- Email: [email protected]
SOME LONG-TERM EFFECTS OF SEVERE MALNUTRITION IN EARLY LIFE
514 Bureau of Medicine and Surgery, Navy Department, for work unit MR005.20-0158A. Cutter Laboratories, Berkeley, California, provided the replacement solutions used in this investigation. Requests for reprints should be addressed to the Publications Office, NAMRU-2, Box 14, A.P.O. San Francisco 96263. REFERENCES
Mudge, G. H., Manning, J. A., Gilman, A. Proc. Soc. exp. Biol. Med. 1949, 71, 136. 2. Schwartz, W. B., Waters, W. C. Am. J. Med. 1962, 32, 831. 3. Hartmann, A. F., Senn, M. J. E. J. clin. Invest. 1932, 11, 327. 4. Ward, Walter E. Personal communication. 5. Watten, R. H., Morgan, F. M., Songkhla, Y. N., Vanikiati, B., Phillips, R. A. J. clin. Invest. 1959, 38, 1879. 6. Watten, R. H., Phillips, R. A. Lancet, 1960, ii, 999. 7. Watten, R. H. in Current Therapy (edited by H. F. Conn); p. 8. Philadelphia, 1969. 8. Fresh, J. W. Unpublished. 9. Lundquist, F., Fugmann, U., Rasmussen, H. Biochem. J. 1961, 80, 393. 10. Beisel, W. R., Watten, R. H., Blackwell, R. Q., Benyajati, C., Phillips, R. A. Am. J. Med. 1963, 35, 58. 11. Sellards, A. W. Philipp. J. Sci., B, Medical Sciences, 1910, 5, 363. 12. Mion, C. M., Hegstrom, R. M., Boen, S. T., Scribner, B. H. Am. Soc. Artif. Int. Organs, 1964, 10, 110. 13. Gutman, R. A., Drutz, D. J., Whalen, G. E., Watten, R. H. Pediatrics, Springfield (in the press). 14. Cori, C. F., Cori, G. T. J. Biol. Chem. 1929, 81, 389. 15. Eisenmann, A. J., Mackenzie, L. B., Peters, J. P. ibid, 1936, 116, 33. 1.
SOME LONG-TERM EFFECTS OF SEVERE MALNUTRITION IN EARLY LIFE RUTH H. KRUEGER Infantile Malnutrition Research
Medical Research Council
Unit, Kampala, Uganda * 152 children who had been treated for protein deficiency between 1954 and 1958 at the Medical Research Council Infantile Malnutrition Unit, Kampala, were traced and examined six to eleven years after their discharge. Two girls were showing signs of puberty. The children were small compared with North American children of European ancestry and control group of Baganda village children with similar geographical and economic backgrounds. The girls were also small compared with a high socioeconomic group of Baganda girls. Bone age, as assessed on X-ray films of the hands and wrists, was one to two years less than chronological age. Mental ability was not assessed.
Sum ary
severe
Introduction THE physical effects of a period of severe retardation of growth have now been fairly well defined in animals. The effects vary from species to species, but on the whole the earlier in life the episode happens, and the more severe and protracted the retardation, the more likely it is to reduce the stature of the adult. This is so even if the animal is perfectly nourished for the rest of its life. It has also been established that a lifetime of poor nutrition reduces adult size.1 The position in man has been less clearly defined. MacWilliam and Deanfound an accelerated growth in the first year after discharge, which tailed off before the local standards for height and weight were attained. The
discrepancy between bone age and chronological however, continued to increase. *
Present address:
age,
c/o R. H. Harland, Lewis’s Bank Ltd., Market Street, Manchester, England.
