Przegląd A ntropologiczny • tom 60, s. 5 7 -6 4 , Poznań 1997
Catch-up growth in children after acute and protracted
diarrhea
Beata Kulik-Rechberger, Hanna Chrząstek-Spruch,
Wanda Furmaga-Jabłońska
Abstract
One hundred and ten children hospitalized because o f acute and protracted diarrhea in the first year o f life were follow ed up for an average period o f 13.7 m onths. T hree anthropological param eters w ere taken into consideration: body height, body w eight and head circum ference. A t the tim e o f the first exam ination all the param eters m easured were significantly decreased bu t children tend to reestablish norm al som atic grow th pattern during the rehabilitation period through th e acceleration o f growth (phenom enon know n as “catch-up grow th”).
B eata K ulik-Rechberger, H anna C hrząstek-Spruch, W anda Furm aga-Jabłońska, 1997; A nthropological Review, vol. 60, Poznań 1997, pp. 5 7 -6 4 , figs 3. ISBN 83-86969-18-0, ISSN 0033-2003
C hild’s development is a process pro ceeding regularly in accordance with the established growth pattern, which is probably genetically determined. A t the same time that development is influenced by paragenetic and environmental factors
[ As h w o r t h, Mi l l w a r d 1986; Wo l a ń-
s k i 1972, 1983; Ku l i k-Re c h b e r g e r
1991]. The latter modify processes o f growth and maturation and when they are disadvantageous, children change their development paths [BRANCO 1979;
Ca s e y, Ar n o l d 1985; Pr a d e r 1978;
Pr a d e r et al. 1963]. Nutrition is re
garded as one o f the most significant environmental factors [DŁUŻNIEW SKA &
Ra k o w s k a 1981, Ko n i e c z n a 1968],
but whether the organism is properly
I Katedra Pedriatrii. Zakład Propedeutyki Pedriatrii Dziecięcy Szpital Kliniczny
20-093 Lublin, ul. Chodźki 2
nourished or not depends not only on quantity and quality o f the supplied food, but also on ability to make use o f it. Therefore malnutrition may result from disturbances o f digestion or absorption, which often m anifest themselves clini cally as diarrhea [HOLM ES et al. 1983;
JALILI et al. 1982; ZALEWSKI 1985]. Depending on duration and intensity o f the nourishment disturbance, it may re sult in underweight (together with dis proportion between the body weight and height) and subsequently in deficit in height and head circumference [BRANCO
1979; Br i a r e s et al. 1975; Ge r k o w i c z
et al. 1980; STOCH, SMYTHE 1976]. A lot o f authors pointed out to the possibility o f compensatory acceleration o f growth in children afflicted with diarrhea after their recovery from an illness or when proper nutrition is restored, phenomenon
58 B eata K ulik-R echberger, H anna C hrząstek-Spruch, W anda F urm aga-Jabłońska
known as “catch-up growth” [A S H WORTH, Mi l l w a r d 1986; Ba r r et al.
1972; Bo e r s m a et al. 1995; D AM EN et al. 1994; Ku l i k-Re c h b e r g e r 1991;
M O SIER 1990; M O SIER et al. 1985; PR A - DER 1978; PRADER et al. 1963; TANNER
1981],
The analysis o f infants’ development following m alnutrition caused by acute and protracted diarrhea from an aspect o f catch-up growth has been the objective o f our research.
Material and methods
One hundred and ten children hospi talized because o f acute and protracted diarrhea in the Infant Clinic o f Medical University in Lublin were subject to long-term examination. The youngest child with early diarrheal symptoms was six days old and the oldest one - eleven months and fourteen days old (average estimated age - three months and two days). The researched group was divided as follows:
1. boys who suffered from acute or protracted diarrhea (n=64);
2. girls who suffered from acute or protracted diarrhea (n=46);
3. boys and girls who suffered from acute diarrhea (n=55);
4. Boys and girls who suffered from protracted diarrhea (n=55).
The first anthropological measure ments o f the children were taken during their hospital convalescence (examina tion I). Subsequent checkups were done (on call) after - on average - 3.6 months (examination II), 7.7 months (examina tion III), and 13.7 months (examination IV) from the first examination. Each time the children were subject to thorough physical examination together with an
thropological measurements. A t the same time detailed information was gathered as regarded their psychomotor develop ment and other factors influencing their growth (parent’s education, social and economic conditions, diseases they suf fered from, nutrition, etc.). Moreover, during each checkup, mothers were ad vised how to properly feed and take care o f their children. Somatometric exami nation was done with Wolariski’s libe- rometer and M artin’s set o f measuring instruments. The selection o f measuring points and the technique o f measure ments were standard.
