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DEDICATION

Remembering Prof. Donald A. Hillman

Professor Donald Hillman died on 4th July 2006. He was a world renowned paediatrician, a champion of International Health, and a strong advocate for improving child health worldwide, particularly in developing countries. This third edition of “The Primary Health Care manual for medical students and other health workers” is dedicated to Don Hillman. His work will forever live on through the generations of undergraduate and postgraduate medical students all over the world whom he mentored and influenced in their careers, together with his wife Liz Hillman.

Dr. Donald Hillman graduated in Medicine at McGill University in Montreal, Canada in 1949. He received his postgraduate education at the Montreal Children’s Hospital, the Hospital for Sick Children in Toronto and at the Massachusetts General Hospital in Boston. He completed his PhD. in Investigative Medicine at McGill University in1961. He subsequently became a Professor of Paediatrics and Associate Dean of Postgraduate studies at McGill University, and a Professor in Paediatrics at Memorial University in Newfoundland.

From 1976 to 1989 Don Hillman and his wife Liz Hillman joined the then new Faculty of Medicine at Memorial University of Newfoundland as Professors of Paediatrics. Don Hillman became Physician-in-Chief and Liz Hillman was Director of Ambulatory Education at the Janeway Child Health Centre. In 1989 The Hillmans joined McMaster University in Hamilton in the field of international health. They later moved on to the University of Ottawa in the same field, now generally referred to as Global Health.

Internationally the Hillmans have also had a long and illustrious career having worked in more than 15 countries as consultants or visiting Professors. This includes Kenya, Uganda, Tanzania, Zambia, South Africa, China, Kuwait, Singapore, Laos, Malaysia, Bhutan, India, Guyana, Philippines and Pakistan. In the early 1970s McGill University teamed up with the Canadian International Developing Agencies (CIDA) to support the development of a new medical school at the University of Nairobi in Kenya. In 1974 Don and Liz Hillman accepted a four year appointment in the Department of Paediatrics and Child Health at the University of Nairobi. They worked together with Prof. Nimrod Bwibo and Dr. Alan Ross to strengthen the teaching of Paediatrics and Child Health at the University of Nairobi. This has now grown to be one of the largest undergraduate and postgraduate medical teaching programmes in Africa. Don and Liz Hillman later moved on to Makerere University in Uganda where they managed another CIDA funded project known as CHAMP (the Child Health and Maternal Educational Programme). They also served in senior advisory positions with UNICEF Kampala

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The McGill and Nairobi programmes and the CHAMP programme in Uganda were later to influence the development of the CIDA funded Primary Health Care East Africa (PHCEA) project in the late 1980s which was negotiated and championed by the Hillmans. The PHCEA project focused on improving the teaching of Paediatrics and Child Health in Kenya, Uganda, Tanzania and Zambia, including the exchange of students and staff. This project produced a popular teaching manual - The PrimaryHealth Care manual for medical students and other health workers - which is still in use today in at least five medical schools and is stocked in several libraries.

The Hillmans have also supported the development of new medical schools at Moi University (in Eldoret, Kenya), at Mbarara University for Science and Technology (Uganda), and at Gulu University (Uganda). Following their retirement in Canada, they continued their active involvement abroad in international health by serving as consultants or visiting professors. They undertook and completed assignments forCanadian External Services Organization (CESO) in Kenya, India, Guyana, Philippines and Pakistan. At the time of Don's death, the Hillmans were working on a project funded by the Royal College of Physicians and Surgeons of Canada in Zambia, Tanzania, Kenya and Uganda.

In recognition of this lifetime commitment and tremendous contribution to Global Health spanning over thirty-five years, the Hillmans received several awards. This includes the Ross Award (1989), the prestigious Orders of Canada (1994), the James H. Graham award (1995) the Lifetime Achievement Award of the Canadian Society for International Health, recognition by the American Academy of Paediatrics, and honorary doctor of laws degrees.

As we celebrate the life of Don Hillman, we thank him and his wife Liz for the tremendous contribution and lifetime commitment to international health, which will remain an inspiration for many years to come, to all of us including many generations of medical students and paediatricians all over the world. We dedicate this third edition of the “Primary Health Care Manual for medical students and other health workers” to our friend Don Hillman.

May His Soul Rest in Eternal Peace!

Prof. Kopano Mukelabai,Department of Paediatrics and Child Health, University of Zambia, Lusaka, Zambia

Formerly: Chairman of the Department of Paediatrics and Child Health at the University of Zambia Dean School of Medicine, University of Zambia (1984-1992)Senior Health Adviser in UNICEF (1992-2009)

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PREFACE TO THE THIRD EDITION

The Third Edition of the Primary Health Care manual has finally been produced. Lack of funding due to the global economic recession, has partly contributed to the delay in producing the current manual. We are very grateful to the University of British Columbia and specifically to Prof. Stuart Macleod and his wife Nancy for their concerted efforts to raise the critical funds needed to print the manual. We are also very grateful to Prof. Elizabeth Hillman and the Hillman Foundation for providing extra funds to print more copies of the manual and for providing funds to distribute the manual.

The third edition of the PHC manual is dedicated to our friend and colleague the late Prof. Donald Hillman who died on 4th July 2006.

Don Hillman, together with his wife Liz mooted the whole idea of the PHC East Africa Project and the subsequent publication of the PHC manual. We have written an obituary printed in this book to honour the life and work of Prof. Donald Hillman.The PHC manual is still very frequently used to teach both undergraduate and postgraduate medical students. This new edition will be distributed free of charge to seven medical schools in five countries in Eastern and Southern Africa. These are Zambia, Kenya, Tanzania, Uganda, and Ethiopia. The first two editions of the manual proved to be extremely popular among medical students and other health workers.

The major preparation of the third edition of the PHC manual took place at a meeting held at the Silver Springs Hotel in Nairobi in October 2008. It was a wonderful and productive meeting with representatives of 10 Universities present, including one representative from UNICEF. Other topics covered during the meeting included; sharing information on the postgraduate curriculum, exchange of staff and students, and conduction of joint research.

With five years remaining towards the attainment of the MDGs by 2015, the PHC manual will make an important contribution in assisting countries to achieve the health related MDGs. A few new chapters have been added to the manual to make it more comprehensive. We have also included the April 2008 Ouagadougou Declaration on PHC in Africa, which was signed by Ministers of Health from all countries in Africa. May the spirit of Don Hillman continue to guide the future direction of the PHC manual and its use by medical students and other health workers!

Finally let me once again thank all my colleagues who participated in the production of this third edition. Their commitment was total as they showed an incredible patience and understanding in waiting for the final production of the new manual. I also wish to thank Ms. Ruth Matano and Ms. Rosemary Mwasya for assisting us in organizing an extremely successful workshop to revise the third edition of the manual. Ms. Matano also assisted in preparing the final script of the new manual.

Kopano Mukelabai, 31st March 2010.

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PREFACE TO THE FIRST EDITION

This manual is designed to meet the learning needs of medical students and other health workers, to achieve competence in the understanding and management of priority problems in Primary Health Care in Zambia, Uganda, Tanzania and Kenya. It is applicable to other countries especially those in Africa with similar health problems.

Each chapter of the manual, has objectives related to an important Primary Health Care topic, and defines the knowledge, skills and attitude required to meet these objectives. The manual is intended to supplement paediatric texts and other reference materials, and is a targeted aid to Primary Health Care problem solving both in tertiary and Primary Health centres, which should both be the major sites for relevant health learning. Some of the chapters contain case illustrations designed to facilitate learning by presenting real-life problems relevant to the topic.

The manual contains self evaluation questions and a list of objectives. Other learning materials supplied by other institutions and organizations like W.H.O., UNICEF, etc. may be very useful. For the manual to be of continuing value, the students and the teachers must add relevant details of priority health problems in their region with particular focus and emphasis on the overall child health programmes. This should include collaborative emphasis on links between the training programmes and the country's health care system, both governmental and non-governmental.

In order to adapt to the rapidly changing field of primary health care teaching, revisions and additions to the problems presented here, must be developed by teachers and students to reflect changing priorities and approaches.

The editor wishes to thank the Canadian Government for providing the crucial financial support through CIDA (Canadian International Development Agency) to the Primary Health Care East Africa Project. Special thanks go to Memorial University of Newfoundland, which was the Canadian collaborating medical school, and its two dedicated faculty members Prof. Donald Hillman and Prof. Elizabeth Hillman.

I wish to acknowledge with thanks the strong support of the Universities of Zambia, Dar-es-Salaam, Nairobi and Makerere, which through their Principals and Deans, gave the widest latitude to their Chairmen of Departments of Paediatrics and Child Health and their staff and students, to successfully implement the Primary Health Care East Africa (PHC/EA) project.

Particular thanks go to the Chairmen of Departments of Paediatrics and Child Health and the Hillmans, who together mooted the whole idea of PHC/EA. Their congeniality, and extreme dedication ensured the smooth implementation of the project's stated objectives.

To Prof. Gabriel Anabwani, the first programme manager of PHC/EA project, who worked so hard to overcome most of the teething problems encountered, I say

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special thanks, and thanks go to all our departmental Secretaries who bore the brunt of retyping the illegible manuscripts. Particular thanks go to Mrs. Jane Thairu, University of Nairobi for typing the draft manuscript on her ACER 910, and to Mrs. Beatrice Mwanamuchende and Ms. Shirley Kapapa of University of Zambia who typed the revised final manuscripts.

Finally my gratitude goes to all our students and fellows whose constant quest for more knowledge was the prime mover for the production of this manual.The following are thanked for contributing directly or indirectly to the manual:

Prof. Donald Hillman, Memorial University, Newfoundland;Prof. Elizabeth Hillman, Memorial University, Newfoundland;Prof. Stuart Macleod, Dean, MacMaster University, Hamilton, Canada; Prof. Vic Neufeld, McMaster University, Canada;Prof. N. Bwibo, former Principal, University of Nairobi, College of Health Sciences;Prof. H. Pamba. former Dean, Faculty of Medicine, University of Nairobi;Prof. W. Makene - former Dean, Muhimbili Medical Center Dar-es-Salaam; Prof. G. Mwaluko, former Dean and Director General, Muhimbili Medical Centre, Dar-es-Salaam;Prof. J. W. Mugerwa, Dean Faculty of Medicine, Makerere University;Prof. R. Owor - Former Dean, Faculty of Medicine, Makerere University; Prof. Julius Meme, former Chairman, Dept. of Paediatrics and Child Health, University of Nairobi;Prof, F. Onyango, Chairman, Dept. of Paediatrics and Child Health, University of Nairobi;Prof. R. Mbise, former Chairman, Dept. of Paediatrics and Child Health, University of Dar-es-Salaam;Dr. E. Mwaikambo, Chairman, Dept. of Paediatrics and Child Health, Muhimbili Medical Center, Dar-es-Salaam;Prof. C. Ndugwa, Chairman, Dept. of Paediatrics and Child Health, Makerere University, Kampala;Prof. K. Mukelabai, Dean and former Chairman of Department of Paediatrics and Child Health, University of Zambia, Lusaka;Dr. Alfred Mutema, Nairobi;Mr. L. Dierick, Nairobi;Prof. Peter Kinyanjui, Common Wealth of Learning, University of Vancouver Canada;UNICEF; All Primary Health Care East Africa Fellows; All Faculty members of departments of Paediatrics and Child Health at Universities of Zambia ; Dar-es-Salaam, Makerere and Nairobi. Finally I wish to thank all my colleagues for their maximum cooperation and patience in implementing the PHC/EA project to the end. This manual lends credit to your dedicated and excellent efforts.

Prof. Kopano Mukelabai, Dean School of Medicine, University of Zambia, Former Chairman of the Department of Paediatrics. University of Zambia.

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A MESSAGE FROM DR. HAFDAN MAHLER, FORMER DIRECTOR GENERAL OF THE WORLD HEALTH ORGANIZATION

Health Care Workers and PHCWorld Health will improve only if the people themselves become involved in planning, implementing and having a say about their own health and health care. But involvement will not just happen. How serious are we about involving individuals, families and communities? Are we prepared- mentally and professionally to listen to their concerns, to learn from them what they feel is important, to share with them appropriate information, encourage and support them. Are we ready to assist them in choosing from alternative solutions, in setting their own targets and evaluating their efforts?

In many cases, so far, the answer is no. We can go on and on developing plans: nothing will happen unless all health workers, all health managers, and key professionals in other sectors come to realize what is at stake.

First, health workers must understand that the concept of primary health care involves new roles for them and a new outlook. Not only should we be concerned with disease prevention and control, we must also be concerned with health promotion and care - and not least with development in general – and with people. Our health technologies must be based on what the people themselves want and need. In other words, the worker should learn first and foremost to act as a facilitator of action by individuals, families and communities. We must stop trying to fit communities into systems and programs we devise, without a real and deep feeling for the social aspects of health problems or the economic constraints-not to speak of the cultural dissonance that is often the backlash of such programs.

Second, health workers must accept their new roles. They must accept new ideas, must be taken to try them out, to adapt them, to broaden their scope and innovate in the partnership approach. Their main concept must be to find ways of helping individuals and communities become self-reliant. It must be made clear that advocating self-reliance in health matters in no way means abdicating our responsibilities and passing them on to someone else. Both lay persons and professionals are essential. They cannot replace each other, but they must work together.

This brings me to my third point: health workers must have the necessary skills to perform these new roles effectively and to make efficient use of existing knowledge. This calls for a training force fully familiar with accumulated experience and keen to provide the kind and quality of professional preparation needed. It also calls for full backing from health managers for such training.

All health care workers must meet these requirements. This manual helps define the role of health workers in Primary Health Care. Your skills and commitment to this role will be of critical importance to the achievement of Health for All by the year 2000.

Halfdan Mahler, Former Director General, World Health Organization

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TABLE OF CONTENTS

Page No.

i Dedication to Prof. Donald Hillman iii Preface – 3rd Edition

iv Preface – 1st Editionix A message from Hafdan Mahler former WHO Director

General

CHAPTERS AND AUTHORS

1 1 PRIMARY HEALTH CARE Elizabeth Hillman, Kate Wotton,

Kopano Mukelabai

16 2 CARE OF NEW BORNRachel Musoke, Mary Shilalukey Ngoma,

Aggrey Wasunna

25 3 INFANT AND YOUNG CHILD FEEDING (IYCF)

Rachel Musoke, Ruth Nduati, Aggrey Wasunna

43 4 CHILD NUTRITIONRuth Nduati, Ahmed Laving, Heena Hooker,

Peter Ngwatu

60 5 EARLY CHILDHOOD DEVELOPMENTRuth Nduati

76 6 GROWTH MONITTORING AND PROMOTION DURING EARLY CHILDHOODDaniel Njai, Rachel Musoke, Ruth Nduati, Aggrey Wasunna

97 7 CHILDHOOD IMMUNIZATIONAmos Odiit, Esther D. Mwaikambo

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Page No. CHAPTERS AND AUTHORS

105 8 CONTROL OF DIARRHOEAL DISEASES Israel Kalyesubula

118 9 ACUTE RESPIRATORY INFECTIONS IN CHILDRENElizabeth Maleche-Obimbo, Ezekiel M Wafula

131 10 ASHMA IN CHILDRENChris M. Ndugwa, Somwe Wa Somwe, Elizabeth Maleche-Obimbo,

Dalton Wamalwa, Dinberu Tefera Muluwork

139 11 TUBERCULOSIS IN CHILDRENElizabeth Maleche-Obimbo, Andrew Ndamira, Catherine Chunda

152 12 MALARIA IN CHILDRENAmos Odiit, Sarah Kiguli, Samuel Ayaya,

Esther D. Mwaikambo

163 13 HIV INFECTION AND AIDS IN CHILDRENGabriel Anabwani, Israel Kalyesubula, Ruth Nduati, Catherine Chunda,Elizabeth Maleche-Obimbo

176 14 ANAEMIA AND SICKLE CELL DISEASE

Catherine Chunda, Chris Ndugwa, N. Kariuki, Nimrod O. Bwibo

186 15 ADOLESCENT HEALTH, DRUG AND SUBSTANCE ABUSES. Bakeera-Kitaka, Amos Odiit, Samuel Ayaya, Esther D. Mwaikambo

194 16. ACCIDENTS AND POISONINGFV Murila, Chris M. Ndugwa, Ruth Nduati, Somwe Wa Somwe, Dalton Wamalwa, Dinberu Tefera Muluwork

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,Page No. CHAPTERS AND AUTHORS

211 17 CARDIOVASCULAR DISEASES IN CHILDHOODChristine Yuko-Jowi, Gabriel Anabwani

222 18 COMMON SKIN DISEASES IN CHILDRENSamuel Ayaya, Amos Odiit, Esther D. Mwaikambo

233 19 ESSENTIAL DRUGS AND RATIONAL USE OF ANTIBIOTICS

Chris M Ndugwa, Somwe Wa Somwe,

Elizabeth Maleche-Obimbo, Dalton Wamalwa, Gabriel Anabwani

Dinberu Tefera Muluwork,

251 20 CHILDREN IN ESPECIALLY DIFFICULT CIRCUMSTANCESNimrod O Bwibo, Mary Shilalukey Ngoma

258 21 HEALTH EDUCATION, COMMUNICATION SKILLS AND COUNSELLINGEsther D. Mwaikambo, Amos Odiit

265 22 INTERGRATED MANAGEMENT OF CHILDHOOD ILLNESS

Kopano Mukelabai,

311 23 APPROACHES TO IMPROVE QUALITY OF SERVICES FOR HOSPITALIZED SICK CHILDRENStephen N. Kinoti

326 24 NATIONAL HEALTH SECTOR REFORMS AND HEALTH CARE

FINANCINGEsther D. Mwaikambo, Stephen N. Kinoti,Amos Odiit, Samuel Ayaya

332 25 BASIC STATISTICS FOR HEALTH CARE

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Dalton Wamalwa and Jeremiah Banda [

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CHAPTER 1

PRIMARY HEALTH CARE

Elizabeth Hillman, Kate Wotton, Kopano Mukelabai

“A world that is greatly out of balance in matters of health is neither stable nor secure. Viewed against current trends, primary health care looks more and more like a smart way to get health development back on track. Thirty years of well-monitored experience tell us what works and where we need to head, in rich and poor countries alike.”

Margaret Chan, World Health Report, Oct 2008

Introduction Like many great and timely ideas, Primary Health Care emerged in several places at the same time. In China, the success of the barefoot doctors, local village health workers trained in first aid with a focus on prevention, improved health for rural Chinese on a grand scale. In South East Asia, the importance of prevention, local midwives, community involvement and good nutrition was documented in Health in the Developing World by John Bryant Africa too was moving towards a focus on more accessible care. In Uganda in the 1960s, Maurice King, a microbiologist teaching at Makerere undertook a locum for a friend in the Karamoja, a remote region of nomadic people with few health care workers. It was an eye-opener and led to his collecting a group of like–minded physicians in Africa for a symposium. From this meeting, a classic text on primary health care, Medical Care in the Developing World, subtitled a Primer on the Medicine of Poverty was published. For the first time the relationship between the catchment area of a health facility and the time it takes to walk to and fro appeared in print. Not unexpectedly almost 90 per cent of those seeking care from a health unit were drawn from a radius of less than 5 km – the distance a mother with a child on her back, or a toddler in tow, could walk in a day. This finding led to a reassessment of the role of hospitals and the need for more accessible care. A pediatrician working in West Africa, David Morley introduced the concept of Under- 5 Clinics dealing with mothers and children, who are the most vulnerable members of the community. In another classic, Pediatrics Priorities in the Developing World, he pioneered an improved design of such clinics to allow more and better care for children and their mothers. About the same time, important aspects of nutrition, such as the onset of kwashiorkor in the older child weaned early when a new child is born, were identified by the Jelliffes and Cecily Williams. This set the scene for the WHO, UNICEF and the NGOs to pull together the WHO Declaration of Primary Health Care in Alma Ata in 1978 with the goal of Health for All by the Year 2000. At the time there was concern that such a lofty goal was unattainable. But health workers in the developing world were insistent that the goal was needed and could be achieved.

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Objectives:

At the end of this session, the student will be able to:

Describe the concept of Primary Health Care.

List 8 elements of PHC

Clarify 8 principles of PHC.

Advocate for community participation.

Learning Activities:

Read the Declaration of Alma Ata, WHO, 1978 Report of the International Conference of PHC; Chapter 1, UNICEF State of the World, 2008 and World Health Report 2008 on PHC and Ouagadougou Declaration on PHC and Health Systems in Africa, 2008

Meet with district and local health staff, UNICEF and NGOs to become familiar with existing PHC programs and available reference materials.

Participate in a community meeting in which community involvement in a PHC issue is discussed.

Outline a PHC approach to a specific child health issue.

Definition of PHC: PHC is spelled out in detail in Article VI of the Declaration of Alma Ata. “Primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-reliance and self-determination. It forms an integral part both of the country’s health system, of which it is the central function and main focus, and of the overall social and economic development of the community. It is the first level of contact of individuals, the family and community with the national health system bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process.” Alma Ata, 1978

Health is defined as a state of complete physical, mental, social and spiritual well being and not merely the absence of disease or infirmity. These four elements of well being influence each other. When the influence is positive the individual enjoys a healthy life. Conversely when the influence is negative the individual suffers ill health. WHO

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The 8 Elements of PHC The eight elements or program of PHC spell out MEDICINE and are sometimes referred to as the New Medicine M - Maternal & Child Health

Child deaths are far more common when births are too many or too close together or occur to mothers who are too young. Children born to women under 20 years of age are almost twice as likely to die in infancy as children born to women in their mid 20s. Births need to be spaced to save lives. When children are born at least two years apart, infant deaths fall from 14% to 6%.

E - Education

Health education needs to be interactive, pervasive and eagerly taken up by all health workers. Female literacy is one of the most important ways to improve a family’s health. Globally four out of ten women are illiterate and in some countries as many as eight out of ten. Educating girls is closely associated with falling infant mortality, decreasing birth rates and improved nutrition.

D – Drinkable Water and Safe Sanitation

Lack of clean, drinkable water causes many diseases. Efforts are needed to make water safe and available for everyone. To result in permanent solutions, women

need to be involved actively in water projects.

I – Immunization One of the greatest success stories of PHC has been immunization. Small pox was the first disease to be eradicated. Great advances have been made in controlling polio and in combining vaccines. Measles remains a challenge because it I requires an intact cold chain. Another challenge is in immunizing all children against the eight killer diseases in the

first year of life.

For almost all children, the most important primary health care worker is the mother.

Teaching Other People May be More Important than Doing it Ourselves.

The Cold Chain The cold chain refers to the need for refrigeration of the vaccine while getting it to the most rural and remote places New technology developed: temperature monitors, cold boxes, Purchase and maintenance of kerosene refrigerators Reliable transport system Retraining of health workers

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C – Control of Endemic Disease Endemic diseases are those commonly found in a region. Malaria is endemic in Sub-Saharan Africa and meningitis is endemic in the meningitis belt of Northern Africa. Appropriate technology has been identified to assist with control of many endemic diseases including insecticide-treated bed nets in malarial areas and ORS for treatment of diarrhea.

I – Treatment of Illness and Injury Curative care for illness or injury is but one of the eight PHC programs. Care needs to be provided close to where people live. Appropriate, accessible treatment also needs to be affordable. In many developing countries poor people now pay two- ten times more out of the own pocket for their health care than is provided by the government. N - Nutrition and Food

Good food is one of the basic determinants of good health. Breast feeding not only provides an excellent source of food for a child but provides important protection from disease in the first few months of life. Breastfeeding for the first two years of life provides valuable protein and energy for children. A healthy, balanced diet for women in pregnancy results in fewer low birth weight babies and fewer pregnancy complications. In some countries low birth weight babies account for as many of one in five births.

E – Essential Drugs

Essential drugs are the basic drugs needed to treat common illnesses and disease in a country. PED DRUGS NEEDED Most developing countries have 20 drugs for rural dispensaries and health centers and a somewhat larger but still limited list of drugs for hospitals. A system to ensure ongoing supply, storage, dispensing and training of staff is a key part of ensuring provision of essential drugs.

Some countries included other programs into the basic health program list such as dental care and mental health but all countries had the basic eight PHC elements.

The 4As Health care and prevention needs to address the 4As Acceptable Affordable Accessible Appropriate

“A health system based on PHC cannot be realized, cannot be developed, cannot function and simply cannot exist without a network of physicians and hospitals with responsibilities for supporting primary health care, promoting community health development action, basic and continuing education of all categories of health personnel and research.” Halfdan Mahler, WHO

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Characteristics of PHC Underlying the eight PHC elements are a number of characteristics or principles. Community Participation

Participation is more than involvement and is much more than contributing labour and time although both are often necessary. Participation means being included in planning, decision-making, implementation and evaluation. Through full participation people grow in knowledge and confidence and can be empowered to make the changes needed to improve their health and that of their families. Participation needs to involve women and the disadvantaged. Intersectoral Collaboration Health is much more than merely the absence of disease. Health involves the food we eat, the work we do, the relationship we have and the education we receive. To fully achieve health we need to work collaboratively with those in other sectors such as education, agriculture, women’s affairs, local government etc. For example, what is taught in school can be improved to ensure children are taught about important health problems, such as diarrhoea and how it can be managed using ORS.

Prevention Since there will never be sufficient resources to treat all current and possible diseases, we need to begin to prevent those that can be prevented. Prevention is not only better for people, it also saves money. Most people, given the information and opportunity are more interested in preventing health problems than dealing with disease. Appropriate Technology Appropriate technology is technology which the community can afford, implement and maintain. It needs to be simple, effective and scientifically sound so it will be sustainable. Simple solutions have been provided which prevent many illnesses. Examples include: Oral rehydration salts; Child to

Child programs in First Aid;

Support Breastfeeding Allow mothers to have their babies with them Let mothers put their babies to the breast soon after birth Help mothers overcome problems Provide correct information to mothers Eliminate routine bottle-feeding Eliminate free samples of breastmilk substitutes Remove all advertising for breast milk substitutes

The Tippy Tap used for washing hands, delivers small

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Training of Traditional Birth Attendants (TBA) in prenatal care; Tippy Taps and energy efficient stoves. Decentralization Decentralization of health care puts control back into the hands of the local community. Decentralization devolves responsibility for health to district health teams and provides them with the training and the resources to do it. Integration of Health Services For the children and their mothers to receive good health care, it is important to provide all the care that they both need at the same place and time. When a mother has spent her day bringing a sick child to the clinic, it is important that she be provided with health education to prevent future episodes, her children are immunized and weighed and contraception advise and antenatal care are provided if appropriate. Sustainability Sustainability is the ability to carry on and maintain services. Attention to sustainability is needed at the time programs are first put in place, so that once established, they can be continued. Hopefully many health programs can be sustained by the community with minimal outside assistance. Equity and Social Justice Equity involves more than being equal. It requires that resources be distributed according to need. Those who have more need for health services should receive more. Social justice is a way to leveling the playing field for all.

“There isn’t a single problem in global health that we don’t have the means to deal with. It is not even that expensive. It just requires commitment, expertise and resources.”

Nils Daulaire, Global Health Council

Approximately three quarters of health budgets are spent on doctors and hospitals providing curative care for a small minority of people, mainly in towns and cities. Approximately three-quarters of disease in the world is preventable through primary health care. Primary health care workers cost a tiny fraction of the cost of training a doctor and are often more effective in promoting good health.

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PHC Responding to a Changing World

Ongoing Challenges

High maternal, infant, and under-five mortality often indicates lack of access to basic services such as clean water and sanitation, immunizations and proper nutrition. Vast differences in health occur within countries and sometimes within individual cities. In Nairobi, for example, the under-five mortality rate is below 15 per 1000 in the high-income area. In a slum in the same city, the rate is 254 per 1000.

Of the estimated 136 million women who will give birth this year, around 58 million will receive no medical assistance whatsoever during childbirth and the postpartum period, endangering their lives and that of their infants.

After thirty years of PHC activity, WHO suggested that many health systems have lost their focus on fair access to care, their ability to invest resources wisely, and their capacity to meet the needs and expectations of people, especially in impoverished and marginalized groups. As well, inequitable access, impoverishing costs, and erosion of trust in health care constitute a threat to social stability.

When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment. Such lessons take on critical importance at a time of global financial crisis.

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“It is in child health that the greatest of all gains can now be made. Today, a solid scientific consensus stands behind a body of knowledge, traditional as well as modern, discovered or rediscovered, which can enable most families to prevent as well as treat almost all the major causes of child death and malnutrition at a cost which they can afford.”

Halfdan Mahler, WHO

Increasing Relevance of PHC

In calling for a return to primary health care, WHO and UNICEF argue that its values, principles and approaches are more relevant now and inequalities in health outcomes and access to care are much greater today than they ever were before.

In far too many cases, people who are well-off and generally healthier have the best access to the best care, while the poor are left to fend for themselves. Health care is often delivered according to a model that concentrates on disease, high technology, and specialist care, with health viewed as a product of biomedical interventions and the power of prevention largely ignored.

Specialists may perform tasks that are better managed by other health workers. This contributes to inefficiency, restricts access, and deprives patients of opportunities for comprehensive care. When health is skewered towards specialist care, a broad menu of protective and preventive interventions tends to be lost.

Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.

Fragmented Health Care

In the developing world, care tends to be fragmented into discrete initiatives focused on individual diseases or projects, with little attention to coherence and little investment in basic infrastructures, services, and staff. Above all, health care is failing to respond to rising social expectations for health care that is people-centred, fair, affordable and efficient.

A primary health care approach, when properly implemented, protects against many of these problems. It promotes a holistic approach to health that makes prevention equally important as cure in a continuum of care that extends throughout the lifespan. As part of

WHO estimates that better use of existing preventive measures could reduce the global burden of disease by as much as 70%.

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this holistic approach, it works to influence fundamental determinants of health that arise in multiple non-health sectors, offering an upstream attack on threats to health.

Primary health care brings balance back to health care, and puts families and communities at the hub of the health system. With an emphasis on local ownership, it honours the resilience and ingenuity of the human spirit and makes space for solutions created by communities, owned by them, and sustained by them.

Working Towards Fairness, Efficiency and Compassion

The core strategy for tackling inequalities is to move towards universal coverage in a spirit of equity, social justice, and solidarity. Fairness, efficiency and compassion in service delivery especially targeting the most vulnerable populations, should be the overarching goals.

Primary health care also offers the best way of coping with the ills of life in the 21st century: the globalization of unhealthy lifestyles, rapid unplanned urbanization, environmental changes and the ageing of populations. These trends contribute to a rise in chronic diseases, like heart disease, stroke, cancer, diabetes and asthma, which create new demands for long-term care and strong community support. A multisectoral approach is central to prevention, as the main risk factors for these diseases lie outside the health sector.

REFERENCES:

UNICEF, State of the World’s Children, 2008. Alma Ata Declaration, Report of the International Conference on Primary Health Care, 06-12 September 1978, WHO Bulletin, Geneva 1978 World Health Report 2008, PHC Ouagadougou Declaration on PHC and Health Systems in Africa, April 2008 “Too many of us still think of medical care systems or interventions rather than thinking along new lines in order to understand the determinants of the new problems and to grasp opportunities that reach beyond the health care system….we do not need just a little bit more health education here and there; we need a new approach to action and a strong alliance to move us forward.’ Halfdan Mahler

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Upstream Downstream – a parable It was many years ago that villagers of Downstream recall spotting the first body in the river. Some old timers remember how spartan were the facilities and procedures for managing that sort of thing. Sometimes, they say, it would take hours to pull 10 people from the river, and even then only a few would recover.

Though the number of victims in the river has increased greatly in recent years, the folks of Downstream have responded admirably to the challenge. Their rescue system is clearly second to none: most people discovered in the swirling waters are reached within 20 minutes; many less than 10. Only a small number drown each day before help arrives; a big improvement from the way it used to be.

Talk to the people of Downstream and they'll speak with pride about the new hospital by the edge of the waters, the flotilla of rescue boats ready for service at a moment's notice, the comprehensive health plans for coordinating all the manpower involved, and the large numbers of highly trained and dedicated swimmers all ready to risk their lives to save victims from the raging currents. Sure it costs a lot but, say the people from Downstream, what else can decent people do except to provide whatever is necessary when human lives are at stake.

Oh, a few people in Downstream have raised the question now and again; "What's going on Upstream? Why are these bodies in the river at all?" But most folks show little interest in what's happening Upstream. It seems there's so much to do to help those in the river that nobody's got time to check how all those bodies are getting there in the first place. That's the way things are sometimes.

Don Ardell

COULD USE AN ILLUSTRATION

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When teeth are together they can break bones. Ankole proverb When spider webs unite they can tie up a lion. Ethiopian proverb The teeth which are together break bone Runyankole proverb There is a path to the top of highest mountain. Do not look where you fell, but where you slipped. African proverb If you don't stand for something, you will fall for anything African proverb Lack of knowledge is darker than night Hausa proverb When the drumbeat changes, the dance changes Hausa proverb Even the mightiest eagle comes down to the tree tops to rest Ugandan proverb A home without a mother is a desert Eritrean proverb Elderliness is not a disease, but a richness. Kiganda proverb Who digs the well should not be refused water. Swahili proverb When a lion roars, he does not catch game African proverb “A new model is needed for research in developing countries. A model that promotes locally applied research that enhances capacity and answers that arise from the community. It could be called micro-research and be based, like micro-finance, on small grants for those who have little access to funding opportunities.” Jerome Kabakyenga, Dean, Mbarara, Uganda and Noni Macdonald, ed. CMAJ

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DECLARATION BY THE International Conference on Primary Health Care and Health Systems in Africa, Ouagadougou, Burkina Faso, 28-30 April 2008 The Conference held in Ouagadougou, Burkina Faso from 28-30 April 2008, declare as follows: I. Deeply concerned by the many public health challenges that our continent is facing

including:

The high burden of disease;

The weakness of health systems with inadequate social protection and insufficient financial and human resources for health, a situation worsened by brain drain;

The widespread poverty among the majority of the population;

The impact of armed conflicts and violence;

II. Recalling the Alma-Ata Declaration of September 1978 inviting all governments and the international community to protect and promote the health of all peoples of the world;

III. Recalling the declaration by Heads of State and government of the Organization of African Unity at its 23rd Ordinary Session in Addis Ababa in 1987 on health as the bedrock of development;

IV. Recalling the commitment made by Heads of State of all countries in the world in September 2000 to achieve by 2015, the eight Millennium Development Goals four of which are related to health;

V. Recalling Regional Committee Resolution AFR/RC50/R1 passed in Ouagadougou in 2000 on Health-for-all Policy for the 21st Century: Agenda 2020;

VI. Recalling Resolution AFR/RC52/R5 adopted in Harare in 2002 on the strategy for accelerating the development of human resources for health and document AFR/RC57/9 on development of human resources for health in the WHO African Region: Current situation and way forward;

VII. Recalling Resolution WHA 58.33 urging Member States to ensure sustainable financing for health, universal coverage and the social security system;

VIII. Recalling the commitment that OAU Heads of State and Government made in 2001 on HIV/AIDS, tuberculosis, malaria and other related infectious diseases during the African Summit in Abuja to allocate 15% of national budgets to health;

IX. Recalling Regional Committee Resolution AFR/56/R6 adopted in Addis Ababa in September 2006 on revitalizing health services in the African Region using the Primary Health Care approach;

X. Recalling Regional Committee Resolution AFR/RC56/R5 passed in Addis Ababa in September 2006 on health financing: a strategy for the African Region;

XI. Recalling the Addis Ababa community health declaration of November 2006 urging States to create an environment conducive to the development of community health and take concrete action to strengthen health systems;

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XII. Recalling the declaration by the third ordinary session of the African Union conference of ministers of health in Johannesburg in April 2007 urging Member States to commit themselves to inter-ministerial collaboration for coordinated, harmonized and comprehensive response to the health challenges that Africa is facing;

XIII. Recognizing the link between health, poverty reduction, good governance, peace and security, gender integration and global commitment to universal access to PHC in order to facilitate the achievement of the Millennium Development Goals;

XIV. Considering that a healthy population is not only a development imperative but also a wealth for African countries;

XV. Considering the scarcity of resources for health in African countries; XVI. Recognizing that notwithstanding efforts by countries, there remain challenges

such as poverty, bad governance, low participation of communities especially women in decision-making process, weaknesses of health delivery systems including inadequacy of motivated and qualified human resources, limited capacity in care provision, weak interface between the community and the formal systems of health delivery resulting, very often, from lack of health awareness;

XVII. Recognizing that Africa will need to make increased efforts before it can achieve the Millennium Development Goals;

XVIII. Aware of the multidimensional nature of health, the importance of, and need for, intersectoral collaboration both internally and externally in order to improve the health status of the populations;

XIX. Realizing the historic opportunity provided by the interest shown in, and importance attached to, health as a factor of development.

The Conference:

1. Reaffirms the relevance and validity, today, of the basic principles and elements of the Alma-Ata Primary Health Care Strategy;

2. Makes a commitment to promote systematically the involvement and increased participation of communities in health development in order to facilitate the achievement of the Millennium Development Goals and improve the well-being of the peoples of Africa;

3. Strongly recommends;

1. To governments:

(a) To establish mechanisms for effective implementation of previous resolutions, declarations and other commitments to strengthen health systems and implement PHC;

(b) To undertake internal and external advocacy for revitalizing the PHC strategy in order to strengthen health systems;

(c) To accelerate the process of decentralization and deconcentration within the health system in order to meet the expressed needs of the populations;

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(d) To revitalize or establish an appropriate coordination mechanism that brings together the inter-ministerial committee, national health committees and other institutions with a view to harmonizing the complementary roles of the various levels of the health pyramid;

(e) To incorporate, in their national and district plans, priority interventions for revitalizing health services based on the PHC approach;

(f) To implement a programme of action to address the human resources for health crisis including effective deployment, stimulation of better performance and adequate response to brain drain;

(g) To strengthen planning and training with emphasis on public health, employment and human resources management and retention;

(h) To allocate resources in an equitable and sustainable manner based on the needs of the different levels of the health system;

(i) To promote intersectoral collaboration and public/private partnership including civil society in order to achieve the Millennium Development Goals;

(j) To revitalize referral systems to support integrated district health services; (k) To mobilize and bring together all development actors to enhance

cohesiveness and synergy in the choice and delivery of the planned integrated services;

(l) To formulate strategic health financing policies and plans fitting into the overall national development framework especially as regards medium-term expenditure and poverty reduction;

(m) To ensure that the financing plan is included in the national socioeconomic development plan;

(n) To promote health awareness among the population and strengthen the capacities of communities to provide for their own health care and be more involved in health activities;

(o) To ensure more effective monitoring, oversight and evaluation of health activities;

(p) To promote operational research on health systems in a manner that will facilitate evidence-based decision making;

(q) To establish mechanisms and conditions that would enable ministries of health to perform their role of leadership, regulation and good governance;

2. To communities:

(a) To organize themselves to take ownership of the management, protection and promotion of their own health;

(b) To be more involved in monitoring and feedback in regard to health services delivery and support within communities;

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(c) To do advocacy among members of the Diaspora for their effective involvement in development activities.

3. To sub regional, regional and international partners:

(a) To support the implementation of health development policies and plans in response to expressed needs;

(b) To commit themselves to proving technical and/or financial support in the long term to ensure sustainability of health actions;

(c) To increase investments in health systems strengthening;

4. To governments and development partners:

(a) Governments should create, at national level, the conditions (meetings, laws, regulations, etc.) needed to translate into concrete deeds the orientations contained in the reference document and the recommendations of the conference to improve the health status of the populations;

(b) Governments and partners should establish mechanisms to follow-up on the recommendations of this conference;

(c) The WHO Regional Office for Africa should produce a report each year for the Regional Committee and partners on the progress in the implementation of the recommendations of the conference;

(d) Governments, in collaboration with partners, should document best practices and encourage the dissemination and sharing of best experiences among countries of the region;

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CHAPTER 2

CARE OF NEW BORN

Rachel Musoke, Mary Shilalukey Ngoma, Aggrey Wasunna INTRODUCTION The fourth millennium development goal (MDG) focuses on reduction of the under five mortality. Many of the programmes that have contributed to the survival of the child under five years have omitted the neonatal period. As a result 38% of all deaths in the first 5 years are in this period. If we do not address the problems of the neonate we are unlikely to meet the global goal improving child survival. Improved survival will thus depend on investment in interventions that cater for newborn care. Within the neonatal period the highest deaths occur in the first 24 hours (25-45%) and up to 75% of deaths occur in the first 7 days. Many of these deaths are also related to the health of the mother. This is the basis of continuum of care approach for mothers, newborns and children (pregnancy, delivery and postnatal care). Health care should start with the girl child ensuring adequate nutrition and growth followed by cultural changes and life skills that enable the girl to prevent adolescent pregnancy. All pregnant women should get good care during pregnancy and delivery. The aim of care is to ensure intact survival of the mother and her baby. Many problems in this period lead to permanent disability. Majority are predictable. Care starts in the community but there should be a close liaison with the health facility. The SEARCH project, India, Gadchiroli, provides a good example of a culturally appropriate, evidence based community newborn care initiative from which many countries can learn, adapt and replicate. Though for child survival we tend to stress goal 4 of the MDG all other goals are equally important. For you cannot improve child survival without reducing poverty (goal 1), improving education and equity of women (goals 2 &3), maternal health (goal 5) as well as reducing infections in the mother (goal 6) and environmental sustainability (goal 7) Objectives At the end of this chapter the student should be able to: Define all terms used in the neonatal period Describe maternal health and education and their effect on the foetus and baby State principles of antenatal and perinatal care State principles of neonatal care List common causes of morbidity and mortality in the neonate Outline strategies that will reduce morbidity and mortality Recognize a sick neonate Organize neonatal services in a district Counsel and communicate with parents about baby care

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LEARNING ACTIVITIES Examine and be familiar with a normal newborn Recognize and infant with birth asphyxia and be able to resuscitate such a baby Recognize, refer or treat and prevent infections of the newborn Learn principle of cord care Be familiar with ways of keeping baby warm Observe and participate in different methods of feeding Recognize other common features of a sick neonate Plan care of low birth weight babies Plan neonatal services in a district Definitions Newborn (neonate)/neonatal period: age/period 0-28 days of postnatal life Early neonatal period: 0-7 days of postnatal life Late neonatal period: 8-28 days of postnatal life Preterm baby: <37 completed weeks of gestation Low birth weight (LBW): birth weight <2500g Small for gestational age: birth weight <10th percentile for gestation Perinatal mortality rate: stillbirths + 7 days postnatal deaths per 1000 births Neonatal mortality: deaths in the first 28 days per 1000 live births MATERNAL HEALTH & EDUCATION Delay/space pregnancies Babies born to young mothers tend to die (most of these pregnancies are unplanned). For healthy outcome for mother and baby the inter-pregnancy interval should ideally be at least 24 months and preferably 36 months. There is thus a need to find ways of providing family planning services to the majority of families Nutrition Pre pregnancy: Ideal is to have a well nourished woman before start of a pregnancy. A stunted child will lead to a stunted adult. Short women have difficulty deliveries. Micronutrient deficiency especially folate may lead to neural tube defects. During pregnancy: Macronutrients predispose to LBW Micronutrients (in particular iron, zinc, vitamin A, folic acid and iodine) lead to LBW, birth defects, pregnancy losses, increased infections. Infections During pregnancy: These may lead to foetal infections, intrauterine growth restriction, and preterm labour or foetal loss During labour and delivery: Baby is likely to pick infection especially if there is prolonged rupture of membranes.

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Maternal Education This is key for access and utilization of health services as well as self care and care for the baby. PRINCIPLES OF ANTENATAL & PERINATAL CARE Antenatal care (ANC) This is a good entry point for health care. About 70% of women in Africa attend ANC at least once during pregnancy. If 90% of women received good quality ANC up to 14% newborn lives would be saved. It is important for health workers in the community to know and record all women who are capable of becoming pregnant and to closely follow up those who are actually pregnant. Women need to be encouraged to attend antenatal care as early as possible. Focused antenatal care aims to respond to the needs of pregnant women with emphasis on: Adequate nutrition for the mother Immunization against tetanus (2 doses in first pregnancy, one for each subsequent pregnancy to a maximum of 5 doses) Preparation for breastfeeding Identification of women at risk of poor pregnancy outcome and referring them to equipped delivery units Treatment/control/prevention of pregnancy disorders (e.g. PET) Screening and appropriate care for HIV infection Birth and emergency preparedness at home Advice and support to develop health seeking behaviours Avoiding harmful practices during pregnancy Being aware of danger signs during pregnancy and child birth and seeking for help early. Danger signs during pregnancy include: Bleeding from the vagina during pregnancy High blood pressure and severe headache High fever Swollen hands and face Convulsions Labour and delivery Presence of a skilled attendant at each delivery to support a clean and safe delivery as well as immediate care of the baby Availability of transport and referral between community and health care facility Emergency obstetric preparedness and prompt referral when severe complications arise. These include: Prolonged labour Breech position Preterm labour Teenage pregnancy HIV positive mother

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PRINCIPLES OF NEONATAL CARE The normal neonate Birth weight 2500-4000g Average 3100-3200g Head circumference 33-37cm Average 34-35cm according to sex Length average 50cm Gestation 37 – 41 weeks Posture is fully flexed when awake Sleeps most of the time; waking up at 2-3 hourly intervals usually when hungry Survival of a newborn baby depend these principles Proper resuscitation/care at birth Ascertain the adequacy respiration Provision of warmth Prevention of infection Early initiation and establishment of adequate breastfeeding Proper Resuscitation/care at birth Emphasis in neonatal resuscitation is on: drying, stimulation and covering to prevent hypothermia followed by airway and breathing. Room air is as good as oxygen in neonatal resuscitation. Drugs are rarely necessary. Basic equipment includes a mucous extractor for clearing the airway. Use of a bag valve and mask may be necessary if baby is not breathing. Establishment of adequate respiration Majority of babies do manage to establish breathing without help. That first cry is so vital. It opens up the lungs with a high pressure. But when this does not happen we all panic and may do more harm than good for the survival of the baby. Since asphyxia is not always predictable preparedness is essential. All persons conducting a delivery should be able to adequately resuscitate a baby. Keeping the baby warm All neonates need extra warmth at birth but care should be taken not to overheat them. LBW infants, asphyxiated babies and all sick babies in general are at more risk than normal term neonates. 1. At birth Babies lose heat very quickly because they are wet at birth. Therefore dry them quickly remove the wet towel and wrap in a dry one. Put the baby next to mother and if possible initiate skin to skin nursing (kangaroo care). Delay bathing the baby till after 24 hours of age. Initiate breastfeeding within 30-60 minutes of birth. For preterm or low birth weight babies, continue with Kangaroo care to keep them warm. 2. Care beyond the delivery room Normal neonate: cover most of the time and keep near mother as much as possible

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Preterm/LBW depend on size and whether well or sick. Well preterm do very well in continued kangaroo care. Sick ones should be managed in a warmed up area. If there is a good follow up programme these babies can be discharged fairly early. In neonatal units heated rooms with a covered baby can be adequate to keep the babies warm. Incubators are best reserved for sick neonates in large hospitals with appropriate back up services. They are expensive, difficult to maintain and require constant supply of electricity. Prevention of infections Clean delivery (clean hands, clean cutting and tying of the cord, clean cloths/towels for wrapping the baby). Appropriate cord care after delivery: Discourage harmful cultural practices; Use surgical spirit until cord drops off and complete umbilical healing Initiation of breastfeeding within the first hour of delivery Reduce overcrowding at health facility partly by avoiding unnecessary admissions and early discharge Leave baby with own mother all or most of the time Recognize infected baby and isolate them early. Although clinical features in an infected newborn can be nonspecific, some of the danger signs include: Fever or lowered temperature Too sleepy or hard to awaken Refusal to feed or feed intolerance Fast breathing and or chest in drawing Pus or redness in the umbilical cord and or eyes Breastfeeding Initiation of breastfeeding within the first hour plays a major role in neonatal survival. As we have seen above it helps to prevent hypothermia and infection. It also helps to establish good breast milk supply and thus the baby will be well nourished from the start. Babies are born with good reflexes (rooting and sucking) for survival and are able to regulate their intake to satisfy normal growth. They will demand to be fed when hungry. If a baby does not demand a feed it usually means he is sick or immature. If breastfeeding is contraindicated, or the mother is too sick to breastfeed an alternative suitable breast milk substitute must be available for feeding the baby. THE LOW BIRTH WEIGHT (LBW) INFANT It is estimated that in Africa 14% of all babies born are LBW. These babies are either born too early (preterm) or suffered poor growth in utero resulting from complications during pregnancy. Preterm babies contribute to about 28% of all neonatal deaths. Paying attention to their care will thus reduce neonatal mortality. The most vulnerable are the babies weighing <1500g at birth and < 33 weeks gestation. They have problems of breathing, feeding and maintaining body temperature and have a higher mortality than the bigger LBW infants. These very low birth weight (VLBW) are best looked after in a referral hospital.