Suckling and Campbell3 traced 27 South African children who had been treated for kwashiorkor. Five years after treatment these children were shorter than the controls, but there was no difference in weight. Garrow and Pike4 examined 65 Jamaican children two to eight years after their treatment in hospital for severe malnutrition, and found them to be slightly taller, heavier, and broader in the chest and to have thicker bone and muscle in the leg than siblings who had never been severely malnourished. In a prospective study of 100 South African children with kwashiorkor treated in hospital, Brock and Hansenó found that three years later they had overtaken their sibling controls in weight and were similar in height, but in both were below the Boston standards.6 Cabak and Najdanvikfollowed 36 Serbian children who had been severely underweight in early life, and found that they were not below the local standards for height and weight when they were 7-11 years of age. Clinical Material and Methods The first 417 children admitted to the M.R.C. unit between 1954 and 1958 were originally classified into four categories.8 The accompanying table shows what was found on trying to trace them. From this it seems that, although 23% of those graded as severe died in the ward whereas only some 7% of the others did, the initial severity made little difference to the survival-rate after discharge. The 152 children found attended the unit for examination between September, 1964, and July, 1965. They were all between the ages of 7 and 16 years and had been treated and discharged six to eleven years before. Little was known about the care and diet these children had received since discharge, although some had attended the unit at various times and others had been seen in their homes on previous follow-up visits. All the children were examined clinically by me. Heights were measured in centimetres with an anthropometric rod, with the external auditory meatus and the lower border of the eye-socket in the same horizontal plane. Weights were measured with an Avery platform scale, with a steelyard indicator, to the nearest 50 g. Both sexes wore light cotton underwear for which no correction was made. A sample of blood was taken by finger-prick, and haemoglobin, haematocrit, aminoacid ratio,9 and serumproteins were determined. A blood-smear was scanned for malarial parasites. The stools were examined for parasites. X-rays were taken of both hands and wrists, palms down, for bone age, which was estimated by comparison with the standards of Greulich and Pyle.10 The plates were read by two independent observers and the agreement between them was good. The age was assessed on each hand as a whole and then on the mean ages of the individual bones, and here again the correlation was good. X-rays of the chest, including the upper abdomen, were taken of each child. The controls were obtained from three village schools situated in the areas from which most of the patients THE FATE OF
417
CHILDREN ADMITTED WITH MALNUTRITION BETWEEN 1954 AND 1958
515 Each of these schools was attended by at least one of the ex-patients. All the children in these schools were measured for height and weight and records were made of their tribe, sex, and age, Unfortunately, their age could not be verified by birth-certificates, whereas the ages of the ex-patients were known more exactly. The 50th came.
percentile for heights and weights for each year of age was nlotted and is referred to as the control percentile (figs. 1-4). The measurements of the height and weight as percentiles were compared with the Boston standards,6 with the Baganda elite standards for girls," and with those of the village control group.
Results and General Clinical , Clinically the 152 children
ap-
peared in good physical health,
but
girls from the highest socio-economic shown in the figure)."
so at the time of admission. Some had scabies and ringworm, but none showed overt signs of malnutrition. Their aminoacid rates varied from 1 to 3, with the median at 2.9 All had a protein per 100 ml. serum over 6-5 g.
and many over 7 g. Hxmoglobin concentrations varied from 10 to 14 g. per 100 ml. (mean 12 g.) and haemato-
Fig. 1-Weight of girls.
112 specimens of the children’s stools were obtained. Only 19 of these contained no parasites, and the incidence of these infestations was as
follows: hookworm, 68; Escherichia coli 44; Trichiuris trichiura 16; Ascaris lumbricoides 12; strongyloides 7 ; Giardia lamblia 8; Entamaeba histolytica 3; iodamoeba 6. 49 of the children had more than one parasite, and there was no correlation between the children’s weights and the parasite
loads.
Weights The
weights of the girls
are
shown
in fig. 1 and of the boys in fig. 2. 94 the 152 children were below the Boston 3rd percentile and only 4 were above the Boston 50th percentile. The 50th percentile for the ex-
patients lies close
to the Boston 3rd whereas the 50th percenpercentile, tile for the village controls is con-
siderably higher, as
the 50th
but not
percentile of the
high Baganda
(not
There is not yet a local standard for boys from a high socioeconomic category, but the differences between the Boston standard, the ex-patients, and the village controls are similar to those of the girls. There was no relationship between the present
they were small for their age and only 2 girls showed secondary sexual characteristics. 104 were attending school; and, of the remaining 48, 7 were mentally defective and had been
crit values were all over 35 %. No clinical abnormalities of the cardiovascular system were found, but 4 had enlarged livers and spleens and 9 others an enlarged spleen only. These children lived in a swampy area and 4 of them had malarial parasites in their blood-smears.
group
as
Fig. 2-Weight of boys.
