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Editor,—The paper by Poskitt and colleagues1 suggests that diarrhoea does not contribute significantly to malnutrition in Gambia and proposes that poor diet is likely to be the main cause. The accompanying commentary by Weaver puts forward the idea that Helicobacter pylorimay also be implicated. The reality is that there are many causes of malnutrition in African children including those mentioned in the paper.
The paper points out that catch up growth after acute diarrhoeal disease requires energy intakes 50% in excess of recommendations. In Gambia micronutrient and macronutrient supplementation has been tried over 14 years without obtaining significant catch up growth,2 as quoted in the paper. Mention is made of the role of enteropathy in causing malnutrition and poor growth. The evidence for this was published in 1991,3 and suggested that impaired mucosal integrity, secondary to chronic inflammation, is largely to blame with 40% of poor growth attributable to poor small bowel function. Thus the effect of enteropathy appears to be significantly greater than any response to dietary supplementation.
Enteropathy is widespread in the tropics and has been termed “tropical enteropathy”, the cause of which is uncertain and could include infection, nutrient deficiency or postenteritis food allergy. Although acute diarrhoeal disease may not contribute significantly towards poor growth, the underlying enteropathy undoubtably does. Clearly, adequate nutrition is crucial for growth, but for many African children this may not be enough.