This study has taken into considera tion three basic morphological features: body height, body weight and head cir cumference. The values o f parameters measured were compared to “Tables o f Physical Development Indexes for Chil dren o f Lublin” [ClIRZASTEK-SPRUCH, SZAJNER-M lLART 1973] being in use at the time o f the research. The results were expressed as the percentage o f deficit or excess o f measured parameters in rela tion to their mean values (treated as stan dard, 0% o f deficit or excess) for the population. That technique made it pos sible to compare the level o f the same feature as well as different ones in the consecutive examinations. The obtained data were subject to statistical analysis employing 7-student test and C-Cochran- Cox test.
Results
Immediately after recovering from di arrhea (examination I) the researched children had significantly (p < 0.001) decreased values o f body weights and, to lesser degree, body heights and head circumferences (Fig. 1) in comparison to
C atch-up growth in children after acute and protracted diarrhea 59
the standard levels. As the children re covered and were given condition advan tageous for their growth (proper care and nutrition), the parameters measured tended to compensate their deficits by accelerated growth (“catch-up growth” mechanism). The rate o f the process was the fastest for body weight, which al ready in examination II, and then in the subsequent ones, did not significantly differ from the standard value (Fig. 1). Body height and head circumference growth were much slower. Although the initial deficit in height considerably de creased over the period o f the research, it did not reach the desired value o f 0% (Fig. 1). Similarly, head circumference did not catch up with the normal value, even if its deficit diminished signifi cantly already between examinations I and II.
•/.
t ---1---1---
r-I l i II I I V
e x a m in a t io n o r d e r
Fig. 1. Percentage variation from norm in body hight, body m ass and head circum ference in successive studies
In order to determine the influence o f gender on child’s development disturbed by a disease, the analysis o f deficits in body height, weight and head circumfer ence was made for separate groups o f girls and boys (Fig. 2). The obtained results proved that as regards body weight, sex did not influence the catch up growth. In the case o f each group the initial deficit in this parameter was simi lar and beginning from examination II body weight was at the normal level both for girls and for boys. The influence o f sex was also unimportant in the case o f head circumference. A t the same time that feature neithersignificantly acceler ated its growth nor reached the desired value. The research has shown, however, a difference between genders in the case o f body height. In examinations I, II and III the deficits in this parameter were significant and equal for boys and girls, but in examination IV the average height for the girls’ group reached the desired value, while in the boys’ group remained considerably decreased.
The analysis o f the obtained values o f the researched parameters in regard to a type o f diarrhea (acute or protracted) (Fig. 3) revealed that the initial deficit in body weight and height was almost twice as much, and head circumference deficit almost significantly higher in children who suffered from protracted diarrhea, than in those who recovered from acute one. As early as in examination II (and then in III) body weight in both groups reached the desired value, but in exami nation IV the children who had been afflicted with protracted diarrheal syn drome showed significant overweight.
Considerable decrease in height de ficit in children who suffered from pro tracted diarrhea took place betw een
ex-60 B eata K ulik-R echberger, H anna Chrz^stek-Spruch, W anda Furm aga-Jabloriska
EXAMINATION ORDER
Fig. 2. P ercentage variation from norm in body hight, body m ass and head circum ference in successive studies according to sex
EXAMINATION ORDER
Fig. 3. Percentage variation from norm in body hight, body m ass and head circum ference in successive studies according to diarrhoea syndrom e
Catch-up grow th in children after acute and protracted diarrhea 61
aminations I and III, as well as between I and IV, while in the case o f head circum ference the deficiency diminished be tween examinations I and II, I and III, I and IV. Due to those changes, beginning from examination III, the average values o f height deficits, and beginning from examination II the average head circum ference deficits did not depend on diar rheal syndrome; however, both parame ters were still far from normal.