516
wrist
was
of the
same
order
as
that
reported by Greulich and Pyle/° and the bone ages were, except in 2 girls, below those to be the children’s chronofrom expected All bones appeared logical ages. than the and more slender lighter and the bones were a standards, boys’ of the female little like those standards.12 There was, however, no correlation between the retardation in the bone age, the severity of the malnutrition, the age of onset of the disease, or the length of time since discharge. In the 2 instances where there was no retardation in the bone age at follow-up, both girls showed signs of puberty. For 24 of the children there are records of the bone ages as estimated on X-rays of the hands and wrists taken at the time of the first admission to the ward. 13 The differences between the chronological age and the bone age as estimated then were compared with the differences found at follow-up. There was no correlation between them.
all
Fig. 3-Height of girls.
1-2 years
Chest and Abdominal X-rays
None of the children had any signs of disease in their chests, and there were no instances of cardiomegaly as measured by the cardiothoracic ratio. Nothing abnormal was discovered in the upper abdomen, and particularly no calcification of the pancreas was observed.
Fig. 4-Height of boys.
weight of the children and the severity of the malnuon admission. However, the child’s percentile position at the original admission remained the same years later at follow-up in all but the 2 girls with secondary sexual characteristics. They had both trition
risen from the 3rd to somewhere between the 25th and 50th percentile of the Boston standards.
Heights The heights of the girls are shown in fig. 3 and of the boys in fig. 4. The findings both for boys and for girls are similar to those for weight, but the differences are greater. Only two of the heights (both of girls) were above the Boston 50th percentile, and the great majority were well below the 50th percentile of the
village controls. Again there was no relationship between the severity of the initial malnutrition and the present height of the children, but, as for weight, there was no change in the percentile positions except in the 2 girls who had reached puberty. Bone Ages The variation in the age of the bones in any one
Discussion From the results it is apparent that an episode of acute malnutrition in early childhood does lead to stunting in height and weight 6-11 years later, which is more than that produced by the usual long-term poor diet of the people in the villages. However, if the village controls were older than they stated (which seems possible) there would be no difference in size between them and the children who had been admitted. This would suggest that the serious overt malnutrition which precipitated the admission may not have had much in itself to do with the slow rate of growth thereafter. This would also explain why there was no correlation between the severity of malnutrition on admission and the degree of somatic deficiencies found many years later. Since the admission and follow-up percentiles of heights and weights remained the same, except for the two postpubertal children, it seems that there is no catch-up in growth before puberty. The two postpubertal girls were close to the elite 50th percentile for height and weight and showed no difference between the chronological and the bone age. Thus, if one can draw any conclusions from the findings in 2 children, although there is little catch-up in growth
517 a very different result might have been obtained had the children studied been a few years older.
before puberty,
the late Prof. R. F. A. Dean with whose initiated and to Prof. R. A. McCance and Dr. E. M. Widdowson under whose guidance it was completed; to Mr. Y. Semindi for help in tracing the patients; to Dr. R. G. Whitehead, Dr. N. E. Wilkes, and Dr. MacDonald for help with the special investigations; and to the Buganda Minister for Primary Education for permission to visit the schools. I
am
grateful
help this study
to
was
REFERENCES 1. 2.
McCance, R. A. Lancet, 1962, ii, 621, 671. MacWilliam, K. M., Dean, R. F. A. E. Afr. med. J. 1965, 42,
297. 3. Suckling, P. V., Campbell, J. A. H. J. trop. Pediat. 1956, 2, 173. 4. Garrow, J. S., Pike, M. C. Lancet, 1967, i, 1. 5. Brock, J. F., Hansen, J. D. L. in Human Body Composition (edited by J. Brozek); p. 245. Oxford, 1965. 6. Stuart, H. C., Stevenson, S. S. in Textbook of Pediatrics (edited by W. E. Nelson); p. 48. Philadelphia, 1964. 7. Cabak, V., Najdanvik, R. Archs Dis. Childh. 1965, 40, 532. 8. Dean, R. F. A. J. Pediat. 1960, 56, 675. 9. Whitehead, R. G., Dean, R. F. A. Am. J. clin. Nutr. 1964, 14, 320. 10. Greulich, W. W., Pyle, S. I. Radiographic Atlas of Skeletal Development of the Hand and Wrist. London, 1959. 11. Burgess, A. P., Burgess, H. J. L. Hum. Biol. 1964, 36, 177. 12. Mackay, D. H. Trans. R. Soc. trop. Med. Hyg. 1952, 46, 135. 13. Jones, P. R. M., Dean, R. F. A. J. trop. Pediat. 1956, 2, 51.