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As mentioned under “keeping babies warm” the LBW over 1500g can easily be kept warm using kangaroo care method unless they have additional problems. They may need stabilization for some time in a neonatal unit before being fully transited to kangaroo care and finally discharged into the community. COUNSELLING AND COMMUNICATION This is an area often neglected in a busy health care facility. Imparting knowledge to the clients is often relegated to the most junior staff and sometimes a student. This should be a dialogue rather than talking down to the client. All through care information from the client needs to be discussed so that the client understands what is going on. If a problem occurred it should be discussed as to how it can be avoided in future. Parents should be encouraged to seek appropriate care early. The need for continued care at a health facility should be communicated as well as what will be done. POSTNATAL FOLLOW UP Most mothers with normal delivery are discharged from a health facility within 24-48 hours of birth while it is also known that most neonatal problems appear in the first week of delivery. It is therefore important to plan an early follow up. Depending on the health care set up in the area this can be a home follow up or at health facility. The first visit is often planned within 7 -14 days. The earlier the better. At this time it is important to check: Adequacy of feeding Cord/umbilicus for possible infection Weight gain – should be back to birth weight The mother should be encouraged to report any concern about the baby as soon as possible STRATEGIES TO REDUCE NEONATAL MORTALITY The common causes of mortality are: Infections 39% (sepsis, pneumonia, diarrhoea and tetanus) Preterm global 28% but 50% in Africa Asphyxia global 23% but 24% in Africa. About 30-50% of deaths occur in the first 24 hours of birth Almost all these conditions are preventable using simple inexpensive solutions that have already been outlined in the chapter but let us summarize them. They all depend on appropriate organization of neonatal care at all levels. Infections Treat maternal infection in pregnancy Giving tetanus vaccine to all mothers Clean delivery, general hygiene and appropriate cord care Early recognition and treatment of the infected baby Early initiation and exclusive breastfeeding Improving health care seeking behaviour in the community

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Where community based newborn care programmes exist, training of community based agents to identify infection and other danger signs in the baby and refer and or provide care such as antibiotic will save newborn lives. Preterm babies Maternal nutrition: adequate intake of both macro and micro nutrients Improve ANC screening and management of pregnancy complications Careful care from birth to prevent infections, adequate feeding and kangaroo care when feasible Perinatal asphyxia Screening in pregnancy for those mothers likely to have cephalo-pelvic disproportion Birth preparedness Emergency obstetric preparedness and prompt referral Skilled attendant at delivery for care of the newborn baby INITIATE BREASTFEEDING WITHIN ONE HOUR OF BIRTH FOR ALL BABIES UNLESS THERE IS A MEDICAL CONTRAINDICATION. IT SAVES LIVES ORGANISATION OF NEONATAL SERVICES This is based on the continuum of care recognizing that most deaths occur at home during child birth and in the first few days post delivery. Integration into and strengthening existing services is important. Often reproductive services omit care of the neonate. But many IMCI programmes have added the ‘N’ (newborn) and ‘C’ (community). In built in this is avoiding of delays – delay in recognition of problems; delay in transport to reach appropriate care; delay in executing care at the health facility. Supportive government policy and planning is needed. Aim at improving health care systems at all levels. All facilities conducting deliveries should provide essential newborn care including neonatal resuscitation, care of the moderate low birth weights infants and establish a good workable referral system. Skilled attendant at delivery is defined as a health worker trained in managing normal pregnancy, delivery and immediate postnatal care. He/she should be able to identify, manage or refer mother or baby with complications. Delivery should take place in a setting with needed equipment, supplies and drugs as well as transport for emergencies. LEVEL 1: HOME/COMMUNITY Strengthen care at household level by empowering the community to act appropriately. This could be done through community participation so that the community owns the programme. Community health workers chosen by the community can be trained to promote health in the community by providing appropriate information, and identify babies that need care at a health facility. Studies in India and elsewhere show that a

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great deal can be done at this level if good training, equipping and supervision is provided. They will also be able to: Advise on appropriate nutrition for the pregnant mother and feeding of babies Educate on hygiene within the households Cultivate health seeking behaviour in the community Recognize problems and encourage families to go for help at the right time In some cases receive training to identify and treat infection and common life threatening newborn conditions or refer appropriately Birth preparedness is important so the community must plan for emergency transport to the nearest health facility. LEVEL 2: DISPENSARY/HEALTH CENTRE Staff: Primarily run by nurses, midwives, and clinical officers (medical assistants) Some have basic laboratory services requiring a laboratory assistant. If available a nutritionist would be desirable. Duties: Supervision and education of the community health worker Health care delivery service to the surrounding community They should be able to: Provide antenatal care and delivery services to women within the catchment area Deal with simple problems in pregnancy labour and delivery Resuscitate a new born baby (All workers) Do routine tests for antenatal mothers Identify and initiate treatment in conditions that require hospital care Supervise care of the neonate in the community At all times the health care provider should be asking two questions: one - am I trained to deal with the problem at hand? two – do I have the equipment or supplies to deal with the problem? If the answer is “NO” to either of these the mother/baby should be referred to the next station that is able to handle the problem. LEVEL 3: DISTRICT HOSPITAL Staff: Doctors, nurses, midwives, clinical officers laboratory technologists (in some countries obstetricians and pediatricians may be available) They should be able to provide comprehensive emergency obstetric and neonatal care. There should be good communication with all the dispensaries and health centres within the district. In addition to what is offered at level 2 of care they should be able to: Deal with complicated problems in obstetrics and paediatrics Have a neonatal unit for care of sick and low birth weight babies Supervise the staff at dispensaries and health centres

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Collect analyze useful information and plan for intervention at different levels Have a good triage system that will recognize emergency neonatal problems LEVEL 4: REGIONAL CENTRE This can be a provincial or a teaching hospital (in some countries the teaching and referral hospitals are graded higher than a provincial hospital) All levels of specialists preferably with neonatologists and neonatal nurses are usually available. There should be good diagnostic services. They would be responsible for Care of normal cases within the catchment area of the hospital More specialized care Training of all cadres of health care workers Supervision and liaising with staff in the lower hospitals Operational research (especially for teaching hospitals) BEYOND SURVIVAL Many babies survive the neonatal period but remain with disabilities that could have been prevented. These should be minimized and if they do occur intervene early. REFERENCES The Lancet 2005: Series on neonatal survival Vol. 365 pages: 821-26, 891-900, 977-988, 1087-98 THE PARTNERSHIP: Opportunities for Africa’s Newborns. Practical data, policy, and programmatic support for newborn care in Africa WHO World health report 2005: Make every mother and child count Home based care for Mothers and Newborns-A Facilitator Guide for training community Health workers – UNICEF /ESARO, September 2007 Baseline Knowledge Attitude and Practice Survey for the Community Based Newborn and Maternal Child Health Initiative in Zambia, MP Shilalukey Ngoma, P Kalesha, RK Mbewe, Tesfaye Shiferaw, RK Mwale, W. Mutale, C. Chabala, C Michelo, S.Sizya, K. Mwinga, N Mugala, G Gundumure, D Kaluba Chinyama, D Mumba and V Mukonka., UNICEF /MOH Zambia, 2008

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CHAPTER 3

INFANT AND YOUNG CHILD FEEDING (IYCF)

Rachel Musoke, Ruth Nduati, Aggrey Wasunna INTRODUCTION IYCF covers the feeding of the child for the first two years of life. Children have the right to adequate nutrition as stated in the Convention on the Rights of the Child. For the young child this means exclusive breastfeeding for the first six months and continued breastfeeding for two years together nutritious complementary foods. Why do we want to invest in infant and young child feeding? Malnutrition is directly and indirectly associated with increased morbidity and mortality of infants and young children. Inadequate feeding in the early years is a major contributor to poor economic development. Metabolic programming which is defined as a stimulus or insult applied at a critical or sensitive period in development, could have long term effect on structure or function of the organism. Early nutrition has a great impact on a number of body systems and of critical importance is the brain growth. Brain growth is highest in foetal life; by the age of 1year it is 60% of adult brain size and by 2 years of age it is 80%. Poor nutrition in these periods leads to irreversible changes that cannot be corrected by better nutrition later in life when the effects manifest as suboptimal education performance and reduced lifetime earnings by >10%. Good nutrition therefore protects foetus, infant and young child from permanent physical and intellectual stunting. Malnutrition underlies up to 60% of the deaths of children aged < 5 years. It is estimated that up to 20% of these deaths maybe averted by universal adoption of appropriate infant and young child feeding practices. Malnourished children often become malnourished adults. Babies of malnourished women are at higher risk of low birth weight, perinatal and neonatal mortality. At the same time malnourished women may also have inadequate breast milk production. Babies of ill mothers and those who are orphaned are more likely to be malnourished and have a higher likelihood of dying. In Africa we are generally grappling with under-nutrition, unfortunately nutritional recovery from this may lead to increased risk of obesity in later life. Early childhood nutrition has a direct bearing on three of the millennium development goals namely: Goal 1: Eradicate extreme poverty and hunger Indicator: Prevalence of children less than five years of age who are underweight Goal 4: Reduce child mortality by two-thirds Indicators: Under- 5 mortality rate; infant mortality; measles immunization Goal 5: Improve maternal health: Reduce maternal mortality rate by three quarters This goal does not address maternal nutrition as an indicator but we know that maternal malnutrition contributes to maternal deaths as well as early childhood nutrition

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OBJECTIVES At the end of this chapter, the student should be able to: Describe the advantages of breastfeeding and outline importance of good nutrition in early childhood Describe the anatomy of the breast Describe the physiology of lactation Describe the composition (biochemistry) of human milk Describe the host resistance and immunological significance of human milk Describe the processes involved in proper management of lactation Diagnose and manage problems associated with breastfeeding Define complementary feeding Describe the process of proper complementary feeding Describe feeding of children of HIV infected mothers Take a feeding history and interpret adequacy of diet according to age of infant or child Describe systems that support, promote, and protect breastfeeding BFHI) as well as encourage appropriate complementary feeding LEARNING ACTIVITIES Visit an antenatal clinic and carry out breast examination with special emphasis on anatomical variations of breasts and nipples Visit an antenatal clinic and interview a pregnant woman on knowledge, attitude and planned practice on breastfeeding and assess the baby friendly hospital initiative (BFHI) activity of the clinic Counsel a mother on importance of breastfeeding Counsel a mother on how to practice exclusive breastfeeding Visit a postnatal ward and practice positioning and attachment of a newly born baby on the breast Visit a newborn nursery (special care unit) and assist in the breastfeeding of sick a baby Visit a child health clinic and counsel a mother returning to work after maternity leave on feeding Visit a local breastfeeding support group and write a report on its activities Visit a prevention of mother to child transmission of HIV (PMTCT) programme and learn how to counsel on feeding options for an HIV infected mother. Take an infant and young child feeding history DEFINITIONS (according to WHO) Infant and young child feeding: The whole complex of dietary, behavioural and physiological process involved in the child’s ingestion of food Exclusive breastfeeding: All the child’s fluid, energy and nutrients are provided by breast milk. Vitamins may be added. Almost exclusive breastfeeding: Use of water or other non-nutritive liquids in addition to breast milk Partial breastfeeding: Mixed feeding with breast milk, (other milks) plus other sources of energy and nutrients.

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Complementary feeding: Other foods or liquids provided along with breast milk. Complementary food: Any nutrient –containing food or liquid given along with breast milk during the period of complementary feeding. Transitional foods: Complementary foods especially designed to meet the nutritional needs of young children. Family foods: Complementary foods that are the same as those consumed by rest of the family Weaning: Putting a complete stop to breastfeeding. BREASTFEEDING Advantages of breastfeeding Breastfeeding has nutritional, immunologic and developmental benefits. Breast milk is a whole food for the newborn and meets all requirements in the first 6 months of life. Breast milk has several components that promote brain development leading to better school performance. Exclusive breastfeeding in the first 6 months of life reduces deaths from diarrhoea by a factor of 7, and pneumonia by a factor of 5. Overall exclusive breastfeeding prevents 13% of under five mortality. Early initiation of breastfeeding reduces risk of neonatal death by a factor of 4, i.e. 16% neonatal deaths are prevented if a baby is breastfed within the first day of life and 22% if initiation within 1st hour of birth. Non breastfed children are more likely to fall sick and be hospitalized than breastfed ones irrespective of their socioeconomic status. Exclusive & continued breastfeeding for the first 2 years of life associated with better growth. Breast milk is a low cost high quality food; it is natural and sustainable resource which offers food security to the child and protects the environment. Breastfeeding contributes to the psychological wellbeing of the infant by promoting bonding between mother and baby. The baby thus feels securely attached to the mother. Babies who are securely attached are able to re-establish a sense of wellbeing after a stressful event. Insecure attachment may signal later dysfunctional development and behaviour. The direct eye-to-eye contact between the baby and mother enables them to interact meaningfully. Breastfeeding on demand helps the young infant develop a sense of basic trust as his needs are met consistently. Breastfeeding may reduce chance of obesity and metabolic syndrome in adulthood. If the mother exclusively breastfeeds and feeds several times a day and night she can be protected from another pregnancy. Child spacing favours child survival. Mother also benefits from breastfeeding as they have reduced risk of postpartum haemorrhage, breast and ovarian cancer. Anatomy of the breast (figure 1) The breast is composed of the main body, areola and the nipple. In the main body are glandular tissues (alveoli) several of which drain into a milk (lactiferous) ducts. These ducts dilate in the areola and are known as lactiferous sinuses which finally open into the nipple. Each alveolus is surrounded by smooth muscles. Milk glands and ducts are

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supported by fat tissue and it is this fat that is mainly responsible for the size of the breast. There is also a good blood and nerve supply. The areola and nipple contain smooth muscles. Each nipple has 15-25 openings. The areola contains several sebaceous glands (Montgomery glands) which secrete a substance that has antibacterial and lubricating properties. There is a rich nervous supply. The skin of the areola and nipple is much darker than the rest of the breast. The sizes of both the areola and nipple vary in different women. Figure 1: anatomy of the breast

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Physiology of lactation Preparation of the breast for lactation: During pregnancy there is proliferation of the ducts and alveoli under the influence of pregnancy related hormones: oestrogen, progesterone, human placental lactogen (HPL) and human chorionic gonadotrophin (HCG). Lactogenesis (initiation of milk secretion): Stage I starts about 12 week before delivery; stage II is the first few days after birth. During pregnancy prolactin hormone stimulates glandular activity and they begin to secrete colostrum. Though there is milk production during pregnancy, increased production is inhibited by placental hormones especially progesterone. Delivery of the baby removes inhibition of prolactin activity resulting in creased milk synthesis. This process rather than suckling is responsible for the initial breast milk production. The volume of the milk produced rapidly increases as the amount of lactose in the milk rises. Stage III lactogenesis (maintenance of established lactation) this stage of lactogenesis depends on an intact hypothalamic-pituitary axis regulating prolactin and oxytocin synthesis and release. These are referred to as the milk production and milk ejection (let down) reflexes. (see Figures 2 & 3) Sucking and emptying of the breasts are very important in maintaining lactation. Sucking leads to release of both prolactin and oxytocin. Prolactin works on the alveolar cells to increase breast milk production while oxytocin produces contraction of the smooth muscles leading to milk ejection. When the breasts are not emptied there is a negative feedback mechanism that inhibits breast milk production. Factors that affect prolactin secretion/release include: Stimulants: nipple stimulation, sight of the baby as well as cry, sleep, sexual intercourse, drugs such as phenothiazides and reserpine Suppressors: stress, pain, L-dopa, ergot preparations, stilboestrol

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Figure 2. Prolactin reflex

Figure 3: Oxytocin reflex

Composition of breast milk Human milk is tailored to the needs of the baby. It contains proteins, carbohydrates, fats, vitamins and minerals in forms that are easily digested and assimilated by the baby. Though composition is divided into stages the changes during the first two weeks of lactation are gradual. However the first 5 days milk is known as colostrum it passes through a transitions period and finally becomes mature by 14 days. Colostrum: a thick yellowish fluid containing less lactose but more protein, fat, fat soluble vitamins and minerals than mature milk. It is rich in immune factors especially immune globulins.

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Mature milk: composition and comparison with other types of milk is shown in table 1. Water: is the largest constituent in which all constituents are dissolved, dispersed or suspended. There is enough water that supplies all that the baby needs in the first 6 months of exclusive breastfeeding even for those that live in very hot climates. Table 1: Composition per 100ml of milk Constituent HUMAN COW FORMULA Water (%) 85-87 87 87 Energy (kcal) 65-67 67 65-67 Protein (g) 0.9- 1.1 3.4 1.5 Casein: whey ratio 40:60 80:20 40:60 Fat (g) 3.5- 4.5 3.4-3.7 3.4 Carbohydrate (g) 7.0 4.8 7.0 Sodium (mmol) 6.5/7.0 22- 25 7.0 Iron (ug) 70 70 120 Proteins: Milk proteins are subdivided into casein and whey proteins. The caseins are in the solid fraction when milk cuddles while the whey proteins remain in the fluid fraction. Caseins are difficult to digest especially for the young infant. Hence in human milk the casein: whey ratio starts low at 80:20 but later in lactation changes to 40:60. Mature cow milk on the other hand has high casein: whey ratio of 80:20. Fats (lipids): About 30-35% of infant’s daily energy is provided by fats. Most of the milk fat is in the hind milk. So if the baby does not empty the breast total energy intake may be low and the baby will fail to gain weight. Human milk has polyunsaturated to saturated ratio of 1.3:1 while that of cow milk is 1:4. Human milk is rich in the essential lipids (linolenic and linoleic acids) that are important in brain development. Carbohydrates: the main carbohydrate in breast milk is lactose although small amounts of other sugars such as glucose are found. Human milk has higher lactose concentration than other mammals. Lactose is metabolized into glucose and galactose which is important in brain development. Lactose facilitates calcium absorption, and promotes growth of lactobacillus bifidus. Micronutrients and minerals: Concentrations of these are adequate for the baby especially in the first six month of lactation. However if the mother is deficient in micronutrients there may be deficiency in the baby. About 50% of iron in human is absorbed versus 10% in cow milk. Digestive enzymes and growth promoters Human milk contains digestive enzymes and one of the most well described is lipase an enzyme that facilitates fat absorption. There are growth factors that promote maturation of the brain and epithelial surfaces. Molecules similar to those found in breast milk have been developed into drugs to treat bone marrow failure.

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Immunologic qualities of breast milk Babies are born with an immature immune system and rely of passive immunity from their mother received through active transfer of immunoglobulins in the last trimester of pregnancy and through breast milk especially colostrum. The latter is often referred to as baby’s first immunization. During pregnancy there is active migration of immune competent cells to the breast where they manufacture anti-infective factors based on the mother’s experience. Breast milk has a wider repertoire of anti-infective factors compared to mother’s plasma. The anti-infective factors include antibodies, soluble components like lysozyme, lactoferrin, lipids and milk fat globules as well as live leucocytes that protect the baby from infection. The components that are there for protection /information are not digested/ destroyed as they traverse through the gastrointestinal tract. Breast milk macrophages home in to the Peyer’s patches where they help promote infant gut mucosal related immunity and in the process may confer cell mediated immunity. Thus breast milk is unique in prevention of infection. (1) There is no risk of contamination; (2) there are several anti-infective properties; (3) it induces immune competence in several body organs (4) it induces maturation of the gut (5) faster gastric emptying. As long as baby and mother have close contact, mother will form protective agents or antibodies against any organism on the baby. Baby will always be protected as long as s/he gets own mother’s milk. But the protective effect is dose dependent—exclusively breast fed are most protected; partially breast fed are better off than those who are not breast fed. MANAGEMENT OF LACTATION Prenatal period: Successful breast feeding depends on knowledge, skills and practice of the health worker as well as the mother/ parents. Mothers/ parents decide on how to feed their babies during pregnancy or even before. Decisions are often dictated by observation or culture. However parents should be given the necessary education to enable them to make a fully informed choice. The aim of the education is to help them breast feed optimally and avoid difficulties .Building confidence at this stage is advantageous. Objectives of prenatal preparation Psychological support / allaying anxiety Remove myths and beliefs that may hinder breast feeding. Provide information which assists the mother / parents to choose how to feed her/their baby. Provide technical skills needed for successful breast feeding. Identify and solve problems Breast examination to identify any past pathology that will interfere with successful lactation. It is better to anticipate and be ready to deal with the problem than to wait for difficulties after the baby has come. Past pathology include: severe trauma, burns, or extensive surgery. Evidence of present pathology e.g. lumps need referral for action. It is important to remember that there are many normal variations in shape and size of breast and nipples. Elasticity of the nipple always improves towards delivery time. There is no need for nipple preparation even when there is inversion. Hoffman exercises and breast shells have shown no proven value. Rubbing, rolling and pulling are not

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recommended- they might even induce premature labour through increased oxytocin release. Essential Prenatal Education Maternal nutrition: assess nutritional status and discuss with the mother on the importance of an adequate diet for her and her unborn baby. Work out ways how she can achieve this using locally available food. Pregnant women are not able to meet their micronutrient needs and therefore will benefit from supplementation with multi-mineral-vitamin mix. Of note anaemic women are at increased risk of pregnancy related haemorrhage, preterm and low birth weight delivery. Explain why she may need supplementation Benefits of breast feeding: start from what the mothers know and fill in the gaps. Importance of early initiation: discuss why this is necessary and what will happen in the delivery room in relation to breast feeding. Initiation should be within the first 30-60 minutes of birth. Early initiation is associated with good milk flow and helps to prevent infection in the newborn. In the first 60 minutes after a delivery, the baby is alert. Breastfeeding during this period improves attachment and is associated with longer duration of breastfeeding. Positioning and attachment: Demonstrate and discuss how this will help prevent problems such as nipple pain, trauma (crack) and since it ensures adequate breast emptying it also prevents engorgement. If attachment is on the nipple and not on the areola, the milk does not flow, resulting in a frustrated baby. Then the baby sucks harder and the mother ends up with cracked nipples. Importance of exclusive breast feeding for 6 months: Exclusive breastfeeding means giving breast milk only, and no water or prelacteal feeds. In the early period many mothers worry that there is not enough milk. Please assure mothers that the colostrum is adequate for the infant and early initiation helps milk flow. Mother who have to go back to work need to plan how they will sustain exclusive breastfeeding. Breast milk is safe for 3 months if frozen, 72 hours in the fridge and 8 hours at room temperature. Show mothers how to express breast milk and to develop a plan that best suits them which may include carrying the baby back to work. Remind them that expressed breast milk is safe and other people will not be tempted to share it with the baby. How to assure enough milk: this is achieved through early initiation and on demand feeding. The more the breast is emptied, the more milk produced. Thus expressing breast milk if separated from the baby supports sustenance of the supply. Encourage her to join a community support group: Mother-to-mother support is very useful in promoting breastfeeding. The health facility can provide opportunity for mothers of young babies to interact and support each other on infant feeding and other related matters. Give the mother written information as much as possible to enable her to remember what she learnt in the clinic

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Perinatal and immediate postnatal period Initiate breastfeeding in the delivery room Demonstrate and assist mother on positioning and attachment of the baby to the breast. The baby is correctly positioned if: the head and baby are straight; tummy to tummy; baby is lifted to avoid neck stretch; mother supports the whole body and not just head and shoulders. Correct attachment: mother supports does not have to support the breast but if she feels she wants to then the correct way is putting the hand and fingers below and thumb just above areola (hand making a ‘C’); baby’s mouth wide open and lips out-turned; most of the areola in baby’s mouth. Sometimes the baby’s tongue can be seen at the angles of the mouth. See figures 4 & 5 Re-emphasize what was learnt in the antenatal period. Figure 4: Baby’s mouth wide open Figure 5: Good attachment

PROBLEMS IN BREASTFEEDING Insufficient breast milk (baby < 6 months old) This is a common complaint from mothers and often by the time they come to the clinic they have already started giving a baby some supplementary feeding. Common complaints from the mother are: baby wants to feed too many times; baby cries a lot; the baby seems to sleep longer when given formula or cow’s milk. In this case it is important to look at the baby and the mother and ask a few questions: Is the baby growing well? If ‘yes’ reassure; if ‘no’ then ask the next question: How is the positioning and attachment? – If not appropriate then the baby may actually be starving because he is not able to get the breast milk out of the breast. If ‘yes’ then go to the next question:

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How often is the baby’s nappy/diaper changed? This can be an indication of amount of urine passed. If frequent (6-8 times) then breast milk is adequate and therefore reassure the mother. If less frequent then explore further by asking: What is her confidence that she can have enough milk? If she has enough confidence then counsel and encourage her mother to continue exclusive breastfeeding and stop any supplement if she had already started. If she lacks the confidence then counsel her on how to ensure adequate breast milk supply. Other conditions that may lead to a perception of not having adequate milk – Periods of growth spurts are associated with increased frequency of feeding. In this case reassure the mother. Mothers often associate a soft feeling breast with inadequate milk. This is the normal texture of the breast and she should be reassured that she has enough milk. Breast engorgement: This is usually due to infrequent and inadequate breastfeeding. It may also be due to poor positioning and attachment. Correct the positioning and attachment and advise her to feed the baby frequently. Help mother to relieve the engorgement by expressing her breasts. She can express until she feels comfortable. It may be necessary to give her analgesics such as paracetamol. She can also use warm or cold packs on her breasts to reduce pain. Wearing a comfortable brassier with wide straps to support but not compress the breasts is useful. Lactating mothers may need a brassier that is 2 sizes larger than their pre-pregnancy size. Reassure them that the breasts will go back to normal size when the baby weans. Mastitis is an infection of the breast that could lead to abscess formation. It commonly occurs in the second or third week postpartum. It is managed with antibiotics, analgesics, warm packs and frequent emptying of the breast. If an abscess develops then incision and drainage should be done in addition to antibiotics. Cracked nipples: The best management of this is prevention. However if it occurs keep the nipple dry by exposing it to air; mother can express breast milk and apply it on the nipple; check for evidence of infection especially candida. The mother may be having vaginal candidiasis. If there is candida infection then make sure you treat both mother and baby at the same time. Show mother how to correctly position and attach baby and encourage frequent breastfeeding. Flat or inverted nipples: After delivery the mother can now be shown how to pull out the nipples and attach baby properly. Mothers with truly inverted nipples need more help. Use of a 20ml syringe can be useful. Remove the plunger and cut off the needle end making a smooth margin. The mother can the use this to apply negative pressure which helps to pull out the nipple just before each feed. COMPLEMENTARY FEEDING Age 6-24 months is considered the period of complementary feeding. Timely and appropriate complementary feeding will reduce mortality; prevent weight loss and more so stunting. This period can be managed well if accurate information and skilled support

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for the family is provided. More often than not inadequate knowledge about appropriate food rather than lack of food is the cause of malnutrition. Biological basis for introduction of complementary foods Oral-motor development function during the 0-6 month period is designed for liquid feeding i.e. breast milk. In the second half of the first year jaw and tongue movement, together with the appearance of teeth equip the baby for other foods other than milk. These continue to develop during the second year by the end which the primary dentition is also completed. Digestion and absorption of complex carbohydrates and fats is suboptimal during the first 6 months but as the baby grows these improve to allow baby to take a variety of foods. Excretory system: Renal function – ability to excrete excess limited. Breast milk has a low solute load to the kidney. Nutritional needs: It is now well established that babies have adequate growth up to 6 months without complementary foods. But by 6 months breast milk ceases to give enough nutrients to babies hence the need to start complementary feeding. A baby who is ready for complementary feeds will want to breastfeed more frequently. The stool will decrease in volume and may have green streaks in it. The first step would be to breastfeed the baby more frequently and if the increased milk supply is still not sufficient complementary feeds should be introduced. Breast milk is adequate until 6 months of age. Risks of early complementary feeding Physiological stress Incomplete digestion –may lead to sensitization; diarrhoea Malnutrition – both over & under nutrition can occur Micronutrient deficiency Generally a negative impact on health. So complementary feeding must be: Timely – introduced when the need for energy and nutrients exceed that provided through exclusive milk feeding Adequate – provide sufficient energy, protein minerals and micronutrients to meet the needs of a growing child (quantity & quality) Safe – hygienically prepared, fed and stored Properly fed – given consistently with the child’s signals of appetite and satiety Very often people talk of a balanced diet when counseling on complementary feeding. It is important to define what you mean by this. To some people it means taking the necessary food groups without thinking of quantities. Perhaps we should be talking

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more in terms of adequacy—this implies that the quality as well as the quantity as considered. The process of complementary feeding Complementary food is best given in its natural state, and use family foods so that by the time the child is weaned s/he is able to feed from the same pot as the rest of the family. But the food has to be specially prepared. Initially the complementary feeds are liquid but not too watery. Consistency should quickly be increased to provide adequate calories. For a breastfeeding baby start with small amounts (1-2 teaspoonfuls) twice a day and gradually increase both quantities and frequency. Remember that: Whatever you add displaces milk. Whatever you add is most often of lower nutritional value than milk Children continue to need breast milk therefore mother should continue breastfeeding on demand. In the 6-12 months milk should make up to 70% of child’s diet. Babies of HIV infected women who are weaned at 6 months need animal source proteins in their diet to meet all their nutritional requirements. Therefore a non breastfeeding baby requires a minimum of 500mls of other milk through the 6-24 month period. In poor communities this may be difficult resulting in malnutrition. An AFASS assessment should be carried out before a mother weans her baby. Give a variety of foods taking into account the nutrient content of the food used. Active feeding i.e. assist the child to eat but do not force feed. Talk to the child and use the meal times as an opportunity for psychosocial stimulation. In the period 9-15months babies go through a stage of recognizing themselves as autonomous from the mother and may refuse to eat. Active feeding then becomes a very important strategy of ensuring adequate nutrition. Avoid excessive amounts of food. Fat cells are made in the first 18 months of life and obesity in this period is associated with the same in adulthood. Food hygiene is very important. Stress hand washing; clean containers; food should be freshly prepared or fully boiled every time the child is to be fed HIV AND IYCF Efforts to promote infant and young child nutrition including breastfeeding were expected to reduce child mortality, morbidity, malnutrition as well as disabilities. With the realization of MTCT of HIV through breast milk, many people stopped breastfeeding promotion. Even worse, exclusive breastfeeding has now become associated with HIV and many mothers do mixed feeding to prove that they are not infected. Significant progress has been made in defining infant feeding practice in the context of HIV. Exclusive breastfeeding is the best option for infant feeding for HIV uninfected mothers. Even in high HIV prevalence regions the majority of women are not infected. Therefore promotion of exclusive breastfeeding is good public health practice and is an incentive for women to avoid infection.

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It is true breastfed babies of HIV infected women are at risk of infection as long as they are breastfed. This risk is particularly high in women who are newly infected, women with advanced HIV disease and those with breast disease (cracked nipples, mastitis etc.) Without intervention up to 20-45% children got infected. The estimated contribution of breastfeeding is 14-15%. Replacement feeding will prevent transmission, but is not a safe intervention for the majority of mothers. Therefore wholesale promotion of formula feeding for HIV exposed babies is dangerous and bad public health practice. Prevention of breast milk transmission of HIV can be achieved through several strategies. Prevent new HIV infection in pregnant and lactating women. Judicious use of anti-retroviral drugs- Women with advanced disease should be put on HAART. New data shows that use of prophylactic HAART during breastfeeding by women not needing treatment also reduces breast milk transmission of HIV Prophylactic ARVs to the infant during breastfeeding may also prevent breast milk transmission of HIV. There are ongoing studies to evaluate the safety of prophylactic ARV by mother or baby and may soon be part of standard practice. Adoption of safer infant feeding practices Exclusive breastfeeding - Good attachment techniques to minimize cracked nipples Prompt treatment of breast disease and use of heat treated breast milk during such episodes Early weaning as soon as a mother is able to provide nutritionally adequate complementary feeds. Early cessation of breastfeeding ( <6mo) may reduce HIV transmission but it increases risk of morbidity & mortality (malnutrition, diarrhoea, pneumonia). HIV infected infants have better survival if breastfed beyond 6 months. Replacement feeding for women meeting AFASS The health worker has a moral and ethical obligation to promote appropriate infant feeding practice. In order to do this, they must help the HIV infected parents make an assessment of the ‘balance of risks’ with the goals being a living HIV free infant. The most recent research shows that HIV free survival of infants of mothers who are on efficacious ARV regimens for PMCT are similar for breastfed and formula fed infants. In resource constrained settings breastfed infants of women receiving HAART have better HIV free survival at 12 months of age compared to formula-fed infants. Counseling HIV infected women on feeding option The aim of counseling is to ensure adequate IYCF irrespective of the option chosen as well as minimizing HIV transmission through breast milk.

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Parents have a right to choose the best feeding option for their child. This should be based on clear, adequate and unbiased information from a knowledgeable health care worker. Once the decision has been made, the health worker continues to support and guide the parents on how to safely practice the chosen method. As early as 1987 the world health organization’s (WHO) stand has been that the choice of infant feeding “should take into consideration the socio-economic and ecological environment of the mother/infant pair and to the extent to which alternatives can safely and effectively be used.” Subsequent consensus statements from WHO/UNICEF/UNAIDS/UNFPA have endorsed the same sentiments. The latest statement of 2006 has the following recommendations: “The most appropriate infant feeding option should continue to depend on the mother’s individual circumstances; exclusive breastfeeding is recommended for the first six months of life unless replacement feeding is acceptable, feasible, affordable, sustainable, and safe (AFASS); when there is AFASS then avoidance of all breastfeeding is recommended.” From this statement we can see that there are two options in the first six months namely exclusive breastfeeding or exclusive replacement feeding. From six months all infants should receive complementary foods. All health workers providing services to pregnant women and mothers of young infants should provide this counseling and support. Remember to inform the parents that there is no particular intervention in an HIV infected parent that will reduce transmission to zero otherwise they get very disappointed when they do everything possible and still end up with an infected child. Adherence & longer duration of optimal infant feeding practice can be achieved through high quality counseling. Exclusive breastfeeding is not the norm in most part of sub Sahara Africa and therefore all mothers need infant feeding counseling support to achieve best practice. Health workers should avoid stigmatizing exclusive breastfeeding. TAKING A FEEDING HISTORY The purpose of a feeding history is to get to know and understand the client, her nutritional status, kind of diet is she taking as well as any medical, physical or mental problems that will impact on breastfeeding. Does she have previous experience? --Yes/no. If yes: How long did she breast feed? What was the duration of exclusive breastfeeding? Were there any difficulties and if so how did they affect breastfeeding? Beliefs/culture: Ask specifically about use of water, juices, and other milks. Any other hindrances that may have significant influence on breast feeding. How is she feeding the current child? Frequency of breastfeeding day and night

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If not breastfeeding ask why? What other milk is she giving and how does she prepare it? Is the child taking any other food or milk? If yes you will want to know what food, how it is prepared, the amount and frequency and how it is fed to the child. A 24 hour food recall is often used and if possible food frequency e.g. in a week helps to judge adequacy of diet. SUPPORT SYSTEMS All mothers need a conducive environment that will help them achieve optimal feeding of their infant and young children. Support will come from: father and immediate family; community; health professionals and their professional bodies; government and partners; all working together for the betterment of child survival. The Working Mother All women work whether they are stay home mothers or work outside the home. Whatever work the woman is bound to affect how she breastfeeds her baby especially during the exclusive breastfeeding period. For each individual woman, the health care provider discusses how she will be able to combine work with breastfeeding. It may mean taking the baby to the work place or being able to express/pump her milk for the period that she is away from her baby. She needs to be guided on how to store the milk depending on facilities at home. Maternity Protection for Working Mothers (maternity Leave) As early as 1919 the international labour organization (ILO) has had regulations on the working mother with aim of enabling her to take time off around the time of delivery but able to keep her job. Unfortunately many employers especially those in the private sector are not happy with this. More recently (yr. 2000) the same organization reviewed the time and increased it from 12 to 14 weeks. This is an improvement but still does not cover the six months of exclusive breastfeeding. Hence the addition of two half hour nursing breaks per day especially during the period of exclusive breastfeeding. The convention passed in 2000 is yet to be ratified by many countries. Find out how your country treats maternity leave. Developing a baby/mother friendly work place will help. If employers are educated on the value and advantage of breastfeeding they can help their employees manage exclusive breastfeeding by either allowing time off or bring the baby to work The Baby Friendly Hospital Initiative (BFHI) In 1889 UNICEF and WHO endorsed a document known as Protecting, promoting and supporting breast-feeding: The special role of maternity services. In it were “The Ten Steps to Successful Breastfeeding.” This document and the Code form the basis of BFHI. To emphasize the importance of the mother some countries have added ‘M’ – BMFHI. A hospital that practices these steps is assessed by independent assessors and if satisfied the hospital is then designated to be baby friendly. Thereafter continued self assessment with occasional external assessment helps the facility to remain friendly.

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Community breastfeeding support group This could be a group purely for breastfeeding activities but for sustainability purposes it may be better to incorporate other activities the group may want to address. Both IMCI and BFHI strongly recommend community support with the realization that IYCF is actually a community activity. Health workers at facilities should be knowledgeable on the activity of the community and work with them for health promotion. If there is no active community support for breastfeeding then the health worker is encouraged to start one. But it is very important that the community own the group the health worker just being an expert advisor. Here experienced and knowledgeable (check accuracy of this knowledge) women help to support breastfeeding mothers through dialogue and sharing. The role and support of men and fathers is emphasized. Community support leans heavily on advocating for behaviour change. The International Code of Marketing Breast milk Substitutes The Code was endorsed by the World Health Assembly in 1981. The code and subsequent resolutions seeks to encourage and protect breastfeeding and to control inappropriate marketing practices used to promote products for artificial feeding. The code applies to artificial milk for babies (formula), other products used to feed babies especially when they are marketed for use in a feeding bottle. The code also applies to bottles and teats. Each member country was required to adopt and enact a law based on the articles of the International Code. There should be a place where violations are reported as well as penalty. Unfortunately many countries are lagging behind but that does not stop health care providers from using it to promote breastfeeding. Various articles of the code apply to mothers /parents (public), health care workers and their health care facilities, as well as the manufactures their agents and indirectly to the shopkeepers. Global Strategy for Infant and Young Child Feeding “WHO and UNICEF jointly developed this strategy to revitalize world attention to the impact that feeding practices have on nutritional status, growth and development, health and thus the very survival of infants and young children.” It encourages all concerned parties to take it seriously and be committed to protect the health and nutritional well being of infants, young children, pregnant and lactating women. It is practical and allows everybody (individuals, health facilities and organization) to be actively involved. Hospital & National policies and strategies All the above support systems will not work to the maximum without government commitment. Health workers are encouraged to support and urge their governments to formulate policies and laws that will enhance child survival. But even without laws health care facilities can go a long way in improving infant and young child feeding. Financial commitment is also very important. Find out what policies are operational in your country. “ The global strategy includes as a priority for all governments to ensure that the health and other relevant sectors protect, promote and support exclusive breastfeeding for six months and continued breastfeeding up to two years or beyond, while providing women access to the support they require – in the family, community and workplace to achieve this goal”

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REFERENCES F. Savage King Helping mothers to breastfeed. AMREF, Nairobi, Kenya R.A Lawrence, R. M. Lawrence. Breastfeeding: A guide for the medical profession. Elsevier Mosby Many of the WHO publications are available on the website: www.who.int/child_adolescent_health

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CHAPTER 4

CHILD NUTRITION

Ruth Nduati, Ahmed Laving, Heena Hooker, Peter Ngwatu INTRODUCTION Good nutrition is essential for satisfactory physical growth and mental development, provides reserves for stress, as well as prevention of acute and chronic illnesses. Compromised nutrition during childhood has lifelong effects on the well being of individuals. The window of opportunity for prevention of these effects is during pregnancy and the first 2 years of life. After two years, malnutrition will have caused irreversible damage. Unfortunately under nutrition is common especially in the developing countries. Four fifths of under-nourished children are found in 20 countries of Africa, Asia, Western pacific and the Middle East. The most important problems are (i) stunting, (ii) severe wasting and (iii) intra-uterine growth restriction. Under nutrition underlies 3.5million child deaths annually. The risk of death increases with severity of malnutrition. Seven of 10 countries having the highest under-five mortality are in Africa and include Democratic Republic of the Congo, Nigeria, Ethiopia, Uganda, Tanzania, Madagascar and Kenya. This chapter will outline the essential nutritional requirements of children, causes of malnutrition, discuss the proven effective public health interventions and address the management and prevention of common nutritional disorders. OBJECTIVES At the end of the chapter, the learner should be able to: Understand the basic nutritional requirements for optimal growth

and development. Discuss the conceptual framework on the causes of malnutrition Outline causes of child hood malnutrition Discuss the impact of childhood malnutrition Outline public health interventions to reduce the high prevalence of malnutrition Assess the nutritional status of a child. Describe the management of severe malnutrition. Describe the aetiology, diagnosis and treatment of other common nutritional problems. Discuss nutrition management of HIV infected children as a model of nutrition

management during chronic illness. LEARNING ACTIVITIES

Visit a well child clinic and assess the nutritional status of a child who is growing well and find out how she is managing to feed child well

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Identify a child who is not growing well and counsel of adequate feeding using foods available to the care give

Participate and write up the care of a child with acute severe malnutrition. Give nutritional advice

Assuming you are visiting a primary school plan a group discussion with the children. You can do this with your peers acting as school children

Plan a diet for a 7 year old HIV infected child who is having moderate malnutrition

NUTRITIONAL REQUIREMENTS OF CHILDREN Individual nutritional requirements vary with age, genetic and metabolic differences. There are basically five different types of nutrients (plus water), all of which the body needs in differing amounts for its various functions. Water Water requirements will vary with environmental temperature, activity and caloric consumption. Daily requirements are 60-100mls/kg at birth and increase with age to 150mls/kg/day by end of the first week of life. Exclusively breast fed babies do not require extra water as breast milk contains 80-90% water. Carbohydrates These provide the main source of energy for body functions. Daily intake should be about 60 grams per 24 hours (0–6 months) and up to 130 grams per 24 hours at 3 years. Dietary sources include breast milk, sugar, and cereals such as maize, wheat, oats, millet, starchy roots and fruits. Fats Fats have high energy and form an important energy store. They help to absorb fat soluble vitamins. About 30% of the total energy required should be derived from fats. Foods rich in fat include oils, margarine, butter, fish, meat, chicken, cheese, groundnuts and soy bean. It is best to use vegetable fats (oils) as they generally contain unsaturated fats which are better for the body than saturated ones. Protein Proteins are essential for growth and repair of tissue cells, synthesis of haemoglobin, enzymes and antibodies. Important sources of protein include milk, eggs, fish, poultry, cheese, soybeans, peas, lentils and nuts. Breast milk is the single most important source of protein during infancy. Vitamins These include Vitamins A, B group, C, D, E and K and are also known as micronutrients. These are consumed in small quantities and they have varying physiological roles in the body. Important sources of vitamins include milk, vegetables, grains, fish, liver, nuts and fruits

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Minerals and trace elements Also grouped under micronutrients, these include sodium, potassium, calcium, magnesium, zinc, iron and iodine consumed in small quantities but essential for the healthy functioning of the body. These are present in most foods mentioned above. Energy requirements Children require energy for growth, physical activity, basal metabolism and heat production. The energy requirements vary depending on the age and activity of the child. The average requirement for the first year is about 80-120 kcal/kg/day and decreases in the subsequent years but increase during adolescence. Each gram of protein or carbohydrate provides 4 kilocalories whereas a gram of fat provides about 5–9 kilocalories. The Food Pyramid – a Tool for Healthy Living We buy and cook food as opposed to nutrients. The food pyramid has been formulated to translate nutrient requirements into foods and a general guidance for daily planning of the menu. The childhood food pyramid used in USA gives guidance on feeding children aged 2-5years and 6-11 years. This can be adapted to local foods in other countries The Food pyramid is based on 6 food groups as listed in table 1 Table 1: Recommended food helpings for adults and children Adults and

adolescents*

6-11 years

Grain group 5-11 servings 6 servings Vegetables 3-5 servings 3 servings Fruits 2-4 servings 2 servings Meat, beans, fish, peas, nuts, and seed

2-3 servings 2 servings

Milk Yoghurt and cheese group 3-5 servings 2 servings Fats and oils, sweets/sugar Use sparingly Eat less NB 1 serving = 1 whole fruit, 125mls of juice, 1 eggs, 30g of meat, 150g of fish, 1 cup of cooked rice or ugali, 1 chapatti, 1 slice of bread, 1 medium potato, 1 medium glass of milk, 1 cup leafy green vegetables, ½ cup cooked vegetables, ½ cup cooked legumes (peas, beans), 2 table spoonfuls of nuts, etc. Ideally these foods should be packaged into 3 main meals and 2 snacks. General principles in selection of foods Cereals (wholegrain), roots and starchy fruits (plantain & cooking bananas) besides providing energy have good fibre content. Vegetables should be steamed/boiled 5-10minutes, in as little water as possible to minimize losses of vitamins and minerals Fruits should be served raw or made into juice. Whole fruits are preferred to juice. Milk is crucial as source of calcium for the growing child. Cabbage, cauliflower and broccoli are good plant sources of calcium but nothing near milk and dairy products.

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Meat-important sources of iron and zinc minerals, high quality protein. Spinach and legumes are also very good sources of iron. Mixing legumes with cereals is desirable e.g. maize and beans. Legumes are deficient in methionine and rich in lysine while grains are deficient in lysine and rich in methionine. Therefore eating either at the same meal or during the same day gives a very good source of proteins comparable to consumption of animal protein. Legumes need to be cooked thoroughly to increase bioavailability of these nutrients. If they are to be prepared for complementary food for babies they should be pre-cooked before milling. Children aged < 2 years The learner should review the chapter on infant and young child feeding. 2-5 years (Pre-schoolers) To help children develop healthy eating habits parents should set an example. Although children are erratic eaters, they should be allowed to determine the amounts they wish to eat within reasonable limits and not be forced to empty their plates. This avoids fights at meal times which may either result in under or over eating both of which are undesirable. Regular growth monitoring is essential to ensure the child is growing well. 6-11 year olds (school children) The key messages in the children’s food pyramid are: Be physically active every day. This is at least an hour of moderate to vigorous physical activity every day. Choose healthier foods from each of the food groups every day. Eat more of some foods groups- vegetables, fruits, grains and a source of calcium. Adolescents This is a period of increased nutrient needs, but in the background of peer pressure, consciousness of physical body image and media makes adolescence quite vulnerable to malnutrition. They should be encouraged to feed well according to the food pyramid. In resource constrained settings few children are able to achieve the above recommendations. The biggest challenge is to achieve adequate intake. In addition the children have to walk long distances to and from school and are likely to go to school hungry. Also for part of the time the children are in school and parents may be unable to influence what the child eats. Teachers therefore are also important especially if food is provided by the school. On the other hand there are increasing numbers of children from affluent families who are beginning to suffer from obesity and for whom these guidelines will help prevent further progression. HELPING FAMILIES TO EAT WELL This includes addressing a number of issues some of which are listed below:

Produce or buy a variety of food for the family (demonstrate with gardens, discuss good buys, food storage)

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Pregnant and lactating women should be well catered for Adequate breastfeeding and complementary feeding. Share food well so the small children are not competing with older family

members Encourage diversity of foods eaten within the household Good preparation to prevent loss of nutrients Teach school children and adolescents about good eating habits, how to prepare

and store food Work with school teachers to ensure good feeding while children are in school Early and adequate care /treatment of illnesses Growth monitoring especially of young children. The growth chart easily picks out

those growing well, or not thus enabling early interventions to forestall progression to severe malnutrition

NUTRITIONAL DISORDERS Definition Malnutrition is broadly categorized into under-nutrition and over nutrition (over weight and obesity). Under nutrition encompassed stunting, wasting, deficiencies of vitamins and minerals (collectively referred to as micro-nutrient deficiencies). Indicators of malnutrition Hunger, the feeling of discomfort from not eating is a good indicator of food

security. One of the Millennium development goals is to reduce by half the number of people who suffer from hunger.

