Mortality in second and third degree malnutrition

Malnutrition has been defined as a pathological condition of varying degrees of severity, and diverse clinical manifestations, resulting from the deficient assimilation of the components of the nutrient complex (GOMEZ, 1955). This disease affects the physico-chemical pattern of the tissues, reduces the defensive capacity to environmental aggressions, lowers both the efficiency and the ability for work, and shortens life (ESCUDERO, 1935; TROWELL, 1948; DAVIES, 1952; ZUBIRAN, 1953). The disease attacks with greater intensity certain social groups, and has a considerable clinical importance during critical stages of development of the child, such as infancy and the pre-school age, which are characterized by rapid growth and high nutritional needs. The causes responsible for malnutrition may be classified as primary -- insufficient food supply, or under-nutrition ; and secondary or conditioned -- poor absorption, increased excretion, increased requirements (JOLLIFFE, 1950). Most of the patients that come to our Department are children suffering from chronic underfeeding resulting from an insufficient diet, both in quantity and quality, to which they have been submitted for at least three-quarters of their lives. When underfeeding is moderate, or has acted for only a short time, the "nutritional reserves" of the organism are only partially depleted, and malnutrition exhibits a mild clinical picture, where the body weight ranges between 76-90 per cent of the theoretical average for the child's age. This, we call first degree malnutrition. As the effect of under-feeding becomes more serious, the picture becomes more marked, resulting in second degree malnutrition. At this stage, the weight is between 61-75 per cent of the theoretical average for the age. The clinical picture, the prognosis, and the treatment become much more complicated, and frequently the patient requires hospital care. In third degree malnutrition, when the nutritional reserves are practically exhausted, the maximum weight is never more than 60 per cent. of the average for the age; while, in addition, there are serious somatic and functional, including psychological, changes. Treatment is very complicated and expensive, and the patient must be hospitalized. At this stage, the disease has a high mortality rate -- figures given by several authors ranging from 30 to 60 per cent. (LEVINDER, 1912; GILLMAN, 1951; DEAN, 1954). This classification of the disease -- according to its varying degrees of severity and its various clinical manifestations -- which has been adopted by us since 1946, has oftentimes been criticised. Recently the Guatemalan research workers have introduced the so-called "concept of Incipient Infantile Pluricarential Syndrome (pre-Kwashiorkor)" (SCRIMSHAW, 1955). In other words, they also accept degrees of severity, but use a different terminology. We have conducted a careful study of both the clinical picture preceding death and of the apparent cause of death in a large group of children suffering from chronic malnutrition due to underfeeding seen between 1949 and 1952, and useful information has thereby been obtained which will assist in assessing the prognosis and the correct form of treatment in this type of case in the future. In due course, we shall also report on a second group studied from 1953 through 1955. MATERIAL Our study consisted of 733 children admitted to the Nutrition Department of the Hospital Infantil de Mexico, from 1949 through 1952. These cases had the following characteristics: (a) Previous diet. All the children had been submitted to a severe and prolonged restriction of food (Table I). The sources of protein were corn, beans, and wheat in small amounts. This diet was deficient in lysine, tryptophane, isoleucine, valine, threonine, methionine and cystine. The biological value of the protein mixture, calculated according to MITCHELL and BLOCK's formula (1946), was only 69 per cent. …