Improving child survival: Malnutrition Task Force and the paediatrician's responsibility

Malnutrition (underweight) contributes to approximately 60% of all child deaths, yet health professionals, policy makers, and donor agencies often fail to recognise its relevance to child survival. There is a need for the paediatric community to champion the importance of adequate nutrition for normal growth and development, and of placing sufficient emphasis on the prevention and treatment of malnutrition. Many severely malnourished children die from inappropriate treatment. Case fatality rates of 25-30% are commonly found and in some hospitals as many as 50-70% will die. Many of these deaths are avoidable. Weaknesses in health systems, inappropriate training of doctors and nurses, inadequate supervision, and lack of support for staff all contribute to compromised quality of care. The International Union of Nutritional Sciences, with support from the International Pediatric Association, Launched a global Malnutrition Task Force in 2005. The main objective is to ensure that an integrated system of prevention and treatment of malnutrition is actively supported as a fundamental aspect of care, and becomes an integral part of all training programmes.     

Malnutrition: a secular challenge to child nutrition

OBJECTIVE: To review current knowledge about child malnutrition, including the historical aspects of the problem, its dimension as a childhood public health problem, its natural history, physiopathology, clinical features, diagnosis and treatment, and strategies used by the health sector to control this disease. METHODS: Information was collected by researching the Medline system, the Bireme library, internet sites of interest, catalogues of publications produced by Brazilian governmental organizations and international institutions dealing with child nutrition. RESULTS: The review pointed out that despite recent world prevalence reduction, child malnutrition is a major public health problem in developing countries. Malnutrition, in any of its forms, contributes for more than 50% of deaths among children under 5 years in those countries. Mortality rates of severely malnourished children treated as in patients have been unchanged for the last five decades. Guidelines for improving the treatment and reducing mortality rates of severely malnourished children treated in hospitals were recently defined by the World Health Organization. Even though some positive results have been achieved by the health sector in reducing child malnutrition prevalence, the effectivity of the interventions is often low. Lack of food might limit the success in treating and preventing malnutrition. Factors that may contribute to the effectiveness of interventions against malnutrition include approaches which reassure the confidence of health professionals about achieving positive results with the proper treatment of malnourished children, establishment of an effective relationship between health professionals and mothers, as well as practical support to mothers in recognizing them as valuable active agents for their children nutrition rehabilitation at the household level. CONCLUSIONS: Throughout the centuries, malnutrition has been the biggest challenge faced by developing countries in order to guarantee to children under five years of age their right of being well nourished and healthy. The current challenge is the proper use of the available scientific knowledge on child nutrition to further reduce the figures for all the types of child malnutrition.     

Programmatic Approaches for Nutritional Care in India: Addressing the Continuum of Care Perspectives

Child health and nutrition is nested within a larger gamut of child care and development, functioning through the health care system. Malnutrition is multidimensional and rooted in poor early childhood care and development that is shaped by environmental, social and economic factors. Current nutrition care interventions are marked by a piecemeal approach, focusing on treating malnutrition but overlooking the need for rehabilitation and care support. Continuum of care (CoC) as an approach aims for a seamless and need-based care, bearing an impact on improved care output, beneficiary participation, care experience and access to care. CoC in nutrition care shall contribute to integration of nutrition and health care services, addressing distal and proximal causes of undernutrition through a gamut of preventive, promotive, treatment and rehabilitative care.     

Falling between two stools: Operational inconsistencies between ICDS and NRHM in the management of severe malnutrition

There has been a welcome interest in the issue of malnutrition by policy makers as well as technical experts in the recent years. The current public health systems for management of malnutrition, the ICDS and NRHM, have attempted to evolve approaches to the management of severe malnutrition. This paper makes a fresh analysis of data from well-accepted existing sources, indicating that 36-44% of all children with Severe Acute Malnutrition (SAM) are likely to be missed by current criteria of screening and referral; simultaneously, a large proportion of children selected for referral to Nutritional rehabilitation centres are likely not to have SAM. The paper also highlights other areas of inconsistencies between the ICDS and the NRHM in the continuum of care required for the prevention and proper management of severe malnutrition. Thus, the paper identifies areas that need further exploration to achieve a seamless and effective program for tackling severe malnutrition.     

Malnutrition treatment to become a core competency

The International Pediatric Association has resolved that the identification and treatment of severe malnutrition should be a core competency for paediatricians and related health professionals worldwide. The Resolution is in response to the urgent need to reduce deaths and disability among young children. The Resolution has implications for the training of doctors, nurses and other health workers as current curricula are often insufficient to confer competency. Results of a survey of national paediatric societies suggest that training institutions need assistance in teaching about malnutrition treatment. Formation of national multidisciplinary teams for advocacy, strategic planning and action are proposed and it is anticipated that paediatricians will play a major role.     

