diet for a period of six weeks, after which time the vitamin B complex is added to the diet in the form of a special cereal mixture. It is also interesting to note that improved nutrition may be ···obtained by including additional vitamin B and perhaps
SOME CAUSES OF MALNUTRITION IN INFANCY
1287
minerals in the regular diet of many infants. This is shown in Fig. 73, where a cereal! mixture rich in vitamin Band minerals was substituted for the regular cereal being given a group of infants.in an orphanage, no other change being made in the diet or routine care. The group receiving the cereal, enriched with vitamins and minerals, had an increased rate of gain in· weight an,d growth as compared to the control group. The individual tolerance of fat, protein, and carbohydrate should be considered in the feeding of infants who are not making normal progress. Carbohydrate intolerance is not frequent, and protein intolerance causes little trouble, except from an allergic standpoint, as in eczema. If this condition develops early in life the infant's nutrition and growth are temporarily interfered with. Fat intolerance is quite frequent;
22.13 24.14
eo
Fig. 73.
it may be recognized by vomiting, crying from colic, frequent stools, or constipation. The effect of fat intolerance upon nutrition is shown by the following case: 1/12/34. (R.D.G.) Age: five weeks. Complaint: Crying. Not gaining. Family History: Negative. Past History: Natural birth; birth weight, 9 pounds 9 ounces. Present Illness: Crying and has not gained since birth. Physical Examination: Negative, stools frequent and contain large number of fat curds. Diagnosis: Colic. Fat intolerance. Treatment: Fat-free milk.
The bacteriologic flora of the intestinal tract has recently received considerable attention and may at times have a re1
Cerevim.
c.
I288
LORING JOSLIN
tarding effect upon nutrition. These cases are frequently diagnosed as chronic intestinal indigestion, and there may be a relationship with celiac disease. The part that the intestinal flora plays in some conditions is not as yet entirely clear, and needs further study. Environment.-The surroundings in which the baby is placed frequently have an important bearing upon its nutrition and general health. The nervous mother, for example,
14 lb ••
-!-
I-
II-f-
I-
-
f-l=i= ~
-I--
I-
,
I-
i-
-,-f--
r
1.3 lb ••
i--i-
r-
l- eI--
1=::::1=
r-
-
r- I-~
r 1--,- -,
I
I -I -
I
11+-
1-1--
12 lb •• 1---
l-
II lbl.
1:- -1=
1-110 lba.
I
I'-i-
i
r'
f
1 -
I
9 lb.
Weeu
I
H 1
2
34.6
1--1-
I
I
6
7
I-
8
\l
Fig. 74. Note.-There was a gain in weight as soon as fat-free milk was given infant, crying also immediately ceased.
usually leaves her mark upon the baby so that the infant is overexcitable, unable to relax, -and generally underweight. Needless to say, the environment outside of the home, as well as within, has an important bearing on the health of the child. Pure fresh air is a prime requisite in the life of ever); infant. When an infant is deprived of an adequate amount of sunshine its nutrition suffers. During the winter months it is frequently advantageous to compensate for this lack by 'exposure to the ultraviolet light. It is· important that a pains-
SOME CAUSES OF MALNUTRITION IN INFANCY
1289
taking investigation be made into the environmental factors in every case of failure to gain weight during infancy. Summary.-Little emphasis has been placed upon the treatment of undernutrition in infancy, but an attempt has been made to stress the importance of making a diagnosis as to the cause of the undernutrition. Without a correct diagnosis the treatment may not only be difficult, but may prove costly because the fundamental cause is untouched. Malnutrition in infancy (except in cases of congenital abnormalities) is a preventable condition and should be treated from a prophylactic, rather than from a curative standpoint.