SECRETORY IgA IN THE SERUM R. A. THOMPSON P. ASQUITH W. T. COOKE
Department of Experimental Pathology, University of Birmingham, Birmingham 15, and Nutritional and Intestinal Unit, The General Hospital, Birmingham 4 antiserum specific for secretory piece, secretory IgA has been identified in serum. It was found in 21 (41%) of 52 patients with untreated adult cœliac disease, 5 (13%) of 38 patients with regional enteritis, and 5 (22%) of 23 patients with ulcerative colitis. It was also found in 9 (9%) of 101 healthy control subjects.
Summary
With the
use
of
an
Introduction
cellulose column equilibrated with the same buffer. After the column had been washed for several hours in the starting buffer, a gradient from O’OlM to 0-3M phosphate was applied by means of a ’Varigrad’. The fractions containing IgA were pooled and concentrated.
Anti-salivary IgA was obtained by injecting a rabbit salivary IgA preparation described above in Freund’s complete adjuvant. Against saliva, the antiserum gave three lines-those of IgA, amylase, and an alpha-2 protein, which represented an intracellular protein released on cell rupture. Against whole serum, the major precipitin line was IgA, with an additional fainter line against IgG. The antiserum was made specific for secretory piece by absorption with whole normal serum, and an IgA-free preparation of salivary amylase and the alpha-2 protein, obtained from pooled normal saliva. Colostral IgA was prepared from pooled human colostrum after the method of Newcomb et a1.6 The preparation gave a single band on cellulose-acetate electrophoresis and a single arc on immunoelectrophoresis against polyvalent anti-human serum (Burroughs Wellcome Ltd.) and against both the unabsorbed and absorbed anti-salivary IgA antiserum. Its protein concentration, estimated by the method of Lowry et al.,6 was 2-8 mg. per ml. Reduction and alkylation of the isolated colostral IgA was carried out using 0-05M dithiothrietol (D.T.E.) followed by iodoacetamide, as described by Newcomb et aJ.6 Antiserum to serum-IgA was prepared by injecting a sheep with the isolated IgA from the serum of a patient with an IgA myeloma. It was made specific for alpha chain by absorption with IgG (Cohn fraction 11). Double-diffusion analysis was performed on 1-5% agar plates made up in 0-15M phosphate buffered saline, pH 7-4. The diameter of the wells was usually 5 mm., and with the
the distance between the centres was 10 mm. Patterns were left to develop for 48-72 hours at 4°C, and the plates were then washed, dried, and stained with amido black before analysis.
Results
Specificity of Anti-secretory-piece
Antiserum
The unabsorbed antiserum was shown to give a spur with isolated colostral IgA over serum IgA (fig. 1). After absorption, as described, it was shown to be specific for the secretory piece both by its failure to react with a number of normal sera or with isolated myeloma IgA from three different individuals,
IgA is the predominant immunoglobulin in external secretions. This secretory form exists mainly as an 11-75 dimer, and it can be distinguished from serumIgA by the possession of an additional peptide fragment with distinct antigenic characteristics, called the transport piece or secretory piece.1-4 Antibodies to the piece can usually be demonstrated by geldiffusion analysis with antisera to secretory IgA as a spur of secretory IgA over serum-IgA. After adequate absorption with serum, such antisera, while no longer reacting with serum-IgA, still react with the IgA in saliva, colostrum, and other external secretions. We report here the finding of secretory IgA in serum. Methods A crude salivary IgA preparation was made from 400 mI. of mouth saliva obtained from two healthy individuals. After centrifugation to remove the cells, the saliva was dialysed against 50% saturated ammonium sulphate. The precipitate was redissolved in 0-OlAf phosphate, pH 7-9, and applied to a diethyl aminoethyl (D.E.A.E.)