Wasting – low weight for height indicates acute weight loss.

Stunting – low height for age indicates chronic malnutrition.

Low birth weight and intra-uterine growth retardation are measures of intra-uterine growth restriction.

Maternal short stature and low body mass index during pregnancy and lactation. The learner should review the chapter on growth monitoring for a detailed discussion on the anthropometric techniques. Conceptual framework of the causes of malnutrition Causes of malnutrition are categorized into: (i) immediate, (ii) underlying and (iii) basic causes. Immediate causes of malnutrition include poor diet, and disease;

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Underlying causes include inadequate care of children and mothers, household food insecurity, unhealthy household environment and lack of health services. Basic causes are related to poverty, unequal distribution of resources at local, national and international level. Health workers are best placed to deal with the immediate causes of malnutrition, and these will be the focus of this chapter. Impact of under-nutrition on child health. Table2: Impact of under-nutrition on under-five mortality and morbidity Condition Annual number of child

deaths Proportionate contribution to Disability adjusted life-years (DALY’s) for children aged < 5 years

Stunting, severe wasting, and intra-uterine growth restriction

2.2 million 21%

Vitamin A and Zinc deficiency

0.6 million 9%

Iron and iodine deficiency Few deaths 0.2% Iron deficiency as risk of maternal death

115,000 0.4%

Sub-optimal breastfeeding (especially non-exclusive breastfeeding in first 6 months of life)

1.4million 10%

DALYS combine years of life lost due to premature death with years of life lived with disability into an indicator that allows assessment of total loss of health from different causes. One DALY is roughly one year of healthy life lost. The nutrition conditions that are included in the analysis are protein energy deficiency, iron deficiency, vitamin A deficiency and iodine deficiency. These estimates may under-estimate the impact of nutrition on health and disease because under-nutrition has a synergistic effect with many infectious conditions that lead to child death. Table 2 is based on a global analysis that set to determine the impact of under-nutrition on child mortality and disability with the latter measured as proportionate contribution of the condition to the disability adjusted life-time years. This analysis based on demographic data from countries of all regions of the world was that maternal and under-five malnutrition is the underlying cause of death for 3.5million children annually, 35% of the burden of disease among children under five years of age and 11% of the total DALY’s.

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Low birth weight Low birth weight contributes to increased mortality from asphyxia, and infections (pneumonia, diarrhoea and sepsis) which account for 60% of all neonatal mortality. Contribution of infectious disease to stunting and intra-uterine growth restriction Infection increases nutrition requirements while at the same time it is associated with reduced intake or even increased losses. Diarrhoea as model of the interaction of infection and nutrition has been well studies and it has been shown that 1.05 (95% CI 1.03-1.07) increase odds of stunting at 24 months with every episode of diarrhoea. Malaria in pregnancy increases risk of foetal death with greatest harm noted in infections during late pregnancy. PREVENTION OF NUTRITIONAL DISORDERS Table 3 Interventions that Affect Maternal and Child Nutrition Sufficient evidence for widespread implementation

Evidence for implementation in specific contexts

Maternal and birth outcomes Iron folate supplementation Maternal supplements of balanced

energy and protein Maternal supplements of multiple micronutrients

Maternal iodine supplements

Maternal iodine through iodized salt Maternal deworming during pregnancy Maternal calcium supplements Intermittent preventive therapy for

malaria Intervention to reduce tobacco consumption or indoor pollution

Insecticide treated bed nets

New born babies Promotion of breastfeeding to individuals or in group counseling)

Neonatal vitamin A supplementation

Delayed cord clamping Infants and children Promotion of breastfeeding individually or in group counseling)

Conditional cash transfers (with nutrition education)

Zinc supplementation Zinc in management of diarrhea De-worming Vitamin supplementation or fortification Iron fortification and supplementation

programs Universal salt iodization Insecticide treated nets Hand washing or hygiene intervention Treatment of severe acute malnutrition Interventions that affect mother and child nutrition can be categorized into interventions that have sufficient evidence for universal implementation and those that are beneficial in specific situations. The interventions are categorized into those that impact maternal and birth outcomes, interventions for newborn babies and interventions for infants and children. The interventions include general nutrition interventions, micronutrient supplementation and disease control interventions. Up to 25% of the DALY’s can be

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averted through comprehensive nutrition interventions. The four most effective interventions are breastfeeding promotion, which would result in a 9.1% reduction in mortality and 21.9% reduction in stunting followed by vitamin A and zinc supplementation and balanced energy supplementation in that order as shown in table 4 below SPECIFIC NUTRITIONAL PROBLEMS Maternal under nutrition Maternal short stature is height < 145 cm while low body mass index is < 18.5Kg/M2. To a large extent maternal short stature is a sequelae of stunting during childhood. Low maternal body mass index is associated with intra-uterine growth restriction and low birth weight. Adequate feeding throughout the girl and adult woman’s life is thus important to prevent low birth weight. Maternal under-nutrition has little effect on the volume or composition of breast milk unless the mother is severely undernourished. But micronutrient content of breast milk is dependent on the intake and nutritional status of the mother and therefore micronutrient supplementation of the lactating woman is a strategy of ensuring adequate supply to the baby. Vitamin A deficiency Vitamin A helps to maintain the integrity of cells on body surfaces and to form retinal pigments and to destroy toxic products that cause tissue damage during infection. Children with vitamin A deficiency are prone to respiratory infections and diarrhoeal diseases. It is the commonest cause of blindness (xerophthalmia) in children. Vitamin A deficiency is a public health problem affecting about 10 million children every year. Vitamin A supplementation reduces childhood mortality for children suffering from diarrhoea or measles infection. Currently WHO recommends that all children Vitamin A supplementation, 100,000IU at 6 months of life and then 200,000 IU every 6 months thereafter until the child is 5 years old. A child with any sign of xerophthalmia, measles, diarrhoea and severe malnutrition should receive oral vitamin A on day 1, day 2 and repeat after 2-4 weeks. Children with corneal lesions should be treated immediately or referred urgently as an hour’s delay in treatment can lead to loss of sight. The doses are: Infant <6 months old: 50,000 IU Infant 6-11 months old: 100,000 IU Child 1-5 year old: 200,000 IU Zinc deficiency A trace element that is essential for growth and development of infants/children. The main source of dietary zinc is meat, eggs, nuts, seeds and grains. Zinc deficiency alters taste and smell; increases risk of diarrhoea, pneumonia and malaria; growth retardation; and delayed wound healing. Zinc supplementation is

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recommended in treating diarrhoea malnutrition and in chronic liver disease. The dose of zinc during treatment is 2-3mg/kg/day Table 4: Indirect indicators of Zinc deficiency Country category of Zinc deficiency Characteristics High risk of Zinc deficiency Prevalence of stunting of > 20%

Estimated prevalence of inadequate zinc intake of > 25%

Medium risk of Zinc deficiency Prevalence of stunting of 10%- 20% Estimated prevalence of inadequate zinc intake of 10%-25%

Low risk of Zinc deficiency Prevalence of stunting < 10% Estimated prevalence of inadequate zinc intake of > 25%

Using the above criteria all the countries in sub Sahara Africa other than Zimbabwe, Botswana and republic of South Africa are classified as having a high risk of Zinc deficiency. Iron deficiency Up to 40% of pregnant women and children worldwide have anaemia, 60% of which is nutrition related. In children peak of iron deficiency is 18 months. The main cause of iron deficiency anaemia is lack of animal source foods (fish, meat, or poultry) in the diet. Iron deficiency increase risk of mother’s death and affects children’s cognitive function. The lower the haemoglobin, the higher the consequences of these conditions. There is some evidence that iron supplementation has some benefit on IQ. Iron supplementation is not recommended during an attack of malaria endemic regions where increased child mortality was reported following iron supplementation. Iodine deficiency Iodine deficiency manifests with enlarged goitre, congenital hypothyroidism and developmental disability. Traditionally these conditions have been used to assess the prevalence of iodine deficiency. Newer methods include concentration of iodine in urine. Iodine deficiency during pregnancy impairs motor and mental development of the foetus and increases the risk of miscarriage and foetal growth restriction. The best prevention is use of iodized salt. Folic acid, B vitamins and other micronutrient deficiencies Calcium deficiency is the leading cause of rickets in sub Sahara Africa. Lack of exposure to sunlight and the relatively infrequent use of vitamin D supplements leads to development of rickets. In-utero vitamin D deficiency can be associated with poor growth and bone mineralization which is further aggravated by low concentrations of vitamin D in Breast milk.

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Folate deficiency causes megaloblastic anaemia. And in pregnancy neural tube defects other defects and possibly increased prevalence of pre-eclampsia. Good sources of folic acid are fruits, leafy green vegetables, and liver. Treatment of deficiency-folic acid comes in a tablet, usually taken once a day Women with B12 deficiency have such low levels in milk that babies start manifesting symptoms that include failure to thrive, stunting, poor neuro-cognitive development or even global developmental delay. All these delays are irreversible. MANAGEMENT OF ACUTE SEVERE MALNUTRTION Definition: Severe acute malnutrition is defined as the presence of severe wasting (<70% weight-for-height or <-3SD) and/or oedema. There is severe wasting of the shoulders, arms, buttocks and thighs with visible rib outlines. Other features include: Irritability, misery and apathy, pale sparse hair, skin changes, oedema and poor appetite. NUTRITIONAL ASSESSMENT OF THE CHILD ASK Ask mother/caregiver (or check the medical records). Has the child lost weight during the past month? Does the child have conditions that put them at nutrition risk like HIV infection, a cough for more than 21 days, active TB on treatment, diarrhoea for more than 14 days, other chronic OI or malignancy LOOK and FEEL Look for signs of severe visible wasting- loss of muscle bulk and sagging skin/ buttocks. Check for presence of oedema of both feet (and sacrum). Check the weight and height. Is the weight-for-height less than -3 z-scores? Is the child

very low weight (weight for age less than -3 z-scores)? Is the child underweight (weight for age less than -2 z-scores)?

Check the MUAC Table 5: Cut-off points for MUAC for children of different ages Age MUAC cut off point for

under-weight MUAC cut off point for severe malnutrition

6months-12 months <12.0cms <11.0cms 1 year-5 years <13.0cms <11.0cms 6 year-9years <14.5cms <13.5cms 10years-14years <18.5cms <16.0cms Look at the shape of the growth curve Has the child lost weight since the last visit? (Confirm current weight by repeating measurement). Is the child’s growth curve flattening? Is the child gaining weight?

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CLASSIFY THE NUTRITIONAL STATUS Table 6: Classification of nutrition status Acute Severe Malnutrition

Poor weight gain Growing well Has conditions with increased nutrition needs

Signs of severe visible wasting, or Oedema present in both feet, or Weight-for-height less than -3 z-scores below median WHO reference value, or MUAC less than:

110mm in infants 6mo-12mo

110mm in children 1yr-5yrs

135mm in children 6yrs-9yrs

160mm in children 10yrs-14yrs

Reported weight loss, or Very low weight (weight for age less than -3 z-scores), or Underweight (weight for age less than -2 z-scores), or Confirmed weight loss (>5%) since the last visit, or Growth curve flattening, or MUAC less than:

120mm in infants 6mo-12mo

130mm in children 1yr-5yrs

145mm in children 6yrs-9yrs

185mm in children 10yrs-14yrs

Child is gaining weight

HIV infection, Chronic lung disease, or TB, or Persistent diarrhoea, or Other chronic OI or malignancy

TREAT MALNUTRITION Care givers of children who are growing well should be encouraged on how to continue to support their children nutritionally. Children who are growing well but have a chronic illness like HIV require 10% more energy calories on top of their usual requirements. Children who are growing poorly or have a condition that increases nutrition requirements such as TB require 30-40% increase in the energy calories. All children classified as severe malnutrition require therapeutic feeding.

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Management of Acute severe Malnutrition (the ‘10 Steps’) (Adapted from WHO guidelines for treatment of severely malnourished children) Remember: Rehydration with intravenous fluids can increase mortality, as can manipulation of abnormal blood chemistry. Aggressive attempts to promote rapid weight gain from the start of treatment are also dangerous as is giving a high protein diet for children with kwashiorkor. Prescribing diuretics to get rid of oedema can be fatal. Iron supplementation to treat anaemia increases deaths in the initial phase of treatment. There are ten essential steps for managing acute severe malnutrition There is an initial stabilization phase where the acute medical conditions are managed; and a longer rehabilitation phase. Note that treatment procedures are similar for marasmus and kwashiorkor. A: STABILIZATION PHASE STEP 1. TREAT/PREVENT HYPOGLYCAEMIA All severely malnourished children are at risk of hypoglycaemia and should be given a feed or 10% dextrose or sucrose on admission. If blood glucose cannot be measured, assume all severely malnourished children are hypoglycaemic. To treat/prevent hypoglycaemia by giving the first feed of F-75. If the first feed is not quickly available, give 50ml of 10% glucose or sucrose solution (1 rounded teaspoon of sugar in 3.5 tablespoons water), orally or by nasogastric (NG) tube, followed by the first feed as soon as possible. The child should then continue with 2-3 hourly feeds of F-75 day and night at least for the first day. Continue monitoring closely for hypoglycaemia, and repeat the 10% glucose or sugar solution every 30 minutes until stable. STEP 2. TREAT/PREVENT HYPOTHERMIA Check for hypothermia axillary temperature <35oC If present warm with blankets, a heater in the room or skin-to-skin contact with mother. Check temperature 2 hourly until it rises to >36.5oC. The child should be kept covered at all times, especially at night. In order to treat and prevent hypothermia, the child should be fed immediately and then 2 hourly. STEP 3. TREAT/PREVENT DEHYDRATION Dehydration is difficult to diagnose in malnutrition. It is either over or under diagnosed. Low blood volume can coexist with oedema. All severely malnourished children with watery diarrhoea should be assumed to have some dehydration. Do not use the IV route for rehydration except in cases of shock. The standard WHO-ORS solution contains too much sodium and too little potassium for severely malnourished children. Instead use special Rehydration Solution for Malnutrition (ReSoMal) Give ReSoMal (orally or by nasogastric tube) 5 ml/kg every 30 minutes for 2 hours, and then continue with 5-10 ml/kg/h for next 4-10 hours. Replace the ReSoMal doses at 4, 6, 8 and 10 hours with F-75 if it still necessary to continue rehydration at these times. Once rehydrated initiate/continue feeding with starter F-75. The progress is monitored half-hourly for two hours, then hourly for the next 6-12 hours, recording pulse rate, respiratory rate, urine frequency, stool/vomit frequency. During re-

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hydration, rapid respiration and pulse rates should slow down and the child should begin to pass urine. Continuing rapid breathing and pulse during re-hydration suggest coexisting infection or over-hydration. If these signs occur, stop ReSoMal immediately and reassess after 1 hour. To prevent dehydration in a severely malnourished child with continuing watery diarrhoea: • If the child is breastfed, continue breastfeeding. • Continue feeding with starter F-75. • Give ReSoMal between feeds to replace stool losses. As a guide give 50-100 ml after each watery stool. STEP 4. CORRECT ELECTROLYTE IMBALANCE All severely malnourished children have deficiencies of potassium and magnesium which may take at least two weeks to correct. Oedema is partly due to these imbalances. Do NOT treat oedema with a diuretic. Excess body sodium exists even though plasma sodium may be low. Giving high sodium loads could kill the child. Prepare food without adding salt. If available give the multi-mineral mix if not give extra potassium (3-4 mmol/kg/day) and magnesium (0.4-0.6 mmol/kg/day). STEP 5. TREAT/PREVENT INFECTION Assume infection even in the absence of clinical signs and start antibiotics immediately on arrival in hospital. Give a broad-spectrum antibiotic(s) {penicillin/amoxicillin and gentamicin} and metronidazole; if no improvement after 48 hours add chloramphenicol; and measles vaccine if child is > 6 months and not immunized (delay if the child is in shock). Treat for malaria in high endemic zones or if the child has a positive blood film for malaria parasites. Mebendazole 100 mg orally twice a day for 3 days if there is evidence of worm infestation. In countries where infestation is very prevalent, give mebendazole to all malnourished children after day 7 of admission. If anorexia persists after 5 days of antibiotic treatment, complete a full 10-day course. If anorexia still persists, reassess the child fully, checking for infections e.g. TB, HIV and potentially resistant organisms, and ensure that vitamin and mineral supplements have been correctly given. STEP 6. CORRECT MICRONUTRIENT DEFICIENCIES Vitamin A orally on day 1, Repeat on day2 & 14 if there are eye signs. Give daily for at least 2 weeks:

A multivitamin supplement, Folic acid (give 5 mg on Day 1, then 1 mg/day), Zinc (2 mg/kg/day), Copper (0.3 mg/kg/day) and

Iron (3 mg/kg/day but only when gaining weight). A combined electrolyte/mineral/vitamin mix for severe malnutrition is available commercially. This can replace the electrolyte/mineral solution and multivitamin and folic acid supplements mentioned in steps 4 and 6, but still give the large single dose of vitamin A and folic acid on Day 1, and iron daily after weight gain has started.

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B: STABILIZATION PHASE STEP 7. START CAUTIOUS FEEDING In the stabilization phase a cautious approach is required because of the child’s fragile physiological state. Feeding should be started as soon as possible after admission and should be designed to provide just sufficient energy and protein to maintain basic physiological processes. The essential features of feeding in the stabilization phase are: • Small, frequent feeds of low osmolarity and low lactose • Oral or nasogastric (NG) feeds (never parenteral preparations) • Energy: 100 kcal/kg/day • Protein: 1-1.5 g /kg/day • Fluid: 130 ml/kg/day (100 ml/kg/d if the child has severe oedema) • If the child is breastfed, encourage to continue breastfeeding but give the prescribed amounts of starter formula to make sure the child’s needs are met. Milk-based formulas such as starter F-75 containing 75 kcal/100 ml and 0.9 g protein/100 ml will be satisfactory for most children. Feed by tube if needed. A recommended schedule in which volume is gradually increased, and feeding frequency gradually decreased is: Days Frequency Vol/kg/feed Vol/kg/d 1-2 2-hourly 11 ml 130 ml 3-5 3-hourly 16 ml 130 ml 6-7+ 4-hourly 22 ml 130 ml For children with a good appetite and no oedema, this schedule can be completed in 2-3 days. Do not exceed 100 kcal/kg/day in this phase. Closely monitor all the amounts of feeds offered and left over, vomiting, stool frequency and consistency and daily body weight STEP 8. ACHIEVE CATCH-UP GROWTH Once appetite has returned and oedema is resolving, a vigorous approach to feeding is required to achieve very high intakes and rapid weight gain of >10 g gain/kg/day. Replace starter F-75 with the same amount of catch-up formula F-100 for 48 hours then, Increase volume of each successive feed by 10 ml until some feed remains uneaten. Modified porridges or modified family foods can be used provided they have comparable energy and protein concentrations. The goal is to provide 150-220 kcal/kg/day of energy and protein 4-6 g/kg/day. However breast milk does not have sufficient energy and protein to support rapid catch-up growth, so give F-100 as indicated. Weigh the child each morning before feeding and plot the weight. Progress after the transition is monitored by assessing the rate of weight gain every 3 days as g/kg/day. If weight gain is poor (<5 g/kg/d), child requires full reassessment. If sign of heart failure (rapid pulse and fast breathing) occur the feeds should be increased slowly.

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STEP 9. PROVIDE SENSORY STIMULATION AND EMOTIONAL SUPPORT In severe malnutrition there is delayed mental and behavioural development. Provide tender loving care, a cheerful, stimulating environment, structured play therapy 15-30 min/day and physical activity as soon as the child is well enough. The mother or the primary care-giver should be involved in the care process (e.g. comforting, feeding, bathing, play) STEP 10. PREPARE FOR FOLLOW-UP AFTER RECOVERY A child who is 90% weight-for-length (equivalent to -1SD) can be considered to have sufficiently recovered and ready to continue at home. The child is still likely to have a low weight-for-age because of stunting. Throughout the hospital stay mother/care- giver should have nutritional counseling on how to prepare and feed energy and nutrient dense meals at home using the food readily available in the household. Good sensory stimulation should be continued at home. Ensure adequate immunization before discharge and give clear instructions for follow up care. HOME MANAGEMENT OF ACUTE SEVERE MALNUTRITION Children with severe acute malnutrition, who have a good appetite and no obvious complications are good candidates for community rehabilitation. This is done with ready to use therapeutic food (RUTF). Community feeding saves money and possible exposure to new infections in the hospital Ready to use food (RUTF) in management of acute severe malnutrition RUTF is an energy dense paste that has nutrients in the same proportion as the WHO F100 formulation. It is made by replacing dry skimmed milk (DSM) in the F100 with peanut butter paste. This gives an energy rich paste that can be eaten directly by the child without addition of water and thus reducing the risk of bacterial contamination. RTUF is associated with greater weight gain than F100 or corn-soy blends used for therapeutic feeding. RTUF does not rely on mother’s cooking skills to prepare. Weekly or fortnightly follow up (weight and MUAC) until the child recovers should be planned. RTUF can be used as a therapeutic feed, when it provides all the nutrients the child requires or as supplement for some of the child’s nutrients while the rest is provided by the home diet. This is most ideal in the recovery phase from malnutrition NUTRITIONAL MANAGEMENT OF CHILDREN WITH CHRONIC DISEASE Children with chronic disease such as HIV have increased nutrient requirements. At every point of contact the child should be assessed to determine whether they have: Severe malnutrition Gaining weight poorly Growing well Having conditions that increase energy requirements such as infection, TB,

HIV infected children who are growing will require 10% additional calories on top of the normal requirements for their age.

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HIV infected children who are growing poorly or have conditions that increase energy requirements such as chronic cough, diarrhoea, or TB require 30-40% more calories in their diet. The table below gives examples of how this can be achieved using a food based approach. The learner should check with the local Ministry of Health on other foods that can be used to meet these additional energy requirements. Table 8: Examples of food portions that can be used to increase energy content of diet for children of different ages. HIV infected child who is

growing well HIV infected child who is growing poorly or has conditions increased nutrient requirements

Additional nutritional requirement on top of normal requirements

10% increased energy requirement

30-40% increased energy requirement

6-11 months 1-2 spoonfuls of fat/oil or 1-2 spoonfuls sugar added to porridge

2 tsp oil & 1-2 tsp sugar to porridge. Aim to add 3 times daily

12-23 months 1-2 spoonfuls of fat/oil or 1-2 spoonfuls sugar added to porridge

extra cup of full cream milk or cheese/peanut butter sandwich (1 slice)

2-5years extra cup of full cream milk / fermented milk in addition to the normal diet

extra cup of enriched milk or cheese/peanut butter sandwich (4 slices)

6-11year extra cup of full cream milk / fermented milk in addition to the normal diet

extra cup of enriched milk or cheese/peanut butter sandwich (6 slices

12-14year extra cup of fruit yoghurt or cheese/peanut butter sandwich in addition to the normal diet

3 cheese/peanut butter/egg sandwiches (6 slices)

If the food items in the table are not available explore with the care giver what can be used as alternatives. OBESITY Obesity is an emerging concept and the prevalence is on the increase all over the world. It results from an inappropriate high calorie intake with low physical activity. Management focuses on encouraging well balanced healthy meals and increasing physical activity. Interventions for obesity include; Promoting an active lifestyle and limit television viewing Limiting high energy-dense nutrient poor foods salty snacks, ice cream fried foods,

cookies and sweetened beverages and emphasize on fruits and vegetables Set regular meal times, preferably eating as a group to promote social interaction

and role model food-related behaviour. The lifestyle changes should involve the whole family since it’s a lifelong programme, needing a lot of support from all concerned bearing in mind a better body image and self

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esteem being inculcated, cardiovascular diseases and diabetes risks reduced remarkably. REFERENCE

1. Black RE, Allen LH, Bhutta Z, Caufield LE, de Onis M, Ezzati M, Mathers C, Rivera J for the mother and child undernutrition study group. Maternal and Child Undernutrition 1: Maternal and child undernutrition: global and regional exposures Lancet 2008; 371:243-60

2. Bhutta Z, Ahmed T, Black RE, et. al. What works? Interventions for maternal

and child under-nutrition and survival. Lancet 2008; 371:417-40.

3. World Health Organization: Pocket book of hospital care for children. Guidelines for the management of common illnesses with limited resources pg 173-195.

4. World Health Organization: Guidelines for an Integrated Approach to the

Nutritional care of HIV-infected children (6 months – 14 years) Final Draft – 6th February 2008

5. www.mypyramid.gov

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CHAPTER 5

EARLY CHILDHOOD DEVELOPMENT

Ruth Nduati INTRODUCTION Child growth and development go hand in hand. While growth is a result of increase in overall size due to increasing number of or enlarging body cells or both, development is the acquisition of increasingly complex skills for individuals’ adaptation and survival. Development is a continuous process from conception to adulthood. Indeed the process of birth is only an event during development. It depends on the maturation of the nervous system. It is cephalo-caudal in progression and although the sequence is the same in al normal children, the rate differs. The initial phase of development involves massive body responses which become specific in later life (for example a six month old child trying to reach an object with the whole body movement while at the two years of age the same child simply stretches the arm to reach the object. Due to its sophisticated and continuous nature, development in a child is amenable to influences both inherent in the body and external. It is estimated that more than 200million under 5 children in developing countries do not achieve their full development potential. In developing country settings there are four well documented risk factors for poor development: (i) stunting (ii) iodine deficiency (iii) iron deficiency, and (iv) sub-optimal cognitive and socio-emotional stimulation. In addition there are four other environmental factors that pose a risk to the development of the child which include maternal depression, exposure to violence, environmental contamination, and infections such as malaria and HIV. These factors interfere with a child’s development and contribute to a trajectory of poor health, lack of readiness for school, poor academic performance, inadequate preparedness for economic opportunities and perpetuation of the general cycle of poverty. Primary care can create an environment that is conclusive to the child’s development. In this chapter, the student will learn about child development and the factors that influence it. Objective At the end of this chapter the learner should be able to; Outline factors that influence development of the infant and child. List the developmental domains Describe the developmental stages of children from birth to age 5 years Carry out a screening development assessment Recognize deviations from normal development Relate developmental to infant feeding practices. List dangers faced by the child because of stage of development Outline strategies for promoting child development. Learning activities Visit a well child clinic and assess developmental stage of babies aged 1-2 months, 2-6 months and 6months to a year.

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Visit the paediatric ward and asses the development of a child admitted with severe malnutrition. Spectrum of growth and development Growth and development encompasses somatic growth where there is formation of tissues and enlargement of the head, trunk and limbs. There is progressive increase in ability to control larger and small muscles. There is also development of social relatedness, thought, language and emergence of personality. Development on the other hand is the process of adaptation of the child to the environment. The environment in which the child is growing needs to provide for their physical and psychological needs. Physical needs include food, good health, activity and rest, warmth, clothing, shelter, good vision and hearing. The psychological needs include security; personal identity, self respect and independence; affection and care; play; opportunity to learn from experience; and role models. Failure to provide for these needs may result in delayed or abnormal development. Early childhood development predicts subsequent school performance. Factors that influence growth and development Factors that influence a child’s development can be classified as; (i) Biological influences Biological clock There is a set time when certain skills are achieved, for example children walk at one to one and a half years all over the world Genetic endowment Parental advance age, especially maternal increased age can lead to chromosomal abnormalities in the conceived foetus. This subsequently causes organ abnormalities including abnormalities in the central nervous system. A foetus that grows to delivery is thus ill suited for normal development. Couple counseling, antenatal genetic screening and therapeutic abortions may be of help in such cases. In-utero exposure to teratogens such as mumps virus, alcohol, drugs of abuse or therapeutic agents Mothers infected with rubella, HIV, toxoplasmosis, cytomegalovirus, severe extra pulmonary tuberculosis may infect her developing foetus with the result of damage to the nervous system amongst other foetal organs. Careful antenatal screening, vaccination and treatment can prevent some of these. Poorly managed maternal diabetes mellitus, hypertension, heart disease, poor nutrition etc can all lead to poor foetal and later, poor child development. Some medicines given to the mother early in pregnancy may lead to developmental abnormalities of the foetus – which become life long. These include radiation (e.g. X-ray) and cancer drugs.

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Nutritional deficiencies in the mother during pregnancy have negative impact on foetal development. For example, folic deficiency may lead to abnormal neurodevelopment of the foetus. Folic acid supplementation is therefore important during pregnancy. Perinatal Asphyxia Perinatal injuries and birth asphyxia to the baby remain a significant cause of morbidity and mortality in children in the developing countries. The brain is particularly vulnerable and this tends to lead to subsequent abnormal development in the child. Proper labour monitoring, conduction of delivery and newborn resuscitation can reduce this problem.. Postpartum illness – meningitis, chronic illness Severe infections in the child, such as meningitis, can cause brain injury with subsequent abnormal development. Some of these infections are adequately prevented through immunization. Malnutrition – stunting, iodine and iron deficiency Proper nutrition is crucial to normal child development. This is discussed in details in the relevant chapters. Exposure to hazardous materials/agents – heavy metals – lead, mercury Some drugs and poisons cause long lasting damage to children, especially if they are not managed well. These include lead poisoning and mercury poisoning. The net effect is impaired development. Prevention of poisoning and appropriate management of affected children is therefore this important. Accidents and injuries Due to their explorative nature, children are always exposed to accidents and injury. Where these involve the vital systems (like brain), there may be impaired subsequent development. This is addressed in detail the relevant chapter. (ii) Environment and social exposure The environment contributes to child development by providing physical needs such as food, shelter, good health, functioning senses and stability. The environment also provides for the psychosocial needs of the child. The child needs appropriate stimulation to develop well. Stimulation is provided for through: Play Affection and care Role models Opportunity to learn from experience Security Personal identity, self-respect and independence (iii) Child’s temperament may also affect their development Several parameters for assessing temperament have been described Activity level - Amount of gross motor movement Rythmicity - how regular is the biological clock Approach and withdrawal adaptability - typical response to a new stimulus, or how long it takes to adapt to novel stimuli

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Threshold of responsiveness - how intense should a stimulus be to evoke a response Intensity of reaction Quality of mood -usual disposition always happy, always unhappy, always hungry in class Attention span and persistence -how long does the child pay attention and stick to a difficult task There is value in understanding a child’s temperament and health workers should help parents understand and accept the characteristics of their children. Behavioral and emotional problems tend to occur when the temperamental characteristics of the child and parents conflict. For example, active children maybe a problem for low-key parents, while slow to warm up children may be pressured by outgoing parents. Parents who live highly structured lives may fare poorly with children whose biological clocks occur less regularly. (iv) Psychological attachment The first year is a time of developing ‘basic trust’ based on mother’s consistent responsiveness to the child’s needs. The attachment reflex is the biologically determined tendency of a young child to seek proximity with parents during periods of stress. Children who are securely attached are able to re-establish a sense of well being after a stressful event such as a physical examination or immunization. Insecure attachment may signal dysfunctional attachment and dysfunctional development and behaviour later on. At all stages development and across different lines of development is fostered by adult caregivers who observe a child’s verbal and non-verbal cues and respond accordingly. Responses to non-verbal gestures create the ground work for language and social development. At all stage development fostered by presenting the child with tasks that are just a little harder than what has been mastered and optimal tasks fall in the ‘zone of proximal development Social factors Factors beyond the mother-infant dyad contribute to a higher or lower level of stress and which impact on the mother-infant relationship. If the mother has an abusive spouse she may become depressed and is therefore unable to respond appropriately to the child. Families are complex sub-systems with defined boundaries, subsystems, roles and rules of interactions. Family with rigidly defined parental systems may deny children an opportunity to participate in decision-making and thereby exacerbate rebelliousness. Change in family structure, or individual behaviour results in role changes until new equilibriums are found for example sick parent who becomes dependant, or loss of parent. Wider societal issues also influence lives of families. Increasing urban poverty may radically change the roles of different family members and in the process adversely affecting child development. The child’s development ultimately influenced by the interaction of biology and social interactions. Case study: Pre-term baby may cry little and sleep long periods of time. A depressed mother welcomes this as good behaviour setting-up a cycle that leads to poor nutrition, slow growth and failure to thrive. The child’s failure to thrive may reinforce the parents’ sense of failure. Later impulsivity, inattention and under-nutrition may interact with

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mother’s depression leading to referral for aggressive behaviour. The cause of the aggression is sum total of prematurity, under-nutrition and mother’s depression. Risk factors versus resilience Resilience is the description that is given to children who make it despite great odds. Children who are temperamentally persistent or athletic demonstrate greater resilience. Socially having one trusted adult often the parent, grandparent or teacher with whom the child has a close relationship helps to nurture resilience. In sub Sahara Africa many children are living in difficult circumstances. Resilient children have better ability to survive. Health workers need to harness and support structures that strengthen children’s resilience. Evaluation of a child should include not only the risk factors but also the protective strengths. STAGES OF DEVELOPMENT Developmental domains Each of these domains has a line of development or sequences of changes until maximal skills are achieved. Gross motor Fine motor Social Emotional Language Cognition Other skills that are important in the older child and which profoundly affecting learning are the ability to pay attention and to concentrate. Development; Has a constant pattern Begins in utero Should be considered longitudinally relating what has happened to what lies ahead Varies in rate between children There is inter-relatedness in the acquisition of the different skills with deficiencies in one area affecting development of another area. For example hearing deficits have profound effect on development of language, as well as socio and behavioral skills. 0-2 months The first year is a period of rapid physical growth and maturation and acquisition of numerous competencies. Growth takes place in spurts that qualitatively change the child’s behaviour Behavioural goals In the first 2 months of life the main behavioural goals are to establish; effective feeding, a predictive pattern of sleeping and waking and social interaction that becomes the basis for future social and cognitive development.

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Physical growth and Motor Development In the 1st week there is a 10% drop in weight which is regained or exceeded by end of second week. During this period the average weight gain 30g/day. The infant’s movements in the first 2 months are largely uncontrolled except for the eye gaze, head turning and sucking. Smiling occurs involuntarily. Babies cry in response to stimuli such as wet diaper, hunger, and over-heating. Crying peaks at 6 weeks of life with at least 3hrs/day, and then declines to 1hr/day. Neurological development contributes to the longer blocks of sleeping time. Learning also contributes to sleeping habits with babies shifting to night time breastfeeding if the mother is away at work during the day. Cognitive development Babies receive visual, tactile, olfactory and auditory stimulus. Infants habituate to the familiar and pay less and less attention to a stimulus that is presented repeatedly. In the first 2 months babies can differentiate among similar patterns and colours and consonants. They respond to facial expressions even when they appear on different faces. They are also able to match abstract properties of stimuli, for instance they can tell difference between sound from movement of lips or from a video-tape Emotional development The key task in emotional development is to develop basic trust. Key to this goal is consistent availability of a trusted adult. Babies who are consistently picked and held in response to distress cry less at one year and have less aggressive behaviour at 2 years. Feeding plays a key role in emotional development. On-demand fed babies link distress with arrival of mother and relief from distress. Babies fed on fixed schedule usually adapt. Babies with unstable biologic rhythms and who are fed on a fixed schedule experience periods of un-relived hunger or unwanted feedings. Similarly babies fed at parents convenience with complete disregard of baby’s need do not experience feeding as the favourable reduction of tension. Babies who have a mismatch between feeding and hunger have increased physiologic instability manifesting as diarrhoea, spitting, poor weight gain) as well as later behavioural problems Success in establishing feeding and sleep cycles increases the parents’ sense of efficacy independent of child’s temperament. Normally anxiety and ambivalence experienced by the mother/parents in the first few days after the birth of their baby settle down as baby develops regular rhythms. Mothers with post-partum depression or blues may have a harder time making the adjustment and need specific support. 2-6 months During the period of 2-6 months the voluntary (social) smile and increased eye-to-eye contact emerges. Parents experience a heightened sense of being loved. At 3-4 months weight gain slows down to 20g/day. Motor and Physical development Early reflexes that limit movement recede. There is loss of asymmetrical tonic neck reflex which means that infants can roll over and also begin to examine objects in the mid-line and manipulate them with both hands. Waning of grasp reflexes means that the child can hold an object voluntarily and also let go. A novel object may elicit purposeful but inefficient reaching. Babies have increased control of truncal flexion

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which then makes intentional rolling possible. Head control allows the baby to gaze across things and not just up and down. The baby also learns to take food from a spoon. Maturation of visual system allows much greater depth and field of site. Sleep requirements are 14-16 hours with 9-10 hours concentrated in the night and up to 70% of the infants sleep 6-8 hours on a stretch. The sleep cycle is short 50-60 minutes compared to the adult 90 min. in adults and therefore babies wake up frequently in the night. Cognitive development The period of 4-6 months is characterized by increased awareness of the environment. The baby no longer focused on the mother only but becomes distracted in her arms. Infant build a sense of self – when he wiggles the toes, he can see and feel the sensation and do it deliberately. Infants explore their bodies, staring intently at their fingers, toes, vocalizing, touching the different body parts. The baby learns what is self and that he has control over it and what is non self which he has no control, for example smell and touch by mother. Emotional development Primary emotions of anger, joy, interest, fear, disgust, and surprise appear in the appropriate context as distinct facial expressions. Face to face expression matches that of the trusted adult, for example a mother and baby smiling to each other. If intensity of stimulation builds the baby turns away. If the mother turns away the baby leans forward and tries to stimulate mother’s attention. Infants of depressed mothers behave differently. They spend less time on co-ordinated behaviour and make little effort to connect and co-ordinate with the parent. The baby shows sadness and loss of energy a parent continues to be unavailable. Babies’ ability to share the emotional state of their parents is the first step in development of communication The 3-6 months period in a child’s life is exciting and interactive. Some parents may interpret the increasing outward look by the infant as rejection. In the paediatric consult, the session is happy. If the paediatric visit is not joyful and relaxed, causes of social stress and family dysfunction, parental illness or problems of infant parent-relationship should be sought. 6-12 months Key themes during this period are; Increased mobility and exploration of the inanimate world, Advances in cognitive understanding and competences New tensions around themes of separation Infant develops will and intention Motor development Physical growth slows down. Motor achievements co-respond to increasing myelination and cerebella growth. Approximately half of the babies are able to sit unsupported by 7months, pivot while sitting by 9-10months, pincer grasp by 9 months, crawling and pulling to a stand at 8 months and walking at 1 year. The increased ambulation increases child’s exploratory range, creates new physical dangers and provides new

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learning experiences. Tooth development starts usually with mandibular incisors and to some extent correspond to skeletal growth. Cognitive development Initially everything goes to the mouth. Later novel things are inspected, passed from hand to hand, banged, dropped, and then mouthed. The pleasure and persistence with which children pursue these activities points towards intrinsic drive or masterly motivation. Masterly behaviour occurs when children feel secure and children with less secure attachments demonstrate limited experimentation behaviour. Object constancy is a major cognitive milestone achieved at around 9 months. The child now understands that an object exists even when it cannot be seen. Once this is achieved an infant will persist in finding objects hidden under a cloth or behind the examiner. Emotional development Development of object constancy corresponds to social and communication changes. Babies begin to differentiate familiar and strange faces and may cling and cry. Separation becomes more difficult. Babies may wake up more often to check parents are still there. There is emerging autonomy – infant no longer consents to be fed and turns away as the spoon approaches or insists on holding it himself. Self-feeding with finger foods – practice newly acquired fine motor skill (pincer skills) and maybe the only way to get the child to feed. Tantrums emerge. The drive for autonomy and masterly conflict with parental control and infants still limited abilities. Communication 7-month old babies are adept at non-verbal communication showing a range of emotions and by nine months realizes that emotions can be shared between two people. As an example, an eight month old baby will show his parents his toys happily. In a clinic setting, a eight month old baby will start crying because she or he has heard another baby cry. By eight to nine months, babbling increases in complexity with multiple syllables (ba-da-ma) and inflection that mimic the native language. This is followed by emergence of true words - sound used consistently to refer to a specific subject. Feeding and sleeping problems re-emerge. Poor weight gain may reflect the struggle between the infant and the parent over control of the infant’s feeding. Discussions with parents may help to pre-empt these difficulties. 9-month examination of the child is difficult because of the babies’ wariness of strangers. Time taken in talking to the mother and playing with the child will ease these tensions. 12-18 months Motor development Further slow down in growth, accompanied by declining appetite. The baby fat burned up with increased mobility. The child has an exaggerated lumbar lordosis makes the abdomen protrude. Brain growth continues with myelinization throughout the 2nd year. Most children walk by one year with highly active fearless infants walking earlier than the more timid ones. Initially the toddler has a wide base gait, knees bent and arms flexed at elbow and entire torso rotates with each step. Several months later centre of

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gravity shifts back and torso remains more stable, knees extend and arms swing on the side. The child is then able to stop, pivot and stoop without toppling over. Cognitive development This stage is characterized by accelerated object exploration and the skills of reaching, grasping and releasing are almost mature. The toddler combines objects in novel ways to create interesting effects. Toys like stacking blocks are very popular and well liked by babies in this age group. Playthings are used for intended purpose e.g. combs for hair, cups for drinking. There is imitation of adult (parents and other siblings) and make believe play Emotional development Before walking the toddler’s predominant mood is irritability. Once they walk they become intoxicated with their new ability to control the distance between themselves and their parents. Toddlers orbit round their parents moving away looking back for re-assurance and then moving further before coming back for re-assurance. In unfamiliar ground the timid child remains close to the parent while in more familiar surrounding the baby may orbit out. Ability to use the parent as the secure position for exploration depends on the degree of attachment relationship. In a strange room, when the parent leaves most children stop playing, cry and try and follow. When the parent returns, the secured attached child instantly goes to the parent to be picked and comforted and then returns to play. Children with ambivalent attachments go to their parents and then resist being comforted and may hit at their parents in anger. Avoidant children may not protest when the parent leaves and may turn away when they return. Insecure response patterns represent strategies that infants develop to cope with punitive or unresponsive parenting style and may predict long-term emotional problems. Role of infant temperament in response to separation is still controversial. Language development Receptive language precedes expressive language. By 15 months use 4-6 words spontaneously, and points to different body parts. They enjoy polysyllabic jargoning and do not mind that others do not understand. Parents often look forward to the milestone of walking. However the ability to wander off means there is a need for increased supervision. At this stage children are at increased risk of injuries. During a health visit an infants who become anxious in their parents arms and turn to strangers are worrisome and further history and assessment is required to determine the caring practices. This maybe a sign of neglect or inconsistent care practices 18-24 months Motor development Children develop improved balance and agility. They are now able to run and climb a staircase. Height and weight increase at a steady rate and head growth slows down. Cognitive development Age 18 months marks the end of sensory-motor stage. Object permanence is fully established and cause and effect are better understood. The toddler begins to

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demonstrate flexibility in problem solving, and for instance may use a stick to reach a toy that is out of reach. Symbolic play is now not tied to the toddlers’ body, for example a toy can be fed. Cognitive changes have significant effect on emotional and linguistic development. Emotional development There is increased clinginess as the child becomes more aware of separation. Separation at bed-time difficult and many children use special blanket or toy as a transition object, which maybe representing the absent parent. Transition objects remain until symbolic language develops. Self conscious awareness develops and an example is when looking at a mirror the child will reach for their own face and not at the mirror. The child will recognize that toys are broken and may ask parents to fix them. When tempted to touch a forbidden object they themselves say no- no-no showing that they are internalizing standards of behaviour. Linguistic development Children continue to develop symbolic language. The vocabulary increases from 10-15 words at 18 months to > 100 words at 2 years as children realize that words stand for things. Once they have 50 words they are able to combine words to make simple sentences. At 2 years able to follow a two step command e.g. ‘put on your shoes and then kick the ball’. Emergence of verbal language skills marks the end of the sensorimotor period. The child learns to use symbols to express ideas and solve problems and this diminishes the need for cognition based on sensation and motor manipulation. Physical limits on child’s exploration become limited with the child’s increased mobility. For example the child is able to climb out of his cot. There is now increased need for behaviour control that is based on language. Children with delayed language acquisition have greater behavioural problems. Language development is facilitated when parents and other care givers use clear, simple sentences, ask questions and respond to children’s incomplete sentence and gestures with the correct words. Regular looking at picture books with a parent provides ideal setting for language development. Age 2-5 years Motor Development There is reduced somatic and brain growth and therefore reduced food intake and appetite. During the period 2-5 years children gain 2Kg in body weight and 7cm in height/year. The child’s prominent abdomen flattens. Physical energy peaks and sleep requirement declines to 11-13hrs/24 hours. Visual acuity 20/30 at 3 years and 20/20 by 4 years. All 20 primary teeth erupted by 3 years. Most children walk with a mature gait and run steadily by 3 years. Acquisition of other skills such as throwing, catching, kicking balls, riding on bicycle, climbing play-ground structures varies widely. Intensity and cautiousness during motor activity are influenced by child’s temperament. Energetic co-ordinated children thrive in an environment that fosters physical competition. Lower

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energy children thrive in environment of quiet play. The child’s handedness established by 3 years. Development of fine motor skills also related to exposure, for example children given an opportunity to hold a crayon develop this skill earlier. Language Language acquisition depends on environment and intrinsic factors and is a critical barometer of cognitive and emotional development. Mental retardation maybe first identified at 2 years from language delay. Child abuse and neglect are correlated with language delay especially ability to convey the emotional state. Delayed language may lead to behavioural problems because the child is frustrated by inability to communicate his ideas and feelings. Cognition Children aged 2-5 years have magical thinking and experience confusion about causality - it rains because people carry umbrellas. - the sun goes down because it is tired and therefore goes to sleep. Play helps children develop masterly over their fears. Children who are abused will often play the role of an aggressor. Drawing and other artistic expression are also play. The games often point towards the experiences the child is undergoing and provide a powerful way of communicating with a child. Play and drawing activities are increasingly being used in clinical settings to communicate with young children. Emotions The child aged 2-5 years has the challenges of reigning in their emotions. Children will have intense feeling for their parents. They use internal images of trusted adults to provide security during times of stress. At the same time children learn what is acceptable by testing the limits. Tantrums occur occasionally. Tantrums that last more than 15 min duration and more than 3 times a day reflect underlying heath, social or emotional problems. They are also curious about genital organs but become intensely private from 4-6 years. The physical developmental characteristics have implications for parents and health care workers. Parents worry about the reduced appetite. Motor precocious children at increased risk of accidents and this is the peak age of non-intentional injuries and poisoning. Parents concerned about hyperactivity may be having inappropriate expectations of their children. Truly reckless children involved in activities without consideration of their safety need protection. Hyperactivity maybe associated with child abuse and neglect. Conservative parents maybe worried that their child is masturbating. DEVELOPMENTAL ASSESSMENT Child development assessment should be carried out at every contact with the child. This assessment provides an opportunity to discuss with the care-giver difficulties they may be experiencing and strategies for promoting the child’s development. There are 4 fields of developmental skills that need to be considered when assessing the development of a young child.