The need for nutrition support teams in pediatric units: a commentary by the ESPGHAN committee on nutrition

The reported prevalence of malnutrition in pediatric hospitals ranges from 15% to 30% of patients, with an impact on growth, morbidity and mortality. Major deficits in nutrition care have been highlighted in European hospitals, and the implementation of nutrition support teams (NSTs) has been suggested as a means to improve malnutrition diagnosis and nutrition care for hospitalized patients.This comment by the ESPGHAN Committee on Nutrition reviews disease related-mechanisms causing malnutrition and consequences of malnutrition and suggests a framework for implementation of NSTs in pediatric units. The recommendations by the Committee on Nutrition include: 1) Implementation of NSTs in hospitals is recommended to improve nutritional management of sick children; 2) The main tasks of the NST should include screening for nutritional risk, identification of patients who require nutritional support, provision of adequate nutritional management, education and training of hospital staff and audit of practice; 3) The NST should be multidisciplinary, with expertise in all aspects of clinical nutrition care; 4) The funds needed to support NSTs should be raised from the health care system; and 5) Further research is needed to evaluate the effects of NSTs in prevention and management of pediatric nutritional disorders, including cost effectiveness in different settings.     

The pediatrician's role in the twenty-first century

Abstract The world's children comprise: (i) those in wealthy, industrialized countries; (ii) those from rapidly industrializing countries; (iii) minority groups including recently arrived immigrants in otherwise affluent and healthy societies; (iv) previously traditional people in rapid transition to urbanized, Western lifestyles; and (v) many millions living in grinding poverty in overcrowded, unhygienic conditions where child mortality is high and often due to malnutrition and infections. Industrialization, affluence, better housing, hygiene and nutrition, better clinical care and disease prevention have helped enhance child health in many countries over the past century. However, this is being offset by obesity, smoking, alcohol and drug abuse and social disruption, mental disease and high rates of violence including homicide and suicide. These 'new morbidities' are worse among minorities and in populations undergoing rapid social change. Social pressures including unemployment, depression and family dysfunction are important. Pediatricians must become active in decisions about the use of public resources in disease prevention, health education and more rational and equitable use of high technology. They should also be active advocates for children and their rights and advise governments about all issues that affect child health, protection and well-being. This is particularly so in the poorest and developing countries. There is a need for better international collaboration, training and exchange programs involving the International Pediatric Association, United Nations International Children's Emergency Fund, World Health Organization and other local, national and regional organizations to help overcome these problems as the next century draws near.     

W.H.O. activities for control of diarrheal disease in developing countries

Significant research advances in recent years have prompted national health administrators to ask WHO to give high priority to technical cooperation in the control of diarrheal diseases A WHO Diarrheal Diseases Control Programme has there-fore been developed consisting of a health services component and a research component. The former is concerned with the incorporation into national primary health care programme of new, effective strategies such as oral rehydration therapy along with education on proper dietetic management to reduce diarrhea-related mortality and malnutrition; and improved maternal and child health practices, better water supplies, sanitation, and food hygiene and epidemic control along with health education as an integral part of all these strategies. The research component of the programme provides support to operational and basic research to determine the best ways of applying new knowledge and to develop new and improved tools for prevention and treatment.     

Applying lessons learnt from research of child pneumonia management in Vietnam

Pneumonia is the leading cause of paediatric hospitalisation in Vietnam, placing a huge burden on the health care system. Pneumonia is also the main reason for antibiotic use in children. Unfortunately many hospital admissions for child pneumonia in Vietnam are unnecessary and inappropriate use of antibiotics is common, as in the rest of Asia, with little awareness of its adverse effects. We explored the value of an alternative approach that, instead of focusing on the identification of children with severe bacterial pneumonia, focuses on the identification of children with ‘unlikely bacterial pneumonia’ to improve patient care and rational antibiotic use. Implementing improved models of care require pragmatic management algorithms that are well validated, but it is ultimately dependent on financial structures, management support and evidence-based training of healthcare providers at all relevant levels. Apart from better case management, sustained reductions in the pneumonia disease burden also require increased emphasis on primary prevention.     

Treating severe acute malnutrition seriously.