Fig. 1-Get-diffusion analysis showing the spur of colostral IgA (C) over serum-IgA (S) against unabsorbed anti-salivaryIgA antiserum (AS).
Mudge, G. H., Manning, J. A., Gilman, A. Proc. Soc. exp. Biol. Med. 1949, 71, 136. 2. Schwartz, W. B., Waters, W. C. Am. J. Med. 1962, 32, 831. 3. Hartmann, A. F., Senn, M. J. E. J. clin. Invest. 1932, 11, 327. 4. Ward, Walter E. Personal communication. 5. Watten, R. H., Morgan, F. M., Songkhla, Y. N., Vanikiati, B., Phillips, R. A. J. clin. Invest. 1959, 38, 1879. 6. Watten, R. H., Phillips, R. A. Lancet, 1960, ii, 999. 7. Watten, R. H. in Current Therapy (edited by H. F. Conn); p. 8. Philadelphia, 1969. 8. Fresh, J. W. Unpublished. 9. Lundquist, F., Fugmann, U., Rasmussen, H. Biochem. J. 1961, 80, 393. 10. Beisel, W. R., Watten, R. H., Blackwell, R. Q., Benyajati, C., Phillips, R. A. Am. J. Med. 1963, 35, 58. 11. Sellards, A. W. Philipp. J. Sci., B, Medical Sciences, 1910, 5, 363. 12. Mion, C. M., Hegstrom, R. M., Boen, S. T., Scribner, B. H. Am. Soc. Artif. Int. Organs, 1964, 10, 110. 13. Gutman, R. A., Drutz, D. J., Whalen, G. E., Watten, R. H. Pediatrics, Springfield (in the press). 14. Cori, C. F., Cori, G. T. J. Biol. Chem. 1929, 81, 389. 15. Eisenmann, A. J., Mackenzie, L. B., Peters, J. P. ibid, 1936, 116, 33. 1.
SOME LONG-TERM EFFECTS OF SEVERE MALNUTRITION IN EARLY LIFE RUTH H. KRUEGER Infantile Malnutrition Research
Medical Research Council
Unit, Kampala, Uganda * 152 children who had been treated for protein deficiency between 1954 and 1958 at the Medical Research Council Infantile Malnutrition Unit, Kampala, were traced and examined six to eleven years after their discharge. Two girls were showing signs of puberty. The children were small compared with North American children of European ancestry and control group of Baganda village children with similar geographical and economic backgrounds. The girls were also small compared with a high socioeconomic group of Baganda girls. Bone age, as assessed on X-ray films of the hands and wrists, was one to two years less than chronological age. Mental ability was not assessed.
Sum ary
severe
Introduction THE physical effects of a period of severe retardation of growth have now been fairly well defined in animals. The effects vary from species to species, but on the whole the earlier in life the episode happens, and the more severe and protracted the retardation, the more likely it is to reduce the stature of the adult. This is so even if the animal is perfectly nourished for the rest of its life. It has also been established that a lifetime of poor nutrition reduces adult size.1 The position in man has been less clearly defined. MacWilliam and Deanfound an accelerated growth in the first year after discharge, which tailed off before the local standards for height and weight were attained. The
discrepancy between bone age and chronological however, continued to increase. *
Present address:
age,
c/o R. H. Harland, Lewis’s Bank Ltd., Market Street, Manchester, England.