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Gross motor Vision and fine motor Hearing, speech and language Socio-emotional and behavioural Cognitive development is assessed on its own in the older child. Table 1: SUMMARY OF FIELDS OF DEVELOPMENT OVERVIEW OF DEVELOPMENTAL STAGES

ACQUIRED SKILL THAT IS MONITORED

UPPER LIMIT OF NORMAL ACQUISITION OF SKILLS

GROSS MOTOR DEVELOPMENT Acquisition of tone and head control Head control 4 months Primitive reflexes disappear Sitting Sits unsupported 9 months Standing, walking running Stands

independently 12 months

Hopping, jumping, pedaling Walks independently 18 months VISION AND FINE MOTOR Visual alertness, fixing and following Fixes and follows

visually 3 months

Grasp reflex, hand regard Reaches for objects 6 months Voluntary grasping, pincer grip, pointer Transfers 8 months Handles objects with both hands, transfers from hand to hand

Pincer grip 12 months

Writing, cutting, dressing HEARING, SPEECH AND LANGUAGE Sound recognition, vocalization Polysyllabic babble 7 months Babbling Consonant babble 10 months Single words, understands simple requests

Saying 6 words with meaning

18 months

Joining words, phrases Joining words 2 years Simple and complex conversations 3 word sentences 2.5 years SOCIAL, EMOTIONAL AND BEHAVIORAL

Smiling, socially responsive Smiles 8 weeks Separation anxiety Fears strangers 10 months Self help skills. Feeding, dressing, toileting

Feeds self with a spoon

18 months

Peer group relationships Symbolic play Symbolic play 2-2.5 years Socio/communication behavior Interactive play 3-3.5 years

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Median age of acquiring a milestone is the age at which half of the children acquire the skills, while the limit ages are usually 2 standard deviation above the median. The limit ages for different development milestones are shown on table 1. These ages are a guide to when the child’s development is normal and when an assessment is required to determine the cause of delay in development. Adjustment for gestational age should be made in the first two years of life during developmental assessment. STRATEGIES FOR PROMOTING CHILD DEVLOPMENT Conceptual frame work Promotion of Early childhood development includes deliberate action to stimulate and promote child development, prevents risks and ameliorates the negative effects of various risks. Poverty is both a biological and psychosocial risk that affects development and function of the central nervous system. In turn this may affect all spheres of development namely sensory-motor, socio-emotional and cognition and language. These in turn affect academic performance, economic performance and worse than this, there is intergeneration transmission as cycle of poverty is perpetuated.

Source: Engle et al. Lancet 2007;369:229-242 Improving food intake and reducing stunting Improving the diets of pregnant women, infants and toddlers reduces stunting. Food supplements among 2-3year olds improves cognition well beyond that age. A long standing study in Guatamela that provided nutrition supplements to children aged less than 3 years, demonstrated benefits in schooling, reading and intelligence tests by participants when they were assessed at the age of 25-42 years. Reducing iodine and iron deficiency There is conclusive evidence that reducing iodine and iron deficiency is associated with improved cognition and behaviour. Use of iodinated salt is an effective way of proving iodine at household level. One of the millennium development goals is universal coverage is defined as 69% of all households use iodized salt. Globally this goal has

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been achieve in Africa. Health workers need to constantly encourage the public to use iodinated salt. Iron deficiency anaemia impedes child development and the detrimental effect in toddlers and infants is not readily reversed with supplements. Supplementation of deficient children has shown positive effect on motor, socio-emotional and language development. Some of the strategies for improving iron security include use of micro-capsulated iron with vitamin C, growing of iron rich foods, and removing phytates from plants at the point of food production in order to reduce inhibition of iron absorption. Iron supplementation of replete children has been shown to be associated with slowing down of linear growth and increased hospitalization and death in endemic areas. Stimulation combined with health promotion Stimulation occurs through responsive and increasing complex developmentally appropriate interactions between care-givers and children that enhance the child’s development. Both cognitive and socio-emotional skills provide the basis of later academic and employment performance. Early stimulation especially in pre-term babies enhances neurocognition. Inadequate stimulation and interaction interferes with the child’s development by affecting neural circuitry. Without interventions, changes in the first 2 years maybe un-recoverable. Observations from developed country settings show that children exposed to quality early childhood development programs have better school performance. Higher verbal and mathematical skills, higher school completion rates, better employment, better health outcomes, and less dependency on welfare. The highest benefits are accrued by disadvantaged children including those that are stunted, younger children compared to older ones, and longer exposure. The quality of the programs matters with child initiated activities, smaller groups, high staff-child ratio, and trained teachers having better outcomes. The process by which early child development services are provided matters. The warmth of the caregiver, emotional tone and variety in environment setting impact on the child’s learning. Currently there are no globally agreed indicators for child development. The individual child is assessed as outlined earlier in this chapter – cognitive, language and socio-emotional development. Social risks These include maternal depression, exposure to domestic and community violence and stigma and loss associated with HIV/AIDS. Studies suggest that women in developing countries experience high levels of stress and depressive symptoms often associated with poverty, lack of support and negative life events. Children of depressed mothers are at risk because of inconsistent or unresponsive parenting. A Jamaican study has shown that participation in parenting classes was associated with reduced levels of stress, however the latter was not associated with improved cognitive functioning of their children. Violence is often as a result of excessive corporal punishment, child abuse or neglect. To date there is limited data on whether programs providing ‘social protection’ to children mitigate against the adverse effects on development.

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Environmental risks Exposure to heavy metals such as lead and arsenic leads to irreversible brain damage. Chelation of lead in exposed children reduces the plasma and bone content but has no effect at all on development. The global shift away from leaded petrol has significantly reduced the number of children exposed to lead. Arsenic is usually dissolved in water from shallow wells. One intervention is to sink deep wells. Infections Control of infections – malaria and HIV/AIDS will reduce number of children at risk of poor development. Cerebral malaria is associated with long-term neuro-cognitive effects. The interventions are described in the respective chapters in this manual. Investing in child development Strategies that have been shown to optimize child development are characterized by; Programs providing direct learning to children and their parents Target the youngest and most disadvantaged child Longer duration High quality and high intensity Integrate with family, health, nutrition and education services, Current coverage of these programs is low. In order to meet the millennium development goal of universal primary education, and poverty alleviation there is a need to expand early childhood development programs. By 2005, only 15 developing countries had made early childhood education compulsory. Communities and governments are not aware of the children’s loss of developmental potential, the potential cost of this loss on individual children and on poverty alleviation. The lack of agreed on global indicators for measuring child development at population level makes it difficult to monitor the interventions. Governments are faced with many acute needs and therefore find it difficult to invest on long-term development. There are also multiple groups interested in the young child resulting in a situation where no one group takes responsibility. There is also the added challenge that there is no single strategy for promoting child development. Health workers need to advocate and promote early childhood development programs with the understanding that events in early childhood affect learning and productivity throughout life. Interventions in early childhood are cost effective improving efficiency and effectiveness of education programs, in one intervention. Increased schooling for girls has long term e3ffect on child survival and development. Early childhood development programs are sustainable in that hey lead to development of new standards and norms of rearing children. Conclusions Normal early childhood development is the foundation for a healthy life in the future. At every contact the child’s development status should be assessed. Communities and

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governments are not aware of the children’s loss of developmental potential, the potential cost of this loss on individual children and on poverty alleviation. Health interaction with the mother and communities is an opportunity to improve community awareness of the importance of child development. BIBLIOGRAPHY Engle P, Black M, Behrman JR, Cabral de Mello M, Gertler PJ, et al. Child development in developing countries Strategies to avoid the loss of developmental potential in more than 200 million children in developing countries. Lancet 2007;369:229-242. Normal Child Development, hearing and vision. In: Lissauer T and Clayden G Illustrated Textbook of Paediatrics 3rd Edition.

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CHAPTER 6

GROWTH MONITTORING AND PROMOTION DURING EARLY CHILDHOOD

Daniel Njai, Rachel Musoke, Ruth Nduati, Aggrey Wasunna

INTRODUCTION Growth is the gradual increase of the body size and shape and it consists of increase in cell numbers and their size. The period from conception to age of 2 years is the fastest growing period in life and is thus much more vulnerable. It is important to ensure adequate growth during this period as insults occurring during this period are irreversible. Growth depends upon adequate nutrition, appropriate physical and social environment, as well as normal health. Up to the age of five years children around the world have the same growth pattern if their health and nutritional needs are met. The growth of a child, visibly displayed on an appropriate chart, is the most important sensitive tool of measuring his health and nutritional status. When growth is charted regularly over a period of time in infancy and early childhood, it is known as growth monitoring. It is often done together with growth promotion as a combined operational child survival strategy in Primary Health Care (PHC). It provides evidence of a child who is growing well and helps to identify the child who is not growing well. When a child is not growing well, appropriate health interventions such as treatment of illness and provision of nutrition are carried out to promote good health and nutrition. Growth monitoring is an essential component of paediatric health surveillance. This is because any problem within the physiologic, interpersonal, and social domains may adversely affect growth. Therefore, the growth of every child brought to a health unit must be carefully assessed with a view to identify under-nutrition and failure to thrive. Health workers have the important responsibility of using growth monitoring and promotion (GMP) strategy to ensure that infants and young children have good health and nutrition. The health workers, therefore, must acquire relevant knowledge, skills and attitude to perform and manage growth monitoring and promotion in the communities they serve. Growth and development are often considered together as it is sometimes difficult to draw the line between the two. As you monitor growth is important to assess development as well. In this chapter, you will learn about growth, measuring growth, growth monitoring, factors that influence growth and development and what can be done to promote optimum growth and development. OBJECTIVES At the end of the chapter the student should be able to: Define growth State the role of individual’s genetic constitution on growth and development State other factors, besides the genetic constitution, which influence growth and development Explain the concept and strategy of growth monitoring and promotion as a means of measuring and promoting health and nutrition of a child.

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Understand the inter-dependency and the differences between growth monitoring and promotion and nutritional assessment. State the importance of growth monitoring in the under fives. List four main objectives of growth monitoring through weight/age charts. State the steps necessary for growth Monitoring and Promotion. Measure the growth accurately, plot the measurements carefully on the growth chart and correctly interpret the child’s growth pattern. Report the measurements to the mother and inform her how her child is growing. Counsel the mother List the seven tasks of identifying growth monitoring needs in the community. Recognize the role on integrating health education and operational research into Growth Monitoring Programme. LEARNING ACTIVITY It is assumed that the student will visit the child welfare clinic and learn from the nurse or doctor how to weigh babies accurately. Find out the kind of scale used. Plot the weight of one or two children on the child health card. Find out whether the majority of children are well nourished or not. Importance of Growth Monitoring Assessment of growth is very helpful in finding out the state of health and nutrition of a child. Continuously normal growth and development indicate a good state of health and nutrition of a child. Abnormal growth, or growth failure, is a symptom of disease. Hence, measurement of growth is an essential component of the physical examination. Growth monitoring enables health workers detect malnutrition early, facilitate early treatment or correction of any conditions that may be causing abnormal growth and development and to provide an opportunity for giving health education and advice for the prevention of malnutrition. Factors affecting growth and development Each child’s path or pattern of growth and development is determined by genetic and environmental factors. The genetic factors determine the potential and limitations of growth and development. If favourable, the environmental factors, such as adequate nutrition, facilitate the achievement of the genetic potential of growth and development. Unfavourable factors acting singly or in combination, slow or stop growth and development. Some of the unfavourable factors are malnutrition, infections, congenital malformations, hormonal disturbances, disability, lack of emotional support, play, language training and primary tender loving care provider. These environmental factors can be removed or minimized. After the removal of an unfavourable factor, there is a period of catch up growth. During the catch up growth period, the growth rate is greater than normal. The greater growth rate continues until the previous growth pattern is reached. Then the growth rate is reduced to the normal rate determined by the individual’s genetic factors. A child with a genetic constitution supporting tallness grows slightly more rapidly than a child with a genetic constitution supporting shortness. Similarly, a child with a genetic constitution supporting cleverness develops more rapidly than a child genetically constituted to be less intelligent.

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INDICATORS OF GROWTH The following measurements are used as indicators of growth. Weight-for-age, height-for-age, weight-for-height, head circumference and mid-upper arm circumference. Weight for age (WAZ) Weight-for-age is the most widely used as it is easily done without too much training. It however does not distinguish between acute (wasting) and chronic (stunting) nutrition or fluid retention/loss. You need to have accurate weighing scales that are calibrated regularly. The biggest draw back with this method is the determination of accuracy of the child's age. The mother may have a written document supporting the date of birth or she may remember accurately the date. Where the two do not provide the age, the mother can be assisted to remember through seasons or event that occurred when the child was born; hence the age can be ascertained. As a general rule, birth weight doubles by 5-6 months, and triples at 12 months. As the age increases the rate of growth gradually slows down. Height for age (HAZ) Height-for-age assesses linear growth. This measurement is of value in determining stunting. It is, however, more difficult to measure especially the length or height of infants and young children. Accurate measurement of the young child requires a stadiometre and training of the health worker. Weight for height (WHZ) This ratio is independent of age and helps in determining body build. It is a useful measurement for distinguishing acute (wasting) from chronic (stunting) malnutrition. Low weight for height (wasting) is more responsive to intervention than stunting. Circumferences Mid-upper-arm-circumference (MUAC) MUAC not routinely used as growth monitoring tool but is very useful in assessing nutritional status of infants and young children. Specific tapes have been designed with different colour bands that help in screening for malnutrition in communities with limited resources and who have minimally educated health workers. Age MUAC cut off point for

under-weight (< than reference value)

MUAC cut off point for severe malnutrition (< than reference value)

6months-12 months 12.0cms 11.0cms 1 year-5 years 13.0cms 11.0cms 6 year-9years 14.5cms 13.5cms 10years-14years 18.5cms 16.0cms Head circumference This is a good measure of brain growth especially in the first 2 years of life. While not strictly part of normal growth monitoring and promotion strategy, head circumference measurement is of great value in follow-up of low birth weight infants, and in children with abnormalities of the central nervous system, e.g. suspected post meningitic

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hydrocephalus. Head circumference charts exist but are not included in country child growth monitoring cards. The normal head circumference at birth is 34-36cms. The head circumference increases 2cm/month for the first 3 months, the 1 cm/month in the period 3-6months. In the period 6-12 months the head circumference increases 0.5cm/month. Overall the head increases by 10cms in the first year of life. The head circumference is a sensitive way of identify children at risk of mental retardation because of poor brain growth (microcephaly) or too large a head with hydrocephalous. Waist circumferences and waist/hip circumference ratios are currently used to monitor obesity in adults. Standard measurements for children have not been developed. DEFINITIONS Definition of Growth Monitoring and Promotion(GMP) Growth monitoring is the regular and sequential weighing of the child, recording the measurements on a growth chart. In doing so the growth can be easily visible and demonstrated or explained to the mother. Growth promotion, on the other hand, is giving the mother of such a child relevant and practical guidance within her means or that of the family or the community on what to do to ensure growth continues well or resumes, in case where it was not proceeding normally. The process of growth monitoring combines identification, communication or education for the individual mother, the family, the community and the health workers on matters related to the growth, treatment of illness and improvement of nutrition. Objectives of Growth Monitoring and Promotion As discussed above, growth monitoring and promotion is a strategy which enables the health workers assess normal growth of infants and young children. These two age groups are vulnerable period of childhood and many factors may interfere with normal growth. All infants and young children should have regular monitoring. On detection of deviation from normal growth the health workers are able to assess and determine the hidden problems such as in adequate nutrition or an infection. After identification of the problem, the health workers can assist the mother and her family to make the right decision regarding the most appropriate intervention required. Thereafter growth monitoring is continued to see if the child catches up on normal growth. Children who do not growth according to their potential, or who fail to achieve the expected developmental milestones should be referred for specialist assessment. The other objective of growth monitoring is to give mothers/parents/caregiver a chance to meet regularly and to discuss what may be done to keep children healthy. Besides use by health workers and parents regular growth monitoring and reporting to the Ministry of Health helps planning and intervention at government level especially in times of food shortage e.g. drought.

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Performance of Growth Monitoring Having grasped the concept of growth monitoring and promotion, the student should learn to perform accurately the task of growth monitoring and promotion. Medical officers require this skill in order to fulfill their roles as health workers and supervisors of other health workers at health facilities and in the community. The following sub-tasks or steps are important in performing growth monitoring and promotion. Accurate and Safe Weighing of Infants and Children Growth is progressive increase in body size resulting from multiplication of cells or increase in size of the cells or both. Growth is measured by taking: weight, length (or height), head circumference, mid upper arm circumference (MUAC). To be useful, these measurements must be taken accurately using reliable equipment and correct measuring techniques. To be reliable, the equipment must be calibrated regularly. For measuring the weight, a beam balance or spring balance is used. The scale chosen should be affordable, easily transported and durable. Different types of scales can be used to measure a child's weight depending on the location of the activity. The selection of the scale should take into consideration who will be using the instrument, the working environment, and cost effectiveness. Weighing scales should be affordable, easily transported and durable. Accuracy within 100g is acceptable. It is recommended that the student finds out the most commonly used weighing scale in his country, as types vary from one country to another. Students should be able to describe the major parts of the scale. An example of a scale is the Salter Scale which is widely used in community growth monitoring. This will be used to illustrate measuring the weight for infants and children. Major parts of Salter Scale: (See figure 1) Upper hook (suspends scale with chain/rope from above) Knob (adjusts pointer to zero) Dial (reading of weight taken in kg) Pointer (points to weight reading) Lower hood (holds pair of pants which suspends child). Each scale is usually supplied with four sets of strong plastic pants but other cotton pants or a basket will do. Before weighing a child, the weighing scale is checked for proper working. The checking is done through weighing a known weight and noting whether that is the weight obtained from the scale. The scale is hung securely from a roof beam or a tree with the dial of the scale at heath workers’ eye level for correct reading. There are five steps of taking the weight of a child: Hang up the scale securely from the roof beam or a tree. The dial should be at eye level to minimize errors in reading. A pair of empty weighing pants is hung on the scale. The pointer of the scale is adjusted to “0” by turning the knob on the top of the scale to account for the extra weight of the pair of pants.

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Figure 1: Growth monitoring using a hanging scale Let the mother prepare the infant for weighing by removing heavy clothes and shoes, including the nappies. After explaining to her that the baby is going to be weighed, the mother is asked to dress the child with the weighing pants as shown in figure 1 above. The loops of the pants are put over the lower hook of the scale. If old enough to understand, the child is asked to hold on to the straps of the pants while the mother stands nearby, talking and calming but not holding the child. The child’s feet should be off the ground as shown in the picture in Fig. 1. A struggling child is calmed with the help of the mother. When the child stops moving, the weight is quickly read to the nearest 10 gm in infants and 100 gm in children. Help the mother to remove the child/infant from the sling carefully Measuring the head circumference – Child 0-24 months The head circumference is measured by encircling the head with an un-stretchable tape measure, or a piece of string in the absence of a tape measure. Stand beside the child. Put the tape around his/her head at the level of the largest perimeter, i.e. across the bumps of the forehead above the supra-orbital ridges and the bumps of the occiput posteriorly.

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Take the measurement without compressing the head. Take the reading at which the tape crosses the zero mark. Ensure that the tape is on the same plane. The piece of string used in the absence of a tape measure is then measured with a ruler to obtain the head circumference Fig 2: Drawing showing measurement of the head circumference. Measuring the mid-upper arm circumference Used in settings with limited resources, the mid upper arm circumference is measured using a tape or string in the absence of a tape. MUAC is taken on the left arm using a non-stretchable tape. Follow the 6 steps in measuring MUAC. Ask the mother to put the child on her lap or carry it in her arms. Request the mother to support the left arm of the child in a bent position.

Identify by palpation the outer part of the acromion (prominent bone of the shoulder)

and the outer part of the olecranon (prominent bone of the elbow).

Using the tape, locate the middle of this segment and mark it off using a pen, on the back of the arm: this is the mid upper arm.

Let the arm of the child rest loosely on the body (may be held). Put the tape around

the arm and take the mid upper arm circumference at this place, without compressing the arm. The tape should be perpendicular to the axis of the arm. The result is the value at which the tape is crosses the zero mark. Make the reading to the nearest millimetre.

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Repeat the measurement and take the mean. If the two readings differ by more than 5 millimetres, take a third measurement and keep the 2 closest readings).

The string used in the absence of a tape measures is then measured with a ruler to obtain the mid upper arm circumference. If available colour coded tapes are extremely useful and can be used by people who have relatively limited training. See Fig 3: Drawing showing the measurement of mid upper arm circumference

Measuring length and height The length of a child is measured in the first 2 years and the height is measured after 2 years of age. Crown-heel length - Child 0-24 months You require a measuring board to do this measurement as shown in figure 4. This

measurement requires the participation of 2 measurers (1 operator and 1 assistant). Follow the following 7 steps in measuring the child’s length.

The operator should ensure that the measuring rod is well fixed on a hard, flat and horizontal table.

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Straighten the child on the table along the measuring rod and support the trunk of the child while the assistant holds the child’s head with the hands and slowly puts it on the fixed head bar of the rod as shown in figure 5.

Ask the mother to stand near the child to help him/her stay calm. Hold the child’s head on the fixed part of the rod. The axis of the child’s eyes must

be perpendicular to the ground. Ensure that the child is straightened flat on the table: shoulders and hips should be aligned, perpendicular to the axis of the body and of the rod.

Figure 4: Height and Length Board Height Board Length Board

Put your left hand on the knees of the child and apply them firmly on the table. With

the right hand, apply firmly the sliding part of the device on his/her heels (the child should not push the sliding part with her/his toes or heels). Check the position of the child. Repeat the procedure if necessary. State the reading by separating the decimal to the nearest millimetre (example: ‘45 centimetres and 3 millimetres’).

An assistant or the mother should hold the child to allow the operator record the reading to the nearest millimetre.

Operator and Assistant: Repeat the procedure in the same way from point 2 and record the second reading. If the two readings differ by more than 5 millimetres, take a third measurement (keep the 2 closest readings).

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Fig 5: Measurement of length in a young child aged < 2 years

Height measurements – children aged > 2 years To measure the height, a bare foot child stands with the feet together. The heels, the buttocks and the occiput lightly touch the measuring device. The head is aligned so that that the external eye angle- external ear canal plane is horizontal. The child is told to stand tall and is gently stretched upward by pressure on the mastoid processes with the shoulders relaxed. The sliding head piece is lowered to rest firmly on the head as illustrated in figure 6. The height is read and recorded. Fig 6: Measurement of height in a child aged > 2 years

Plotting Weight, Height Information on Child Health Card A baby should be issued with a child

health card/booklet on first contact with health services. Besides growth monitoring, the card incorporates important information about the child, mother, and family and it enables the health worker to have access to the information at every contact with the child without embarrassing the mother by asking the same information at each visit. Information included will vary according to the country issuing it but the growth charts are going to be identical. The reading of weight obtained must be plotted on growth

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chart which is found on the Child Health Card. The growth chart is the second tool used in growth monitoring and promotion. The student should familiarize himself with the child health card used in his own country. One needs to understand the child health card first. The basic components of the health card are: Personal details: Child's name, registration number and sex. Parent's name and address. Birth dates. Potential risk factors or reasons for special care: Low Birth Weight. Problem calling for special care such as low-birth weight, twins, large family, spacing of less than 2 years, etc. History of sibling death. Use of Health Services: Date when child is first seen. Immunization record and national schedule for immunization. Other key factors which may affect growth: Breastfeeding. Complementary feeding. Child spacing. Other possible components: Treatment of diarrhoea. Treatment of illness. The graph on which the child's weight can be plotted against age is on the inside of folded Child Health Card. Please note the following (see fig. 2) Horizontal lines represent weight of the child in kilograms or height in cms. Vertical lines represent age of child in months. WORLD HEALTH ORGANIZATION (WHO) CHILD GROWTH STANDARDS These were launched in 2006 and many countries have adapted or are in the process of adapting them to replace the older variety. They are truly international and are based on the growth curves of breastfed infants. They establish breastfeeding as the norm for early childhood feeding. The student should check in their respective countries how far the adaptation process is. It may take a bit of time before the older ones are completely phased out. Note: the older charts which were being used in the region had only two lines. The lower line represented the 3rd percentile weight for age for girls, and the upper one 50th percentile for boys. The new charts separate boys and girls, and include weight for age,

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height for age. The generic charts have a middle line representing the 50th percentile, +1SD and -1SD representing one standard deviation above and below the mean, +2SD and -2SD representing two standard deviation above and below the mean, +3SD and -3SD representing three standard deviation above and below the mean. The SD lines are also called Z-scores. Growth chart lines are the Z-score – upper most is the +3 Z-score while the lower most is -3 Z-score. Others may include + or -2, and + or -1 Z-score according to decisions of different countries. Normally 97% of normal children fall with the bounds of the + 2 SD. Children growing at > 2SD are moderately underweight or over weight while those that are at > 3SDare severely malnourished (over-weight or under-weight). Any child falling outside of these needs intervention. But as pointed out below the most important thing is that the child follows his/her line of growth.

Fig 7: How to Plot the Weight on Growth Chart

The birth weight is plotted in the middle of the month of birth which is written in the first heavily marked box below which the year of birth is written as shown in chart A above. The successive months of each year are then filled. If the child initiates growth

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monitoring later and the birth weight is not known the first weighted is plotted in the box that corresponds to the age of the child as shown in chart B. Chart C shows how to locate the point to mark the weight of the child. The successive weights are connected with a line on the growth chart as shown in chart D to produce an individual child’s growth curve or pattern. This plotting of the weights on the growth chart is indispensable in growth monitoring. Un-plotted, the individual weights indicate the sizes without indicating whether the infant or child is growing well or not. You need to study a blank growth chart to be thoroughly familiar with its contents see. When the growth curve is plotted, the health worker and the mother can see at a glance whether the child is gaining weight appropriately by watching the direction of the child’s pattern. The direction is more important than the position of the curve on the child health chart. Interpretation of the growth It is very important to know how to interpret correctly the individual child’s growth on the Child Health Card. Interpretation simply means determining whether the child is growing appropriately or not. The interpretation is done by watching the direction of the child’s growth pattern. The direction of the growth curve indicates how the child is growing. Normal growth curve A healthy child’s growth curve is parallel to the printed growth curves on the chart. It is important to consider various factors in plotting and interpreting the growth of an individual child. For the premature infants, over diagnosis of growth failure can be avoided by subtracting the weeks of prematurity from the postnatal age when plotting the growth measurements. The presence of a neurological abnormality such as cerebral palsy in very low birth weight babies may limit catch-up growth. Figure 8: A Good Growth Curve The direction of the growth curve is more important than the position of the curve on the chart. The weight growth pattern of the larger term infants will be above the pattern of the average term infant. On the other hand, the weight growth pattern of the smaller term infants will be below the pattern of the average term infant. A small baby whose growth pattern is below the bottom line in the growth chart is healthy if that child’s growth pattern is parallel to the bottom percentile line. As long as the baby is gaining weight at an acceptable rate indicated by the baby’s growth curve being parallel to the printed curves, the mother should not worry about the position of her child’s growth

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curve on the child health card. Figure 9 below is an illustration of a child who is growing well. Fig 9: A normal growth curve

LEARNING ACTIVITY

To illustrate this we shall use the example of an infant called Wambui, born in

February 2008, whose birth weight was 3kgs, who attended a growth

monitoring session for the first time in July 2008, when his weight was 6.0kg.

He was seen again in September of the same year and he weighed 7.5kgs.

Write the name and birth weight in the right hand corner of the card. Print the year 1994 at the beginning below the first box of the first year, and then subsequent years. Print February in the first box of the first year, then fill the subsequent months for each year. Place a dot in the middle of the column as illustrated in figure 2, for the birth weight (middle of February) and the second dot in the middle of July, September boxes, at the respective weights. Join all the subsequent recordings (dots) with a straight line. Using this information, plot

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Wambui’s growth on a growth chart on the blank child health card below. Is Wambui’s growth adequate? Why do you say so?

Fig 10 Growth chart – Plot Wambui’s growth curve.

Wambui’s growth curve is constantly going upwards. A constantly upward going curve parallel to the printed lines shows GOOD growth. The mother, the person most responsible for the child’s good health, is informed how her child is growing and praised for her good efforts. Horizontal growth curve Fig. 11: A Static (horizontal) Growth Curve

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A horizontal (flat) growth curve like the one in Fig. 11: horizontal growth curve. A horizontal growth curve indicates DANGER! The horizontal growth curve means the child is not growing, a sign of disease, especially malnutrition. A child who is malnourished cannot grow properly, cannot resist diseases, and is in danger of getting killer diseases. You should take a thorough history from the mother to establish the cause of growth failure and then give the mother the relevant and practical guidance within her means or the means of the family or of the community on what to do to ensure continuation of normal growth or resumption of normal growth in case where there was growth faltering manifested by horizontal or downward deviation of the growth curve. The mother is encouraged to give the child food containing enough calories, protein, vitamins and minerals. Thereafter, growth monitoring helps to determine the adequacy or inadequacy of catch-up growth. A downward growth curve Fig 12: A Downward Growth Curve A curve deviating downwards, as shown in Fig. 12 A growth curve deviating downwards , indicates a VERY DANGEROUS situation. The child is losing weight. The child needs extra care immediately. The baby may be suffering from malnutrition, tuberculosis, AIDS or other medical conditions. The mother is advised to take the baby to hospital for investigations and treatment. Any infant who does not gain weight for one month or a child who does not gain weight for two months should receive urgent attention. Such a child is becoming malnourished. Catch-up growth Successful nutritional rehabilitation is associated with a growth spurt. During the growth spurt there is a very steep increase in weight. The weight finally levels off at the appropriate weight for height. The weight of HIV infected children may level off at low weight for height. Increased caloric intake results in increased adipose tissue rather than lean body mass.

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In the real world, children may experience different types of growth patterns over the period of early childhood. Fig.13 Another horizontal curve is an illustration of another child’s growth curve. The child was growing well until about 5 months of age. From this point, the growth curve started being flat. The horizontal deviation indicates static growth. This is not good and action should have been taken by the health worker and the parents of the child earlier. Depending on the individual’s growth pattern, an infant at the 5th percentile of weight for age may be growing normally, may be failing to grow, or may be recovering from growth failure. In chart 13 the child was growing on the -3 line in the first 5 months but gaining weight well. From the 5th month, the child ‘s weight gain slowed down and eventually became static. As illustrated at the bottom right hand corner of the growth chart, important events that affect the child’s growth should be recorded above the weight on the Growth Chart. Such events include diseases, weaning, introduction of solids and stopping of breastfeeding. Fig 13. A horizontal growth curve

Reasons for special care: At the bottom of the Growth Chart there is a box that lists some of the factors that may make a child particularly vulnerable to malnutrition. These factors include low birth weight, twins, large family, child spacing of less than 2 years, and history of sibling death. A tick or mark should be made next to any of the reasons that apply. This will then remind you to be particularly alert to any signs of growth faltering and may suggest the reasons for poor growth. You can then plan how best to help this particular child.

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There are also weight for height charts and tables. Weight for height below the fifth percentile is a good indicator of acute undernutrition. Measuring weight for length/height. Weight for length/height is also used for monitoring growth. A child with acute severe wasting has weight for length/ height Z score of -3. Such a child should be admitted for treatment of malnutrition. Growth monitoring will help you to detect growth failure early so that severe malnutrition can be prevented. Growth monitoring should be continued up to the age of 5 years as a component of well child care. Encourage parents to have their children weighed. The health worker should avoid keeping the mothers waiting for too long and should have the children undressed very shortly before their being weighed. You must always report the findings to the mother or caretaker, inform her how the child is growing and counsel her.. Consequences of Failure to intervene appropriately Failure to intervene promptly through prompt treatment of illnesses and nutritional rehabilitation or both, delays growth recovery and failure to recover the original percentiles, important observations are. Severe protein energy malnutrition combined with a non-stimulating environment results in irreversible intellectual harm. Adverse intellectual consequences of severe malnutrition can be modified by a stimulating environment if it is introduced before the age of three years. Providing increased stimulation and nutrition to at risk children significantly improves the intellectual outcome of the children. Intervention before the age of three years yields better results than later interventions. Counseling the Mothers Counseling the mother is the process of helping the mother to decide herself the best action she can take to promote her child’s good health. This is the most important step for the success of growth monitoring and promotion, whatever the educational level of the mother. The health worker give information that is relevant to the child’s problem on the material visit. The health worker deliberately builds on what the mother knows. At the end of the session, the health worker asks the mother checking questions to determine whether the mother has understood the instructions. The health worker should avoid the closed (yes or no) questions and ask only the open questions (those requiring the mother to give an explanation). The health worker should boost the mother’s self-esteem by praising her whenever she answers or acts correctly. Whenever the mother is doubtful about the instructions, the health worker should carefully repeat the instructions and correct any mistakes in a sensitive manner. Counseling of mothers can also be done in a small group. Such a group allows more sharing of ideas and advice among the mothers themselves. The health worker facilitates the discussion, listens to the mothers very attentively, and provides the necessary information that the mothers can use to promote the health of their children. The success of a mother whose children are growing well become the best source of information for the advice to other mothers. Always remember that mothers are concerned about the health and welfare of their children and they will do anything to make their children grow well.

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When Should Growth Monitoring and Promotion Start In order to detect growth failure, growth monitoring should start as early as possible, soon after birth, effective growth promotion focuses on the youngest ages and attempts are made early to foster participatory action by mothers. There are two major advantages of starting growth monitoring/promotion early: Growth failure can be detected early for it to be corrected before the child becomes malnourished Growth promotion is easier to initiate in early infancy when positive growth can be used as positive reinforcement. During early infancy mothers have more control over the environment of their children, are prepared to devote more time and efforts to the health of their children and can be effectively used as agents of change. How Often and for how long should the Child be Seen for Growth Monitoring and Promotion The frequency of growth monitoring is determined by the velocity of growth and the additional services that the child is being provided with such as immunizations. During the first year of life there is rapid growth and development. The child makes a major transition from intrauterine life to postnatal life and from being totally dependent on breast milk to consuming an adult diet. These rapid changes make a child vulnerable to malnutrition. Careful and frequent monitoring of growth enables prompt interventions. The child should be monitored monthly in the first 24 months of life, 2-3 monthly in the third year of life and then twice a year thereafter. It is desirable that sessions of growth monitoring/promotion should coincide with immunization visits in the first half of infancy in order to save the mother time and ensure compliance. KEY to a Successful Growth Monitoring Programme Health worker training and motivation to participate in growth monitoring. Participation of mothers in growth monitoring activities Community mobilization for growth monitoring Giving the mothers the growth chart to use as a passport into the health services Sharing with mothers, families, school teachers and the community the meaning of the growth chart Encourage local people to take charge of the growth monitoring for example the local pre-school facility may be the desired community facility for growth monitoring Make sure that the waiting time is minimized and mothers are attended to promptly. Utilize the time spend in the queue for health education in relevant topics.

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CONCLUSION The present chapter has outlined the role of growth monitoring and promotion in promoting child health within PHC setting. GMP a low cost effective strategy is used to visualize growth of young children to their mothers and health workers. Growth monitoring also provides a tool for evaluating other interventions for promoting child health. It provides education and communication stools for appropriate action to be taken at the household level to support normal growth of children. Nutrition and health information obtained as part of GMP should be used for re-assessment and modification of ongoing child health intervention. SELF EVALUATION QUESTION Why is Growth Monitoring /Promotion important to: an individual child a community. Discuss the major difference between nutritional assessment and growth monitoring and promotion. Compare and contrast a growth monitoring session at a health centre and at a village outreach session. Point out the advantages and disadvantages of holding session at each site. Describe how you would set-up a growth monitoring/promotion programme in a small rural fishing village. Outline the role of health education in the promotion of growth monitoring in the community.

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BIBLIOGRAPHY Cowman H: Growth Monitoring as a critical means to provide primary health care. Indian Journal of Paediatric (Suppl.) 1988 55, 574 - 577. De Onis M, Garza C, Victora CG et al. The WHO multicenter growth reference study (MGRS): Rationale, planning, and implementation. Food and Nutrition Bulletin 25 No 1 (supplement 1) March 2004 De Onis M, Garza C, Onyango AW, Martorell R. WHO Child Growth Standards. Acta Paediatrica Vol 95 (supplement 450) April 2006 Genece E., and Rhode J.E.: Growth Monitoring as entry point for Primary Health Care Indian Journal of Paediatrics (Suppl.) 1988. 55.S 78 - 83. Griffiths M. I Growth Monitoring: Making it a tool for education. Indian Journal of Paediatrics (Suppl.) 1988. 55. 559 - 566. Growth Monitoring UNICEF: Social statistics bulletin Vol. 6 1983 pp.1 Guide to health workers in Uganda. Ministry of Health Uganda. Janeway C.: The State of Worlds Children 1983 pp 64. Kenya Ministry of Health. How to use a child health card.. A Guide for Health Workers in Kenya. Page 17. King MH Nutrition for developing countries. A Weight for Age Graph Showing Growth page 1.3 fig 1.7 Lalitha, N.V. and Standley: Training workers and supervisors in growth monitoring Indian Journal Paediatrics (Suppl.) 1988 55, 548. Morley D, and Woodland M. See them grow. McMillan Tropical Community Health Manual. McMillan Press, 1979. Rohde, J.E.: Beyond Survival; Promoting Health Growth, Indian Journal Paediatrics (Suppl.) 1988 55 - 85. Stanfield P, Brueton M, Chan M, Parkin M, Waterston T. Diseases of children in the subtropics and tropics. ELBS Edward Arnold, Hodder and Stoughton, Kent (UK) 1991. Acknowledgement – MR Kariuki Kamau for the help with the illustrations.

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CHAPTER 7

CHILDHOOD IMMUNIZATION

Amos Odiit, Esther D. Mwaikambo INTRODUCTION Immunization as an element of primary health care is one of the most powerful and cost-effective means of preventing infectious diseases but remains tragically underutilized in many African countries. Percentage of one year old children who are up to date with their immunization has risen from 20% in 1980 to about 80% in 2006. However this still falls of the 90% target for developing countries Over the last few years, Polio has been controlled in most African countries with only a few reporting cases of wild polio virus. Measles mortality has reduced greatly, all of these following mass immunization national immunization days. Pentavalent vaccine containing Haemophilus Influenza type-B and Hepatitis B in addition to DPT has been introduced in the region for the last 6 to 8 years. This has substantially reduced the mortality from Haemophilus influenza type-B (meningitis and pneumonia). There is an ongoing disease surveillance of vaccine preventable diseases that is also going to provide information to help in the introduction of new vaccines in the region e.g. pneumococcal and rota-virus vaccines. OBJECTIVES At the end of this chapter the student should be able to: List vaccine preventable diseases Identify vaccine preventable diseases included in the EPI Outline immunization delivery strategies Describe immunization schedule and coverage in your country Describe the procedures of administration of vaccines Describe the vaccine cold chain Outline the common problems to be anticipated in an immunization programme Describe the efficacy of each EPI vaccine Educate other health workers and the community of immunization Evaluate immunization programmes Indicate possible future developments in immunization LEARNING ACTIVITIES Observe health workers in a health care facility administering vaccines. Note the various steps from the time the parents enter the facility to the time they leave. Evaluate the health team performance. Participate in administration of vaccine in the same facility under supervision of qualified health worker Note how the immunization programme in the facility is organized and what problems the health workers encounter in performing their task

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Interview five parents attending the facility picked at random and ask them when they last brought their children for immunization and determine this was according to EPI immunization schedule. THE EXPANDED PROGRAMME OF IMMUNIZATION (EPI) The expanded programme of immunization focus on eight diseases. Measles affects all un-immunized children, kills over 2.0 million children annually. Pertussis kills about 600,000 children each year and causes severe complications in many others. Neonatal tetanus is contracted through contamination of umbilical cord. It kills about 800,000 neonates per year. Tuberculosis attached each year about 10,000,000 children and can be very severe in young children. Polio has been the major cause of lameness in developing world until recently. Diphtheria is now less common but kills about 10 to 15% of its victims. Haemophilus influenza type-B has been one of the major causes of bacterial meningitis and pneumonia in children until recently after introduction of an effective vaccine. Hepatitis-B does not manifest early in childhood, but children get infected as they grow up and subsequently the disease may lead liver cirrhosis and cancer of the liver. The challenges facing the immunization programme is to deliver basic vaccines to all susceptible infants and tetanus toxoid to women of reproductive age. STRATEGIES FOR DELIVERY OF IMMUNIZATION The options in the delivery of immunizations are: Fixed (static) facility delivery: this is the immunization services carried out in the health facility whereby a child is brought to the facility for vaccination Outreach immunization services. In this type of service the health workers travel from the health facility to the community to deliver immunization Mobile teams – health workers go from the health facility to vaccinate children from house to house (using a mobile vehicle) Intensive mass campaigns – this involves extensive sensitization of the communities and the health workers delivering the service in designated points in the communities. IMMUNIZATION SCHEDULES Immunization scheduling is influenced by two biomedical factors. The age at which the infant can develop active antibodies The number of vaccine doses which must be given in order to evoke immunity. The schedule varies from country to country

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World Health recommended schedule is as follows: AGE Vaccine At Birth

BCG and OPV

At 6 weeks after birth

OPV2, DPT, Hib and HepB

At 10 weeks after birth

OPV3, DPT2 Hib2 HepB2

At 14 weeks

OPV4, DPT3, Hib3, HepB3

At 9 months

Measles

Key: HepB B Hepatitis B Vaccine Hib Haemophilus Influenza type-b BCG Bacille Calmette Guerin OPV Oral Polio Vaccine DPT Diphtheria, Pertussis and Tetanus It is recommended to give four does of Oral Polio in the first year of life. The first OPV (OPVo) is given at birth or within the first two weeks after birth. The other three OPV doses are given four weeks apart along with other vaccines as above. Extra doses of OPV may be given at school age just after five years and at entry to secondary or during national immunization days. Interrupted immunization need not be started afresh. The remaining doses should be given as if the prolonged interval has not occurred. Children who have their first contact with EPI services after 6 weeks of age and less than 9 months should receive BCG, DT and OPV first and continue OPV and DPT at four weeks intervals as above. An infant encountered after two weeks of age forfeits OPVo and will have to wait for OPV one. Five doses of Tetanus Toxoid (TT) to the mother will give longer immunity to the mother and she will be able to pass adequate immunity to her offspring, preventing neonatal tetanus. The schedule for TT in women of reproductive ages DOSE

MINIMUM INTERVAL

DURATION OF ROTECTION

TT1

STARTING DOSE

0 YEARS

TT2

4 WEEKS

3 YEARS

TT3

6 WEEKS

5 YEARS

TT4

ONE YEAR

10 YEARS

TT5

ONE YEAR

LIFE LONG

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For pregnant mothers two doses may be given in first pregnancy at four weekly intervals starting as early as possible. The rest of the TT doses may be given in the subsequent pregnancies ADMINISTRATION OF VACCINES AND IMMUNIZATION TECHNIQUE Wash your hands before handling vaccines Ensure that you are working in a clean and well organized environment Clean and risk your equipment thoroughly before sterilizing them If for sterilization you are using boiling methods, and then do the following: Ensure that boiling water cover all the equipment and boil for at least 20 minutes Ensure that sterilizer lead is properly in place during boiling. For steam sterilizer read the manufacturer’s instructions and following them strictly Use one sterile needle and syringe per injection per child PRECAUTION IN HANDLING VACCINES All vaccines must be stored between 0 - 8 degrees centigrade at all times Ensure DPT and TT are never frozen while in storage between they their potency when frozen. Polio and measles are the most sensitive vaccines Check expiry date and the name of the vaccine before drawing it for administration Discard any opened but used vaccine at the end of day. Open a new vial even if only one child remains to be vaccinated. For BCG remember to reconstitute a new vial every four hours and avoid exposure to light VACCINE DOSE AND ROOT OF ADMINISTRATION 1. BCG is given intradermally into the deltoid area of the right upper arm Since BCG dose varies with age and manufacturer careful read the manufacturer’s instructions. 2. For OPV give two drops orally only 3. For DPT vaccine 0.5 mls. is given intramuscularly in the anterior mid thigh in the quadriceps muscle. 4. Measles vaccine is given 0.5 mls IM in the deltoid muscle 5. Tetanus Toxoid for pregnant mothers is given I.M 0.5 mls in the left deltoid muscle. Remember to tell the mother about the side effect of each type of vaccine given to the child and advise her on what to do should they happen. RECORD KEEPING Enter daily immunization on to the summary sheet everyday Record on the child health card the immunization given and the date in which they were given. Remember to give the mother a return date and stress the importance of completing all the immunization.

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COLD CHAIN MANAGEMENT The cold chain is a system that ensures that the vaccines are kept between 0 and 8 degrees centigrade between transportation from the manufacturer to the people to be vaccinated. The cold chain is necessary because the vaccine lose their potency when exposed to higher temperatures. Successive exposures have cumulative impact on vaccine potency. Once lost, potency cannot be restored. A typical cold chain consists of four levels: National Regional or provincial Health centre of hospital Local health post or other location where vaccinations are carried out Breaks in cold chain may occur at any of these levels At every level of cold chain the key elements are: Establish procedures for transport, storage and monitoring of vaccines Have well trained well supervised personnel able to maintain and monitor vaccine distribution according to established procedures Well maintained equipment to store and transport vaccines at the proper temperature In case of power failure remember to transport vaccines in a cold box to the nearest district with power supply IMMUNIZATION PROBLEMS Lack of resources which include staff, supplies and equipment is the major constraint in the delivery of effective immunization services in developing countries. In a tropical environment with unreliable electricity supplies and lack of vehicles to carry vaccines the cold chain is highly vulnerable to interruption with consequent loss of vaccine potency. Although no vaccine is total without adverse reaction, the risk of serious complications of vaccines used in EPI is much lower than the risks of natural diseases. Important reasons for the less than optimal immunization coverage include: postponement of immunization of children, who are ill, who have upper respiratory tract infection, who have fever, diarrhoeal diseases or who are malnourished. Yet these are the very children who most need immunization. There are no major contraindications to immunization. A severely ill child requiring hospitalization may have immunization deferred but should have all the immunization brought up to date before discharge. An infant between 6 and 9 months of age seen in the health unit may be vaccinated against measles when: There is a measles epidemic When there has been contact with a measles case

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Such children vaccinated against measles before 9 months of age will have to be revaccinated at one year. Common side effects of vaccines are mild and severe ones are very rare: Low grade fever with skin rash may occur for 4 – 7 days after measles vaccination Reactions to oral polio vaccine, including paralysis similar to poliomyelitis, diarrhea, perhaps one in every million doses BCG vaccination will cause a small sore at the vaccine site. The sore usually disappears after one or two months. Rarely this sore will become a chronic ulcer BCG adenitis with abscess formation may occur Most common side effects is local infection an abscess formation at the injection site because of needle and syringe contamination Infants with clinical AIDS should not receive live vaccines e.g. BCG or OPV, but should be given the other vaccines. EFFICACY OF VACCINES Vaccines differ in their efficacy that is the ability to produce immunity in a susceptible population vaccinated under optimal conditions. The table below shows efficacy of various EPI vaccines. VACCINE

%Vaccine efficacy

Measles

>95%

Polio

>95%

Diphtheria

>95%

Pertussis

>60%

Tetanus

>95%

BCG

Variable

HepB-B

??

HiB

??