Severe acute malnutrition (SAM) affects approximately 13 million children under the age of 5 and is associated with 1-2 million preventable child deaths each year. In most developing countries, case fatality rates (CFRs) in hospitals treating SAM remain at 20-30% and few of those requiring care actually access treatment. Recently, community-based therapeutic care (CTC) programmes treating most cases of SAM solely as outpatients have dramatically reduced CFRs and increased the numbers receiving care. CTC uses ready-to-use therapeutic foods and aims to increase access to services, promoting early presentation and compliance, thereby increasing coverage and recovery rates. Initial data indicate that this combination of centre-based and community-based care is cost effective and should be integrated into mainstream child survival programmes.     

Child nutrition in developing countries

Malnutrition permeates all aspects of health, growth, cognition, motor and social development of young children in developing countries. More than 50% of deaths in these children can be attributed to malnutrition, most often in conjunction with serious infection. Irreversible and lifelong sequelae prevent children from reaching their full potential. Child survival initiatives and programs have accomplished much to save the lives of children from common and preventable illnesses, but the quality of the survivors' health needs to be improved, with much more attention paid to nutrition of the preschool and school child. Promotion of nutritional health must become an integral part of primary health services, especially for infants, preschoolers, schoolchildren, and women. Promotion of exclusive breastfeeding and appropriate complementary feeding and weaning are essential inputs. A daunting challenge is to improve diet quality through the raising and consumption of small animals by rural subsistence households to enhance maternal and child nutrition. School feeding from preschool onward must be an integral part of education so children are in a condition to learn. An excellent example of such programs is the WHO initiated Integrated Management of Childhood Illness, which integrates nutrition into the care of both sick and well children. The Early Child Development Program initiated by the World Bank and UNICEF has taken hold in many countries. Nutrition outcomes are closely linked with health and education activities starting in the preconception period through pregnancy, lactation, and childhood. Investment in human capital early in life will optimize the growth and social and economic development of children, families, and communities.     

Treating severe acute malnutrition seriously

Severe acute malnutrition (SAM) affects approximately 13 million children under the age of 5 and is associated with 1-2 million preventable child deaths each year. In most developing countries, case fatality rates (CFRs) in hospitals treating SAM remain at 20-30% and few of those requiring care actually access treatment. Recently, community-based therapeutic care (CTC) programmes treating most cases of SAM solely as outpatients have dramatically reduced CFRs and increased the numbers receiving care. CTC uses ready-to-use therapeutic foods and aims to increase access to services, promoting early presentation and compliance, thereby increasing coverage and recovery rates. Initial data indicate that this combination of centre-based and community-based care is cost effective and should be integrated into mainstream child survival programmes.     

Newborn resuscitation in resource-limited settings

Every year, an estimated 4 million newborn infants die worldwide in the first 4 weeks of life. A large majority of these deaths occurs during the first day of life. One of the United Nations' eight Millennium Development Goals is to decrease child mortality; prevention of neonatal deaths by appropriate resuscitation will have a significant impact on achieving this goal. Newborn resuscitation needs to be carried out in all the settings where asphyxiated babies are born, including: community or domiciliary settings for home births; rural health centers/midwifery stations, where attendants with basic resuscitation skills might be available; district-level facilities where staff are available but skills vary; and urban referral and tertiary care centers. Individuals at all levels require training and seldomly used skills need to be maintained so that, when required, resuscitation can be carried out efficiently and effectively. Simple resuscitation techniques include: positioning, drying, and keeping the baby warm; assessing the heart rate, color, and respirations; recognizing the need for, and administering, assisted ventilation with a bag and mask or tube and mask. These maneuvers can be carried out with simple equipment and appropriate training. Research in developing countries remains sparse, with 90% of research being done in more developed parts of the world, which experience just 10% of the problems. The significant gaps in our understanding include: failing to agree on a definition of the term ‘asphyxia’, lack of knowledge of the impact of community approaches on the prevention and management of asphyxia, and a failure to recognize the best method to determine heart rate.     