Suckling and Campbell3 traced 27 South African children who had been treated for kwashiorkor. Five years after treatment these children were shorter than the controls, but there was no difference in weight. Garrow and Pike4 examined 65 Jamaican children two to eight years after their treatment in hospital for severe malnutrition, and found them to be slightly taller, heavier, and broader in the chest and to have thicker bone and muscle in the leg than siblings who had never been severely malnourished. In a prospective study of 100 South African children with kwashiorkor treated in hospital, Brock and Hansenó found that three years later they had overtaken their sibling controls in weight and were similar in height, but in both were below the Boston standards.6 Cabak and Najdanvikfollowed 36 Serbian children who had been severely underweight in early life, and found that they were not below the local standards for height and weight when they were 7-11 years of age. Clinical Material and Methods The first 417 children admitted to the M.R.C. unit between 1954 and 1958 were originally classified into four categories.8 The accompanying table shows what was found on trying to trace them. From this it seems that, although 23% of those graded as severe died in the ward whereas only some 7% of the others did, the initial severity made little difference to the survival-rate after discharge. The 152 children found attended the unit for examination between September, 1964, and July, 1965. They were all between the ages of 7 and 16 years and had been treated and discharged six to eleven years before. Little was known about the care and diet these children had received since discharge, although some had attended the unit at various times and others had been seen in their homes on previous follow-up visits. All the children were examined clinically by me. Heights were measured in centimetres with an anthropometric rod, with the external auditory meatus and the lower border of the eye-socket in the same horizontal plane. Weights were measured with an Avery platform scale, with a steelyard indicator, to the nearest 50 g. Both sexes wore light cotton underwear for which no correction was made. A sample of blood was taken by finger-prick, and haemoglobin, haematocrit, aminoacid ratio,9 and serumproteins were determined. A blood-smear was scanned for malarial parasites. The stools were examined for parasites. X-rays were taken of both hands and wrists, palms down, for bone age, which was estimated by comparison with the standards of Greulich and Pyle.10 The plates were read by two independent observers and the agreement between them was good. The age was assessed on each hand as a whole and then on the mean ages of the individual bones, and here again the correlation was good. X-rays of the chest, including the upper abdomen, were taken of each child. The controls were obtained from three village schools situated in the areas from which most of the patients THE FATE OF
417
CHILDREN ADMITTED WITH MALNUTRITION BETWEEN 1954 AND 1958
515 Each of these schools was attended by at least one of the ex-patients. All the children in these schools were measured for height and weight and records were made of their tribe, sex, and age, Unfortunately, their age could not be verified by birth-certificates, whereas the ages of the ex-patients were known more exactly. The 50th came.
percentile for heights and weights for each year of age was nlotted and is referred to as the control percentile (figs. 1-4). The measurements of the height and weight as percentiles were compared with the Boston standards,6 with the Baganda elite standards for girls," and with those of the village control group.
Results and General Clinical , Clinically the 152 children
ap-
peared in good physical health,
but
girls from the highest socio-economic shown in the figure)."
so at the time of admission. Some had scabies and ringworm, but none showed overt signs of malnutrition. Their aminoacid rates varied from 1 to 3, with the median at 2.9 All had a protein per 100 ml. serum over 6-5 g.
and many over 7 g. Hxmoglobin concentrations varied from 10 to 14 g. per 100 ml. (mean 12 g.) and haemato-
Fig. 1-Weight of girls.
112 specimens of the children’s stools were obtained. Only 19 of these contained no parasites, and the incidence of these infestations was as
follows: hookworm, 68; Escherichia coli 44; Trichiuris trichiura 16; Ascaris lumbricoides 12; strongyloides 7 ; Giardia lamblia 8; Entamaeba histolytica 3; iodamoeba 6. 49 of the children had more than one parasite, and there was no correlation between the children’s weights and the parasite
loads.
Weights The
weights of the girls
are
shown
in fig. 1 and of the boys in fig. 2. 94 the 152 children were below the Boston 3rd percentile and only 4 were above the Boston 50th percentile. The 50th percentile for the ex-
patients lies close
to the Boston 3rd whereas the 50th percenpercentile, tile for the village controls is con-
siderably higher, as
the 50th
but not
percentile of the
high Baganda
(not
There is not yet a local standard for boys from a high socioeconomic category, but the differences between the Boston standard, the ex-patients, and the village controls are similar to those of the girls. There was no relationship between the present
they were small for their age and only 2 girls showed secondary sexual characteristics. 104 were attending school; and, of the remaining 48, 7 were mentally defective and had been
crit values were all over 35 %. No clinical abnormalities of the cardiovascular system were found, but 4 had enlarged livers and spleens and 9 others an enlarged spleen only. These children lived in a swampy area and 4 of them had malarial parasites in their blood-smears.
group
as
Fig. 2-Weight of boys.