HEALTH EDUCATION The mother should be informed about: Which diseases the child is being immunized against, Possible outcomes if the child were not immunized, What side effect to expect after vaccination, When they have to bring back their children for next immunization

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EDUCATION AND SUPERVISION OF HEALTH WORKERS Personnel in an immunization programme perform a wide variety of tasks ranging from communicating with clients to carrying technical procedures. Training personnel to carry out those tasks and supervising them is essential to the success of the immunization programme. WHO, PAHO and UNICEF have developed courses and training materials to teach supervisory and operational skills at all levels. In addition to this several countries have established their own training programmes. To ensure that all children needing immunization are properly vaccinated with potent vaccines field workers must learn to: ensure that cold chain is maintained at all levels. give immunization talks both to individual child care-givers and to the whole population. misconceptions about vaccination are detected and addressed optimally integrated surveillance for vaccine preventable diseases is established and maintained A good system is essential to a successful programme and people always work more carefully when they know that their performance is being evaluated. The essentials of good supervision are: Sufficient funds for supervision at all levels Frequent supervisory visits to the field Written job descriptions specifying performance standards of all tasks. Check list to guide supervisors in evaluating performance Recognition of good performance by supervisors Investigations to determine reason for poor performance and to develop strategies for improvement. Standard training programme for supervisors COMMUNITY AWARENESS AND INVOLVEMENT IN IMMUNIZATION Most of the effective immunization programmes have included aggressive communication activities. It does little good to provide immunization services unless parents are convinced that immunization is valuable, know where and when services are available and understand when children should receive vaccines. There are three important components of communication strategy: Audience – the main audience of immunization programme are parents of young children Messages – these perform a dual role, first to create public awareness and support, and secondly to provide specific information that people need in order to use immunization services. The a message to be effective it should be compatible with audience attitudes, beliefs and experience Communication channels – mass media can reach most people but person to person communication and other strategies are important to re-enforce these media particularly

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at the antenatal clinics, under five clinics, outpatient clinic, inpatient wards, women’s clubs, schools, and child to child programme. EVALUATION Evaluation assesses performance at all levels based on predetermined objectives. The main areas to evaluate progress in an immunization programme relate to: access to vaccination, e.g. OPVo coverage immunization delivery processes vaccination coverage disease incidence or prevalence SURVEILLANCE The main objective of surveillance for vaccine preventable diseases is to inform the programme on different aspects of the diseases under surveillance. The vaccine preventable diseases currently under surveillance in different countries of the region include: Polio, Measles, HiB, Neisseria meningitidis and strep pneumonia. The essential elements of a surveillance system are: Disease recognition; Disease reporting Number of cases Number of deaths Characteristics of cases Location and dates of out-breaks Immunization status by vaccine, dose and age groups Feed back and utilization of results. There are two measurement systems used in immunization coverage, one based on service statistics and the other on sample surveys. NEW DEVELOPMENTS New biotechnology including recombinant DNA, monoclonal antibody and protein synthesis continues to spur vaccine research. The diseases where such research is currently underway include: Malaria, Rota virus, AIDS, Respiratory syncytial Virus (RSV). New vaccines against cholera and typhoid fever are being developed to replace the current ones which are being used. Rota and Human Papiloma virus vaccines have been developed and their field efficacy studies are in progress SAFETY OF INJECTIONS Disposable syringes and needles used for giving injections for treatment and immunization should be safely disposed of. They should be put in special containers and taken for incineration. Small portable incinerators are now available in small health centres. Disposable needles and syringes should never be thrown away into a garbage pit from there can be collected for re-use, or pose a danger to children.

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CHAPTER 8

CONTROL OF DIARRHOEAL DISEASES

Israel Kalyesubula INTRODUCTION Diarrhoea is defined as the passage of three or more, watery or loose stools in a 24 hour period: a loose stool being one that would take the shape of the container. It is described as acute diarrhoea if it has lasted less than 14 days; persistent diarrhoea if it has lasted beyond 14 days and dysentery if the stools are bloody. It is one of the leading causes of illness and death among children in developing countries. It is estimated that 1.3 thousand million episodes of diarrhoea and 3.2 million deaths from diarrhoea occur annually among children under five years in the developing countries. Overall, children experience an average of 3.3 episodes of diarrhoea per year. In some areas, the average exceeds nine episodes per year. Diarrhoea contributes about 25-30 per cent of the total deaths in the under fives. About 80 per cent of deaths occur in the first two years of life. The main cause of death from acute diarrhoea is dehydration, which results from the loss of fluid and electrolyte in the diarrhoeal stools. Other contributory factors include: preexisting malnutrition serious undercurrent infections such as pneumonia and delay in seeking care in cultures that believe that the diarrhoea is due to “false” teeth that would need to be extracted. Diarrhoea is an important cause of malnutrition by reducing appetite, and reduced absorption of nutrients. A vicious cycle is created as malnutrition predisposes to increased frequency of infective and persistent diarrhoea which worsens the malnutrition. Correct case management of diarrhoea both at home and at health facilities saves many lives. This includes the use of hypo-osmolar oral rehydration salt (ORS) solutions combined with zinc supplements. Antibiotics are used in selected types of diarrhoea. OBJECTIVES At the end of this chapter the student should be able to: Define diarrhoea Outline the difference between acute and persistent diarrhoea Describe the role of diarrhoea on the burden of illness in children in the developing countries List the risk factors for diarrhoea morbidity and mortality in children List the viral, bacterial and parasitic causes of diarrhoea Describe the pathophysiology of diarrhoea Describe the complications of diarrhoea and explain how diarrhoea causes dehydration and malnutrition Describe dysentery and persistent diarrhoea

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Describe the standard case management of diarrhoea: assess, classify dehydration and manage diarrhoea (10) Describe traditional methods of treating diarrhoea and their complications (11) Describe dangerous methods of treating (12) Outline the strategies for prevention and control of diarrhoea in children (13) Explain the role of appropriate feeding in diarrhoea LEARNING EXPERIENCE Practice proper history taking in a child with diarrhoea, with emphasis on detecting the severity of dehydration Observe and participate in assessing the degree of dehydration Calculate the amount of fluids required by a child with some dehydration and assist the mother in giving ORS to her child Demonstrate to the mother how to prepare ORS Advise the mother on how to manage and prevent diarrhoea at home Using the case illustration given below, the student to perform role play, with one student acting the health worker role while the other acting the mother role Review epidemiology, aetiology and pathophysiology of watery diarrhoea Review the diarrhoea case management video CASE ILLUSTRATION 1 Monde, a 12 months female from Kalingalinga shanty compound is brought to a local hospital with a two day history of diarrhoea and vomiting. The child was previously well and was breast fed for six months only. The mother who is single had to start work as a house help, so her 12 year old sister who is a school drop out looks after the child while the mother is at work. She feeds the child on maize meal porridge and fresh cow’s milk. They draw water from a well one kilometer away and the family uses a pit latrine. On examination the child is afebrile. She is restless, irritable, and has sunken eyes. She is thirsty and drinks eagerly and the skin pinch goes back slowly. Problems to solve. Using the above case, carry out a role play with one student acting the role of a health worker and the other the role of the mother. In the process assess, classify and manage Monde and give the mother advice on how she should take care of Monde at home. Use the list below to help you in the role play 1. List all Monde’s signs of illness 2. Record how you would classify Monde’s dehydration and list all the signs that you use to classify the dehydration 3. Look at the treatment plan under the classification in which you put Monde and describe how you would manage her. 4. What would you tell Monde’s mother about how to treat the child at home? What would you do to help her manage the child at home? 5. What would you tell her about how to manage the next attack of diarrhoea in case it occurs? 6. What would you tell her about how to prevent occurrence of similar attacks in future?

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CASE ILLUSTRATION 2 Mukasa is a six month old male from Kisugu who was admitted in Kawempe health centre 10 days ago with diarrhoea. His condition appears to have deteriorated with swinging temperatures. He refuses to breast feed and appears to be uncomfortable and crying most of the time. On examination Mukasa looks toxic and in pain. Problem to solve List all Mukasa’s signs of illness Record how you would review Mukasa’s history of his illness, emphasizing previous treatments before admission to the health centre. Reexamine Mukasa to establish the possible cause of Mukasa’s illness. How should the health centre staff have managed this baby? AETIOLOGYAND EPIDEMIOLOGY A quick guide to aetiological causes of diarrhoea: Diarrhoea with no fever and no blood in stool Rota virus Cholera Food poisoning etc Diarrhoea with fever and blood in stool Shigella Escherichia coli etc Diarrhoea with blood in stool but no fever Amoebic dysentery Salmonellosis (typhoid in infants) Diarrhoea with fever and no blood in stool: Otitis media Pneumonia Urinary tract infection Meningitis Malaria etc N.B: Students should widely consult and fill in and expand this table. Types of diarrhoea Three clinical syndromes of diarrhoea described below have been defined, each reflecting a different approach to treatment. Acute watery diarrhoea The term refers to diarrhoea that begins acutely, lasts less than 14 days and involves the passage of frequent watery stools without visible blood. Vomiting and fever may be present. Acute watery diarrhoea causes dehydration and when food intake is reduced, it also contributes to malnutrition. The main cause of death in acute watery diarrhoea is dehydration often associated with delay in seeking care and inappropriate treatment at home or in the health facility. Health workers must be aware of complications of

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anaemia and septicaemia as a result of traditional healers extracting infants’ teeth by way of managing diarrhoea. The most important causes of acute watery diarrhoea in young children in developing countries are rota virus, Escherichia coli, Campylobacter jejuni, Vibrio cholera and Cryptosporidium. Dysentery This is diarrhoea with visible blood in the stool. Important effects of dysentery include anorexia, severe abdominal pain and rapid weight loss. The main cause of dysentery is Shigella. Some types of Escherichia coli and Salmonella may also be a cause. Entamoeba histolytica can cause dysentery but it is rare in young children. Persistent diarrhoea This is diarrhoea that begins acutely but the duration is 14 days or more. It may begin either as watery diarrhoea or as dysentery. Marked weight loss is frequent and dehydration is a frequent finding. There is no single microbial cause for persistent diarrhoea, shigella, enteropathogenic E. coli and cryptosporidium may play a greater role than other causative agents. About 10 percent of acute diarrhoea episodes become persistent. It is commonly associated with malnutrition, recent introduction of animal milk feed, young age intercurrent infections and infection and immunological impairment. It is associated with increased mortality, contributing to 35 percent of the diarrhoeal deaths. Epidemiology of Diarrhoea Transmission of agents that cause diarrhoea The infectious agents that cause diarrhoea are usually spread by the faecal-oral route, which includes the ingestion of faecally contaminated water or food and direct contact with infected faeces. Risk factors for diarrhoea Failing to breast feed exclusively for the first 6 month Poor complementary feeding practices including hygienic preparation of food Using infant feeding bottles Storing cooked food at room temperature Using drinking water contaminated with faecal bacteria Failing to wash hands: After defaecation After disposing of faeces or Before handling food Failing to dispose of feaces hygienically Poor personal and domestic hygiene Lack of immunizations Malnutrition Measles infection Immunodeficiency or immunosupression states

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Age Most diarrhoeal episodes occur during the first two years of life. The incidence is highest in the age group 1-11 months especially when complementary feeding is introduced. This reflects combined effects of declining levels of maternally acquired antibodies, lack of active immunity in the infant, the introduction of food that may be contaminated by bacteria and direct contact with human and or animal feaces when the infant crawls. Seasonality Distinct seasonal patterns occur in many geographical areas. In tropical areas, rota virus diarrhoea occurs throughout the year, increasing in frequency during the drier, cool months, whereas bacterial diarrhoea peak during the warmer rainy season. Asymptomatic infections Most enteric infections are asymptomatic, the proportion of which increase beyond two years of age 1owing to the development of active immunity. During asymptomatic infections which may last several days or weeks, stools contain infectious agents. People with asymptomatic infections play an important role in the spread of enteric pathogens, especially as they are unaware of their infection and take no special hygienic precaution. Epidemics Two enteric pathogens, Vibrio cholera 01 and 0134 and Shigella dysenteriae type 1 (Shigella shigae), cause major epidemics especially in the developing countries in which morbidity and mortality in all age groups may be high. Aetiology Pathogenic organisms are identifiable in as much as 75 per cent of patients with diarrhoea. The organisms most frequently associated with diarrhoea in young children are shown in Table 1 below.

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Table 1: Pathogens frequently identified in children with acute diarrhoea in developing countries Pathogen Percentage of Recommended cases antimicrobial treatment Virus Rota virus 15-25 None Bacteria Enterotoxigenic and enteropathogenic E. coli 10-25 None Shigella 5-10 Nalidixic acid Campylobacter jejuni 10-15 None Vibrio cholera 01 5-10 Tetracycline*

and 0134 Cotrimoxazole Salmonella (non-typhi) 1-5 None Protozoa Cryptospridium 5-15 None No pathogen found 20-30 None *Tetracycline is contra-indicated in children below eight years of age Rotavirus This is the most important cause of severe, life-threatening diarrhoea in children under 2 years of age worldwide. There are four sero-types. Infection with one serotype causes a high level immunity to that serotype and partial immunity against the other serotypes. Nearly all children are infected before the age of two years and repeat infections are uncommon. Rotavirus is probably spread by person to person transmission. Enteropathogenic E. coli (ETEC) This is an important cause of diarrhoea in both adults and children. The diarrhoea it causes is mediated by toxins closely related to cholera toxin. It is spread by means of contaminated water and food. Shigella Shigella is the most important cause of dysentery, being found in about 60 per cent of all episodes and in nearly all severe episodes. There are four serotype: S. sonnei, S. boydii, S. flexneri and S. dysenteriae. S. flexneri is the most common serotype in developing countries, but S.dysenteriae type 1, causes the most severe disease. It is spread mostly by person to person transmission. Antimicrobials to which Shigella are sensitive provide effective treatment, but resistance is common. The most useful antimicrobials are nalidixic acid and ciprofloxacin.

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Campylobacter jejuni In developing countries, C. jejuni causes disease mostly in infants. It also infects animals, especially dogs and chickens and is spread by contact with their feaces or consumption of contaminated food, milk and water. Vibrio cholera V. cholera causes non-invasive diarrhoea which is mediated by toxins and extensive coverage of the villae by the bacteria adhering to their surfaces. Antimicrobials can shorten the duration of the illness. Tetracycline is widely used, but because of resistance, other antimicrobials effectively used are cotrimoxazole, furazolidine or chloramphenicol. Enteric pathogens can also be found in about 30 percent of healthy children, making it difficult to know whether a pathogen isolated from a child with diarrhoea is actually the cause of that child’s illness. This is especially true for Giardia lamblia, enteropathogenic E. coli and Campylobacter jejuni. On the other hand, Shigella and rotavirus are rarely identified in healthy children, their presence in a child with diarrhoea is a strong aetiological evidence. Table 1 shows that antimicrobial agents are recommended only when infections with shigella or V. cholera is suspected on the basis of clinical signs (especially in epidemics) or confirmed by laboratory investigations. For all other agents and thus the majority of acute diarrhoea episodes in young children, antimicrobials are either ineffective or inappropriate. For agents such as salmonella the use of antimicrobials can actually prolong the intestinal infection. A number of other pathogens are not shown in Table 1 can cause acute diarrhoea in children in developing countries but their role is either minimal or not well defined yet. They include a number of viruses, bacteria and protozoa. Other conditions associated with diarrhoea (see the guide to aetiological causes of diarrhoea) Children with infections such as malaria, urinary tract infections and other systemic infections may present with diarrhoea. It is important that these conditions be identified and appropriate treatment be given besides ORS. NB: Never give antibiotics to a child presenting with diarrhoea and fever before confirming the absence of meningitis. It may lead to partially treated meningitis with subsequent permanent mental damage. PATHOGENESIS AND PATHOPHYSIOLOGY Pathogenetic Mechanisms Generally this is either by destruction of intestinal epithelia or toxin production. The loss of the normally absorptive villous cells and their temporary replacement with immature secretory crypt cells, causes the intestines to secrete water and electrolytes. Villous damage is also associated with a loss of disaccharidase enzymes, leading to reduced absorption of disaccharides, especially lactose. Recovery occurs when the infected cells are replaced by healthy ones in 2-4 days. Toxins alter epithelial cell function and reduce absorption of sodium by the villus and increase the secretion of chloride in the crypts, leading to secretion of water and electrolytes.

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Viruses such as rotavirus, replicate within the villous epithelium of the small bowel, causing patchy epithelial cell destruction and villous shortening. The pathogenic bacteria cause diarrhoea by: Production of a toxin (secretory diarrhoea), as happens with enterotoxigenic E. coli and V. cholera. Invasion and destruction of epithelial cells (invasive diarrhoea), as occurs in shigella, enteropathogenic E. coli, C. jejuni and salmonella infections. The protozoa such as Giardia lamblia and cryptosporidium adhere to the small bowel epithelium and cause shortening of the villi, which may be how they cause diarrhoea. Pathophysiology Watery diarrhoea is caused by a disturbance in the mechanism of transport of water and electrolytes especially sodium and chloride in the small intestines, and this is the basis of management of diarrhoea through oral rehydration therapy and feeding. Normally, sodium is actively absorbed from the bowel lumen by the villous epithelial cells (Fig.1). After this sodium is transported out of the epithelial cells into the extracellular fluid (ECF) by an ion pump known as Na+K+ ATPase. This creates an osmotic gradient that facilitates absorption of water. There are several mechanisms through which sodium is absorbed in the gut (Fig 2). Sodium linked to chloride iron direct as sodium ion Exchanged for hydrogen ion and linked to the absorption of organic substances such as glucose or amino acids, a mechanism that is less affected even under disease conditions. Secretion of water and electrolytes on the other hand occurs in the crypts of the small bowel epithelium where sodium chloride is transported from the ECF into the epithelial cells where sodium is pumped back into the ECF, but chloride is passed into the lumen. Interference with these two mechanisms leads to more secretion than usual plus reduced absorption as occurs with infections, will lead to diarrhoea. CONSEQUENCES OF WATERY DIARRHOEA Patients with watery diarrhoea produce stools containing large amounts of sodium, chloride, potassium and bicarbonate ions. Average electrolyte content, mmol/l Na+ K+ Cl- HCO-

Cholera Adults 140 13 104 44 Children (below 5 years) 101 27 92 32 Non-cholera diarrhoea Children (below 5 years) 56 25 55 14 ORS solution 90 20 80 30 Hypo-osmolar ORS

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All the acute effects of watery diarrhoea are caused by the loss of water and electrolytes from the body. Additional amount of water and electrolytes are lost when there is vomiting. It is further increased by fever. These losses lead to dehydration, acidosis and potassium depletion. The water and electrolytes loss are normally compensated for by water and salt intake in drinks and food. Complications of severe diarrhoea include shock, acute renal failure, malabsorption, anaemia, convulsion and death. DEHYDRATION This is the most dangerous complication because it can cause decreased blood volume (hypovolaemia), cardiovascular collapse and death if not treated promptly. Dehydration is more severe in children because, children have a higher percentage of body water (70-75 percent) compared to adults (55-60 percent). In addition, water intake in children is less and vomiting is more frequent contributing to the fluid deficit. Biochemically, dehydration can be classified as: isotonic, hypotonic and hypertonic. Isotonic dehydration This is the most common type of dehydration caused by diarrhoea. There is equal loss of water and electrolytes and it is characterized by: Balanced deficit of water and sodium Normal serum sodium concentration (130-150 mmol/l) Normal serum osmolarity (275-295 mOsmol/l) Substantial loss of extracellular fluid Hypotonic dehydration Loss of electrolytes more than that of water. There may be excess intake of plain water, or intravenous infusion of 5 percent glucose in water. It is characterized by: Deficit of water and sodium but with a greater deficit of sodium Low serum sodium concentration (<130 mmol/l) Low serum osmolarity (<275 mmol/l) Hpertonic dehydration There is increased water loss compared to electrolyte loss. May result from increased intake during diarrhoea of hypertonic fluids (such as sugar salt solutions) or insufficient intake of water. It is characterized by: Deficit of water and sodium but there is more water deficit Elevated serum sodium concentration (>150 mmol/l) Elevated serum osmolarity (>295 mOsmol/l) Severe thirst out of proportion to the degree of dehydration Seizures may occur, especially when serum sodium concentration exceeds 165 mmol/l

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PRINCIPLES OF MANAGEMENT OF DIARRHOEA AND DEHYDRATION Rehydration therapy The goal in managing diarrhoea is to correct deficit of fluid and electrolytes (rehydration therapy), and then replace further losses as they occur until diarrhoea stops (maintenance therapy). The mainstay of management of diarrhoea is oral rehydration therapy (ORT) supported by zinc supplementation. The majority of diarrhoea and dehydration are effectively managed by use of this method. Only in very severe dehydration, is intravenous rehydration indicated during the resuscitation phase, followed by ORT. Feeding All children with diarrhoea should be given plenty of food to prevent malnutrition. For children less than 6 months continue breast feeding. Breast milk is the best food for young babies. If the child is six months or older, or is already taking solid food, give cereals or another starchy food mixed with vegetables, pulses, meat and fish. Add one or two teaspoonfuls of oil to each serving to increase energy supply. Dairy products and eggs are also suitable foods for children with diarrhoea. Fresh fruits or fresh juices should be given because they provide potassium. During the diarrhoeal episode, offer food more frequently at least six times a day. After the diarrhoea stops, offer the same food and give an extra meal each day for two weeks. Antimicrobials in the treatment of diarrhoea Although pathogenic organisms can be isolated in about 75 percent of patients with diarrhoea, the majority do not need antibiotic treatment. ORS together with zinc supplements is adequate treatment. The only diarrhoeal diseases in which antibiotics are indicated are: Shigella Vibrio cholera and When there are intercurrent infections such as pneumonia urinary tract infection. Always look for signs of meningitis and give appropriate antibiotic cover. Antidiarrhoeal (antisecretory and antimotility) drugs There are no indications for these drugs in diarrhoea, they neither reduce the frequency nor the duration of diarrhoea and some of them are contraindicated. ASSESSMENT OF THE PATIENT WITH DIARRHOEA Every child who presents with diarrhoea should be carefully assessed before his or her treatment is planned. Clinical assessment consists of a brief history, including previous treatment attempted, and examining the child. Its objectives are to: Detect dehydration and degree of dehydration by using standardized clinical features (IMCI) Diagnose dysentery if present from history of bloody diarrhoea Diagnose persistent diarrhoea from the duration of the diarrhoea Determine the patient’s nutritional status

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Diagnose concurrent illness, such as meningitis, septicaemia resulting in some traditional treatment of diarrhoea and pneumonia Determine the child’s immunization status, especially that of measles Delete the sections highlighted and use table 12 in the WHO pocket book of Hospital care for children Assessing and management of a child for dehydration Detection of dehydration is based entirely on signs observed as shown table 3 below. Table 3 Assessment for dehydration General Condition* Well, alert Restless or Lethargic or irritable unconscious floppy Eyes Normal Sunken Very sunken and dry Thirst* Drinks normally Thirsty, drinks Drinks poorly or not thirsty eagerly unable to drink 2. FEEL Skin Pinch* Goes back Goes back Goes back quickly slowly very slowly > 2 seconds DECIDE: (Classify) NO SIGNS OF SOME SEVERE DEHYDRATION DEHYDRATION DEHYDRATION TREAT: Use plan A use plan B Use Plan C *Key signs NB skin turgor is not reliable in a malnourished child. Sunken fontanelle in babies can also be used. A child is in shock when the following are present: cold extremities, weak peripheral pulses, low blood pressure and reduced urine output. To decide on the presence and degree of dehydration of dehydration, one needs at least 2 (two) of the four signs shown in Table 3. Once the degree of dehydration has been made, the treatment plans A, B or C should be used as appropriate.

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In this space insert charts 13, 14, and 15 i.e. plans A, B, and C of diarrhoea treatment from the WHO pocket book of hospital care for children Age < 4

months 4-11 mo

12-23 mo

2-4 yrs 5-14 yrs 15 yrs and older

Weight < 5 kg 5-7.9 kg

8-10.9 kg

11-15.9 kg

16-29.9 kg

30 kg or more

In mls. 200-400 400-600

600-800 800-1200 1200-2200

2200-4000

In mls. based on 75 mls/Kg

375 592.5-600

817.5-825

1192.5-1200

1200-2242.5

2250

Treatment of diarrhoea at home Home treatment as given in (plan A) is an essential part of the correct management of diarrhoea in order to prevent dehydration and nutritional damage are to be prevented. Effective home treatment of diarrhoea can only be given by the mother/care giver. It is she who must prepare the oral fluid and give it correctly provide nutritious and well prepared food and decide when the child needs to return to the treatment center. She can do these tasks only if she understands clearly what need to be done and how to do it. The best opportunity to learn about the home treatment of diarrhoea is when she brings her child to the treatment center for diarrhoea. The mother must be trained on how to continue the treatment of her child at home, and how to give early home therapy for future episodes of diarrhoea. When properly trained a mother should be able to: Prepare and give appropriate fluids for ORT Give the child plenty of nutritious food to prevent malnutrition Take the child to a health facility if the diarrhoea does not get better, or if signs of dehydration or another serious illness develops Talking with the mother about home treatment A doctor must be able to communicate effectively with the mother. To improve his communication capacity the doctor must learn to: Listen to the mother and must take her concerns seriously Speak to her in terms she can understand Be supportive and encouraging giving her praise and help rather than criticism Use teaching methods that require her active participation. Assessment of the patient for other problems (figure 6) Once a patient has been assessed for dehydration, he/she should be assessed and managed for: Dysentery from the positive history of blood in stool. The patient with dysentery should be put on an antibiotic recommended by the country’s IMCI guidelines (see also table 1). A stool taken for culture and sensitivity may be useful. Persistent diarrhoea. The patient with persistent diarrhoea should be carefully investigated and all possible ailments identified and treated. Malnutrition using the age and the weight to or weight to height/length decide on the presence of wasting or stunting and oedema to decide on presence of severe

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oedematous (kwashiorkor or marasmic kwashiorkor) or severe non-oedematous malnutrition (marasmus). Children who are malnourished must be given prescribed feeding treatment to provide 100-200 calories per kilogramme body weight per day and four (4) grammes of protein per kilogramme body weight per day. Figure 6: Assessment of the Patient for other problems ASK ABOUT BLOOD IN THE STOOL ASK WHEN IF DIARRHOEA HAS LASTED AT LEAST 14 DAYS Refer to hospital if: The child is under 6 months Dehydration is present (refer the child after treatment of dehydration) Otherwise, teach the mother to feed her child as in plan A except: Replace animal milk with a fermented milk product such as yoghurt Assure full energy intake by giving 6 meals a day of thick cereal and added oil, mixed with vegetables, pulses, meat or fish. Tell the mother to bring the child back after 5 days: If diarrhoea has not stopped, refer to hospital If diarrhoea has stopped tell the mother to| Use the same foods for the child’s regular diet After 1 more week gradually resume the usual animal milk Give an extra meal each day for at least 1 month. LOOK FOR SEVERE UNDERNUTRITION ASK ABOUT FEVER ANDTAKE TEMPERATURE PREVENTION OF DAIRRHOEA It is important to teach communities on steps to prevent diarrhoea and these include: Exclusive breastfeeding Appropriate complementary feeding Hygienic preparation and storage of food at all times Clean drinking water Hand washing before feeding and use of the toilet Safe disposal of stools for all (including those of small children) Complete immunization especially measles REFERENCE: WHO Pocket book of Hospital care for children

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CHAPTER 9

ACUTE RESPIRATORY INFECTIONS IN CHILDREN

Elizabeth Maleche-Obimbo and Ezekiel M Wafula

INTRODUCTION Acute respiratory infections (ARI) can be divided into upper respiratory tract infections (URTI) and lower respiratory tract infections (LRTI). The former consists of common cold, otitis media, sinusitis, pharyngitis, and tonsillitis, while the latter includes laryngo-tracheobronchitis (LTB), bronchiolitis, and pneumonia. Learning Objectives By the end of this chapter, the student should be able to: Describe the anatomy of the respiratory system Outline the aetiology and epidemiology of acute respiratory infections in children in developing countries. Discuss the diagnosis and management of acute infections of the upper respiratory tract. Discuss the diagnosis and management of acute infections of the lower respiratory tract. Understand how to prevent morbidity and mortality from acute respiratory infections. Learning Activities Assess, classify and outline treatment of children presenting with cough and difficulty in breathing to the out-patient department Participate in the management of a child admitted to the ward with severe pneumonia from admission to discharge. Manage a child presenting to the hospital with stridor. Review the integrated management of childhood illness (IMCI) slides and/or video covering the topic of acute respiratory infection in children Familiarize yourself with the standardized ARI case management charts provided by IMCI on child presenting with cough, and with stridor. The Anatomy of the Respiratory System The upper respiratory tract includes the nose, ears, naso-pharynx, pharynx, tonsils and larynx. Any structure below the larynx is part of the lower respiratory tract, including the trachea, bronchi, bronchioles, lung parenchyma, and pleura. Epidemiology of Acute Respiratory Infections ARI is common in children under five years, in whom four to eight infections occur per year. ARI accounts for 40 – 60 percent of the children in outpatient clinics, and 30 – 50 percent of paediatric admissions, an indication of the high magnitude of the condition. ARI is the most common cause of mortality in infants and young children. It contributes to 20 – 50 percent of deaths among children less than five years of age in developing countries. The majority of ARI deaths are due to pneumonia, a LRTI. Pneumonia

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together with diarrhoeal disease, malaria, malnutrition and human immunodeficiency virus (HIV) infection contribute to over 75% of all the deaths in children under five years in developing countries. This signifies the seriousness of these five childhood diseases. Among children under 5 years, ~1 in every 3 children will have an episode of pneumonia within a year, and approximately 10% will require hospital admission. In 2002 the World Health Organization (WHO) estimated that pneumonia contributes to an estimated 15-25% of childhood deaths in Sub-Saharan Africa; and according to regions, contributes to 15-20% mortality in Southern African countries, and 20-25% of mortality in Eastern, Central and Western African countries. Risk Factors for LRTI Various factors prevalent in resource-poor settings contribute to increased risk for ARI in children. These factors include high prevalence of underlying illness such as malnutrition and HIV infection; high prevalence of other tropical diseases such as malaria, diarrhoea and measles; environmental factors such as overcrowding and indoor pollution from cooking fuels such as wood, charcoal or kerosene. Malnutrition a common disorder in children is a very significant risk factor for ARI in children. Available evidence shows that prevalence of pneumonia among severely malnourished children is as high as 72%, and that pneumonia occurs 19 times more commonly in malnourished compared to well nourished children, and that pneumonia death is 27 times more frequent in this high risk group. Aetiology of Acute Respiratory Infection The majority of URTI are due to viruses. Acute tonsillitis, streptococcal pharyngitis and retropharyngeal abscesses are predominantly due to bacterial infection. Bronchiolitis is commonly caused by viral infections of the lower respiratory tract, including respiratory syncytial virus, parainfluenza and influenza viruses among others. Aetiology of Pneumonia In developing countries, bacteria account for 30-60% of pneumonia, viruses for 25-40%, and atypical pathogens such as opportunistic organisms for up to 25%. Mixed bacterial-viral infection account for 10-15% of pneumonias. The specific aetiology (especially with respect to bacteria) varies according to age of child, presence of malnutrition or of underlying HIV infection. In young infants (under 2 months) common bacterial causes of pneumonia include group B beta haemolytic streptococcus, gram negative bacteria such as E coli and Klebsiella pneumoniae, and Chlamydia trachomatis. Viral pneumonia is not common in this age group. In infants and young children under five years most common bacterial pathogen is streptococcus pneumonia, followed by Haemophilus influenzae, and staphylococcus aureus. In the older child in addition to streptococcus pneumonia and staphylococcus aureus, mycoplasma pneumoniae, and Chlamydia pneumoniae cause disease.

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In addition to the above described pathogens, severely malnourished and HIV infected immuno-suppressed children, are prone to gram negative bacterial pneumonia and pneumocystis jiroveci pneumoniae (PCP), the latter seen especially in HIV infected children under age 6 months and severely immuno-suppressed. Viral causes of pneumonia in children include respiratory syncytial virus (most common), parainfluenza virus, influenza virus and adenovirus. These viral infections of the lower respiratory tract may frequently manifest as croup or bronchiolitis. Standard ARI Case Management The traditional approach in the diagnosis of respiratory syndromes, especially of pneumonia, is known to be associated with frequent mis-diagnosis. Effective control of pneumonia requires early detection, and institution of appropriate antibiotic therapy. Guidelines developed by the World Health Organization (WHO) and UNICEF for management of a child presenting with ARI emphasize the recognition and management of ARI at out-patient level, be it at the dispensary, health centre, or hospital out-patient department. They are simple enough to be effectively used by community health workers and mothers to recognize early pneumonia, and therefore seek attention early. The detection of pneumonia is based on two important clinical parameters; respiratory rate and chest indrawing. Every child presenting to an out-patient facility with history of cough and/or difficult breathing must undergo a thorough assessment, their illness diagnosed and classified, and given appropriate treatment. If the parent does not give history of cough and/or difficult breathing, the health worker must inquire about it. Ultimately it is most important to differentiate very sick children needing in-patient management from those that are less sick and may be treated at home. For objective management, the children are divided into two groups based on age as follows: two months to five years (the young child) and under two months (the young infant). This is shown in figures 2 and 3. Assessment of Children with Cough and/or Difficult Breathing Every child presenting with cough and/or difficult breathing, it is important to determine age, duration in days, whether they are breathing fast, have difficulty in breathing, stridor or wheeze, fever, whether there is history of exposure to someone with TB in the family, history of choking or sudden onset, know HIV infection, whether child has been immunized against BCG, DPT, Hib or measles, and if there is personal or family history of asthma. It is also important to determine if the child has symptoms suggesting very severe illness as follows: Danger Signs In assessing the child with ARI, it is important to ask and look for clinical features or “danger signs” that suggest severe illness, and are associated with high mortality risk. Any child presenting with these danger signs (listed below) should be admitted into the hospital for care.

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Child aged two months to five years, ask and look for: Is the child able to drink? Has he/she had convulsions? Are they abnormally sleepy, or difficult to wake? Do they have stridor when calm? Are they severely malnourished? Do they have chest indrawing? Are they wheezing? Child aged less than two months (young infant), all the above symptoms/signs are important, plus the following: Is the baby unable to feed? Does he/she have fever (≥ 380C) or hypothermia (< 35.50C)? The young infant is given special attention, because their ARI mortality is higher, and their disease presentation and treatment are significantly different from older children. Bacterial infections in young infants may present with non-specific clinical signs, making it difficult to distinguish pneumonia from sepsis and meningitis, and can lead to severe illness and death rapidly. The differential diagnosis of a child presenting with cough or difficult breathing is outlined in table 1 below.

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Table 1: Differential diagnosis of the Child Presenting with Cough or Difficult breathing

Classification of Children with Cough and Difficult Breathing After assessment, a child aged two months to five years with ARI should be placed into one of the following categories of ARI:

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Very severe disease Severe pneumonia Pneumonia (non severe) No pneumonia: cough or cold A diagnosis of pneumonia may be made in any child with cough or difficult breathing plus fast breathing defined by the following respiratory rates: Age < 2 months: ≥ 60/minute Age 2 – 11 months: ≥ 50/minute Age 1 – 5 years: ≥ 40/minute Any of the danger signs puts a child in the very severe disease category. In the absence of danger signs, chest in-drawing characterized by the in-movement of the lower chest wall when the child breaths in places them in the severe pneumonia category. The presence of fast breathing in the absence of danger signs or chest in-drawing places the child in the (non-severe) pneumonia category. Finally children with no danger sign, no chest in-drawing, not breathing fast, have “no pneumonia: cough or cold”. All young infants under two months of age with pneumonia are severely ill, and must be admitted to hospital for care. In this age group there are only three categories of ARI illness, that is; Very severe disease, severe pneumonia, and no pneumonia: cough or cold. Investigations that may be carried out include pulse oximetry and chest x-ray in children with severe forms of pneumonia, or children with HIV.

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Table 2: Classification of the Severity of Pneumonia

Treatment Guide to treatment is as outlined in the table 2. Specific details on antibiotic therapy, oxygen and supportive care are outlined in the following paragraphs. Antibiotic Therapy Antibiotics for very severe pneumonia Antibiotics should be given for 10 days in children with very severe pneumonia. Give intramuscular (IM) or intravenous (IV) ampicillin (15mg/kg every 8 hours) and gentamicin (7.5mg/kg once a day) for 5 days. If child improves, complete the treatment at home or in hospital with oral amoxicillin (15mg/kg three times a day) plus gentamicin once daily for a further 5 days Alternatives: IM or IV chloramphenicol (25mg/kg every 8 hours) until child improves, and then continue oral chloramphenicol 4 times daily for total course of 10 days

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IM or IV ceftrioxone 80mg/kg once daily If child does not improve or deteriorates within 48 hours check for complications. If none is apparent switch to Chloramphenicol to gentamicin (dose as above) with cloxacillin (50mg/kg every 6 hours). When child improves continue on oral cloxacillin 4 times daily for total course of 21 days. Ampicillin/gentamicin to cloxacillin/gentamicin Antibiotics for Severe Pneumonia Antibiotics should be given for a total course of ten days for children with severe pneumonia. Give benzyl penicillin (50,000 units/kg IM or IV every 6 hours) for at least 3 days If child improves switch to oral amoxicillin 25mg/kg twice a day for total antibiotic course of 5 days. If child does not improve or deteriorates within 48 hours: Evaluate for complications of pneumonia (as for very severe pneumonia or atypical pneumonia). If there are no apparent complications, switch to IM or IV chloramphenicol until child improves, then continue with oral chloramphenicol for a total course of 10 days Antibiotic therapy for non-severe pneumonia: Treat the child as an outpatient, give antibiotics for 3 days, (5 days in areas of high HIV prevalence). Give amoxicillin 25mg/kg twice a day for 3 – 5 days. Give the first dose in the clinic, and teach mother how to give the other doses at home. Oxygen Therapy Oxygen should be given to ALL children with very severe pneumonia, and to children with severe pneumonia who have respiratory rates ≥ 70/minute or severe lower chest wall indrawing. Where pulse oximetry is available, give oxygen to all children with oxygen saturation < 90%. Use nasal prongs (preferred), a nasal catheter, or a nasopharyngeal catheter. Nasal prongs – oxygen flow rate of 1 – 2 litres/min (0.5 l/minute for young infants) Nasal catheter or nasopharyngeal catheter – flow rate of 1 - 2 litre/min (0.5 l/minute for young infants). Continue with oxygen until signs of severe respiratory distress subside, or oxygen saturation is stable above 90%. The nurse should check every 3 hours that nasal catheters or prongs are in correct place and ensure no mucus is blocking them. Supportive Care Fever: Above 380C, give paracetamol (15mg/kg every 6 hours) Fluids: Ensure adequate daily fluids

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If able to take orally encourage continued breastfeeding, or other oral fluids. If unable to take orally (reduced level of consciousness, convulsions, severe respiratory distress) give intravenous fluids cautiously. Wheeze: Assess for asthma or bronchiolitis, provide rapid-acting bronchodilator (see chapter on asthma) Clear airways: Clear nasal mucous, remove any thick secretions in the throat by gentle suction. Nutrition: Encourage mother to continue feeding the child. Monitoring and Follow-up The severely ill child should be monitored every 3 hours by nurses, and twice a day by the doctor. Home Care Advise to the Mother for the Child with non-severe pneumonia. For children with cough or cold, advise the mother to: Continue feeding during the illness, and increase the frequency of feeding when the acute phase of the illness is over. This is intended to reduce the chance of the child developing malnutrition. To increase the amount of fluids she gives the child during the illness. Fever, and increased respiratory rate, together with poor appetite could lead to dehydration. She can give safe, home made cough remedies such as warm water, honey and lemon drink to help soothe the cough. Avoid cough syrups Complications If the child has not improved over 48 hours, or has worsened, evaluate for complications or review the diagnosis. A chest x-ray and other investigations in accordance with the suspected complication or alternative diagnosis should be sought. Common complications of pneumonia include pneumatocele, pneumothorax, empyema, pleural effusion. Possible alternative diagnoses are outlined in table 1. Bronchiolitis Children presenting with the first attack of wheeze may have bronchiolitis, especially if they are less than one year old. Bronchiolitis is a lower respiratory viral infection which typically is most severe in young infants, occurs in annual epidemics and is characterized by airways obstruction and wheezing. Secondary bacterial infection may occur, and is common in some settings. If in addition to wheeze the child has increased respiratory rate and/or chest indrawing their disease should be managed as for pneumonia. Those children presenting with recurrent wheeze and features of pneumonia/severe pneumonia should be treated first with a rapid acting bronchodilator such as inhaled salbutamol (by metered dose inhaler and spacer, or nebulisation) or subcutaneous adrenaline, and reviewed after 30 minutes. If the symptoms improve (reduced wheeze, and respiratory rate) treat as asthma. If symptoms persist, treat as pneumonia.

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EAR INFECTIONS

The most common ear infection is otitis media. This is an infection of the middle ear. The middle ear is considered a part of the respiratory system. It is connected to the pharynx by the eustachian tube.

Ear infections are caused by both viruses and bacteria similar to those that cause pneumonia, that are streptococcus pneumoniae and haemophilus influenzae.

Ear infections rarely cause death, but they cause many days of illness. Sometimes the infection can spread from the ear to the mastoid bone leading to mastoiditis, or to the brain leading to brain abscess or meningitis. They, (ear infections) are the main causes of deafness in the developing countries.

The common presenting features of ear infections are, fever, ear pain and pus discharge from the affected ear. As for pneumonia children presenting with ear problem, should he assessed, classified and treated.

Assessing a Child Presenting with Ear Problem

The following are important in the assessment of a child presenting with an ear problem; (I) Does the child have ear pain? (2) Does the child have pus discharge from the ear? If yes, for how long;? (3) If you have an otoscope find out if the ear drum is red and dull with no light

reflex. These strongly suggest ear infections (4) Feel for tender swelling over the mastoid bone- that is behind the ear The point

of mastoid tenderness in young, infants may be above the ear- Classifying a Child with an Ear infection

A child with an ear problem should be put into one of the following categories; (1) Mastoiditis (2) Acute Ear Infection (3) Chronic Ear Infection

Mastoiditis

A child with a tender swelling behind the ear is classified as having Mastoiditis. Such patients must be referred urgently for in patient treatment with parenteral antibiotics similar to those used for pneumonia. Some of them may require surgery.

Acute Ear Infection

A child with pus discharge from the ear for less than two (2) weeks, or ear pain or a red immobile ear drum has Acute Ear Infection.

The child should be given antibiotics to treat the Acute Ear- Infections. When there is pus discharge, the treatment is wicking. This facilitates drying of the ear. Ear drops

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should be avoided as they keep the ear moist, delay healing and do not reach the infection.

Chronic Ear Infection

A child who has had pus discharge from the ear for more than two weeks, has Chronic Ear Infection. This is the main cause of deafness in children. The most important and elective treatment, is keeping the ear dry by wicking.

Bacteria that are found in the ear two weeks after onset of pus discharge are due to secondary infections. Commonly grown are bacteria such as peudomonas, proteus and gram negative enteric organisms. Sometimes, fungi are isolated. A chronically draining ear will heal only if it is dry. Drying the ear by wicking is time consuming but it is the only effective therapy. The infections do not respond to antibiotics. Do not apply any fluid into the ear.

THROAT INFECTIONS

Throat infections are common reasons for children seeking medical attention. Sore throat is a major complaint that accompanies common colds. The large majority are caused by viruses. They get better in a few clays with good home care and no additional treatment. Antibiotics are not indicated in these patients. Most children only need a safe, soothing remedy for the sore throat.

The indications for antibiotics in sore throats are the following; (I) Diphtheria infections (a very uncommon infection) (2) Streptococcal pharyngitis () Peritonsillar abscess (4) Retropharyngeal abscess

Streptococcal pharyngitis is more common in the age group five to 15 years and rare in the under five year olds. It is treated with antibiotics to prevent the complication of acute rheumatic fever and the subsequent acute rheumatic heart disease. Assessment of a child presenting with Sore Throat

The following are important in the assessment of a child with a sore throat; (1) Is the child able to drink? (2) Does the child have an exudate in the throat? (3) Does the child have enlarged tender cervical lymph nodes'?

Classify the illness

Children with sore throat can be placed in three categories as follows;

(1) Throat abscess

(2) Streptococcal sore throat

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(3) Simple viral sore throat

Throat Abscess

A child who is not able to drink at all is classified as having a Throat Abscess. Besides this, they may present with drooling of saliva and tenderness at the angle of the jaw. Although it is not common, children may develop abscesses behind the throat or around the tonsils. The abscesses make it difficult for the child to swallow water. A child with throat abscess should be referred for inpatient treatment and, if needed, to drain the abscess. These patients should be given parenteral antibiotics such as benzylpenicillin and chloramphenicol.

Streptococcal Sore Throat

Streptococcal sore throat (also referred to as streptococcal pharyngitis or strep throat), is caused by Lancefield group A beta haemolytic streptococcus. A child who presents with tender, enlarged lymph nodes in the front of the neck, AND a white exudate on the throat is classified as having Streptococcal Sore Throat. Such patients normally have no features suggestive of viral nasopharyngitis which include rhinorrhoea, conjunctivitis and cough. A child with streptococcal sore throat should preferably be given benzanthine penicillin single injection. This treatment will prevent the development of rheumatic fever. Note that group A beta haemolytic streptococcus does not respond to cotrimoxazole and this drug must not be used.

Simple Viral Sore Throat The majority of sore throat are due to viruses, and get better in a few days with good home care and no additional treatment. Most of these children only need a safe, soothing remedy for the sore throat, to keep the throat moist. These patients should not be given antibiotics.

PREVENTION OF ARI Standard ARI case as given in this chapter has greatly reduced deaths in the under fives. Prevention of pneumonia on the other hand requires reduction of the risk factors outlined earlier. Of particular importance is reduction in early childhood undernutrition which is estimated to be the underlying cause of mortality in about 60% of deaths in the under fives. Avoiding overcrowding, cooking inside the house, and smoking are also important. Currently conjugate vaccines against H influenzae and streptococcus pneumoniae have become available. These are either already incorporated in the childhood vaccination programmes in the region or are soon to be included.

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REFERENCES Pocket book of hospital care for children: guidelines for management of common illnesses with limited resources. WHO 2005 Shann F Etiology of severe pneumonia in children in developing countries Pediatr Infect Dis 1986; 5:247-52 Forgie IM, O’Neill KP, Lloyd-Evans N et al Etiology of acute lower respiratory tract infections in Gambian children: II Acute lower respiratory tract infection in children ages one to nine years presenting at the hospital Pediatr Infect Dis 1991; 10:42-7 Forgie IM, O’Neill KP, Lloyd-Evans N et al Etiology of acute lower respiratory infections in Gambian children: I Acute lower respiratory infections in infants presenting at the hospital. Pediatr Infect Dis 1991; 10:33-4

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CHAPTER 10

ASHMA IN CHILDREN

Chris M. Ndugwa, Somwe Wa Somwe, Elizabeth Maleche-Obimbo,

Dalton Wamalwa, Dinberu Tefera Muluwork

LEARNING OBJECTIVES At the end of this chapter, the student should be able to

define asthma list factors leading to the development of asthma understand the pathogenesis of asthma make a diagnosis of asthma grade the severity of an acute exacerbation of asthma treat a child with an acute exacerbation of asthma classify severity of chronic asthma manage a child with chronic asthma educate patients and families on asthma prevention

Learning activities

Make a home spacer as described in the IMCI guidelines Practice inhaler technique Practice peak flow measurements

Definition Asthma is a chronic inflammatory condition with reversible airway obstruction. It is characterized by recurrent episodes of wheezing, often with cough, which respond to treatment with bronchodilators and anti-inflammatory drugs. The prevalence of asthma childhood in Africa ranges from 2% to 18% and seems to be increasing. Pathogenesis The pathogenesis of asthma is unclear. It however has significant genetic and environmental components. Host factors important for the development of asthma include atopy, airway hyper responsiveness, obesity, and male sex. Environmental factors include allergens (e. g house dust mite, pollen), viral infections (e. g rhinovirus), and pollutants (e. g smoke) and exercise in dry cold weather.

Mechanisms of asthma Though the clinical spectrum of asthma is variable, the presence of airway inflammation is a constant feature. Inflammatory cells, i.e. mast cells, eosinophils, T- lymphocytes,

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release bronchoconstrictor mediators and specific cytokines that are responsible for the airway hyper responsiveness as well as epithelial damage and remodeling (figure 1).