Discussion
Numerous studies have proved that sufficiently strong and long-lasting dis advantageous stimulus acting on young organism o f a child disturbs its somatic development [PRADER 1978, SOLOMONS
1985]. In the case o f our research that function was fulfilled by acute and pro tracted diarrhea. Although the somatic deficiencies resulting from that disease were not as serious as in some other de scribed cases [B A R R et al. 1972; BRANCO
1979, So l o m o n s 1985, St o c h, Sm y t h e
1976], they were noted and follow-up observation confirmed that initial levels o f body parameters had been improper. In subsequent examinations the accel eration o f growth in order to “catch up with own development pattern” was re corded. The phenomenon was particu larly apparent in the case o f body weight, for which the catch-up growth was com pleted as early as in examination II, i.e. after an average o f 3.6 months from the end o f the disease, the weight reached the value adequate to body height. Boys and girls similarly reacted to the im proved conditions for growth. Different were, however, reactions as regarded the type o f diarrhea. The mean body weight, which in examination I was lower in children who suffered from protracted
diarrhea than in those recovering from acute one, in examination II was similar, and in examination III reached values significantly higher than the right ones.
Fast growth o f body weight after re covery from an illness and institution o f a proper diet is a commonly known phe nomenon. In that period children have increased appetite and take more food. A t the same time activation o f anabolic processes and accelerated accumulation o f substrates in tissues takes place
[ As h w o r t h, Mi l l w a r d 1986], Proper
treatm ent o f m alnutrition in early child hood quite often results in overweight. The reason for that effect is the fact that the growth o f body w eight is faster than that o f height [B A R R et al. 1972]. Particu larly fast rate o f weight growth was usually noted in children with higher deficit in weight than in height. An aver age rate o f weight growth for children with height deficit, but weight proper for that height was slower than in those with weight deficit only. [ASHW ORTH, M ILL WARD 1986; Pr a d e r et al. 1963]. Our
research has also proved that higher ini tial weight deficit in the group o f chil dren who suffered from protracted diar rhea resulted in faster rate o f growth for that parameter.
W hereas the “catch-up” in body weight was complete already in exami nation II, height deficit was still signifi cant in examination IV, although it had diminished, compared to examination I. It is possible that the time o f observation was too short. A lot o f authors have maintained that the “reconstruction” o f the latter feature requires more time than o f the former one [B A R R et al. 1972;
Br a n c o 1979; So l o m o n s 1985; St o c h,
SMYTHE 1976] and in some cases may be even impossible [BRIARES et al. 1975].
62 B eata K ulik-R echberger, H anna C hrząstek-Spruch, W anda Furm aga-Jablońska
In the course o f our observation the girls, contrary to the boys, completed their catch-up growth o f body height already in the first year. Their case has illustrates the fact that the accelerated growth o f body weight and height does not take place in the same time. Only after the body weight reaches the value proper in relation to its height, will the rate o f its growth diminish and the accel eration of height growth begin. A SH WORTH, MlLLW ARD [1986] have ob served the similar mechanism. On the basis o f their own analysis o f changes in body weight and height in the period of accelerated growth they advanced the hypothesis that the rates o f weight growth and height growth in children with deficiency in both those parameters (body height deficits in relation to chil dren’s age, body weight deficits in rela tion to their height) limited each other. As has been proved on laboratory ani mals, the delay in compensatory growth o f body hight is caused by higher rate of increase in body weight, and lasts until the weight reaches the value proper for its hight. Subsequent decrease in the rate o f weight growth' results from the accel erated growth o f hight. Hence the con clusion that organisms tend not only to compensate their growth, but also to restore proper proportions between body weight (consisting also o f the soft tissue weight) and body height. At the same time it seems that it is weight that adjusts itself to height [M O SIER 1990, ISAKSSON
1990].