516
wrist
was
of the
same
order
as
that
reported by Greulich and Pyle/° and the bone ages were, except in 2 girls, below those to be the children’s chronofrom expected All bones appeared logical ages. than the and more slender lighter and the bones were a standards, boys’ of the female little like those standards.12 There was, however, no correlation between the retardation in the bone age, the severity of the malnutrition, the age of onset of the disease, or the length of time since discharge. In the 2 instances where there was no retardation in the bone age at follow-up, both girls showed signs of puberty. For 24 of the children there are records of the bone ages as estimated on X-rays of the hands and wrists taken at the time of the first admission to the ward. 13 The differences between the chronological age and the bone age as estimated then were compared with the differences found at follow-up. There was no correlation between them.
all
Fig. 3-Height of girls.
1-2 years
Chest and Abdominal X-rays
None of the children had any signs of disease in their chests, and there were no instances of cardiomegaly as measured by the cardiothoracic ratio. Nothing abnormal was discovered in the upper abdomen, and particularly no calcification of the pancreas was observed.
Fig. 4-Height of boys.
weight of the children and the severity of the malnuon admission. However, the child’s percentile position at the original admission remained the same years later at follow-up in all but the 2 girls with secondary sexual characteristics. They had both trition
risen from the 3rd to somewhere between the 25th and 50th percentile of the Boston standards.
Heights The heights of the girls are shown in fig. 3 and of the boys in fig. 4. The findings both for boys and for girls are similar to those for weight, but the differences are greater. Only two of the heights (both of girls) were above the Boston 50th percentile, and the great majority were well below the 50th percentile of the
village controls. Again there was no relationship between the severity of the initial malnutrition and the present height of the children, but, as for weight, there was no change in the percentile positions except in the 2 girls who had reached puberty. Bone Ages The variation in the age of the bones in any one
Discussion From the results it is apparent that an episode of acute malnutrition in early childhood does lead to stunting in height and weight 6-11 years later, which is more than that produced by the usual long-term poor diet of the people in the villages. However, if the village controls were older than they stated (which seems possible) there would be no difference in size between them and the children who had been admitted. This would suggest that the serious overt malnutrition which precipitated the admission may not have had much in itself to do with the slow rate of growth thereafter. This would also explain why there was no correlation between the severity of malnutrition on admission and the degree of somatic deficiencies found many years later. Since the admission and follow-up percentiles of heights and weights remained the same, except for the two postpubertal children, it seems that there is no catch-up in growth before puberty. The two postpubertal girls were close to the elite 50th percentile for height and weight and showed no difference between the chronological and the bone age. Thus, if one can draw any conclusions from the findings in 2 children, although there is little catch-up in growth
517 a very different result might have been obtained had the children studied been a few years older.
before puberty,
the late Prof. R. F. A. Dean with whose initiated and to Prof. R. A. McCance and Dr. E. M. Widdowson under whose guidance it was completed; to Mr. Y. Semindi for help in tracing the patients; to Dr. R. G. Whitehead, Dr. N. E. Wilkes, and Dr. MacDonald for help with the special investigations; and to the Buganda Minister for Primary Education for permission to visit the schools. I
am
grateful
help this study
to
was
REFERENCES 1. 2.
McCance, R. A. Lancet, 1962, ii, 621, 671. MacWilliam, K. M., Dean, R. F. A. E. Afr. med. J. 1965, 42,
297. 3. Suckling, P. V., Campbell, J. A. H. J. trop. Pediat. 1956, 2, 173. 4. Garrow, J. S., Pike, M. C. Lancet, 1967, i, 1. 5. Brock, J. F., Hansen, J. D. L. in Human Body Composition (edited by J. Brozek); p. 245. Oxford, 1965. 6. Stuart, H. C., Stevenson, S. S. in Textbook of Pediatrics (edited by W. E. Nelson); p. 48. Philadelphia, 1964. 7. Cabak, V., Najdanvik, R. Archs Dis. Childh. 1965, 40, 532. 8. Dean, R. F. A. J. Pediat. 1960, 56, 675. 9. Whitehead, R. G., Dean, R. F. A. Am. J. clin. Nutr. 1964, 14, 320. 10. Greulich, W. W., Pyle, S. I. Radiographic Atlas of Skeletal Development of the Hand and Wrist. London, 1959. 11. Burgess, A. P., Burgess, H. J. L. Hum. Biol. 1964, 36, 177. 12. Mackay, D. H. Trans. R. Soc. trop. Med. Hyg. 1952, 46, 135. 13. Jones, P. R. M., Dean, R. F. A. J. trop. Pediat. 1956, 2, 51.