Lower airway injury

. Persistent inflammation

Aberrant . Airway hyper responsiveness Repair . Remodeling

. Airways growth and differentiation

ASTHMA Figure 1. (Adapted from Nelson textbook of pediatrics, 18th edition) Diagnosis of asthma Diagnosis of asthma is made on the basis of a history of recurrent cough and episodes of wheezing. Physical findings may include audible wheeze with prolonged expiration. Prompt response to bronchodilator may help in making a diagnosis of asthma. The diagnosis can be strengthened by measuring the peak expiratory flow (PEF) which provides an assessment of the severity of airflow obstruction as well as air flow variability and reversibility. Other causes of recurrent wheezing or persistent cough must be considered and excluded, i.e. chronic rhino-sinusitis, gastro-oesophageal reflux disease, pulmonary tuberculosis and foreign body aspiration. Children presenting with these conditions are unlikely to respond to bronchodilator therapy.

Environment . Allergens . Infections . Pollutants . Microbes . Stress

. Biological and genetic risk . Atopy .

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Assessment of an acute exacerbation of Asthma Table 1 : Severity of Asthma Exacerbations Mild Moderate Severe Respiratory

arrest imminent

Breathless Walking Can lie down

Talking infant – softer shorter cry; Difficulty feeding Prefers sitting

At rest Infant stops feeding Hunched forward

Talks in Sentences Phrases Words Alertness May be

agitated Usually agitated

Usually agitated

Drowsy or confused

Respiratory rate

Increased Increased Often > 30/min

Normal rates of breathing in awake children: Age Normal Rate < 2 months < 60/min 2-12 months < 50/min 1 – 5 years < 40/min 6 – 8 years < 30/min

Accessory muscles and suprasternal retractions

Usually not Usually Usually Paradoxical thoraco-abdominal movement

Wheeze Moderate, often only end expiratory

Loud Usually loud Absence of wheeze

Pulse/min < 100 100 – 120 > 120 Bradycardia Guide to normal pulse rate in children

Infants 2 – 12 months – normal rate < 160/min Preschool 1 – 2 years < 120/min School-age 2 – 8 years < 110/min

Sa O2 % (on air)

> 95% 91 – 95% < 90%

Hypercapnia (hypoventilation) develops more readily in young children than in adults and adolescents.

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Table 2. Management of acute exacerbation of asthma Mild to Moderate exacerbation

Severe exacerbation Life-threatening asthma

Salbutamol inhalation via spacer and mask: 2 puffs every 10 minutes to a maximum of 10 puffs

If good responses then reduce the frequency to 2-4 puffs every 2 to 4 hours.

Or Salbutamol

nebulisation 2.5 mg<2 years 5 mg>2 years

AND Start prednisolone

at beginning of treatment 1 mg/kg (Max 40 mg) PO OD for 3 days

Discharge if

improving. If poor response after 1-2 hours admit and manage as severe exacerbation

Humidified oxygen by nasal prongs or nasal catheter (1-2 l/min) Salbutamol inhalation or mobilization as for moderate exacerbation PLUS Inhaled ipratropium bromide via spacer or nebulizer 4-6 hourly 125 mcg< 1 year 250 mcg if 1-5 years 500 mcg>5 years AND prednisolone PO If poor response after 1 -2 hours or vomiting, give IV hydrocortisone 4 mg/kg every 6 hours If poor response after a further 2 hours give IV aminophylline 5 mg/kg infusion over 20 min then slow infusion at the rate 1 mg/kg/hour Admit to wards Reassess every 2 hours

Admit to PICU or special ward and treat as for severe exacerbation. If not improving, Prepare for intubation and Mechanical ventilation

Adapted from GINA 2007 guidelines # SC adrenaline 1:1000 0.01 mg/kg (Max 0.5 mg) may be used where inhaled bronchodilator therapy is unavailable. Oral salbutamol may be used as an alternative < 1 year: 1mg per dose, > 1 year 2 mg per dose every 6 hourly.

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Classification of Asthma Severity by Clinical Features Before Treatment Table 3 : Classification of Asthma Severity by Clinical Features Before Treatment Intermittent Symptoms less than once a week Brief exacerbations Nocturnal symptoms not more than twice a month Peak expiratory flow (PEF) ≥ 80% predicted PEF variability < 20% Mild Persistent Symptoms more than once a week but less than once a day Exacerbations may affect activity and sleep Nocturnal symptoms more than twice a month PEF > 80% of predicted PEF variability < 20–30% Moderate Persistent Symptoms daily Exacerbations may affect activity and sleep Nocturnal symptoms more than once a week Daily use of inhaled short acting beta agonists PEF 60 - 80% of predicted PEF variability > 30% Severe Persistent Symptoms daily Frequent exacerbations Frequent nocturnal asthma symptoms Limitation of physical activities PEF ≤ 60 of predicted PEF variability > 30%

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Management of a child with chronic asthma

Patient education Patients /Caregivers should be educated on the following: a. Identification and avoidance of risk factors including

indoor cooking with charcoal, wood or paraffin stoves parental smoking contact with pets

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b. Correct use of asthma medication including understanding the difference between reliever and controller medication c. Correct use of inhaler and devices (inhalers, spacers, masks, age appropriate) d. Early recognition of acute asthma exacerbation and taking appropriate steps

Learning activity To make a home-made spacer using a 500 ml drink bottle refer to the WHO IMCI guidelines.

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References

1. British Thoracic Society. Management of Asthma Guidelines, April 2004

2. Standard Treatment Guidelines and Essential Drugs List for South Africa. Paediatric Hospital Level. 1st Edition 1998.

3. Papadopoulos NG and Kalobatson A. Respiratory viruses in childhood asthma.

Curr Opin Allergy Clin Immunol, 2007; 7(1): 91-95

4. Tomlinson R. Postcard from Africa: Hospital management of asthma. Arch dis child, 2002; 87:356

5. AL-Hajjaj MS. Bronchial asthma in developing countries: A major social

and economic burden. Annals of Thoracic Medicine, April-June 2008, vol 3, 2:39

6. Fischer GB and Camargos PAM. Paediatric asthma management in developing countries. Paediatric respiratory reviews, 2002, 3: 285-291

7. Busse VW and Lemanske RF. Asthma. New Engl Jour of Med, February 2001,

Number 5, vol 344:350-362 8. GINA. Global strategy for asthma management and prevention 2007 report.

8. WHO/UNICEF Integrated management of childhood illness for high HIV settings, 2006.

9. Zar HJ et al. Home-made spacers for bronchodilator therapy in children

With acute asthma: A randomised trial. Lancet 1999; 354:979-982

10. Zar HJ et al. Randomized controlled trial of the efficacy of a metered dose

Inhaler with bottle spacer for bronchodilator therapy in acute lower airways obstruction. Arch Dis Chil, doi: 10, 1136/adc.2006.101642.

11. WHO. Pocketbook of Hospital Care for Children. Guidelines for the management of common illnesses with limited resources 2007.

12. Kenya association for the prevention of tuberculosis and lung disease (KAPLD).

Consensus statement on the management of asthma in Kenya, 2005.

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CHAPTER 11

TUBERCULOSIS IN CHILDREN

Elizabeth Maleche-Obimbo, Andrew Ndamira, Catherine Chunda INTRODUCTION Tuberculosis (TB) is a major cause of illness and death worldwide especially in Asia and Africa. Globally, there were an estimated 9.2 million new cases, and 1.7 million TB - related deaths, of which approximately 400,000 were in children, and 0.2 million in HIV positive individuals in 2006. In Africa, cases of TB are on the increase due to poverty, political instability, overcrowding, malnutrition and HIV infection. Paediatric TB accounts for approximately 10 – 20% of all reported cases. The emergence of HIV infection has grossly altered epidemiological patterns of TB. About one third of the estimated 40 million people living with HIV worldwide are co-infected with TB, and they have a five-fold higher mortality than in individuals with TB alone. Learning Objectives By the end of this chapter, the student should be able to 1. Discuss the epidemiology of Tuberculosis (TB) in children 2. Understand the aetiology and pathophysiology of TB in children 3. Describe the clinical presentation of TB in children 4. Understand the approach to making a diagnosis of TB in a child 5. Outline the treatment of various forms of TB in children 6. Discuss the diagnostic and treatment challenges of TB in the immuno-compromised child 7. Describe the principles of prevention of TB in children Learning Experience Practice taking a history in a child suspected to have TB Assess for physical signs suggestive TB Perform a and interpret tuberculin skin test Participate in giving BCG to a newborn Find out how your country manages to do contact tracing of children of parents with sputum positive pulmonary TB Epidemiology of tuberculosis in Children Risk factors for TB infection in children include the following: Young age: the younger the child is, the higher the risk of infection and disease progression; infants are at a higher risk due to poorly developed immune system Infants in close contact with sputum positive adults

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Children with severe malnutrition HIV infected children Post-measles or post-pertussis infection Non-immunized children (higher risk of severe tuberculous disease) Other immuno-suppressive states such as diabetes mellitus, malignancies, steroid therapy etc. Other population based factors greatly influence prevalence and epidemiological patterns of childhood TB in different geographical regions: 1. Intensity of the epidemic: In populations where TB cases are widespread, there is an increased chance of exposure of children in that population to infection. 2. Age structure of the population: The younger the population, the higher the likelihood of having many children infected with TB. (In Africa up to 50% of the population is below 18 years) 3. Delay in diagnosis and treatment of adult index cases This may be due to i) Delayed presentation of sick adults to health facilities ii) Lack of diagnostic tools: iii) Poor contact tracing and screening of child household contacts of these infected adults iv) Poor health infrastructure contributes to all the factors above. Children are more likely to progress to active TB disease than adults, with infants and children under 5 years at greatest risk. Those who do not develop active TB disease are described as having latent TB. The likelihood of developing disease is highest shortly after exposure (6 – 8 weeks) and decreases with time. Aetiology and Pathophysiology of Tuberculosis TB is caused by Mycobacterium tuberculosis, an obligate aerobic organism that is highly sensitive to light (direct sunlight kills bacilli in 5 minutes) and heat (bacilli die within 20 minutes at 60°C) but highly resistant to dry conditions (bacilli can survive for weeks and later cause infections as dust particles). Other non-tuberculous Mycobacteria may also cause disease, notably M. bovis, M. avium and M. africanum; these are described as atypical mycobacterial infections. Routes of infection The bacilli may enter the human body by any of the following routes: Inhalation Ingestion Inoculation Inhalation of bacilli through the respiratory tract is by far the most common portal of entry (over 98% of cases); inhaled bacilli settle in the lower respiratory tract. Local infection at the portal of entry is usually followed by spread to regional lymph nodes (primary complex). In most children, this primary infection remains quiescent but may result in progression of disease in any of the following ways:

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Within the lung: multiplication of bacilli initially within alveoli and alveolar ducts before spreading to the lung parenchyma and pleura to cause tuberculous pneumonia, pleurisy, and in older children, pleural effusion and cavitation hilar lymph node inflammation and enlargement, leading to compression of bronchi which leads to lobar or segmental collapse (atelectasis) tonsillar infection: spread to cervical lymph nodes haematogenous (and lymphatic) spread, leading to military TB, involving the lung, pericardium, meninges, abdomen, bone and joint Enlarged focus (coin shadow). Development of any of the above lesions largely depends on immune status of the individual child as well as BCG vaccination status. The table below shows the approximate time frame within which each of the pathological lesions develops:

Stage Duration Features

1 3-8 weeks Primary complex, Tuberculin positivity

2 ~ 3 months Haematogenous spread (TBM & miliary TB)

3 3-4 months TB pleurisy/pneumonia 4 Up to 3 yrs Bone & Joint

5 Up to 12 yrs Genitourinary

CLINICAL PRESENTATION OF TUBERCULOSIS Most children with symptomatic TB will present with the following common general symptoms: chronic cough, lasting more than 21 days, persistent fever and/or night sweats (>14 days) and poor weight gain or loss of weight. In addition to the general symptoms described above, depending on the site of the active TB infection, the child may develop symptoms and signs specific to the site of the active infection. These clinical features are described below: Pulmonary TB This is the commonest form of TB occurring in children. There excessive sweating, tachypnoea, respiratory distress, nausea and vomiting. Younger children may present with wheezing due to bronchial obstruction by enlarged hilar lymph nodes (primary complex). Even with more than one lobe involvement in young children respiratory signs may be absent. Older children and adolescents may present with similar disease to

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adults with productive cough; sputum may be purulent or blood stained (haemoptysis) and there may be signs of apical lobar consolidation and in advanced disease, cavitation. Pleural effusion This tends to occur in older children. They presents with progressive breathlessness (dyspnoea), chest pain, tracheal shift away from affected side, stony dull percussion note, and may have a pleural rub (in early stages) and reduced breath sounds over the affected lung. They may or may not have cough. Lymph Node Disease Presents with progressive painless enlargement of one group of lymph nodes. Most commonly involved areas are cervical, submandibular, tonsillar and supraclavicular lymph nodes. The nodes are enlarged, discrete (but may be matted together), firm, non-tender, and fixed to surrounding structures. Eventually fistula formation may develop, discharging caseous material, which is pathognomonic of TB lymphadenitis. Abdominal TB Tuberculous infection in the abdomen may present with progressive abdominal swelling and abdominal pain associated with persistent fever and weight loss. Examination may reveal abdominal distension with ascites, abdominal mass (enlarged lymph nodes), enlarged liver and/or spleen. Progressive intestinal obstruction by enlarged lymph nodes may manifest as constipation with vomiting, and abdominal distension. Commonly involved tissues include the jejunum, ileum, Payer’s patches and appendix. Generalized peritonitis may occur, though not common. TB Meningitis The clinical presentation of TB meningitis can be described in three stages as follows: Stage I: Child presents with non-specific symptoms and signs of persistent fever, headache, irritability and drowsiness (1-2 weeks). Stage II: Progression to more specific symptoms and signs of meningeal irritation – neck stiffness, positive Kerning’s sign, positive Brudzinski sign, convulsions, hypertonia, vomiting, cranial nerve palsies and focal neurological signs. Stage III: Child develops features of severe neurological disease including coma, hemiplegia, decerebrate or decorticate posturing and abnormal vital signs. Tuberculous meningitis may be differentiated from pyogenic meningitis due to the insidious onset of symptoms (over weeks) and long history of ill health, as compared to the acute onset (over days) of pyogenic meningitis Tuberculoma Tuberculomas present with features of space occupying lesions in accordance with their location within the brain. Accompanying symptoms include headache, persistent fever, weight loss or poor weight gain. Parietal lesions will cause paraparesis or hemiparesis and progress to full paraplegia or hemiplegia. Children may in addition develop features of raised intra-cranial pressure such as vomiting and diplopia. Osteo-articular TB This is caused by haematogenous spread of TB bacilli, initially infecting the metaphyses of weight-bearing bones and joints (vertebrae, knee, hip, elbow and ankle), and may

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manifest several months to years after the primary TB infection. The child presents with initially mild pain, swelling at the site, with minimal or no tenderness, refusal to use the limb, associated persistent low-grade fever and poor weight gain. TB of the vertebra (Pott’s disease) presents initially with mild back pain which slowly gets worse, abnormal posturing and reluctance to walk, progressing to inability to walk. Examination may reveal rigidity of spine, minimal or no tenderness and abnormal curvature of spine; in advanced stages, collapse of the vertebral body may lead to formation of a gibbus (pathognomonic of TB spine), and to spinal compression with resultant loss of motor function of the lower limbs and loss of bladder and anal sphincter control. Disseminated Disease (Miliary TB, TB Septicaemia) This is caused by haematogenous spread of TB bacilli to multiple organs of the body; it is usually associated with miliary lesions in the lungs, followed by miliary seeding of various body organs (most numerous in liver, spleen and bone marrow). It is more common in infants and severely immunosuppressed individuals (HIV infected and severely malnourished children), and usually presents as an early complication of primary disease (within 2-6 months of primary infection). Onset is usually insidious, with persistent fever, weight loss, malaise, anorexia, and features of pneumonia and abdominal involvement plus, with or without meningeal, bone marrow or urogenital involvement. DIAGNOSIS OF TUBERCULOSIS IN CHILDREN The gold standard for diagnosis of TB is the identification of Mycobacterium tuberculosis in body specimens, by microscopic examination, confirmed by positive culture of the bacillus. Specimens may be obtained from suspected site of infection, and include sputum (pulmonary TB), pleural aspirate (pleural effusion), lymph node aspirate or biopsy (TB lymphadenitis), cerebro-spinal fluid (TB meningitis), ascitic tap or fine needle aspirate (FNA) from abdominal mass (abdominal TB), joint aspirate (TB arthritis) etc. Challenges to diagnosis: Children, especially infants, malnourished and HIV infected children tend to manifest with pauci-bacillary disease, and TB bacilli may not be identified from body specimens even in the presence of active TB disease. Secondly, the majority of affected children (under 8 years) are unable to expectorate , and therefore confirmation of diagnosis of PTB, the most common form of TB in children through microbiologic confirmation is not possible. Thirdly, in resource-poor settings, many health facilities diagnostic tests may not be available. In situations where one is unable to make a microbiologic confirmation of TB infection, the World Health Organization has developed the following approach to clinical diagnosis of TB in children.

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These four criteria are defined more explicitly below: 1. Chronic symptoms suggestive of TB Chronic cough: An unremitting cough that is not improving and has been present for more than 14 days Unexplained fever: Fever continuing for > 14 days, after common causes such as malaria or pneumonia have been excluded Unexplained weight loss or failure to thrive: As reported by parent/guardian or older child, take weight of child, examine child’s growth chart. History of exposure to an adult with probable or definite PTB 2. Physical signs highly suggestive of TB a. Pulmonary TB – there are no specific clinical features that differentiate

pulmonary TB from other forms of pneumonia or pulmonary disease b. Extra pulmonary TB Physical signs highly suggestive of extra pulmonary TB include: non-painful enlarged cervical lymphadenopathy with fistula (abscess) formation Gibbus, (deformity of spine resulting from vertebral TB) especially of recent onset. Physical signs requiring investigation to exclude or support diagnosis of extra pulmonary TB Meningitis with a sub-acute onset (developing over several days to weeks), not responding to standard anti-meningitic antibiotic treatment. Pleural effusion, one sided. Distended abdomen with ascites with or without palpable lumps. Non-painful enlarged lymph nodes without fistula (abscess) formation Non-painful swelling or deformity of bone or joint. In addition, documented weight loss or failure to gain weight, especially in child with adequate nutritional intake, is a good indicator of chronic disease in children, of which TB may be the cause. Investigations relevant to rule out or support diagnosis of extra-pulmonary TB Site of Suspected TB Infection Practical approach to diagnosis Peripheral lymph nodes Lymph node biopsy or fine needle aspiration Miliary TB (disseminated) Chest X-ray and lumbar puncture TB meningitis Lumbar puncture (CT scan where available) Pleural effusion Chest Xray, pleural tap Abdominal TB Abdominal ultrasound, ascitic tap Osteo-articular X-ray of bone/joint, joint tap or synovial

biopsy Pericardial TB Ultrasound, pericardial tap

Box 1: Key features suggestive of TB The presence of three or more of the following should strongly suggest a diagnosis of TB Chronic symptoms suggestive of TB Physical signs highly suggestive of TB A positive tuberculin skin test Chest X-ray suggestive of TB

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All specimens should be subjected to microscopy (acid fast bacilli stains and white cell counts) and mycobacterial cultures. Biopsy specimens should also be subjected to histology. CSF, pleural, ascitic, and pericardial aspirates should also be subjected to biochemical analysis (protein and glucose concentrations). Laboratory tests are discussed in greater detail below. 3. A positive tuberculin skin test (TST) This is an indication that the child has been infected with the Mycobacterium tuberculosis. Tuberculin purified protein derivative antigen is injected intradermal, and an induration appearing at the site of injection within 3 days indicates that the child’s immune system has been sensitized to M.TB (therefore indicates previous infection with the bacillus). Immunocompetent children react more vigorously, immuno-compromised children (HIV, severe malnutrition, or very severe forms of TB disease such as military or TB meningitis) may have blunted or absent reaction even in the presence of active TB infection. Therefore the interpretation of the TST test is as follows: High-risk children – HIV infected, severely malnourished children Positive TST = induration of 5mm or more. Negative TST = no induration, or induration <5mm All other children Positive TST = induration of 10mm or more Negative TST = no induration, or induration <10mm (It is important to appreciate that in the high risk children, a negative TST reaction may be a false negative, i.e. does not rule out the presence of M.TB infection in this group of children) 4. Chest X-ray suggestive of TB The following radiological pictures are suggestive of TB in children Persistent opacification in the lung with enlarged hilar or subcarinal lymph nodes. Miliary pattern of opacification in both lungs Large pleural effusions* Apical infiltrates with or without cavity formation* Enlarged hilar adenopathy with lobar collapse* *These radiological pictures are seen mainly in older children and adolescents. Bacteriologic Confirmation Obtaining specimens Sputum may be obtained through expectoration by child, sputum induction, or removal of swallowed sputum by aspiration of gastric contents early in the morning.

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Expectoration: Older children (>8years) should be encouraged to cough up sputum into a sputum container. Ideally 2-3 specimens should be obtained; an on-the-spot specimen (at first clinical evaluation), an early morning specimen, and a second on-the-spot specimen (at a follow-up visit) Gastric aspiration: Lay the child on their back or side, attach a syringe to the nasogastric tube, then insert the NGT into the stomach. Withdraw (aspirate) 5-10ml of gastric contents. If no fluid is aspirated, insert 5-10ml of normal saline and attempt to aspirate again. Transfer the aspirate to a sterile container (sputum collection container). Add an equal volume of sodium bicarbonate solution to the specimen (neutralizes acid and prevents destruction of TB bacilli). Laboratory Assays Microscopy Common stains for identification of M.TB include Ziehl Nielssen staining, an acid-fast stain in which mycobacteria appear as pinkish-red bacilli. Immunofluorescent staining is more sensitive in identification of the bacilli, however requires a specialized microscope. Specimen culture Mycobacteria may be cultured using: - Solid media such as Lowenstein Jensen – result in 3-8 weeks. - Liquid media such as Liquid Bactec (media observed drug susceptibility) result in 5-14 days. Biochemical analysis of specimens (CSF, aspirates): High protein levels Low glucose levels Treatment of Tuberculosis Goals of treatment Clinical cure Restoration of normal growth and development Restoration of normal childhood activities Prevention of transmission to other children Prevention of relapse Prevention of drug resistance Approach to treatment Currently available anti-TB drugs are either bactericidal or bacteriostatic. Combination therapy in treatment of TB is the golden rule and monotherapy is strongly discouraged since drug resistance is highly likely to occur given the long duration of therapy. Development of appropriate anti-TB regimens is based on the fact that: a) Most children have pauci bacillary pulmonary disease b) Extra-pulmonary TB is more common in children than adults c) Severe and disseminated TB occurs mainly in very young children (below 3 years)

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Recommended treatment regimens Anti-TB treatment is given in two phases: 1) Intensive phase The purpose of the intensive phase is to rapidly eliminate most of the organisms and to prevent emergence of drug resistance; this phase, therefore uses more drugs than the continuation phase. 2) Continuation phase This phase is intended to eradicate dormant bacilli and thus uses fewer drugs. Table 3: Summary of Recommended TB Treatment Regimens:

Diagnostic Category

TB Cases

Regimen Intensive Phase

Continuation Phase

I a

- New smear-positive pulmonary TB - New smear-negative pulmonary TB with extensive parenchymal Involvement - Severe forms of extra-pulmonary TB other than TB meningitis (miliary TB, spinal TB, abdominal TB, renal TB, adrenal TB, TB pericarditis, bone and joint TB, etc) - Severe concurrent HIV disease

2RHZE

4RH

I b

TB Meningitis

2RHZS*

4RH

II

Previously treated smear-positive pulmonary TB: - relapse - treatment after interruption/default - treatment failure

2RHZES/ 1RHZE

5RH

III

- New smear-negative pulmonary TB (with less severe parenchymal involvement - Less severe forms of extra-pulmonary TB (e.g. TB adenitis)

2RHZ

4RH

IV Multi-drug resistant (MDR) TB Refer to TB specialist centre

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* Note that in treatment of TB meningitis, streptomycin replaces ethambutol since the latter does not cross the blood – brain barrier MANAGEMENT OF TB IN THE HIV INFECTED CHILD The diagnosis and treatment of TB in the HIV infected child has several challenges which shall be outlined in this section. Diagnosis Chronic symptoms HIV infected children frequently have recurrent or persistent HIV-related illnesses and consequently the chronic symptoms suggestive of TB (chronic cough, persistent fever, weight loss or poor weight gain) are frequently present in the HIV infected child as part of HIV disease itself, and could suggest TB or many other underlying HIV-related diseases. Physical sign: Due to their deteriorating immunity, HIV infected children with pneumonia or meningitis frequently respond poorly to antibiotic therapy, as such, this sign may suggest TB, but may also suggest many other pathogenic infections. Tuberculin Skin Test (TST) Due to poor cell mediated immunity, HIV infected children with advancing disease may have poor immune response to tuberculin antigen, therefore have negative TST test even in the presence of active TB infection. Suggestive Radiology: HIV infected children frequently present with atypical radiological pictures even in the presence of PTB, such as more widespread disease, absence of lung opacities due to their inability to mount a good inflammatory response to existing micro-organisms. Microbiologic Confirmation of TB infection HIV infected children may have pauci-bacillary disease, therefore making it difficult to identify mycobacteria from their various body specimens. Because of the above reasons, TB may be over-diagnosed in these children due to high frequency of symptoms and signs suggestive of TB that they may present with. However TB may also be missed due to atypical presentation, anergic TST and negative bacteriologic tests. In approaching diagnosis of TB in an HIV infected child, one should use the same approach as outlined above – microbiologic diagnosis, and /or clinical diagnosis by evaluating for suggestive symptoms, signs, radiology and positive TST. One must have a higher index of suspicion in these children. Treatment of Tuberculosis in the HIV infected Child Several factors must be considering when planning treatment of TB in the HIV infected child as follows:

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Child will require anti-TB drugs as well as antiretroviral drugs (6 drugs), consideration to timing of initiation of both therapies, and selection of drugs with consideration of drug interactions. Consideration of adverse effects of drugs Severely immuno-suppressed children may have severe forms of TB slower response to anti-TB therapy, therefore may require more aggressive therapy Timing of Initiation of Therapy Scenario A: TB develops in child not yet on ART In this scenario, anti-TB therapy should be initiated immediately the diagnosis of TB is made, in accordance with treatment guidelines as outlined earlier in this chapter. Antiretroviral therapy should be initiated soon after, within the next 2-8 weeks. This allows for initial containment of TB bacillary load as well as identification and management of any early adverse reactions during the first weeks of anti-TB therapy before introducing the ARV drugs. Scenario B: If child develops TB while on ART In this scenario, one must evaluate as follows: 1. Is this TB that was incubating at time of ART initiation, or immune reconstitution inflammatory syndrome (IRIS)? TB is likely if: TB develops < 6mths after ART initiation No other evidence of CD4 decline or clinical progression (Viral load remains controlled – if assay available) In this scenario, give standard anti-TB therapy, however, care should be taken to ensure that ARV drugs used are compatible with the anti-TB drugs. 2. Is this ARV treatment failure? This is likely if: TB develops > 6mths after ART initiation Evidence of CD4 decline or clinical progression (other stage 3-4 defining illness) (Viral load increase - where assay available) In this scenario, anti-TB therapy should be initiated, however ARV therapy should be re-evaluated by HIV specialist to identify reason for failure of ARV regimen, and plan how to proceed regarding the patients ART (meanwhile the patient should continue with their existing ART regimen alongside the anti-TB therapy) Selection of antiretroviral therapy regimen Rifampicin, an enzyme inducer, may induce rapid metabolism of non-nucleoside reverse transcriptase inhibitors (most affected is nevirapine) and most protease inhibitors (most affected is lopinavir). In general therefore, one should avoid combining rifampicin with nevirapine or with lopinavir. If these are the only drugs available, possible approaches include: increase the dose of nevirapine by 30% during the period of anti-TB therapy (monitor closely for NVP adverse effects), or boost lopinavir with additional ritonavir to achieve LPV: r in 1:1.

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Acceptable ART regimens for use with rifampicin: Two NRTI drugs + efavirenz (age above 3 years) Two NRTI drugs + ritonavir boosted lopinavir, with supplemental ritonavir to provide LPV: r at ratio of 1:1 Two NRTI drugs + nevirapine (age below 3 years where LPV/r + r option not feasible) Vitamin B6 supplementation: HIV infected children frequently are malnourished, and care should be taken to give them concurrent vitamin B 10mg once daily during the period they are on isoniazid, to reduce risk of neurotoxic adverse effects of INH. Prevention of Tuberculosis in Children Diagnosis of paediatric TB is difficult and treatment of diagnosed cases involves meticulous calculation of optimum doses and several months of follow-up. Treatment default and poor compliance are therefore major challenges in the treatment and control of TB. Prevention of infection is therefore the most realistic way to control the TB epidemic and should form the basis of all TB control programmes. Preventive measures take different forms: 1. Prevention of infection: Prevent contact with individuals likely to have sputum-positive pulmonary TB. Prompt diagnosis and treatment of suspected cases of pulmonary TB using appropriate combination therapy. Contact tracing and treatment. 2. Prevention of drug resistance: Promotion of the DOTS policy to avoid default and non-compliance Improve surveillance to detect multi-drug resistant (MDR) TB Ensure proper dosage calculation based on patient’s body weight 3. Reduce vulnerability of children to developing TB: Improve nutritional status of children BCG vaccination of all infants at birth (protects children from severe forms of TB) Isoniazid prophylactic therapy to children exposed to open TB especially HIV infected children, and children under five years. Prevention of mother-to-child HIV infection 4. Health education: Ensure that all people (especially community leaders) understand The epidemiological importance of TB The common symptoms and signs of TB The importance of completion of therapy

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REFERENCES

Global tuberculosis control - surveillance, planning, financing. WHO Report 2008. Geneva, World Health Organization. http://www.who.int/tb/publications/global_report/2008. Guidance for national tuberculosis programmes on the management of tuberculosis in children. WHO 2006. Geneva, World Health Organization. WHO/HTM/TB/2006.371. Jeena PM, Pillay P, Pillay T and Coovadia HM. Impact of HIV-1 co-infection on presentation and hospital related mortality in children with culture proved pulmonary tuberculosis in Durban, South Africa. Int J Tuberc Lung Dis 2002;6:672-678. Mukadi YD, Wiktor SZ, Coulibaly IM et al Impact of HIV infection on the development and clinical presentation and outcome of tuberculosis among children in Cote d’Ivoire. AIDS 1997;11:1151-1158. La Porte CJ, Colbers EP, Bertz R, Voncken DS, Wikstrom K, Boeree MJ, Koopmans PP, Hekster YA, Burger DM. Pharmacokinetics of adjusted-dose lopinavir-ritonavir combined with rifampin in healthy volunteers. Antimicrob Agents Chemother. 2004 May;48(5):1553-60. Madhi SA, Huebner RE, Doedens L, Aduc T, Wesley D, and Cooper PA. HIV-1 co-infection in children hospitalised with tuberculosis in South Africa. Int J Tuberc Lung Dis 2000:448-454. Niemi M, Backman JT, Fromm MF, Neuvonen PJ, Kivisto KT. Pharmacokinetic interactions with rifampicin: clinical relevance. Clin Pharmacokinet. 2003;42(9):819-50.

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CHAPTER 12

MALARIA IN CHILDREN

Amos Odiit, Sarah Kiguli, Samuel Ayaya, Esther D. Mwaikambo

INTRODUCTION It has been estimated that 90% of the African population live in malarious zones and malaria is a direct cause of approximately 12% of all deaths of African children below five years of age. Malaria is, therefore a threat to child survival and development. It is a major cause of foetal loss and low birth-weight (LBW) particularly in primiparous mothers. The risk of severe malaria is greatest during pregnancy, early puerperium, early childhood and in individuals where malaria coexists with other infections, stress or chronic diseases and in individuals with little or no immunity to malaria. Over the last 10 years, management of malaria has been bogged down by high resistance of P. Falciparum to choroquine, sulphadoxine-pyrimethamine. Currently, artemesinin containing combinations are recommended at Primary Health Care level. Protein energy malnutrition (PEM), anaemia and malaria often coexist and aggravate each other. The effect of malaria, starting from pregnancy (anaemia, LBW and abortion), infancy (anaemia and death) and young children can result in:- Sapping the energy and growth in children Poor education and stunted growth in children Low work output Reduced or slow economic development Therefore, control of malaria as an integral part of Primary Health Care (PHC) is very important for a health community OBJECTIVES At the end of this chapter, the student should be able to:- Explain the transmission of malaria Explain the epidemiology of malaria and measure the extent of the problem in your community Explain the pathophysiology of malaria in children including:- - The clinical features of uncomplicated and complicated malaria. - Diagnose uncomplicated and complicated malaria Enumerate complications of malaria in children Treat uncomplicated and severe attacks of malaria Identify and treat drug resistant malaria List methods of control and prevention of malaria

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LEARNING ACTIVITIES During your paediatric rotation, make a clinical diagnosis of malaria and confirm it by laboratory investigations During your paediatric rotation, note the number of children admitted with malaria and the major complications. During your community assignment, estimate the frequency of malaria in schools based on the frequency of anemia, hepato-splenomegaly and positive blood smear; During your community assignment, determine the availability and common use of antimalarial drugs. AETIOLOGY AND TRANSMISSION OF MALARIA Malaria is caused by protozoa of the genus plasmodium. The species which affect man are P.falciparum, P.vivax, P.malariae and P.ovale. P. falciparum is the most important cause of malaria in human beings. Transmission is from man to man by the following ways:- The bite of an infected female anopheles mosquito, commonly Anopheles gambiae and Anopheles fenestus Transplacental infection from an infected mother. Through blood transfusion Factors perpetuating malaria transmission i) A reservoir of parasites in human population from which the mosquitoes can pick the infection in form of Gametocytes. ii) Presence of mosquito breeding sties. Stagnant water bodies such as in pits, puddles, fishponds, edges of swamps and creeks. iii) Suitable climatic conditions such as the mosquito to survive and the parasite to develop within the mosquito. Warm moist conditions with relative humidity of 60% and mean daily temperature of 18oC. Methods Used to estimate Prevalence of Malaria: The following are methods used to estimate the prevalence of malaria in a community:- 1. Spleen Rate This method estimates the proportion of children in the age group two to ten years who have splenomegaly (see table 1 below) Table 1: WHO Classification of Malaria Endemicity Malarial Endemicity Spleen Rate

(in children 2-10 yrs of age) Spleen Rate (in adults)

Hypoendemic 0-10% Mesoendemic 11-50% Hyperendemic >50% >25% Holoendemic 75% Low The low adult spleen rates in holoendemic areas indicate considerable immunity acquired by intense exposure to perennial transmission.

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2. Parasite Rate This is a proportion of the population in which malaria parasites are found using blood films. 3. Parasite Count This can be reported as parasites against leucocyte count for exact amount of blood related to a count. (parasites/µl) PATHOGENESIS OF MALARIA Haemolysis and tissue ischaemia account for the majority of pathophysiological changes. The higher the parasite could worsen the prognosis. Release of interleukins from infected erythrocytes is responsible for clinical features such as fever. Infected erythrocytes become sticky and are coated with fibrin which causes agglutination and obstruction in small vessels, this leading to local hypoxia. In addition, the following disturbances may occur:- 1. Anaemia More severe with P.Falciparum because it invades red blood cells of all ages and frequently produces a high level of parasitaemia; Mechanisms of anaemia in malaria infection are:- direct lysis of red blood cells caused by dysfunction of Na+ Pump splenic removal of parasitized red blood cells; autoimmune destruction of infected and non infected coated erythrocytes; reduced incorporation of iron into bone; impaired erythropoiesis due to direct bone marrow suppression form malarial toxin; increased intramedullary destruction of red blood cell precursors and erythrocyte maturation arrest from folic acid and PABA deficiencies. 2. Hypoglycaemia Occurs due to depleted glycogen stores and competition for serum glucose by the parasite. Reduced food intake and the increased secretion of insulin in patients treated with quinine also contribute to hypoglycemia. There may also be use of traditional herbs that contribute to protracted hypoglycaemia. 3. Thrombocytopenia Can occur due to splenic sequestration and bone marrow depression 4. Hypergammaglobulinaemia, hypocholesterolaemia, hyperbilirubinaemia and raised transaminases do occur frequently due to fever and liver dysfunction. 5 Hepatomegaly is due to congestion from parasitized cells in sinusoids, and centrilobular veins and due swollen parenchymal and Kupffer cells; 6. Hyperkalemia and hyponatremia are seen in acute attacks of malaria. They are due to increased destruction of red blood cells and intravascular volume

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expansion occurring as a compensatory response to the vasodilatation caused by malaria toxins; 7. Acidosis can occur due to increased lactate and pyruvate production as the parasites use glucose; Splenomegaly occurs due to hyperplasia of reticuloendothelial system and vascular congestion. Tropical splenomegaly syndrome (TSS) occurs due to an abnormal immune response to persistent malarial antigen stimulation in an endemic region; 9. In the brain parasitized red blood cells are preferentially sequestrated in deep capillaries causing clogging and subsequent ischemic changes, congestion, oedema and central nervous system manifestations. Pulmonary oedema may complicate cerebral malaria, severe anaemia, high parasitaemia or be caused by fluid overload during management. CLINICAL FEATURES The clinical picture of malaria in children depends on child's age and immunity. The non-immune infants and children who contract malaria for the first time also have a variable clinical picture. They may present with restlessness, drowsiness, listlessness or refusal to feed. They may also have headache, nausea and pallor. A clear cut cold stage and rigor are uncommon. Vomiting can be severe causing dehydration and electrolyte imbalance. Fever is invariable, often continuous although it may also be irregular. Convulsions often occur. Signs of cerebral malaria include fever, impaired or loss of consciousness, convulsions, with normal cerebral-spinal findings. DIAGNOSIS OF MALARIA Definite diagnosis of malaria is made by establishing the presence of malaria parasites in the blood by examining a blood smear. However, due to delays in blood testing in developing countries, malaria should be suspected in all cases of fever in endemic areas. Proper history taking and physical examination is mandatory to differentiate malaria from other febrile conditions such as urinary tract infection, meningitis, tonsillitis, viral infection, etc. Some investigations (other than a blood smear) may be necessary in order to exclude the coexistence of other infections. A malaria negative blood slide does not exclude malaria infection. Diagnosis of malaria may also be made by detection of antibodies in the blood using the rapid diagnostic tests (RDT's). Since malarial antibodies persist in the blood of the patient after the infection, these tests are therefore only useful for surveys or research work and in subjects in whom parasites are difficult to find. Counting Malaria Parasites in a blood film using parasite per micro litre method Counting malaria parasites reflects the degree of parasitaemia, which in turn is related to prognosis. A thick blood film is made and examined under the oil objective of a microscope. Two hundred leucocytes are counted using a tally counter. At the same time using a separate tally counter, the number of malaria parasites in the fields is counted. When

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10 malaria parasites or more are counted in the fields where 200 leucocyte have been counted, then the result is rerecorded showing parasites per 200 leucocytes. If after counting 200 leucocytes 9 or less parasites are counted, counting is continued until 500 leucocytes. Parasites are recorded per 500 leucocytes. Parasite count is then converted to parasites per micro litre using the mathematical formula below: Number of parasites x 8000 = Parasites per micro litre Number of leucocytes COMPLICATIONS OF MALARIA A. Falciparum Malaria The high invasive power of P.Falciparum leads to the rapid destruction of erythrocytes and the resulting anaemia can be very severe. Infections in which five to twenty percent of red blood cells contain parasites are uncommon. The progressive destruction of red blood cells leads to anaemia. Micro thrombi thrombi are formed by parasitized red blood cells leading to local anoxia of various organs. The resulting changes in the various organs e.g. the brain, liver, kidney, bone marrow, lungs, etc. are responsible for complications. The complications can be very severe in those with low immunity. Severe infections occur in endemic regions, most commonly between the ages of six months to three years and are responsible for almost all the deaths directly attributable to malaria in these areas. These severe attacks can develop with great suddenness and manifest themselves as:- Hyperparasitaemia: The density of the asexual forms in the peripheral blood exceeds 5% of the red blood cells or parasites per micro litre Cerebral malaria; Gastrointestinal malaria with diarrhoea and vomiting; Hyperpyrexia; (T > 39o rectally) Severe anaemia (packed cell volume of less than 20%); Algid malaria which presents as peripheral vascular collapse due to adrenal failure; may have concurrent gram negative septicaemia Black water fever (massive intravascular haemolysis leading to haemoglobinuria) Acute Renal Failure (usually acute tubular necrosis due to presence of sequestrated infected red blood cells in the renal tubules and hypovolaemia). Disseminated intravascular coagulopathy (DIC) due to consumptive coagulopathy; Metabolic acidosis resulting from anaerobic tissue respiration, dehydration and renal failure; Hypoglycaemia due to starvation from anorexia, vomiting, and use of quinine and also due to competition for serum glucose by malaria parasites. Pulmonary Oedema due to sequestration of parasitized red blood cells in the lungs and from heart failure and IV fluid overload. B. Vivax, Quartan and Ovale Malaria Complications of acute attacks of vivax, quartan or ovale malaria are relatively uncommon but the infection may undermine the general condition of the growing child and aggravate other intercurrent diseases. High temperature seldom persists. Cerebral and intestinal symptoms are rare, but nephrotic syndrome is a complication often seen with chronic plasmodium malariae.

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Vivax and Ovale malaria may be associated with relapses. This is due to some of the circulating parasites (merozoites) returning to the liver and remaining dormant until a later date when the immunity wanes and re-seeding of the blood occurs. TREATMENT OF MALARIA A. Treatment of malaria in infants and children poses special problems because of the following reasons:- Acute attacks of malaria are more severe than in adults; Vomiting is common and reduces the treatment options as oral medication may not be possible; Cerebral malaria is more common than in adults; Gastrointestinal complication presenting with diarrhea and vomiting can cause severe dehydration; Anaemia may be severe enough to require blood transfusion; Compliance with medications can be poor because children cannot be made to understand its importance, therefore, parent' health education and their cooperation re absolutely vital in the treatment of malaria. Except in case of drug-resistance, quick acting schizonticides are more preferable than slow acting ones in the treatment of acute attacks of malaria. Treatment of simple versus complicated infection will be discussed separately thus:- Guidelines for treatment of uncomplicated malaria The recommended first line treatment for malaria treatment is Artemesinin – based combination therapies (ACT). There are different ACT formulations in the market. Artemether (20mg)/Lumefantrine (120mg) is one such combination recommended by the World Health Organization (WHO). For dosage, see table below:

Wt Category (kg) Age Day 1 Day 2 Day 3 5-14 4mo-

3years 1tab, 12 hourly

1tab, 12 hourly

1tab, 12 hourly

15-24 3yrs-7yrs 2tabs, 12 hourly

2tabs, 12 hourly

2tabs, 12 hourly

25-34 7yrs-12yrs 3tabs, 12 hourly

3tabs, 12 hourly

3tabs, 12 hourly

>34 ≥ 12yrs 4tabs hourly 4tabs, 12 hourly

4tabs, 12 hourly

Other ACT combinations available in the market are: Artesunate + Amodiaquine: a three day course Artesunate + Sulfadoxine/pyrimethamin. This regimen is given as separate tablets, not co-formulated Artesunate + Mefloquine.

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A combination of amodiaquine and sulfadoxine/pyrimethamine is also used in some areas. Second line antimalarial treatment Oral quinine is the recommended second line malaria drug. Indications or reasons for choosing second line antimalarial drug include: Failed first line antimalarial treatment ii) First line drug contraindicated in the particular patient. in infants <3 months of age or whose weight is <5kg Treatment of complicated malaria (severe) P. Falciparum infection can cause a medical emergency of the first order especially when over 5% of the red blood cells are infected. These patients may present with convulsions, stupor, copious vomiting and diarrhea, anaemia, acute abdominal crisis or acute renal failure. For these types of patients speed is absolutely vital in order to save them. Therefore, quinine which has a more rapid schizonticidal action than other schizonticidal drugs is the drug of first choice. It is given intravenously at a dose of 20mg/kg of body weight for first dose diluted in 10mls/kg of 0.45% sodium chloride in 5% glucose and then 10mg per kg every eight hours until the patient is well enough to take oral medications. Quinine intravenous infusion should be run slowly over 4 hours to avoid cardio-vascular complications including cardiac arrest. Intravenous quinine is associated with hypoglycaemia due to stimulation of insulin and should be given in a dextrose solution. Oral quinine 10mg kg every eight hours should then be administered to make up to seven days of quinine therapy. In addition to the correction of anaemia, hypoglycaemia, water and electrolyte imbalance if they exist should be corrected. Supportive treatment in severe malaria Hyperpyrexia (axillary temp ≥ 38.5oC) Paracetamol 15mg/kg every 6-8hours Tepid sponging Dress lightly Severe anaemia (Hb ≤ 5g/dl) Blood transfusion 20mls/kg of whole blood or 10mls/kg of packed red blood cells Congestive heart failure Oxygen Iv furosemide 1.0 -1.5 mg/kg Correct severe anaemia (blood transfusions) Dehydration & Electrolyte imbalance from vomiting, anorexia IV Normal saline, Ringer's lactate or Darrow's 1/2 strength Darrow's solution. 20mls/kg over 30 min. Total amount of iv fluid and rate of infusion depends on the level of dehydration. OR If facilities for iv drip are not available, give deep iv quinine 10mgs salt/kg before referral.

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For intramuscular quinine, the quinine should be diluted in normal saline to concentration of 100mg salt/ml. The intramuscular site should be in the antero lateral thigh region. OR Intramuscular Artesunate 2.4mg/kg loading dose, followed by iv. 1.2mg/kg at 12 and 24 hours, then 1.2mg/kg daily or 6 days. OR Intramuscular Artemether 3.2mg/kg (loading dose) followed by 1.6 mg/kg daily for 6 days. When the patient is able to swallow, the daily dose can be given orally. Artemesinin Suppositories: 40mg/kg, loading dose intra rectally, then 20mg/kg given 24, 48, & 72 hours later, followed by oral first line drug. MALARIA DRUG RESISTANCE Malaria drug resistance is defined as the ability of a strain of a malaria parasite to survive and multiply inspite of an antimalarial drug in usual or even higher than usual does. Drug resistance (R) is divided into three types depending on its severity viz:- RI drug resistance with recrudescence. Parasites reappear in blood within fourteen days following initial clearing of symptoms and parasites; RII drug resistance with low parasitaemia which never clear completely; RIII drug resistance with persistently high parasitaemia for twenty-eight days. There should be no re-infection and the drug given should be well tolerated. Clinically, drug resistance should be suspected when there is:- Persistence of fever and no improvement forty-eight hours after starting drug treatment; Poor laboratory response to the antimalarial treatment when blood test is done daily as treatment proceeds. MALARIA CONTROL The World Health Organization (WHO) has defined levels of malaria control interventions (Tactical variants) with ultimate aim of malaria eradication. Malaria control is also part of Primary Health Care since 1978. Tactical Variant I Aims at reducing and preventing both mortality and morbidity due to malaria using antimalarial drugs. Essential drug programme should therefore be encouraged for efficient distribution of antimalarial drugs to the acutely ill patients.