Infant abuse in Osaka: Health center activities from 1988 to 1999

BACKGROUND: In 1988, the first survey of child abuse in Japan was conducted in Osaka Prefecture as a joint effort between medical, health and welfare agencies. Ensuing surveys in 1988 revealed that infant abuse had a death rate of 10% in Health Center. METHODS: In 1996 and 1999, surveys were performed on 130 and 215 abused children under 18 years of age. They were studied in terms of their activity of Health Center, including help, means of involvement by health visitors. RESULTS: Fifty-five percent of children were detected via health centers. In 69% of cases, health visitors listened to parents and promptly contacted other agencies. Ninety-five percent of cases had home visits. The concerted effort of the health centers with allied disciplines in Osaka Prefecture yielded the following changes: the mortality rate decreased from 9.8% in 1988 to 2.3% in 1996, and institutionalized cases tripled from 13.7% in 1988 to 39.5% in 1999. The rate of admission to day care centers increased from 22.4% in 1988 to 58.7% in 1999. Along with the constant support of health visitors, day care centers provided secure support and protection for parents and infants. CONCLUSIONS: Effective prevention and treatment become possible only when treatment of the child's physical and psychological health, mental care for parents and tangible support for childrearing and daily life were undertaken in a concerted way. To this end, a systematic commitment of all child agencies, child guidance centers, as well as medical, health educational, welfare and other allied disciplines is required.     

Nutritional Status and its Correlates Among Tribal Children of Melghat,Central India

Objective

To find out the magnitude and epidemiological determinants of malnutrition among 0–6 y tribal children.

Methods

A community based cross sectional study was done in the villages of Melghat in central India. The information of 540 children in the age group 0–6 y was collected. The newly developed WHO growth standards were used to calculate conventional indices of malnutrition (underweight, stunting and wasting) and composite index of anthropometric failure (CIAF). Univariate and multiple logistic regression analysis were used to find out the correlates of malnutrition.

Results

The prevalence of malnutrition among these tribal children in terms of underweight, stunting, and wasting were 60.9 %, 66.4 % and 18.8 % respectively. Malnutrition in terms of composite index of anthropometric failure (CIAF) was 76.3 %. The important correlates of malnutrition that emerged out of this study were the age of child, age of mother less than 20 y at her first pregnancy, practice of not feeding colostrum, calorie deficit diet, anemia and morbidities like diarrhea and acute respiratory illnesses.

Conclusions

The prevalence of malnutrition was high in tribal children. The health care delivery at village level should be strengthened for early diagnosis and prompt treatment of anemia and other morbidities in children. The strategies are needed to delay the child bearing age in this community and improve breast feeding practices.     

Novedades en las recomendaciones de reanimación cardiopulmonar pediátrica

Cardiac arrest has a high mortality in children. To improve the performance of cardiopulmonary resuscitation, it is essential to disseminate the international recommendations and the training of health professionals and the general population in resuscitation.This article summarises the 2015 European Paediatric Cardiopulmonary Resuscitation recommendations, which are based on a review of the advances in cardiopulmonary resuscitation and consensus in the science and treatment by the International Council on Resuscitation. The Spanish Paediatric Cardiopulmonary Resuscitation recommendations, developed by the Spanish Group of Paediatric and Neonatal Resuscitation, are an adaptation of the European recommendations, and will be used for training health professionals and the general population in resuscitation.This article highlights the main changes from the previous 2010 recommendations on prevention of cardiac arrest, the diagnosis of cardiac arrest, basic life support, advanced life support and post-resuscitation care, as well as reviewing the algorithms of treatment of basic life support, obstruction of the airway and advanced life support.     

Feasibility of engaging caregivers in at‐home surveillance of children with uncomplicated severe acute malnutrition

Many factors can contribute to low coverage of treatment for severe acute malnutrition (SAM), and a limited number of health facilities and trained personnel can constrain the number of children that receive treatment. Alternative models of care that shift the responsibility for routine clinical and anthropometric surveillance from the health facility to the household could reduce the burden of care associated with frequent facility‐based visits for both healthcare providers and caregivers. To assess the feasibility of shifting clinical surveillance to caregivers in the outpatient management of SAM, we conducted a pilot study to assess caregivers' understanding and retention of key concepts related to the surveillance of clinical danger signs and anthropometric measurement over a 28‐day period. At the time of a child's admission to nutritional treatment, a study nurse provided a short training to groups of caregivers on two topics: (a) clinical danger signs in children with SAM that warrant facility‐based care and (b) methods to measure and monitor their child's mid‐upper arm circumference. Caregiver understanding was assessed using standardized questionnaires before training, immediately after training, and 28 days after training. Knowledge of most clinical danger signs (e.g., convulsions, edema, poor appetite, respiratory distress, and lethargy) was low (0–45%) before training but increased immediately after and was retained 28 days after training. Agreement between nurse–caregiver mid‐upper arm circumference colour classifications was 77% (98/128) immediately after training and 80% after 28 days. These findings lend preliminary support to pursue further study of alternative models of care that allow for greater engagement of caregivers in the clinical and anthropometric surveillance of children with SAM.