SECRETORY IgA IN THE SERUM R. A. THOMPSON P. ASQUITH W. T. COOKE
Department of Experimental Pathology, University of Birmingham, Birmingham 15, and Nutritional and Intestinal Unit, The General Hospital, Birmingham 4 antiserum specific for secretory piece, secretory IgA has been identified in serum. It was found in 21 (41%) of 52 patients with untreated adult cœliac disease, 5 (13%) of 38 patients with regional enteritis, and 5 (22%) of 23 patients with ulcerative colitis. It was also found in 9 (9%) of 101 healthy control subjects.
Summary
With the
use
of
an
Introduction
cellulose column equilibrated with the same buffer. After the column had been washed for several hours in the starting buffer, a gradient from O’OlM to 0-3M phosphate was applied by means of a ’Varigrad’. The fractions containing IgA were pooled and concentrated.
Anti-salivary IgA was obtained by injecting a rabbit salivary IgA preparation described above in Freund’s complete adjuvant. Against saliva, the antiserum gave three lines-those of IgA, amylase, and an alpha-2 protein, which represented an intracellular protein released on cell rupture. Against whole serum, the major precipitin line was IgA, with an additional fainter line against IgG. The antiserum was made specific for secretory piece by absorption with whole normal serum, and an IgA-free preparation of salivary amylase and the alpha-2 protein, obtained from pooled normal saliva. Colostral IgA was prepared from pooled human colostrum after the method of Newcomb et a1.6 The preparation gave a single band on cellulose-acetate electrophoresis and a single arc on immunoelectrophoresis against polyvalent anti-human serum (Burroughs Wellcome Ltd.) and against both the unabsorbed and absorbed anti-salivary IgA antiserum. Its protein concentration, estimated by the method of Lowry et al.,6 was 2-8 mg. per ml. Reduction and alkylation of the isolated colostral IgA was carried out using 0-05M dithiothrietol (D.T.E.) followed by iodoacetamide, as described by Newcomb et aJ.6 Antiserum to serum-IgA was prepared by injecting a sheep with the isolated IgA from the serum of a patient with an IgA myeloma. It was made specific for alpha chain by absorption with IgG (Cohn fraction 11). Double-diffusion analysis was performed on 1-5% agar plates made up in 0-15M phosphate buffered saline, pH 7-4. The diameter of the wells was usually 5 mm., and with the
the distance between the centres was 10 mm. Patterns were left to develop for 48-72 hours at 4°C, and the plates were then washed, dried, and stained with amido black before analysis.
Results
Specificity of Anti-secretory-piece
Antiserum
The unabsorbed antiserum was shown to give a spur with isolated colostral IgA over serum IgA (fig. 1). After absorption, as described, it was shown to be specific for the secretory piece both by its failure to react with a number of normal sera or with isolated myeloma IgA from three different individuals,
IgA is the predominant immunoglobulin in external secretions. This secretory form exists mainly as an 11-75 dimer, and it can be distinguished from serumIgA by the possession of an additional peptide fragment with distinct antigenic characteristics, called the transport piece or secretory piece.1-4 Antibodies to the piece can usually be demonstrated by geldiffusion analysis with antisera to secretory IgA as a spur of secretory IgA over serum-IgA. After adequate absorption with serum, such antisera, while no longer reacting with serum-IgA, still react with the IgA in saliva, colostrum, and other external secretions. We report here the finding of secretory IgA in serum. Methods A crude salivary IgA preparation was made from 400 mI. of mouth saliva obtained from two healthy individuals. After centrifugation to remove the cells, the saliva was dialysed against 50% saturated ammonium sulphate. The precipitate was redissolved in 0-OlAf phosphate, pH 7-9, and applied to a diethyl aminoethyl (D.E.A.E.)
Fig. 1-Get-diffusion analysis showing the spur of colostral IgA (C) over serum-IgA (S) against unabsorbed anti-salivaryIgA antiserum (AS).