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Tactical Variant II Aims at reducing and preventing both mortality and morbidity due to malaria. This calls for antimalarial drugs for both curative and chemo prophylaxes for the high risk vulnerable groups with include: The non-immune immigrants; The pregnant women Under-fives with special problems, e.g., sickle cell anaemia Tactical Variant III This objective is to prevent mortality and reduce malaria prevalence and morbidity. It adds the reduction of man-vector contact to tactical variant II. Tactical Variant IV Aims at achieving countrywide malaria control. It is concerned with surveillance after malaria control has been achieved and ensures that resurgence does not occur. The long term aim is eradication of malaria. Drugs Used for Chemoprophylaxis The drugs used for prophylaxis against malaria include: Proguanil, chloroquine, sulphadoxine-pyrimethamine, mefloquine. Resistance to chloroquine is very high and therefore this drug can no longer be used alone as a casual prophylaxis. Sulphadoxine- pyrimethamine is used as chemoprophylaxis during pregnancy (second and third trimester only) and is known to have reduced the incidence of low birth weight. Problems Associate with Chemoprophylaxis 1. Due to drug resistance it is not certain which prophylactic (single or combination) is best for non immune immigrants and pregnant women whose choices are rather limited; 2. For under-fives, chloroquine chemoprophylaxis is not advised except in those with special problems, e.g. Sickle cell anaemia because: It is not easy to achieve continuous suppression in a significant proportion of those children. It might interfere with their development of acquired protective immunity; It may accelerate the development of drug resistance; It uses scarce resources that could have been better used for better treatment Problems of Vector Control Resistance of vector to most insecticides Technical problems to cover all the endemic areas Expensive mosquito nets and repellants A large mosquito breeding habitat (swamps) Human activity interfering with environment

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IMMUNITY AND VACCINE DEVELOPMENT Immunity to malaria parasites can be natural or acquired. Natural Immunity Genetic Immunity is seen in: Some black communities due to some form of natural selection, e.g., Duffy blood groups and P.vivax infection. Population with long exposure to P.Falciparum is probably due to natural section. However, there is no evidence of absolute natural immunity of man to human malarial parasites. There has been a degree of relative resistance to infection with P.Falciparum in patients with Glucose-6-phosphate dehydrogenase deficiency and in children with sickle cell trait (HBAS) or other hemoglobinopathies. Natural immunity can be reduced by splenectomy. Acquired Immunity Immunity is due to stimulation of combined humoral and cellular (phagocytic) protective mechanisms by previous infections. There is also transient acquired passive immunity from the mother to child, mainly through the placenta and breast milk, but does not go beyond six to nine months of age. The period between passive acquired and actively acquired immunity to malaria accounts for the child's most dangerous malaria infections in endemic areas. Malaria antibodies in the blood neutralize the toxin of the parasite or interfere with its multiplication. However, the immunity is strain specific. Acquired immunity of high degree is associated with a high level of gamma-globulins in plasma, (IgG, IgM). Vaccines The mechanism for the protective role of antimalarial vaccine is poorly understood but there is evidence that humoral (IgG and IgM), cell mediated responses (T-cells) and non-specific responses (e.g., killer cells) are involved. Efforts to produce useful vaccines to the malaria parasites are still in progress and there are prospects that a broad-spectrum vaccine (which is effective against all antigens) will be available before long. SPF 66 - This is the malaria vaccine designed and produced by Prof. Manual Patarroyo in Bogota, Colombia. SPF 66 is a synthetic peptide consisting of amino acid sequences derived from three sexual stage proteins and derived from the circumsporozoite protein of plasmodium falciparum. This vaccine was initially received with skepticism after initial clinical testing showed some success. Clinical tests done in Tanzania and the Gambia showed variable results. The Tanzania study showed a clinical efficacy of 30-60%, while studies in the Gambia, done in children under 1 year, showed no protection at all. However, this study was one over a short period of time in a low malaria endemicity season.

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REFERENCES Jellife D.B. and Stanfield J.P. (eds) Malaria in: Diseases of Children in the Sub-tropics and Tropics 3rd ed. The English Language Book Society and Edward Arnold (Publishers) Limited 1982, 827 -856. Morley, D. (ed): Malarial in Children. Paediatrics Priorities in Developing World. The English Language Book Society ad Butterworths, London 1980: 248-256. Malaria Control Programme, Ministry of Health, Uganda: Management of Uncomplicated Malaria, A practical guide for Health Workers, 3rd ed, Kampala, 2005: 11-40. Wilcokes, C. and Manson-Bahr P.E.C (eds): Manson's Tropical Diseases. The English Language Book /Society and Bailliere Tindal, London, 17th Edition, 1976: 39 -86. Parry E.H. O (ed): Communicable Diseases. Principles of Medicine in Africa. Oxford University Press, Nairobi, Ibadan, 1976: 209-217. Hendrickse R.G. Barr DGD, Mathews (eds) Malaria in: Paediatrics in the Tropics. 1st ed, Blackwell scientific publications. 1991, 695-710. Genton B, Smith T, Bae K, Narara A, et al, Malaria: how useful are clinical criteria for improving the diagnosis in a highly endemic area, Trans Roy Soc Trop Med and Hyg. (1994) 88, 537-541. World Health Organization, Communicable disease cluster Department of prevention, Eradication Social Mobilization and Training Unit: Diagnosis and Management of Severe Falciparum Malaria, Uganda adaptation 2002. Cox M.J. Kun D.E., Tavul L, Narfara A, et al: Dynamics of malaria parasitaemia associated with febrile illness in children from a rural area of Mandary, Papua New Guinea. Trans Roy Soc Trop Med and Hyg. (1994) 88, 191-197. Brenan J.G. Campbell C.C. Combating Severe Malaria in African Children. Bull WHO 66 (5) 1988) 611-620. Greenwood A.M, Armstrong R.M. Byass P, Snow R.W., Greenwood B.M: Malaria Chemoprophylaxis, Birth Weight and Child Survival Trans Roy Soc trop Med & Hyg. (1992) 86, 483-485. Payne D. Use and Limitation of Light Microscopy for Diagnosing Malaria at the Primary health Care Level. Bull. WHO 1988 66 (5) 621-626. Malaria Diagnosis: Memorandum from WHO meeting. Bull. WHO (1988) 66 (5) 575-594. Hendrickse R.G, Adeniyi A: Quartan Malarial Nephrotic Syndrome in Children. Kidney-Int 1979 July, 16 (1); 64-74.

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CHAPTER 13

HIV INFECTION AND AIDS IN CHILDREN

Gabriel Anabwani, Israel Kalyesubula, Ruth Nduati, Catherine Chunda, Elizabeth Maleche-Obimbo

INTRODUCTION The term AIDS stands for Acquired Immune deficiency Syndrome. The first case was reported in 1981 in the US among men who have sex with men. Uganda was the first African country to report a case of AIDS in 1982. Between 1982 and 1986, AIDS cases were identified in many other eastern and southern African countries. Since then HIV/AIDS has rapidly evolved into a global pandemic. UNAIDS estimated that by the end of 2006 there were about 40 million people living with HIV/AIDS globally. Within Sub-Saharan Africa (SSA), southern Africa is the worst affected region. HIV infection has increases child mortality and essentially wiped the gains made in promotion of the child survival packages. OBJECTIVES At the end of this chapter the student should be able to: Describe the epidemiology of HIV/AIDS Describe the modes of transmission of HIV/AIDS in children Outline principles of HIV/AIDS prevention and control The 4 pillars of prevention of mother-to-child transmission of HIV The role of male circumcision in HIV prevention Other modes of HIV prevention in children Describe the natural history of HIV infections Describe the diagnosis and staging of HIV in children Laboratory diagnosis Early infant diagnosis Provider initiated testing Clinical and immunological staging Describe the management of HIV and its complications The role of co-trimoxazole therapy Isoniazid preventive therapy Immunization Nutrition Treatment of OIs and other conditions Antiretroviral therapy Monitoring of ART Psychosocial care and support Learning activities Visit an antenatal clinic and talk with staff on how mothers are counselled on being tested for HIV

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Does a role play to mimic testing and counselling in a clinic During your obstetric rotation make sure you participate in the care of a mother with HIV infection Participate in the care of an HIV infected child Explore how the community cares for an HIV infected family THE EPIDEMIOLOGY OF HIV AND AIDS The prevalence of paediatric AIDS is a direct reflection of the prevalence of HIV infection in women of child bearing age. In sub-Saharan Africa, women represented 57% of all people living with HIV/AIDS. In eastern and southern Africa the prevalence of HIV infection among pregnant women ranges from 6 to 40% in most countries although in some regions in southern Africa prevalence rates exceed 50%. The magnitude of the problem is shown in table 1. Without intervention, 30-40% of HIV infected women will transmit the infection to their babies. The risk of transmission is highest in women with high viral loads and in those with advanced disease. Mother-to-child transmission of HIV can take place during pregnancy, at the time of delivery and during breastfeeding. The estimated absolute transmission risk without intervention as follows: 10% during pregnancy, 10-20% during delivery, and 10-20% during breastfeeding. With the use of antiretroviral drugs HIV transmission can be reduced to as low as 1% in non-breastfeeding populations and to as low as 5-6% in breastfeeding populations. Table 1: Estimated HIV Magnitude in Children aged <15 years in 2007

Number of Children < 15

Global Sub-Saharan Africa

Living with HIV 2.0 million 1.8 million Newly infected with HIV

370,000 330,000

Dying of HIV/AIDS 270,000 240,000 Without interventions HIV-1 infected children have a nine-fold increased risk of dying in the first two years of life compared to non-infected children. If the mother dies, regardless on the HIV infection status there is a 3-8 fold increased risk of death. The ultimate goal for PMCT is to have HIV-free survival and therefore the strategies for PMCT are geared towards preventing HIV transmission from mother-to-child and promoting the survival of the mother and child. There is evidence that sexually transmitted diseases (STDs) enhance the transmission and acquisition of HIV. Recent evidence suggests that the key driver of the HIV epidemic in Africa is the combination of the low prevalence of male circumcision and high prevalence of multiple concurrent sex partner.

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MODES OF TRANSMISSION There are three main modes of transmission: Mother to child transmission (MTCT) or vertical transmission Contact with infected blood or blood products Sexual contact or horizontal transmission More than 90% of paediatric HIV infections are acquired through mother to child route. Contact with blood or blood products may result in HIV infection through use of unsterilized syringes and instruments, scarifications and transfusion with contaminated blood or blood products. Sexual exposure especially in adolescents, sexual abuse (rape and defilement both male and female), early marriage, prostitution and multiple concurrent sex partners all increase the risk of sexual acquisition of HIV. PRINCIPLES OF HIV/AIDS PREVENTION AND CONTROL The 4 pillars of prevention of mother-to-child transmission of HIV The role of male circumcision in HIV prevention Other modes of HIV prevention in children The “Four Pillars” of prevention of mother-to-child transmission of HIV In populations affected by HIV the four pillars that are key promoting HIV-free survival of children include: Primary prevention of HIV in young people Prevention (voluntary) of unwanted pregnancies in HIV infected women Care and support of the HIV-infected woman Promotion of the survival of the mother and other family members. Primary prevention aims at prevention of HIV in young un-infected people. Strategies to achieve this include the ABC strategy i.e. Abstain from sex, if not be faithful to your partner and use a condom correctly all the time. Knowing one’s HIV status and that of one’s partner; treating STDs and avoiding of intergenerational sex are important in achieving primary prevention. Parents and caregivers can play an important role in helping young people achieve primary prevention. Parental roles include: providing the adolescence with a sense of being loved; respecting them as individuals; behaviour control by setting limits; provision and protection; and modelling appropriate behaviour for them. Current evidence shows that male circumcision can reduce the risk of transmission by at least 60%. This is augmented by avoidance of multiple concurrent sexual partners. Voluntary prevention of unwanted pregnancies may be achieved through engaging in less risk sexual behaviour; integrating counselling and testing in family planning services; and through the use of effective family planning methods. The third pillar involves the care and support of the HIV-infected woman during pregnancy and lactation. The three most effective interventions with respect to preventing transmission are HIV testing, provision of effective antiretroviral prophylaxis and treatment and modification of infant feeding. HIV testing should be offered routinely to all pregnant women in the antenatal clinics and maternity. Antiretroviral prophylaxis should start early (28 weeks or earlier) and consist of at least AZT with single dose NVP

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being used for those who present only in labour. At birth, all exposed infants should be offered single dose NVP plus AZT for four weeks regardless of whether the mother received prophylaxis. Mothers who meet treatment criteria should be commenced on HAART as soon as possible. For further details refer to the latest WHO guidance on antiretroviral drugs for treating pregnant women and preventing infection in infants. Breastfed infant are at risk of HIV and this risk increases with the duration of breastfeeding. Replacement feeding is the best way to prevent infection in such babies. HAART in breastfeeding mothers significantly reduces the risk of transmission through breastfeeding. When either HAART or replacement feeding are not possible, exclusive breastfeeding offers the next best option for the survival of HIV exposed infants. Animal proteins are required in complementary foods of non-breastfed babies in order to meet their nutritional requirement. The fourth pillar is to do with the survival of the family unit, that is, the mother, child and other family members. For the woman this includes prevention and treatment of opportunistic infections (co-trimoxazole and INH prophylaxis), psychosocial and nutritional support, family planning and provisional ART if eligible. For the infant, the essential package includes adequate nutrition, immunization, routine de-worming, growth and development monitoring, treatment of acute infections, provision of multivitamin and micronutrient supplementation, co-trimoxazole prophylaxis, early infant diagnosis and provision of ART if eligible. For all other members of the family, HIV testing and where appropriate OI prophylaxis and ART treatment should be instituted. For successful HIV prevention in children, universal PMTCT coverage is essential. For children surviving rape, defilement or needle-stick or sharps injuries, post-exposure prophylaxis should be offered immediately without waiting completion of police formalities. Male children should be offered safe circumcision before they reach puberty. THE PATHOPHYSIOLOGY AND NATURAL HISTORY OF HIV INFECTIONS HIV is retrovirus of the lentiviridae group. Several retroviruses have been described as infections of various animal species (goats, sheep, cats and non-human primates). These viruses characteristically are immunosuppressive or oncogenic. These viruses are called retroviruses because they have the ability to make a DNA template from a RNA strand. Three retroviruses have been documented to cause disease in man. HTLV-1 causes T-cell leukaemia and Tropical spinal paralysis while HIV-1 and HIV-2 cause AIDS. The virus is made of a RNA core surrounded by a glycoprotein (gp) envelope that has several important components - gp 160, gp 120 and gp 41 - that facilitate the attachment of the virus to the target cells. The virus has a predilection to immune competent cells that contain the CD4++ receptor such as T4 cell tissue macrophages, dendritic cells in the brain and Langerhan’s cells. Once the virus enters the cells it makes the DNA template which them attaches and integrates into the cell genome. Thus the cell is infected for life.

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Figure 1: Structure of human immunodeficiency virus

HIV like other viruses is easily destroyed by boiling, steaming or direct sunlight. Due to its lipid containing envelope pf, the virus can be destroyed by various chemicals such as hypochlorite (household JIK), glutaldehyde and formaldehyde as well as alcohols, acetone, phenols and several detergents. HIV infected individuals develop antibodies initially to the envelope proteins and eventually the core proteins. Detection of these antibodies is the basis of HIV ELISA (enzyme linked immuno absorbent assay) The HIV virus progressively destroys CD4+ cells until immune deficiency develops. The natural disease course appears to follow two broad patterns in children – ‘rapid progressors’ and ‘slow progressors’. Rapid progressors experience rapid progression to AIDS and death within 6-24 months and this pattern tends to occur among children infected in utero or around birth at a time when their immune system was very immature. These children often present with an array of clinical characteristics including wasting, pneumocystis carini (jiroveci) pneumonia, sepsis, hepatosplenomegaly and a rapidly progressive CNS disease. Slow progressors tend to survive beyond 2 years, and some may progress slowly beyond 5-10 years before developing AIDS. This tends to be the course of disease among children infected after birth through breastfeeding, at a time when their immune system was slightly more mature. Studies among African children show about 50% of HIV infected children die before 2 years, 75% die by age 5 years, and only 25% survive beyond age 5 years. This mortality is higher than that seen among HIV infected children in industrialised countries likely because the higher prevalence of other causes of morbidity and mortality in the African setting – including malnutrition, infectious diseases and poor access to health care. Therefore, early diagnosis and appropriate treatment are critically important. Infection with HIV-2 which is found more commonly in West Africa progresses much more slowly than infection with HIV-1.

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THE DIAGNOSIS AND STAGING OF HIV IN CHILDREN Laboratory testing The mainstay of HIV diagnosis is the HIV ELISA antibody test. This assay is cheap and relatively easy to perform. One can use a rapid test consisting of (a) Determine-screening test (b) Stat Pak as a confirmatory test and (c) Unigold as a tie-breaker in case of discordance. This is a reliable test and enables the patients to get their test results within fifteen to twenty minutes. However, in young children (<18 months) whom may have acquired HIV antibodies from their mothers, this method is not accurate. In such children the more expensive but accurate DNA PCR is required to confirm the diagnosis. This test removes the DNA (sometime RNA) from mononuclear cells and amplifies sequences of genetic material which match the HIV virus and then tests for the genetic material. It is currently the most accurate and sensitive method of diagnosing HIV infection in young children. Although it is relatively expensive and requires stringent laboratory conditions, costs have been declining and it is becoming more widely accessible in developing country settings. Early infant diagnosis Definitive early infant diagnosis using Dry Blood Spot (DBS) can be achieved by collecting blood on filter paper and sending it to a designated reference laboratory for testing. In HIV exposed infants, DBS should be collected during the first postnatal visit at 6 weeks or at first contact. Provider initiated testing All children presenting for sick child services should be offered HIV testing as part of their care. Children of adults diagnosed with HIV or tuberculosis also should be screened for HIV infection status. CLINICAL AND IMMUNOLOGICAL STAGING Clinical Staging Clinical WHO HIV staging can help in diving infected children into those with no or mild symptoms (WHO Stages I and II) and those with moderate or severe disease (WHO Stages III and IV). This staging (see table 2) helps identify children who need immediate antiretroviral therapy. TABLE 2: WORLD HEALTH ORGANISATION CLINICAL STAGING OF HIV DISEASE IN CHILDREN UNDER 12 YEARS WITH ESTABLISHED HIV INFECTION

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CLINICAL STAGE I (ASYMPTOMATIC) Asymptomatic Persistent generalized lymphadenopathy CLINICAL STAGE II (MILD) Unexplained persistent hepatosplenomegaly Papular pruritic eruptions Fungal nail infections Angular chelitis Lineal gingival erythema Extensive skin warts (papilloma virus or molluscum contagiosum) Recurrent oral ulcers Unexplained persistent parotid enlargement Herpes zoster Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsilitis) CLINICAL STAGE III (MODERATE) Unexplained moderate malnutrition or wasting not adequately responding to standard therapy Unexplained persistent diarrhoea (14 days or more) Unexplained persistent fever (above 37.60C, intermittent or constant, for longer than 1month) Persistent oral candidiasis (after first 6-8 weeks of life) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis or periodontitis Lymph node tuberculosis Pulmonary tuberculosis Severe recurrent bacterial pneumonia Symptomatic lymphoid interstitial pneumonitis Chronic HIV-associated lung disease including bronchiectasis Unexplained Anaemia (<8g/dl), neutropenia (<500/mm3) or thrombocytopenia (<50,000/ mm3) for more than 1 month CLINICAL STAGE 4 (SEVERE) Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy Pneumocystis pneumonia Recurrent severe bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia ) Chronic Herpes simplex infection (orolabial or cutaneous of more 1 month duration, or visceral at any site) Extrapulmonary tuberculosis

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Kaposi's sarcoma Oesophageal candidiasis (or candida of trachea, bronchi or lungs) Cytomegalovirus infection; retinitis or CMV infection affecting another organ, with onset after age 1 month Central nervous system toxoplasmosis (including meningitis) Disseminated endemic mycosis (extrapulmonary histoplasmosis, coccidiomycosis) Chronic cryptosporidiosis (with diarrhoea) Chronic isosoporiasis Disseminated non-tuberculous mycobacteria infection Cerebral or B cell non-Hodgkin lymphoma HIV encephalopathy Progressive multifocal leukoencephalopathy HIV-associated cardiomyopathy or nephropathy Presumptive HIV Diagnosis In order to avoid delays in starting antiretroviral therapy due to lack of laboratory confirmation, a presumptive diagnosis of HIV should be made if an exposed infant presents with any stage III or IV conditions. Infants who are started on ART this should have their diagnosis confirmed at the earliest opportunity. Immunologic Staging To identify children needing immediate ART the WHO has developed a system of classifying the level of immune deficiency for HIV infected children using their absolute CD4+ count or CD4+ percentage (Table 3). CD4+% = (absolute CD4+ count per mm3/ total lymphocyte count per mm3) x 100. Children with absolute CD4+ count or with CD4+% below that indicated in the table 3 are defined as having severe immuno-deficiency (severely immuno-suppressed). Table 3: age-specific CD4+ Criteria for Severe HIV Immune Deficiency Immunologic Category Age-specific CD4+ Criteria for Severe Immuno-

deficiency < 18 months 18mo - 5 years 5 – 12 years

CD4+% < 25% < 20% < 15% CD4+ count cells/mm3 < 1500 < 750 < 350 Treatment of Opportunistic Infections and Conditions (OIs) OIs are infections or conditions which occur as a result of poor immunity or which become more severe because of poor immunity. The causative agents may be normal flora or cause mild illnesses in children with normal immune systems. Common causative agents include mycobacteria tuberculosis, pneumococci, candida albicans and human papilloma virus type 8. Treatment of OIs is the same as in HIV negative children. However, in some children treatment may be prolonged.

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MANAGEMENT OF HIV AND ITS COMPLICATION Co-trimoxazole therapy Prophylaxis against PCP especially in infants is associated with reduced mortality. All infants should be started on prophylaxis until they are proven to be uninfected. Generally this is started at six weeks to coincide with the first immunization. Isoniazid preventive therapy Preventing TB in children less than 5 years who are in household contact with an adult with Tb is important. But before prophylaxis exclude active disease in the child. Antiretroviral Therapy for HIV infected Children The goal of Antiretroviral Therapy is to improve the quality of life and ensure normal growth and development through the following: Achieving complete viral suppression Restoring the immune system Preventing OIs To achieve these goals it is necessary to use highly active antiretroviral therapy (HAART), that is, a combination of a least three drugs which interrupt replication at two or more sites in the viral replicative cycle.

RT

Provirus

ProteinsRNA

RNA

DNA

DNA

RT

Viral protease

Reversetranscriptase

Viral integrase

RNA

RNA

Binding, fusionand entry

DNA

ARV action sites

Several classes of antiretroviral drugs are currently in use (Table 4). However, some of the newer classes of drugs may not be widely available. Commonly used ARVs in

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resource restricted countries include reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors and protease inhibitors. Reverse Transcriptase Inhibitors (RTIs) inhibit the viral reverse transcriptase enzyme (RT) thus preventing the virus from making DNA copies of its own RNA, an essential step in viral replication. They include zidovudine (AZT), lamivudine (3TC), abacavir (ABC) didanosine (ddI) and stavudine (d4T). Non-nucleoside Reverse Transcriptase Inhibitors (NNRTIs) bind directly to the RT enzyme thereby blocking its activity. They include nevirapine (NVP) and efavirenz (EFV). Protease Inhibitors (PIs) inhibit the protease enzyme thereby preventing protein cleavage and assembly in the last stages of new virus production in the CD4+ cell. This class of drug is usually reserved for second line ARV regimens. PIs include ritonavir, lopinavir, nelfinavir and indinavir. Table 4: Classes of Antiretroviral Drugs Class of ARV Drug Name of Drug Use in children < 12

years Nucleoside RTI (NRTI) Nucleotide RTI (NtRTI)

Zidovudine (ZDV or AZT) Stavudine (d4T) Lamivudine (3TC) Didanosine (ddI) Abacavir (ABC) Emtricitabine (FTC) Tenofovir (TDF)

Yes Yes Yes Yes Yes No* Selected

Non-Nucleoside RTI (NNRTI)

Nevirapine (NVP) Efavirenz (EFV)

Yes Yes

Protease Inhibitor (PI)

Nelfinavir (NFV) Lopinavir/ritonavir (LPV/r) Indinavir (IDV) Saquinavir (SQV) Ritonavir (RTV) Atazanavir (ATV)

Yes Yes Selected Selected Selected No*

*May be used in adolescents. When to Initiate ART in Children The medical criteria for starting ART in children vary according to the age of the child. It is now generally agreed that all children below 1 year of age with a confirmed HIV positive test must be put on antiretroviral drugs regardless of their immune status and those identified after one year of age should be evaluated and put on treatment when they fulfill the treatment criteria (Table 5).

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Table 5: Criteria to Start ART in Children Age Infants <

12 months 12 – 35 months

36 – 59 months

5 years and over

CD4+ % All infants require ART

< 25% < 20% < 15% Absolute CD4+ Count

< 750 < 500 < 350

WHO Clinical Stage 3 or 4 3 or 4 3 or 4 Preparing a Child for ART Medical Preparation: Do the following baseline tests to check bone marrow, liver and kidney function: Full blood count (resources limited, do Hb) Liver function tests (resources limited, do alanine transaminase or ALT) Renal function tests (resources limited, do serum creatinine) Do baseline CD4+ if possible and where indicated Investigate for TB** if TB is confirmed, treat TB before initiating ARVs Treat any inter-current illnesses Nutritional counselling and supplementation where indicated Counselling Preparation: Counsel the parent/guardian on the following: Up to three adherence counselling sessions may be necessary, however, if the caregiver has another child or she/he herself/himself on ARVs this may not be necessary. Caregivers must be counselled on when and how to administer the drugs, possible adverse effects of the drugs and how to recognize them, and should be encouraged to bring the child on treatment back to clinic if they have concerns or if the child becomes ill. Care should be taken not to overload caregivers in one session as successful counselling is a continuing process and not an event. Table 6: First Line Antiretroviral Therapy Child Characteristics

Recommended Regimen

Child previously NOT exposed to nevirapine for prevention of mother-to-child HIV transmission Age below 3 years or weight < 10kg

zidovudine (AZT)* + lamivudine (3TC) + nevirapine** (NVP) or abacavir (ABC) or stavudine (d4T)

Age above 3 years and weight > 10kg

zidovudine (AZT)* + lamivudine (3TC) + nevirapine** (NVP) or abacavir (ABC) or efavirenz (EFV) or stavudine (d4T)

Child previously exposed to nevirapine (stat NVP for PMCT or breastfeeding while mother on NVP-based ART) All ages zidovudine (AZT)* + lamivudine (3TC) + lopinavir/ritonavir

or abacavir (ABC) (LPV/r) or stavudine (d4T)

*In cases of severe anaemia (Hb < 7g/dl) or neutropenia substitute d4T for AZT

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Immune Reconstitution Inflammatory Syndrome Within weeks of starting HAART some patients may develop an acute inflammatory syndrome that can be quite debilitating. These are severely immune depressed patients in whom CD4+ cell recovery occurs rapidly. The ensuing inflammatory process as the immune system responds to previously quiescent infection (e.g. TB or PCP) is called immune reconstitution inflammatory syndrome (IRIS). Management of IRIS includes identifying the underlying disease process and use of steroids may be required to control symptoms. Patients developing IRIS or IRIS-like symptoms should be referred for specialist care. Follow up and monitoring The frequency of visits, and clinical and laboratory monitoring that should be performed during each visit is indicated below: Table 7: Follow-up schedule monitoring schedule for patients on antiretroviral Therapy

Activity 1st Wk 2

Mth 1

Mth 2

Mth 3

Mth 6

Mth 9

Mth 12

Thereafter in stable patients

Weight, height

Clinical evaluation

+ + + + + + + + Every 3 months

Check adherence &

side-effects

+ + + + + + + + Every 3 months

Check ART drug dosages

+ + + + + + Every 3 – 6 months

FBC* + + + + + Every 6 months

LFT or ALT**

+ + + + + Every 6 months

Creatinine + + Every 12 months

CD4+ + (+) + Every 6-12 months

Viral load

(HIV PCR)***

(+) (+) (+) Every 6-12 months

Lipid profile, fasting blood sugar****

+ + + Every 6 months

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*FBC = full blood count; ** LFT = liver function tests. Minimum, assay serum alanine transaminase (ALT or SGPT); *** RNA PCR for viral load; ****For children on protease inhibitors; ( ) Parenthesis indicates test is optional, perform if affordable or if deemed necessary. At each visit:

Plot the physical growth of the child on growth chart. Address ongoing medical problems; treat any intercurrent infections, if present. Give co-trimoxazole prophylaxis and Provide nutritional supplements (such as multivitamins) Carry out and record an objective assessment of adherence.

The most important determinant of treatment success is adherence. Greater than 95% adherence is necessary for optimal therapy that is one that ensures complete viral suppression and maximal durability of the first line regimen. If a child misses more than 1 dose in ten days it implies < 95% (suboptimal) adherence, and health-worker should counsel parent to identify causes of missed doses ways to address them immediately. Psychosocial care and support Children receiving ART and their caregivers do require psychosocial care and support. Such support should aim to empower the child and the caregiver to cope with the numerous challenges that they may face. These include stigma, feelings of depression, helplessness, and loneliness. Studies indicate that chronically ill children who are disclosed to in a timely manner have better outcomes compared to those who are not disclosed to regarding the nature of their illness. A process of HIV disclosure that is sequential and empowering and which involves caregivers in partnership with care providers should be mastered by all those involved in the management of HIV infected children. It is important to remember that HIV disclosure is not an event; rather it is a process. Psychosocial support can be achieved through instituting the following activities: Peer clubs Parents’ support groups Organized outings e.g. Camp Drama clubs Classes for caregivers.

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CHAPTER 14

ANAEMIA AND SICKLE CELL DISEASE

Catherine Chunda, Chris M. Ndugwa, N. Kariuki, Nimrod Bwibo INTRODUCTION Anaemia is defined as a reduction in haemoglobin level or oxygen carrying capacity or blood below the level that is expected for age and sex. It is a world wide health problem but especially in the developing countries. It is a common disorder in childhood where it causes mobility and mortality. In an individual child with anaemia, there are usually multiple causative factors. At the end of this chapter, the student shall be able to: Define anaemia Describe the variation of haemoglobin level by age Describe the morphological classification of anaemia. Describe the various causes of anaemia Describe the clinical tubes of anaemia Describe the clinical features of anaemia Describe the laboratory investigations for an anaemic child 8. Describe the management and prevention of anaemia LEARNING EXPERIENCE Practice the examining a child with anaemia in the clinic. Participate in the planning for investigation of a child with anaemia. Check on treatment chart how a child with anaemia is managed while on the ward at the hospital. Haematological Classification of anaemia The basic causes of anaemia are grouped into four, namely: Impaired haemoglobin production There is a decreased rate of production of red cells. Here the bone marrow is aplastic making it impossible to produce adequate red cells. Deficiency in haematinics: Here too there is decreased production of red cells but due to lack of raw materials. This occurs in iron deficiency. Folic acid and B12 deficiency Blood loss (bleeding) which may be acute or chronic. In this category, the haemoglobin is lost with the loss of red blood cells. This occurs in hook worm anaemia, in trauma, and in hemophilia. It also occurs in leukaemias due to thrombocytopenia. Haemolysis of red blood cells. This occurs in sickle cell anaemia and other haemoglobinopathies. it also occurs in malaria

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Red cell morphological types of anaemia Besides measuring anaemia in terms of haemoglobin level, anaemia can be categorized in three groups according to red cell size. Microcytic Anaemia In this group the red cells are smaller in size than normal. This occurs in iron deficiency anaemia, thallasaemia and lead poisoning. The red cells in these diseases are pale, being less filled with haemoglobin (hypochromic) Normocytic Anaemia In this group, the red cells are normal is size and are usually filled with haemoglobin thus referred to as normochromic. This occurs in Malaria anaemia acute blood loss anaemia. The cells in haemolytic anaemias ( sickle cells anaemia) are in this category. Macrocytic Anaemia In this group, the average red cells are larger than normal. This occurs in folic acid deficiency and in B12 deficiency. Variation of Haemoglobin Level Haemoglobin level varies with age. The level at which haemoglobin level indicates anaemia also varies with age. At birth the haemoglobin level ranges from 16 to 18 gm/dl. In the neonate a haemoglobin level below 14.5 gm/dl is considered anaemia. At 8-12 weeks of life, the normal haemoglobin level is 11-12 gm/dl. In the age group 6 months to 12 months, the haemoglobin level is 12+gm/dl. At adolescent the haemoglobin level rises to 14 – 15gm/dl. At that stage the cut-off level for anaemia is 9gm/dl. Table – Haemoglobin level below which anaemia is present according to WHO Age Hb gm/dl 6 months to 4 years 11 5 years to 11 years 11.5 12-14 years 12 Apart from this quantitative change in haemoglobin, there is a qualitative change in the haemoglobin. At birth, the majority (50-95%) of haemoglobin is foetal haemoglobin with only a small portion being adult haemoglobin. The foetal haemoglobin decreases rapidly in inverse proportion to adult haemoglobin, so that by one year of age, only a small amount of foetal haemoglobin is still present with majority being adult haemoglobin. The specific causes of anaemia vary with the age of the child. In the newborn period for example, anaemia occurs due to blood loss from umbilicus or bleeding from the placenta during labour or as a part of ante-partum haemorrhage. In identical twins foeto-foetal transfusion causes anaemia in one and plethora in the other twin. Anaemia also results from haemolytic disease of the newborn, and haemorrhagic disease of the

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newborn. In infancy on the other hand, anaemia is commonly caused by malaria, blood loss and dietary iron deficiency. Aplastic bone marrow may also cause anaemia in this period. Sickle cell anaemia which is prominent later can also cause anaemia in infancy. In childhood, the major causes of anaemia are malaria, sickle cell anaemia and chronic blood loss like hookworm anaemia, and dietary iron deficiency as in case of lack of dietary iron or folic acid. Several other factors like infections, renal disease, leukaemias can cause anaemia in this age group. IRON DEFICIENCY ANAEMIA Iron deficiency anaemia is of two types: nutritional and hookworm, the basic mechanisms being lack of haemopoietic raw material and chronic blood loss respectively. Iron Metabolism: The foetus acquires its iron from the mother across the placenta. This transplacental transfer of iron from the mother to the foetus is negligible during the first and second trimester of pregnancy but it increases tremendously during the third trimester. A foetus born prematurely does not have this benefit of acquiring the peak transfer of iron. Foetal iron stores are 75mg/kg body weight both in the preterm and full term infant but the preterm infant does not have large amount of total iron. A full term infant born to a non-anaemic mother receives sufficient iron during foetal life to maintain its needs for at least 3-4 months of infancy. The majority, seventy per cent, of the neonatal iron stores is in the form of haemoglobin in the cells. The bulk of the remainder is in storage form in the liver and other reticuloendothelial tissues. The other forms of iron are myohaemoglobin, cytochromes, catalases and other iron containing enzymes. Several factors occurring during pregnancy, childbirth and early neonatal period contribute to the development of iron deficiency anaemia. In extreme maternal iron deficiency anaemia, as occurs commonly in many tropical countries, the foetus acting like a successful parasite has normal haemoglobin at birth, but runs short of iron stores and develops iron deficiency anaemia in early infancy. Preterm infants out strip their iron requirements when they grow rapidly since they have inadequate iron stores. Early clumping of the umbilical cord denies the neonate blood which is in the placenta which if allowed to be transfused into the baby, contributes so much haemoglobin. Early clumping therefore predisposes to the development of iron deficiency. Blood loss from the placenta in APH or from the cord at any time. or during foeto-foetal transfusion causes iron deficiency. Generally, the following factors contribute to iron deficiency in the preterm low birth weight infants:- (i) Low iron stores at birth (ii) Rapid growth and hence increased iron demands (iii) Insufficient iron intake from the diet (iv) Disturbance in iron balance from blood loss and infections, the latter of which is a common problem in the preterm infants. In the preterm infants there is rapid growth and unless there is adequate iron supplements, the relatively smaller neonatal iron stores become rapidly depleted and anaemia develops by 2-3 months of age. In infancy and childhood, iron absorption is regulated by several mechanisms namely:-

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the amount of iron in the diet, the nature of the dietary iron, presence of phosphates and phytic acid, presence of ascorbic and hydrochloric acid and the iron status of the body. Cow’s milk has little iron but in human milk is also low in content but is of high bio-availability and most of it is extracted and absorbed by the infant. Dietary iron is absorbed in the upper jejunum. Inorganic (ferric iron), is changed to ferrous iron which is then absorbed. Ferric iron is not absorbable. Hydrochloric acid and ascorbic acid enhance iron absorption whereas phytic acids in cereals and phosphates inhibit iron absorption. Iron containing haem compounds (Meat) is split from the protein complex to globin and is absorbed directly. DMT-1 (divalent metal transporter) is involved in transfer of iron from the lumen of the gut across the enterocyte microvilli. While hepcidine, a regulator of intestinal iron absorption allows iron to enter portal plasma. Low hepcidine levels in iron deficiency increases this process. After absorption through gut mucosa, the iron is carried across the mucosal membrane and is carried by iron binding protein to the liver and other reticuloendothelial tissues where it is stored or to the bone marrow where it is utilized to form haemoglobin of red cells. There is a mucosal block which controls absorption of iron. Approximately two-thirds of stored iron is in the form of ferritin. The other stored iron is in the form of haemosiderin. In childhood, the causes of iron deficiency, in addition to those mentioned in the infants, are inadequate iron intake, hookworm infestation and malabsorption. Iron deficiency occurs when there is absolute low dietary intake as when the infants and children are not given iron rich food like cereals, green leafy vegetable or meats. Food may be rendered deficient of iron through fault preparation as in overcooking of the green vegetable. Infants who are on prolonged milk are not receiving a diet with good source of iron. The other causation factor of iron deficiency anaemia is hookworm infestation which is discussed elsewhere but suffice it to say that the severity of this type of anaemia depends upon: worm load, age of the child, type of hookworm parasite and the dietary iron intake. Ancylostoma duodenale sucks more blood than Nector americanus. An adult Nector americanus sucks on average 0.15 -0.2ML of blood per day while Ancylostoma duodenale sucks 0.05ML per day. The worm sucks the blood as it feeds. It then wonders off to another site leaving the old site bleeding. Iron deficiency anaemia is often complicated by other deficiencies such as PCM, pyridoxine, folic acid and nicotinic acid. In such anaemia, response will not occur to administration of iron therapy alone without correction of the other deficiencies at the same time. Clinical Features: Iron deficiency anaemia occurs at any age and is most common in infancy and pre-school children: 2-5 years of age. As the development of anaemia is usually gradual, the children tolerate it well without development of symptoms. Such patients are encountered on routine physical examination without symptoms whatsoever. Children with severe iron deficiency anaemia, with haemoglobin levels of 3-5gm% may walk into clinics without signs of decompensation and anaemia may be discovered as an incidental finding, while the child is attending the clinic for some other illness. Often, the children come to hospital for other illness like pneumonia which precipitate cardiac decompensation. The symptoms of iron deficiency anaemia are pallor, irritability, lethargy, lack of vigour, easy tiring on physical activities, poor appetite, poor attention spurn, lack of alertness, increased tendency to pyogenic infections and pica or eating soil.

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Clinical examination reveals a pale child, with pale skin, mucous membrane, sclera, palms and soles of the feet and nail beds. There may be brittleness of the nails with spooning of the nails, koilonychia. There may be history of melaena, dark stools containing altered blood due to chronic bleeding from the gut. In severe anaemia, there may be signs of cardiac decompensation, and heart failure such as tachycardia, breathlessness, palpitation, cardiac enlargement, raised jugular venous pressure shown by engorged neck veins and oedema of the feet or face. There is also gallop rhythm and heart murmurs. Laboratory Investigations: There are typical laboratory features of iron deficiency anaemia. Usually the haemoglobin or haematocrit (packed cell volume, PCV) is low. The peripheral blood smear is quite valuable and in itself alone the diagnosis can confidently be made. The red cells are microcytic, small in size, hypochromic, lack adequate colour, poikilocytosis, cell of various shapes, that is, distorted shapes. There are increased target cells and elongated cells. Blood indices are low. Mean cell volume MCV is reduced, less than 78, mean corpuscular haemoglobin (MCH) is low, less than 27 uug, and mean corpuscular haemoglobin concentration (MCHC) is less than 30 percent. Reticulocytes are either normal or reduced. Confirmatory tests are rarely done. They include determination of serum iron, and total iron binding capacity (TIBC) also known as transferring. Serum iron is low; normal values are 120, but in iron deficiency levels of 10-60ug are found. Transferrin is normally 450ug but this is usually a third, 150. Iron saturation is usually 32 percent but in iron deficiency it is about10 percent. Bone marrow shows reduced or no haemosiderin, serum ferritin is reduced to below l0ug/litre. Laboratory investigations should also provide/ assistance in the causation of iron deficiency anaemia. Stool is examined for hookworm ova and the worm load assessed. Occult blood is also determined as a measure of blood loss in the gut. In tropical areas where hookworm is a prominent factor in the causation of anaemia, the stool shows variable quantities of hookworm ova, a feature of worm load. Differential Diagnosis: There are a few conditions from which iron deficiency anaemia should be distinguished. There are Thalassaemia minor and lead poisoning in which microcytic hypochromic cells occur. A good history and physical findings would provide assistance. In thalassaemia, there is a family history of the disease. The family has relationship with Mediterranean people and the spleen and liver are enlarged. In chronic lead poisoning, there is history of lead in the community particularly old lead paint. Fortunately, lead paint is no longer manufactured. Management: The management of iron deficiency anaemia begins with a correct diagnosis and grading of severity of anaemia as well as establishing the underlining causes. Where the cause is known as in hookworm iron deficiency anaemia, the hookworms are eradicated by deworming as discussed elsewhere. In most cases, the iron deficiency anaemia is mild or moderate and responds to oral therapy using ferrous sulphate or ferrous gluconate. The recommended dose is 4.5-5mg/kg/day in three divided doses given between meals. Iron can be administered with food or milk. Iron therapy is given for a long time, usually 3-6 months to correct haemoglobin and

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replenish iron stores in the tissues. The difficulty is ensuring that the medicine will be taken while the child is at home. Administration of oral iron is followed by reticulocyte response. The reticulocyte count which is initially low, increase in number and the haemoglobin eventually rises. The patients with low haemoglobin have more rapid response than those with higher levels. Lack of response by increase in reticulocyte response or a rise in haemoglobin means a number of things: (i) The oral Iron has not being taken at all, or (ii Taken in inadequate amounts, (iii) The diagnosis may be wrong (iv) There is unrecognized blood loss (v) There is impaired utilization of iron due to intercurrent infections or renal disease. Patients with malnutrition (PCM) will not respond to iron therapy alone without an increased intake of protein. Administration of folic acid improves the response to iron therapy as folic acid deficiency often coexists with iron deficiency. A quicker and a much more effective way of correcting haemoglobin and replenishing iron stores is the administration of parenteral iron such as iron dextran (Imferon) or iron sorbital. These are indicated where there is severe anaemia or where the patient is not tolerating oral iron. Parenteral iron can be calculated and given either as infusion or intramuscularly in multiple sites. Where anaemia is very severe or life threatening, blood transfusion is indicated to relieve hypoxia and save life. Care should be taken in giving blood transfusion. As chronic hypoxia leads to weakened heart muscle, rapid blood transfusion expands the plasma volume which the flabby cardiac muscles cannot cope with, resulting in precipitated heart failure. To avoid such a calamity, several precautions are taken namely:- (i) Total blood given is calculated as 5m1/kg (ii) Blood transfusion is given slowly. (iii) Only red blood cells or packed cells are used. (iv) Diuretics are given preceding the transfusion to avoid expansion of plasma volume. (v) Digitalization as prophylaxis to heart failure is done during transfusion, but this is debatable as the drug is thought to be ineffective without heart failure. (vi) Small packs of blood are preferred so as to avoid the danger of large quantities of blood running in from a big 500m1bottle. (vii) Evidence of heart failure is looked for in the course of blood transfusion and transfusion stopped when signs start. Prevention: Iron deficiency anaemia is prevented by various inexpensive methods. During pregnancy, mothers should receive iron and folic acid tablets. This ensures good iron stores in the foetus at birth. Iron supplement should be effected in all preterm infants starting from the second week of life. During prolonged milk feeding iron supplementation is advised. Iron rich foods such as a dark green leafy vegetables, meat and cereals are recommended during infancy and early childhood. Normal infants require 1mg of elemental iron daily which they obtain from dietary intake of 12-15mg of iron.

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ANAEMIA DUE TO MALARIA Anaemia of malaria is one of the three common causes of anaemia in tropical Africa. The other two being iron deficiency and sickle cell anaemia. Red cells which are parasitized by malaria parasites haemolyze easily as the parasites bust out on their maturity. Cells which are parasitized are also trapped and destroyed in the reticuloendothelial tissue, mainly in the spleen, bone marrow and liver. Plasmodium falciparum attacks both young and old red cells while the other species of malaria parasites, tend to parasitize the older red cells only. The resulting anaemia is therefore much more severe in falciparum infection than in the other species of malaria parasites. Peripheral blood smears show Parasitized red cells, polychromasia, anisocytosis, poikilocytosis and target cells. The red cells are normochromic, normocytic. Clinically, the patient has anaemia and the features of malaria namely fever, diarrhea and vomiting, weakness, enlarged spleen anorexia and failure to thrive. The anorexia may lead to dietary deficiency. Haemolysis depresses the bone marrow complicating the picture of anaemia. Malaria parasitaemia may also depress bone marrow temporarily. The treatment of anaemia of malaria focusses on both anaemia and, malaria. Artemisin is given for malaria. When anaemia is severe, blood transfusion is necessary and life saving. Blood transfusion is recommended at dosage of 10ml/kg. Iron therapy is not useful unless there is concomitant iron deficiency anaemia. SICKLE CELL ANAEMIA Sickle cell anaemia results from a genetic disorder in the formation of haemoglobin. Instead of the normal adult haemoglobin, these patients have abnormal haemoglobin in their red cells. This abnormal haemoglobin crystallizes out whenever there is lowered oxygen tension as occurs in pneumonia. The red cells with crystallized haemoglobin become deformed in sickled cells which are picked up and haemolysed in reticuloendothelial tissue giving rise to jaundice and anaemia. The many the sickle red blood cells are destroyed by haemolysis, the severe is the resulting anaemia. Much haemolysis occurs during attacks called crises. The more frequent the crises occur, the more severe is the resulting anaemia, which is often brought about by infections such as malaria and pneumonia. Exposure to cold during cold season also precipitate a crisis. Clinical Features The child with sickle cell anaemia will have other clinical features of sickle cells disease such as hand foot syndrome (swollen tender hand, finger feet and toes) these occur in early infancy. The child will have abdominal pain and distension. The distension is due to enlarged spleen and sometimes also enlarged liver. As they grow they also get pain in the limbs and back. The features for sickle cell anaemia will include; pallor of hand and soles of the feet and nail beds, pale mucous membrane and pale conjunctiva. The sclera, and mucous membranes, the soles of the feet and palms will be jaundiced. Patients with sickle cell anaemia will in addition have cardiac enlargement with heart murmurs.