Our research has also revealed that, similarly to body weight and height, al though less clearly, head circumference deficit depends on the type of diarrhea (higher deficit following protracted diar rhea). The deficiency o f that feature in
children diminished already in an early stage of our observation, so the accelera tion of head circumference growth took place before the acceleration o f body height growth. CASEY, ARNOLD [1985] have noticed the similar sequence. As in the case o f body height or weight, the higher deficit in head circumference in children who suffered from protracted diarrhea caused faster growth of that parameter and in result, the values of the deficiency for both types o f diarrhea were similar in examination II. As in the case o f body hight, different opinions exist in regard to the possibility o f com plete catch-up in head circumference in children with high deficit o f that parame ter [GERKOWICZ et al. 1980; STOCK, SMYTHE 1976]. In the case o f our re search it is possible that the catch-up growth of head circumference was not completed because the time o f observa tion was too short.
Summing up, diarrhea has a slowing- down influence on infants’ development. However, given the advantageous condi tions, the organism has a potential to compensate deficits by the acceleration o f its growth rate.
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Streszczenie
Przeprow adzono badania długofalow e 110 niem ow ląt hospitalizow anych z pow odu ostrej i przew lekłej biegunki. Pierwsze pom iary antropom etryczne w ykonano w czasie pobytu dziecka w szpitalu, w okresie je g o rekonw alescencji, badania kontrolne przeprow adzono w odstępach średnio 3, 6 m iesiąca (badanie II), 7, 7 m ies. (badanie III) i 13, 71 mies. (IV) od badania pierw szego (I). W niniejszym opracow aniu uw zględniono trzy podstaw ow e cechy m orfologicz ne: długość (wysokość) ciała, m asę ciała i obw ód głowy. W yniki pom iarów przedstaw iono w postaci odsetkow ych wielkości niedoboru lub nadm iaru cech w stosunku do ich średniej w ielkości w populacji. M aterial liczbow y poddano analizie statystycznej przy pom ocy testów / - S tudenta oraz C - C ochrana i Coxa.
W w yniku przeprow adzonych badań stw ierdzono, że u dzieci, w krótkim okresie po biegunce (badanie I) charak teryzowały się istotnie (p<0,001) obniżonym i w stosunku do przyjętej norm y w artościam i, głów nie m asy ciała, a w m niejszym stopniu długości ciała i obw odu głowy (rys. 1). Po pow rocie do zdrow ia b adane param etry w ykazyw a ły tendencję do w yrów nania sw oich niedoborów przez przyspieszenie tem p a w zrastania („catch-up grow th”). N ajszyb sze tem po obserw ow ano w przypadku m asy ciała i ju ż w badaniu II cecha ta nie w ykazała istotnych odchyleń od normy. T em po w zrastania długości ciała i obw odu głow y było znacznie w olniejsze i „catch-up” tych cech nie byl kom pletny. N ie stw ierdzono aby płeć m iała w pływ na zachow anie się m asy ciała czy obw odu głow y (rys. 2). W ykaza no natom iast, że w badaniu IV średnia długość ciała dziew cząt osiągnęła w artość n ależn ą natom iast u chłopców
64 B eata K ulik-R echberger, H anna C hrząstek-Spruch, W anda Furm aga-Jabłońska
n iedobór tej cechy pozostał nadal istotny. W w yniku analizy w ielkości badanych cech w zależności od rodzaju przeby tej biegunki (ostra b ąd ź przew lekła) stw ierdzono, że początkow y niedobór m asy i długości ciała był niem al dwukrot n ie w iększy, a n iedobór obw odu głow y niem al istotnie w iększy u dzieci po biegunce przew lekłej n iż po ostrej (rys. 3). J u ż w bad an iu II a także i III w obu grupach m asa ciała osiągnęła w artość oczekiw aną, n atom iast w badaniu IV dzieci po zespole biegunkow ym przew lekłym w ykazyw ały isto tn ą nadw agę. Tak szybkiego tem pa w zrastania nie obserw o w ano w przypadku długości (w ysokości) ciała i obw odu głowy. Począw szy od bad an ia III, średnie w ielkości niedobo rów długości (w ysokości) a od II średnie w ielkości niedoborów obw odu głow y nie różniły się w zależności od rodzaju zespołu biegunkow ego, jed n ak że cechy te nadal istotnie odbiegały od normy.
W yniki naszych badań w ykazują, że zaburzenie odżyw iania w postaci ostrej czy przew lekłej biegunki hamuje rozwój dziecka, je d n a k , w optym alnych w arunkach je g o organizm posiada zdolność do „nadrabiania” niedoborów przez przyspieszanie tem pa w zrastania.