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Laboratory Investigation Haemoglobin level is low usually about 7gmldl. The red cells are normocytic and normochromic. Sickling test is positive. Haemoglobin electrophoresis shows haemoglobin SS instead of the normal hemoglobin AA. Management Throughout life the child with sickle cell anaemia should receive malaria prophylaxis to avert malaria infection precipitating sickle cell crisis. The patient should be given daily folic acid to replace folate last from the blood during sickle cell crises. Folic acid is needed in the blood for the development of red blood cells otherwise megaloblastic anaemia will develop as the body runs short of folic acid for normal synthesis of red blood cells. Folic acid supplements is given orally in the dose of 2.5mg daily for children below 5 years of age while those above 5 years of age receive 5mg daily. Iron should not be administered to anaemic sickle cell patients. Normally the iron is stored in the body following sickle cell crisis. Any additional iron is likely to cause iron poisoning. Severe anaemia is management by blood transfusion. Megaloblastic Anaemia Megaloblastic anaemia is uncommon in tropical countries. When it occurs, it occurs on infants early childhood in the form of folic acid deficiency and rarely due to B12 deficiency. Folic Acid Deficiency Folic acid deficiency is caused by (i) deficient intake (ii) deficient absorption of folic acid dietary deficiency is usually corresponded by rapid growth in infancy and young children or by infection which increase folic acid requirements. It also occurs in sickle cell anemia as described earlier. The normal daily requirement is small, about 20-50 ug/day. Human milk and cow’s milk have adequate amounts of folic acid. Powdered milk is a poor source of folic acid and must be supplement. Ascorbic acid deficiency impairs the availability of dietary folic acid conjugates. Routine folic supplements are recommended for very low birth weight infants. Folic acid deficiency occurs in Kwashiorkor and marasmus. Vitamin B12 Deficiency Dietary B12 is absorbed in combination with glycoprotein ( intrinsic factor) secreted by the parietal cells of the gastric funds. The bi2 intrinsic factor complex that is formed passes to the terminal item where specific absorptive sites exist. In the presence of intrinsic factor and ionic calcium vitamin biz the intestinal mucous and enters the blood. Vitamin B12 deficiency results from (i) inadequate intake (ii) lack of secretion of intrinsic factor by the stomach (iii) lack of adequate consumption in inhibition of the B12 – intrinsic factor complex of (v) abnormalities involving the receptor sites in the terminal item. Vitamin B12 is present in many foods, dietary deficiency is rare. If may be seen in extreme dietary restriction. Since vitamin bi2 is so common, the cases of vitamin biz are normally due to failure to absorb the vitamin. Both folic acid and vitamin B12 deficiency share some clinical features of anaemia with other deficiencies like iron deficiency. Besides this, the affected infants with folic acid deficiency are irritable and have chronic diarrhoea and stunted growth.

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Laboratory features apart from the general low haemoglobin level include typical megaloblasts and giant metamyelocytes and hypersegmented megakaryocytes. Megaloblastic anaemia responds to folic acid administration in the daily dose of 5mg daily for 2-3 weeks. Folic acid should be administered together with ascorbic acid. As folic acid is the more common cause of megaloblastic anaemia, it should be given alone. Dietary deficiencies of folic acid if considered should be corrected by giving green vegetables proteins , liver and kidney which are rich in folic acid. Aplastic Anaemia Aplastic anaemia is a rare form of anaemia. It is caused by bone marrow failure. Where bone marrow fail to produce. Red blood cells as well as white blood cells and the platelets. This result in pancytopenia. It may be congenital or acquired. The acquired form is sub divided into; idiopathic and secondary aplastic anaemia,. The idiopathic type forms the majority of the cases being responsible for about 50% of the cases and has no known aetiology. The congenital form of aplastic anaemia is also known as Fanconi's anaemia and is associated multiple congenital defects involving the skeletal system, skin, kidneys and the chromosomes. The skeletal defect includes: hypoplastic or absent thumb and thenar eminence, absent radius, syndactyly and abnormalities of the long bone. There are skin lesion such as hypopigmented spots and patches of pigmentation. There may also be ptosis of the eyelids, abnormal ears and mental retardation. The secondary form of aplastic anaemia results from a variety of insulting environmental factors. Table – agents that cause aplastic anaemia Drugs: chloramphenicol, barbiturates, aminophylline, sulphonamides, nitrogen mustard and 6- mercaptopurine Toxic agents: infections, uraemia, herbs Chemicals: DDT, lead Physical agents: Radiation Miscellaneous: haemolytic disorders such as sickle cell anaemia, hereditary spherocytosis, multiple blood transfusions, and malnutrition The incidence of aplastic anaemic vary according to the presence of the causative factors. The clinical features of aplastic anaemia depend on severity of bone marrow involvement, the degree of anemia, and the coexisting causative agents. The patient presents with failure to grow with stunting and wasting. There may be bleeding, epistaxis, haematuria all due to thrombocytopenia. The level of anaemia is usually profound with very low haemoglobin below 5 /dl. The patient is prone to infections. Laboratory investigations show low haemoglobin level of normocytic normochromic type. There are no normoblasts as in the case of leukaemia. Reticulocyte, white blood

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cells and red blood cells are very low. Bone marrow trephine instead of bone marrow aspiration is done and this helps in assessing cellularity of the bone marrow. From these clinical and laboratory features together with history of exposure to toxic substances drugs, infection and irradiation confirms the diagnosis. Management of aplastic anaemia is fraught with difficulties. The main stay of treatment is repeated blood transfusion. Unfortunately repeated blood transfusion may lead to development of antibodies to blood making it difficult to continue with blood transfusion. Repeated blood transfusion may lead to yet second problem that of haemosiderosis. This can be anticipated and avoided by administration of desferrioxamine an iron chelating agent administered during the course of blood transfusion. This chelates iron from the tissues testosterone administration may stimulate red cell production leading to a possible emission. routine administration of antibiotics as a prophylaxis for infection can also be tried but is safer to detect infection early and institute effective antibiotic treatment. REFERENCE: Akinkugbe F M Iron deficiency anaemia, East Africa Med J 55:151 1979 Bwibo N O Haemoglobin response following intramuscular imferon in children with iron deficiency anaemia, East Africa Med J 47:254, 1976 Bwibo N O Haematological diseases in the tropics in: Paediatric Practice in Developing countries, Editor GJ Ebrahim, McMillan Press Ltd, London 1981 pp 239-256 Eicholzer M, Tonz O and Zimmerman R Folic acid: a Public Health Challenge Lancet 367:1352, 2006 Ganz T. Hepcidin a regulator of intestinal iron absorption by macrophages clin Haematol 18: 171, 2005 Shayeghi M, Latundo – Dada G O, Oakhil J S et al Identification of an intestinal heme-transporter cell 122:789, 2005 Wang RH, Li C, Xux et all -A role of SONA D4 in iron metabolism through the positive regulation of hepcidine expression Cell Met 2:399, 2005

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CHAPTER 15

ADOLESCENT HEALTH, DRUG AND SUBSTANCE ABUSE

S. Bakeera-Kitaka, Amos Odiit, Samuel Ayaya, Esther D. Mwaikambo INTRODUCTION In many developing countries adolescents have not had special services made available to them. Problems such as adolescent pregnancies, STIs, early marriages, child labour, child prostitution, civil strife creating orphans, destitute children and the generally unfavorable economic conditions, have all contributed to the deterioration in the health status of adolescents; hence the need for separate adolescent health care services. This has become even more critical because of the current HIV/AIDS epidemic that is affecting mostly adolescents, especially girls. The definition of an adolescent varies in terms of age limits, from one organization to the other. The definition adopted in this book is that by the World health organization which is: A person aged 10 – 19 years. The adolescent period can further be sub-divided to: Early adolescents (10 to 13 years, Mid Adolescent (13 to 15 years) Late adolescents (16 to 19 years). Characterizing adolescents this way helps pick out the unique psychological issues that are faced by different groups The issue here is not so much the age definition of the adolescent but rather the fact that SSS is characterized by a very young population with 50% of the population in many countries being below 20 years of age. In 1990, 31% of Africa’s population was between the ages of 10-24 years. This makes adolescents a large part of the general population in any country in the SSA region. The health of the adolescent is therefore very important in determining the future general and reproductive health of the populations in the region. In SSA, the health problems of the adolescent population are very similar. This chapter therefore discusses the major adolescent health needs, their health problems, approaches towards, their management and the organization of services that can adequately respond to their health needs, especially in SSA. THE NORMAL ADOLESCENT Reproductive biology development Milestones in social responsibility Risky behavior patterns and their consequences Recreation (sport, music, drama, education) as viable alternatives that can maintain health and prevent major social problems What preventive and curative services are available for adolescents and where these are? Methods for the prevention of STDS and HIV infections Methods for the prevention of drug abuse

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Learning objectives At the end of this chapter the student should be able to: Define adolescent by age range according to WHO definition Determine the size of the adolescent population in your country using available statistics Describe methods used in determining the adolescent health status List the priority adolescent health problems in your country and the African region. Describe practical ways in which the community can be involved in development and promotion of adolescent health. Describe ways in which adolescent themselves can participate in improvement of their health Learning Activities To facilitate learning, students will be exposed to and participate in activities targeted to adolescents in the community in both rural and urban settings. These will include: Assessment of adolescent health status to determine their knowledge, attitudes and practices in a defined community Identification of specific adolescent health problems in that community and in determining possible solutions Prepare a report describing the major adolescent health problems in that community and the country and suggested ways to resolve them Participate in peer education and a counseling activity lead by adolescent Describe possible or ongoing activities aimed at improving adolescent health Describe possible policy and programmatic actions that can lead to improved adolescent health Identify gaps in knowledge in the areas of adolescent health Adolescent Sexual activity Many factors such as early puberty breakdown of tradition norms and values, foreign influence through television and media, economic hardships, urbanization and schooling have led to more and more liberal attitudes and practices by adolescent leading them to initiate sexual activity at an early age with about 80% of adolescents having their first sexual intercourse by 19 years of age. Recent unpublished survey results from the rural areas in East, Central and Southern, Africa have shown that 75% of girls interviewed had their first sexual experience before the age of 16 years. Most of the sexual intercourse was unprotected and could have led to infection with an STD or to pregnancy. Preventive actions should include: Education on milestones in reproductive biology development and social responsibility Promotion of appropriate behavior patterns to prevent early sexual indulgence. Promote education to change risk behavior Recreation (sports, music, drama, education)

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Adolescent pregnancy and fertility Teenage pregnancies contribute up to one third of all pregnancies in Africa South of the Sahara. In East Africa they contribute to about 20-30% of all pregnancies occurring in women aged 15 to 49 years while adolescents comprise 35% of all obstetric cases. It is well known that teenage pregnancies have a higher incidence of complications and maternal mortality. The DHS in the region have shown that adolescents contribute about 11.5% of all births in Eastern and southern Africa suggesting that a large proportion of adolescent pregnancies end up as abortions. Furthermore 81% of all girls aged 15 to 19 years interviewed in Rural Kenya had at least one pregnancy. In addition to the health risk that the adolescent pregnancy poses, such unplanned pregnancies lead to high school drop-outs with loss of career opportunities and severe psychological and social consequences. Preventive Actions would include: promotion of abstinence and use of contraceptives. Contraceptive use among adolescents Few countries have liberalized contraceptive use for adolescents. Among these are Botswana and Seychelles. Even in these countries adolescent contraceptive use is very low. The reasons for this state of affairs is the negative perception that contraception use is associated with multiple partners in the case of married couples and increased sexual activity among the youth. In a four country study involving Tanzania, Seychelles, Uganda and Zimbabwe undertaken by the Commonwealth Regional Community Secretariat, results showed that whereas the contraceptive knowledge was as high as 80% among adolescents, use was as low as 5%. Similar results are available from the DHS studies. Promotion actions would include: Education of adolescents on appropriate contraceptives and Continued training of medical personnel and equip them with better counseling techniques in relation to contraception for the adolescents. Abortion among adolescents In 1993 abortion contributed to 30% of maternal mortality in the countries of East Central and Southern Africa. Over 20% of these were among teenagers. In Sub Saharan Africa (SSA) 30-60% of all women hospitalized for complications of abortion are teenagers. In a survey involving 1058 adolescent girls, 9% had attempted to have an abortion. Of these, 53% had fallen ill and 25% had been hospitalized for treatment of complications. Unsafe abortion is therefore a major problem among adolescents. Preventive actions: Education on the magnitude and consequences of unsafe abortion in terms of morbidity and mortality

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Promoting knowledge and attitudes that prevent the need for abortion through sexual abstinence, contraception Post-abortion counseling and contraception for adolescents to prevent repeated unwanted pregnancy Early Marriage Many societies in SSA have cultural practices that encourage marriage of girls in early adolescence. This is associated with fertility, reduced educational opportunities for the affected, and health complications such as premature delivery, toxemia of pregnancy, anemia obstructed labour, Vesico-vaginal fistulae (VVF) and various forms of injuries to the birth canal. This is of particular importance in the rural areas where early marriage is commonest and access to health care is least. Preventive action Public awareness of the negative effects of early marriage Advocacy for protection of children’s and adolescent’s rights for education and career development and in prevention of their sexual exploitation Advocate for enforcement of law that prevent early marriages Advocate for change of cultures and subcultures that practice early marriage Sexually transmitted Infections, HIV/AIDS Unprotected sex as is the practice among adolescents is associated with high incidence of STIs. It is also true that adolescents are more biologically vulnerable to STIs due to their immature physical development. In addition to these, economic forces that lead adolescents to accept being used sexually for financial favors and often ending up in prostitution all further exacerbate the likelihood of contracting an STI or HIV infection. They are also misinformed about STIs and AIDS and thus unprepared to take appropriate preventive action. An estimated 36% of women aged 15-24 had an STI. The incidence of STIs and HIV infection are rising at a very high rate in the region. Public awareness and practical preventive approaches must be developed and implemented. These interventions must involve adolescents themselves. There is evidence that aggressive treatment of STIs especially gonorrhea and genital ulcer disease is associated with a 42% reduction in the incidence of HIV infection. This is an important finding that must be made use of. Following increase of ARVs and PMTCT there is an increasing number of children who acquired HIV infection perinatally and are now reaching adolescence. This particular group of HIV infected children will sex education, peer group support and readily available counseling services.

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Management Formal and informal education on the mechanisms of transmission of STDs and HIV infection. School curricula must have adequate content in this regard. Similarly, teachers must be educated on mechanisms of transmission of the common STDs, and HIV and preventive activities, as they are an important source of information for the adolescent. Provision of special health service facilities that the adolescents are comfortable to use. These should have diagnostic facilities, treatment and counseling. Services for the diagnoses and treatment of STDs should be decentralized to the health centre level to ensure easier access to the majority of the population. Drug and Substance Abuse: Adolescents like to experiment and take risks including using illicit drugs and alcohol. The problem of drug and substance abuse in Africa has reached alarming proportions although accurate data is not available. The drugs abused range from alcohol, tobacco, various stimulants and the more addictive forms such as cannabis sativa, etc. Addiction to drugs for the adolescent is often the end of the road in as far as education and career development are concerned. Various factors have been blamed for drug and substance abuse among adolescents. These include being idle, poverty, lack recreation during leisure time, peer pressure, unemployment, lack of guidance and inadequate family support. Preventive actions Put in place national policies that expressly prohibits drug trafficking and use, accompanied by appropriate penalties and other preventive legal actions. Undertake public education and create awareness on the dangers of drug abuse to the society and the individual. Develop treatment, counseling and support systems in the communities for individuals diagnosed to be drug dependent. Involve youth groups in programmes aims at the control of drug abuse. Create community recreation centres Encourage students in schools to join social and academic clubs and ensure presence of such clubs in all schools in the country Encourage and support peer education to improve adolescent health It is recognized that peer education is a powerful tool to improve adolescent health. It is important that adolescents themselves are involved in the identification health problems and development solutions to the problems. Results of the commonwealth study referred to earlier, showed that it was possible to involve the adolescents themselves in the collection of the reproductive health data, and in the development of interventions and in mobilizing community support of the programme. In addition the study demonstrated a positive change in the knowledge, perceptions and practice on sexuality especially among girls. After a year of intervention, there was demonstrable positive change in knowledge perceptions and practice in sexuality, especially among girls.

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Special Problems of the Pre-adolescent Child: The preadolescent girl is undergoing physical development, which may be interfered with by malnutrition and lead to stunting of growth. This often leads to poor pelvic development and cephalo-pelvic disproportion a common complication during child birth. This can be prevented through community and school based health programmes. A special predicament faces the preadolescent who is out of school. Even less services are available to him or her whole being more vulnerable to neglect, communicable disease, malnutrition and consequently poor physical and psychological development. Current state of inadequate education in reproduction, sexuality and life skills essentially allows them to enter adolescence without any preparation. This predisposes them sexually transmitted diseases, and unwanted pregnancies. Pre-adolescent children need at least minimum information regarding their own reproductive potentialities and the problems associated with risky sexual behaviour. In addition to health care provision to students, the education system should ensure that curricula contain adequate health promotion and disease prevention topics. It is accepted that the commonest source of most health information to school children in this age group is the teacher. This is particularly true of reproductive biology and sexuality. It is equally true that the primary school teacher has often not been prepared enough to take up this task. There is urgent need to address this matter. Health Care Services for the Adolescent 3 models are proposed: Adolescent services integrated in Paediatrics Purely adolescent service Adolescent services integrated in adult care In developing adolescent health services, emphasis should be made on making the services Youth friendly. (A one “stop shop” with privacy). Services for the adolescent should be integrated into the regular facilities of the clinics and hospitals but separate from those of the adults and children. There is need to improve the available systems through development of procedures, guidelines and protocols through: For the Specially Disadvantaged Pre-adolescents and Adolescents: Under this category falls the street children, orphans, mentally and physically disabled. Over the last decade more than ever before there had developed a large population of orphans due AIDS, civil strife, road traffic accidents etc; poor obstetric care leading to birth asphyxia or other injury and adolescent pregnancy leading to abandoned children. These are growing problems and not enough is being done for these groups. Special programmes to identify them early and provide them with the necessary support Community interventions to improve adolescent reproductive health:

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Intervention matrix to improve some aspects of teenage Reproductive Health Objective IEC content Activity Materials To raise awareness on reproductive potential

Concept of family Puberty in boys and girls Emotional changes towards opposite sex

Discussions, lectures, demonstrations, role plays, simulations, observations, reading

Leaflets on puberty, diagrams of reproductive organs, films on puberty

To educate on endemic STDs in the study area

Gonorrhea, syphilis, HIV/AIDS, chancroid, pubic lice,

Discussions, lectures, demonstrations, role plays, simulations, observations, reading

Leaflets on STDs

To enable youths educate others on HIV/AIDS

HIV/AIDS transmission and the disease process

Discussions Films on AIDS

To educate on dangers of HIV/AIDS to youth

Dangers to the individual the family and the nation

Group discussions on dangers and honesty about AIDS

Leaflets

To enable youths avoid HIV and other STDs

Sex in and out of marriage, tips on choosing a spouse, saying no as a contraceptive

Group discussions, role plays, condom use, demonstrations

Condoms

To enable youths get counseling on STDs

Where to get services, and description of what happens during counselling

Discussions, tour of youth centres

The Youth Centre

To enable youths describe conception, pregnancy and childbirth

Ovulation, ejaculation, conception, pregnancy, MCH services, men and MCH services

Discussions and demonstrations

Leaflets, posters, and reference books

To enable youths learn tips of responsible parenthood

Responsible parenthood, FP services, FP counseling

Discussions, tour of youth centres

Physical address of youth center, leaflets, films

To enable youths describe problems of teenage childbearing

Problems e.g. injury, complication, responsibilities

Discussions, distribution of leaflets and posters

Posters, leaflets, films

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Priority Research Needs in adolescents The field of adolescent health remains an elusive one. Little is known about factors that determine the behaviour of adolescents and therefore what would be the best strategies to adopt for various interventions. Operations research is therefore needed to determine. How to influence public opinion to improve the health of adolescents. How best to organize adolescent health services in health care facilities and the community. How to integrate preventive and curative services in health care

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CHAPTER 16

ACCIDENTS AND POISONING

FV Murila, Chris M. Ndugwa, Ruth Nduati, Somwe Wa Somwe, Dalton Wamalwa, Dinberu Tefera Muluwork

INTRODUCTION Accidents and poisoning are important causes of childhood morbidity and mortality worldwide. Mortality is highest in the one to five year age group. Primary health care workers need to be familiar with the common types of accidents and poisoning in their own environment in order to be able to plan interventions and curative services as well as setting strategies for prevention. OBJECTIVES At the end of this chapter, you should be able to: List common types of accidents in your country Indicate first aid measures and comprehensive management of each type. List different circumstances in which accidents occur and describe measures for their prevention. List six common agents of poisoning in children. Give the specific toxic effects, first aid measures and comprehensive management for each type of poisoning. List eight circumstances that predispose children to poisoning and describe measures to prevent poisoning. Describe the forms of poisoning and indicate the commonest cause of each in your country and the relative importance as causes of morbidity and mortality. Outline the management of a snake bite. LEARNING ACTIVITIES Spend time in the casualty department of your hospital and count the number of child accident victims. Participate in the management of an injured child. Visit the burns unit in your hospital and observe the management of a child with burns. Clerk a child with poisoning. Visit the toxicology department in your area and discuss common types of poisoning encountered Visit a nearby zoo and learn about poisonous snakes. Case illustration Kamau aged four years and Otieno aged two years were well when their mother left them asleep in the afternoon. The mother did not have a domestic helper so she locked the children in the house. Two hours later when she came back she found her two children unconscious on the floor. Clutched in the hands and scattered on the floor were sugar coated aspirin tablets used by an older sibling with rheumatoid arthritis. The

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mother rushed both children to the local General Hospital. One hour later, both children were breathing fast, running a fever and convulsing. Form a student group and discuss the following: Question 1 What are the metabolic derangements that led to fever, fast breathing, convulsions and coma in these children? Question 2 What is the management of these children? The doctor on call started treatment on both children. He carried out some investigations and decided to refer the children to a tertiary care health facility. Question 4 What investigations do you think these were? Question 5 What therapy was the referring doctor hoping that these children would receive? Question 6 How would you prevent a similar occurrence in this family and your community? The secretaries during both discussions should be prepared to report back to the class in a plenary. The facilitator should move from group to group, observing the group dynamics and generally be available for any questions and clarifications. FACTORS THAT CONTRIBUTE TO THE OCCURRENCE OF ACCIDENTS AND POISONING IN CHILDREN 1. Developmental stage Accidents and poisoning are commonest in the toddler aged 9 months to the child aged five years with a peak incidence in the age group of one to two years. At this age the children are at a developmental age that is characterized by: a strong exploratory instinct without a social conscience: a strong desire for oral gratification- children of this age put things into the mouth as a way of exploring them. a different sense of taste from adults and they often like to swallow things that taste strange or bitter to adults. a strong desire to assert their own autonomy coupled with strong negative feelings that drive a child to what is forbidden.

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2. Gender Although accidents and accidental poisoning are reported to occur more frequently in boys, two Kenyan studies found an equal distribution in both boys and girls. 3. Child-caring practices Lack of adequate supervision is probably the single most important contributor to poisoning. In many rural and urban areas, young children are left in the care of young siblings. Children aged 3 years or more are increasingly attending school and thus the older children are not available to assist the mother with babysitting. A disturbing pattern of child rearing is emerging where children less than three years of age are sometimes left at home on their own, as mothers go to the garden or to the market. The collapse of the extended family structure has led to limited options of alternative child caring arrangements. 4. Poverty Young children living in socio-economically deprived environments especially peri-urban slums are at greater risk of accidents and accidental poisoning. This is because many families now live in single room houses. As a result it is difficult to find a safe place to store drugs and other poisonous agents, or even to be able to prevent exposure to burns and scalds. The risk is further increased when both parents are either under mental stress or are working away from home leaving the children under inadequate supervision. 5. Children with special needs The lack of special amenities for children with special needs results in parents having to care for these children in their homes. ACCIDENTS Accidents can occur at any age as the child or adolescent interacts with his/her environment. In developed countries, accidents are the leading causes of death in children over the age of one year. In adolescents, alcohol and drug abuse contribute to road traffic accidents. Accidents can be classified as: Household accidents which occur within and around the home. They include falls from high surfaces, cuts and burns. Out-door accidents that occur primarily away from home. They include road traffic accidents, thorn pricks, animal kicks and bites, falls from fruit trees and drowning. The type of accident is determined by the child’s environment and gender. Among school age children girls are most likely to experience burns and scalds in the house as they assist their mothers with the house work while boys are more likely to be injured outside as they tend animals or play.

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The very young child is more prone to falling than the older child. The falls could be from a bed, a high apartment building or a rough out-doors. Toddlers are more prone to burns/scalding compared to older children. Two studies were carried to document the prevalence of accidents in Marigat Division a rural area in Kenya and in Kibera urban slum of Nairobi. The peak occurrence of accidents was in the under fives and the prevalence was comparable in boys and girls. Table I: characteristics of accidents in urban and rural populations below 20 years of age in Kenya.

Characteristic Urban population Rural population (Kibera urban slum) (Marigat-Baringo district) N=1576 Prevalence of accidents 111(7%) Age distribution 0-4 67.8% 51 (56%) 5-9 34 (30.6%) 10-14 17 (17.1%) 15-19 7 (6.3%) Types of injuries Puncture wounds (stings, bites, thorn pricks) 55 (49.6%) Burns/scalds 29 (26%) Incisive wounds 11 (9.9%) Fracture dislocations 5 (4.5%) Others 11 (9.9%) Falls 50.5% ROAD TRAFFIC ACCIDENTS Road traffic accidents are a major global public health problem and worldwide, the number of people killed in road traffic accidents each year us estimated at 1.2 million. Deaths from road traffic injuries account for around 25% of all deaths from injury. Among both children aged 5-14 years and young people aged 15-29 years, road traffic injuries are the second-leading cause of death worldwide. In Nairobi it is estimated to be the leading causes of death in children aged 5-15 years. Children are involved in accidents as passengers, cyclists or pedestrians crossing roads to school or while playing near or on the road. Management of Road Traffic Accidents The management of road traffic accidents depends on the severity of the injuries. A quick history and examination should be carried out to establish the severity of the injuries.

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The following steps should then be taken: - 1. Establish a clear airway and support respiration if necessary. 2. Control any bleeding- a simple pressure bandage may very useful, but bleeding arteries may require to be sutured to arrest bleeding. 3. Make a quick appraisal of the blood loss and treat shock if present. Look for internal haemorrhage remembering the possibility of ruptured viscera and massive bleeding into tissues. 4. Clean and debride wounds before stitching. 5. Immobilize fractures immediately and plan to set them when the patient is stabilized. 6. Carry out necessary investigations such as x-ray while continuing to closely monitor the patient. 7. Administer tetanus toxoid 8. Give analgesics to relieve pain. Prevention of Road Traffic Accidents 1. Adequate supervision of children. 2. Children should be taught the basics of road safety at school or at Children’s Traffic clubs. 3. Adequate play ground space and recreation in order to prevent children from playing near or on the road. 4. Public education to increase knowledge and utilization of road safety measures pertaining to children such as infant car seats, safety belts, bicycle crash helmets and wearing reflectors when walking in the dark. 5. A road traffic system designed for safe sustainable use. BLUNT-TRAUMA, CUTS AND FALLS Blunt trauma, cuts, falls, and puncture wounds are common accidents in children. Cuts usually results from objects such as knives in the household or farming implements as children work in the garden. Blunt injuries follow episodes of assault or animal kicks. Falls are an important form of injury and were found in the studies described above to be common in the urban environment while puncture wounds were common in rural areas. Small babies fall from high surfaces where they have been left unattended. In a few occasions head injuries followed by mental retardation and epilepsy have occurred. In urban areas toddlers and even school aged children fall down the stairs and from apartment buildings with inadequate safety measures while school aged children may fall from trees or from jumping off moving vehicles. Falls from a height put children at risk of hip injuries. Thorns pricks are important in rural areas where children walk bare footed. The wound may become septic and may be a source of tetanus. The principles of management are as detailed above.

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DROWNING AND NEAR DROWNING MANAGEMENT Children run the risk of drowning when they play around water without adequate supervision. High risk groups include toddlers, preschool children and patients with seizures. A toddler may drown in a bucket or basin filled with water. Older children in rural areas drown in rivers, pit latrines and excavation sites filled with water. Management On the scene Resuscitation 1. Initiate ventilation -clear the mouth of any debris and hold the child upside down and pat on the back to facilitate the removal of inhaled water and then do mouth to mouth resuscitation. 2. Start external cardiac massage if there is no palpable pulse. 3. Give oxygen at the earliest opportunity. In Hospital 1. All children with near drowning should be admitted for at least twenty four hours observation, no matter how well they look. 2. Cardiopulmonary resuscitation should be continued until spontaneous breathing is restored. 3. Children who fail to respond to the above measures should be transferred to an intensive care unit. Burns Burns cause 10% mortality of all hospital admissions. It is estimated that 20 people per million population die from burns with half of them dying before hospital admission. Children account for a large proportion of all burns admission in eastern and southern African countries. Burns are a leading pediatric surgical emergency. They are responsible for 30% of acute paediatric surgical admissions and, like other accidents and poisoning, the peak incidence is between one and three years of age. Scalds are most important burns in childhood usually from hot tea, water and porridge. The majority of burns occur at home. In the Margate study 82% of the burns were in children aged less than five years and there were significantly more girls who were burnt than boys. The possibility of child abuse should always be considered when a child presents with burns. Burns Wounds Management First aid The burnt body part should be immersed immediately in cold water to cool the tissues and to prevent further progression of the burn. The burnt area should be covered in a clean cloth and health care should be sought from the nearest facility.

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Hospital Management of Burns There are two methods of treating burns, the open method and the closed method. In both methods one aims to provide an aseptic environment so that the burn can heal rapidly. In second and third degree burns topical antibiotics are indicated. The drug of choice is sulphadiazine although, silver nitrate, povidone-iodine, and gentamicin ointments have been used. Open method In the open method, the burn is left open and a topical agent is applied twice daily. This method has an advantage in that bacterial growth is not enhanced. However, it has the disadvantage that the wound is more painful and there is increased fluid loss. Closed method An occlusive dressing is applied after a topical agent is applied. There is an increase in the re epithelialization of the wounds but the method has the potential of increasing bacterial growth. In major burns the following should be done: 1. Determine the percentage of body surface area burnt. 2. Determine the degree of the burn whether superficial, second degree or third degree. 3. Treat pain with analgesics. 4. Determine the fluid loss which occurs through oozing. 5. Monitor the urine output. 6. Treat any infection. 7. Give tetanus toxoid. Prevention of Burns 1. Make sure hot liquids, fire and match boxes are not accessible to children. 2. Young children should be adequately supervised. 3. The fire places should be out of reach of young children. POISONING A poison is any substance that causes harm if it gets into the body. Harm can be mild (for example, headache or nausea) or severe (for example, fits or very high fever), and severely poisoned people may die. Almost any chemical can be a poison if there is enough in the body. Acute exposure is a single contact that lasts for seconds, minutes or hours, or several exposures over about a day or less. Chronic exposure is contact that lasts for many days, months or years. Routes of Exposure Through the mouth by swallowing (ingestion) Most poisoning happens this way. When poisons are swallowed they go to the stomach from where they are absorbed into the blood. The longer a poison stays in the gut the more will be absorbed into the blood and the worse the poisoning will be. Through the lungs by breathing into the mouth or nose (inhalation)

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Poisons in the form of gas, vapour, dust, fumes, and smoke or fine spray droplets may be breathed into the mouth and nose and go down the air passages into the lungs. Through the skin by contact with liquids, sprays or mists Children may be poisoned if the chemical is sprayed or splashed onto the skin, or if they wear clothes soaked with chemical. By injection through the skin Poisons can be injected through the skin from a syringe, or a pressure gun, or during tattooing, or by the bite or sting of a poisonous animal, insect, fish or snake. The injection may go directly into the blood stream or under the skin into muscle or fatty tissues. Epidemiology Poisoning is divided into accidental poisoning and non accidental or self poisoning. Most cases of accidental poisoning occur within the home. The poisoning agents are usually household agents, medicaments and plant material. General characteristics of poisoning include: 1. Poisoning accidents in the home happen to young children aged between 1 and 4 years with a peak at 2 to 3 years. At this age children want to explore. They can crawl or walk round the house on their own and by the age of 2 they can probably climb onto a chair to reach a high shelf. They can open drawers and cupboards, and they may be able to open screw-top bottles. After the age of five years and particularly in developing countries poisoning often occurs in groups, usually of friends, for example following food poisoning, pesticide and carbon monoxide poisoning. 2. Accessibility of the poisoning agent is the single most important environmental risk factor. Paraffin is the commonest poisoning agent in this region. Children of health workers who have large amount of drugs in the house or siblings of children on chronic treatment with drugs such as anticonvulsants, or major tranquillizers are at increased risk of poisoning 3. Most drug containers in use in the region are easy to open and do not have a child lock 4. Many pediatric drug preparation are sugar coated or sweetened and may be mistaken for sweets. 5. Seasonal variations in poisoning occur. In farming areas it is noted that hospital admission due to chronic heavy metal poisoning occur more in the rainy months probably from increased use of agro-chemicals for farming purposes. Carbon monoxide poisoning is common during the cold season whereby a lighted charcoal burner in a room without adequate ventilation is the usual cause. 6. Illiteracy contributes to the risk of poisoning in that individuals who are unable to read will be unable to follow safety precautions written on the labels of various drugs and chemicals. 7. Inadequate labeling of drugs and chemicals increase the risk of poisoning. It also leads to lack of recognition of poisoning and late institution of appropriate therapy. Unfortunately health workers often fail to label the drugs that they dispense.

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8. Administration of the wrong drug or the wrong dose; for example caregivers may administer different brand names of the same medicine or they may give larger doses than those prescribed with the hope of speeding up recovery. There are instances where health workers have administered the wrong medicine or the wrong dose with a fatal outcome. Non-Accidental Poisoning (Self-poisoning) Self poisoning is usually seen in older children and adolescents suffering from depression, serious illness, or alcohol dependence in an attempt to commit suicide or to attract attention. Non-accidental poisoning is commoner in girls than boys, but the males are more likely to be successful with their suicide attempt compared to females. The agents that are commonly used in suicidal attempts are organophosphates. Consequences of Poisoning The effects of poisoning maybe none, mild or severe depending on: The amount of poison ingested. The nature of the substance The age of the child. The nutritional status of the child. The state of the stomach-whether empty or full of food. The effects of poison The effects of poisons can be local or systemic. A local effect is limited to the part of the body in contact with the chemical A systemic effect is a more general effect that occurs when a poison is absorbed into the body. Local effects On the skin chemicals can cause itching, rash, pain, swelling, blisters or serious burns. In the eye irritant or corrosive chemicals can cause severe pain, burns, scars or even blindness. Irritant or corrosive chemicals may lead to damage in the mouth, throat or inside the stomach. The child will present with abdominal pain, vomiting, diarrhoea, haematemesis and melaena stools. If the throat is burnt it may swell very quickly, so that the child cannot breathe. Inside the air passages and lungs irritation from vapours and gases can cause coughing, choking and lung oedema Systemic effects There are many ways in which poisons can cause harm by damaging organs such as the brain, nerves, heart, liver, lungs, kidneys, or skin. Poisons can also lead to muscle paralysis. When there is acute exposure, the effects happen soon after exposure and do not last very long. But, in some cases, the effects of a poison are not seen for several hours or even days after an acute exposure. Common Substances Causing Poisoning in Children The commonest substances causing poisoning in East and Southern Africa are household chemicals followed by drugs.

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Table II: Substances causing poisoning in children Poisoning agents Example Household Agents Paraffin, Organophosphate pesticides (malathion, diazinon) Carbamate (rat poison), disinfectant, bleach Medicaments Aspirin, paracetamol, Anti-convulsant drugs (carbamazepine, phenobarbitone), Haematinics (iron and vitamins) Major tranquilizers (phenothiazines) Some herbal therapies Plants Mushrooms, datura stramonium (the young leaves being confused with amaranthus leaves) Food and beverages Alcohol, Herbal teas (crotalaria, heliotropium) Aflatoxins on inadequately stored grains Cyanide in incompletely cooked cassava leaves, Contaminated food stuff (Botulism, salmonellosis) MANAGEMENT The management of the poisoned child is at two levels; at home where first aid is administered and in the hospital where specific treatment is given. First aid at home First aid treatment should be administered by the person who finds the child after the poisoning episode. Care should be taken so that the first aid treatment does not cause severe complications that may be worse than the original poisoning. The aim of the first aid is to remove the poison before it is absorbed or to delay or stop the continued absorption of the poison. 1. The mother or the care provider should give a lot of fluids, for example milk or milk mixed with raw egg to induce vomiting. Administering milk mixed with raw egg provides proteins that readily bind the poison. Saline solutions should be avoided because they lead to electrolyte imbalance. 2. Children who are poisoned by paraffin or a corrosive agent should not be made to vomit.

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3. Containers of medicines or poisons should be brought along to the hospital for identification. Treatment in hospital The clinician should take a brief history, examine the child thoroughly and rapidly and then do the following: 1. Ensure a clear airway and support respiration. 2. Treat shock if present. 3. Remove poison from the body before it is absorbed, by inducing vomiting or doing a gastric lavage except when kerosene or a corrosive has been ingested. 4. Reduce absorption by administering activated charcoal which absorbs many toxins and prevents subsequent absorption. 6. Anti-dotes should be used but these are available for very poisons. 7. General supportive measures are important to ensure adequate hydration, temperature control, fluid and electrolyte balance, nutrition intake and control of convulsions and cardiac arrhythmia. Table III: Antidotes to some poisoning agents. Poisoning agent Antidote Heavy metals Dimecaprol (BAL), EDTA Iron Desferrioxamine Narcotics Naloxone Nitrites and nitrates Methylene blue Phenothiazines Diphenyhydramine (Benadryl) Organophosphates Atropine PARAFFIN (KEROSENE) POISONING Paraffin poisoning is the commonest type of poisoning in children in east and southern Africa. Paraffin is a common household agent used as a fuel for cooking and lighting. It is commonly stored in beverage bottles and children ingest it thinking it is a beverage. Paraffin poisoning should be suspected from the history or the smell of paraffin on the child’s breath. Small amount of paraffin cause minimal symptoms. A 10 ml dose may be fatal. A dose of 1 ml/kg causes central nervous system (CNS) depression which manifests as drowsiness and coma. A history of coughing, choking, wheezing and fast breathing as well as vomiting is suggestive of aspiration resulting in a hydrocarbon pneumonia that takes several weeks to resolve completely. Weakness, dizziness, headaches and coma also occur. An acute hemorrhagic necrotizing disease has been described, evolving over 24 hours and resolving spontaneously over 3-5 days. Management of paraffin poisoning

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1. Induction of emesis is contra-indicated because it facilitates the aspiration of paraffin into the lungs. 2. In severe poisoning a cuffed endo-tracheal tube is used to aspirate the poison from the stomach. 3. All children presenting with a history of paraffin poisoning should be observed in hospital for 6 to 24 hours. 4. Supportive care, including oxygen and mechanical ventilation, should be given as needed. For repeated fits diazepam should be given by intravenous injection. ORGANOPHOSPHATE POISONING Organophosphates are commonly used pesticides. Poisoning can occur as a result of inhalation, skin contact or through ingestion. Organophosphates are ingested accidentally by children or deliberately by adolescents. Children working in the agro-industry maybe exposed to inhalation during the spraying of crops such as coffee. The symptoms of organophosphate ingestion occur within 30-60 minutes. Mild poisoning presents with anorexia, and tremors of the tongue and eye lids, while the older child may complain of impaired vision, headache, dizziness, weakness, anxiety, and substantial discomfort. Moderate poisoning is characterized by nausea, salivation, tearing, abdominal cramps, vomiting, slow pulse and muscular fasciculation. Severe poisoning presents with severe diarrhoea, difficulty in breathing, pinpoint and non reactive pupils, pulmonary oedema, coma, hyperglycemia, and rarely acute pancreatitis. Treatment of organophosphate poisoning Treatment depends on the severity of the poisoning; in a severely poisoned child the priority should be to establish an airway, administer oxygen, reduce respiratory secretions through suction, and control convulsions if present. Specific treatment: 1. Administer atropine until atropinization is achieved - pupils become fully dilated and the mucus membranes become dry. The dose of atropine is repeated 30 minutes until full atropinization. Interruption of atropine has been associated with development of fatal pulmonary edema or respiration failure. The patient should be observed for 3-4 days to ensure that the poison has cleared from the body. 2. Immediately remove contaminated clothes, shoes, socks and jewellery. Decontaminate the skin, nails, hair and mucus membranes by washing with soap and copious amounts of cold or lukewarm water for at least 15 minutes. Be careful not to get any of the chemical on your own skin or clothes, or to breathe in vapours. `Gastric lavage or vomiting should be induced if no symptoms have appeared.

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3. Give activated charcoal to absorb any organophosphate that may be in the gut. 4. Administer the specific antidote-PAM 1 mg in aqueous solution through a slow intravenous infusion. This drug should be given after achieving full atropinization. The drug can be repeated in 30 minutes but can only be given twice in a 24 hour period. This drug is only useful in the first 24-48 hours after an episode of poisoning. It can be given intramuscularly if an intravenous dose cannot be given. Obidoxime chloride can be used if pralidoxime is not available. ASPIRIN (SALICYLATE) POISONING Accidental aspirin poisoning is common in young children. The poisoning is suspected if the child has a history of ingesting aspirin containing tablets or multiple drug therapy by the mother with different generic forms of aspirin. Acute on chronic salicylate poisoning may occur in children on chronic treatment with salicylates. Aspirin uncouples oxidative phosphorylation which results in excess heat production, excess sweating leading to dehydration. Aspirin interferes with glucose metabolism resulting in hyper-or hypoglycaemia. The patients often present with hyperventilation, sweating, dehydration, and sometimes diarrhoea and vomiting. In moderate poisoning the respiratory centre is stimulated resulting in respiratory alkalosis to which the kidney responds by producing alkali and in the process K+ is depleted and H+ is substituted resulting in acidic urine. Aspirin poisoning causes metabolic acidosis in the young child that is classified as mild (blood pH>7.4 and urine pH>6.0), moderate (blood pH<7.4 and urine pH<6.0,) and severe (blood pH<7.4 and urine pH is <6.0) In severe cases convulsions and coma occur. Older children may present with vomiting, hyperpnoea, lethargy, tinnitus, and sudden deafness. Management of salicylate poisoning 1. Emesis followed by a gastric lavage using a wide bore gastric tube should be carried out. Salicylates have been recovered in the gut up to 20 hours after ingestion. 2. To prevent further absorption of ingested salicylates, activated charcoal should be administered every 4 hours until charcoal appears in the stool. 3. Serum electrolytes, especially Potassium and Bicarbonate, as well as serum and urine pH should be monitored. Urine pH is easily monitored in the side- lab using urine dipsticks. 5. Mild aspirin poisoning can be managed successfully with oral fluids. Oral rehydration solution (ORS) is ideal in that it provides at least 30meq/I of

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Bicarbonate and 20meq/l of K+. Urine pH and that serum salicylate should be monitored. 6. Moderate poisoning presents with moderate dehydration and depletion of urinary

Potassium. Treatment should be started immediately with ORS using the protocol of moderate dehydration. I/V fluids should be administered in addition to maintain a urine flow of 3-5 ml/kg/min and a urine pH>7.0. An isotonic fluid with Bicarbonate constituting half the electrolytes should be used. Once hydrated, the fluid can contain more free water and 40meq of K+ per liter of fluid.

7. Severe poisoning is characterized by severe dehydration. Rehydration should be

carried out and hypokalemia corrected by giving Bicarbonate 0.5-2.0 meq/l over the first 6-8 hours and K+ 1.40 meq/l. The urine will not become alkaline until K+ is administered. An acid pH limits salicylate excretion in the kidney leading to a prolonged half life. A urine flow of 3-6 ml/kg/min should be maintained.

8. If the patient is able to take fluids orally ORS, orange juice, bananas and milk are useful in alkalinizing urine. 1.5g of KCL may be added to 1 liter of ORS to increase the K+ content to 40 meq/liter. 9. Vitamin K should be administered to prevent possible haemorrhage. 10. Haemodialysis is indicated in patients presenting with renal failure or pulmonary oedema. 11. For repeated fits, diazepam should be given by intravenous injection. IRON POISONING Iron poisoning in children is related to the availability of iron containing tablets in the house. Severe iron poisoning will depend on the amount of elemental iron that is absorbed. Five stages of intoxication occur: haemorrhagic gastroenteritis 30-60 minutes after ingestion of the iron and maybe associated with shock, acidosis and coma. This phase lasts 4-6 hours. Phase of improvement when patient looks better and lasts 2-12 hours. Phase of delayed shock that occurs 12-48 hours after ingestion and is usually associated with a serum iron level of>500mg/dl. Metabolic acidosis, leukocytosis and coma may occur; there may be hyperglycaemia at first and hypoglycaemia later. Liver damage with hepatic failure. Residual pyloric stenosis that usually develops 4 weeks after the initial poisoning. A plain abdominal x-ray will demonstrate the un-absorbed tables in the stomach. Diarrhoea, vomiting, leucocytosis (>15, 000µL), hyperglycemia, and a positive abdominal x-ray have been shown to correlate positively with a serum iron of>300µg/dl.

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Management of iron poisoning 1. Emesis and gastric lavage using a large bore nasogastric tube should be carried out. 2. Do not give activated charcoal because it does not bind iron. 3. Desferrioxamine should be given to all patients with signs and symptoms of severe poisoning such as shock, unconsciousness, convulsions, severe vomiting or acidosis, or a serum iron concentration greater than 5 mg/l. It can be given intramuscularly or intravenously. PREVENTION OF POISONING 1. Safe storage of drugs and household agents, out of reach of children and preferably under lock and key. 2. Safe packaging of drugs and chemicals in unattractive colours in child safe containers. 3. Containers of food and beverages should not be used to store drugs or harmful chemical agents. 4. Health workers should give health education on safe use of drugs dispensed to patients. 5. Unused medication should be disposed of. 6. Chemicals and drugs should be clearly labeled with the pharmacological or chemical names. There should be clear indications of their use, safety precautions relating to handling and storage as well as some information on their toxicity and anti-dotes, whenever available. Drugs which are dispensed in hospitals should be clearly labelled, with the strength of the preparation and frequency of administration indicated. 7. Public education on safe handling of agro-chemicals. This should include the use of protective clothing, storage of agro-chemicals and disposal of empty containers by burying. 8. Manufacturers should be encouraged to pack agro-chemicals in small packages to meet the needs of the peasant farmers. The containers should be clearly labeled indicating contents, safety precautions and disposal, in the commonly used language. 9. Non accidental poisoning is a psychiatric emergency that can be prevented by developing good communication and a supportive environment for the adolescents within the family.

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SNAKE BITES Snake bites are common in rural, peri-urban and hilly areas. Children and adolescents engaged in outdoor play are the most vulnerable group. Most snakes are non-poisonous. However the mambas, viperidae (true vipers) and afro-asian cobras are some of the deadliest snakes. It is important that the health workers be familiar with the common snakes in the area and their physical appearance in order to determine whether the attacking snake is poisonous or not. All snake bites should be considered potentially dangerous and urgent treatment should be instituted. Snake bites are more serious in the children because of the relatively large volume of venom injected into the small volume of a child. The snake bite victim is usually frightened and unable to give history. Examination of the wound is useful since bites by non poisonous snakes lack distinct fang marks and there is no swelling or pain. Clinical features of a poisonous snake bite - Bite site: pain, swelling, tissue discoloration and regional lymph node swelling. - Hemorrhagic symptoms: bleeding at the wound site, venipuncture sites, epistaxis and bleeding in other body parts is pathognomonic of a snake bite. - Danger signs: drowsiness, slurred speech, excessive oral secretions, difficulty in breathing and coma. Management of snake bites First aid When a patient has been bitten on the extremities a tourniquet should be applied proximally. The tourniquet should be tight enough to occlude venous and lymphatic return BUT PRESERVE THE PULSE. The involved limb should be immobilized and kept in a slightly elevated position. Cold packs should not be applied on the limb and maybe harmful. The patient should be kept quiet and transferred to a hospital immediately. If transportation is not immediately available an incision (1 cm length and 0.5 cm depth) should be made between the fang marks after cleaning the area. The flow of blood helps to wash the toxin away. Hospital management 1. Excise a block of skin and subcutaneous tissue 1 cm around the fang marks if a dangerous snake was involved and the bite was within 2 hours. 2. An intravenous line should be established to enable administration of emergency drugs as the need arises. 3. Tetanus toxoid should be administered to all patients with a snake bite. 4. A full blood count should be carried out. 5. Blood should be grouped and cross matched in readiness for a transfusion. 6. Paracetamol may be given for pain 7. If the wound becomes infected, treat with antibiotics 8. Rapid spread of swelling and progress of symptoms is indicative of the need to administer anti-venom. Anti-venom should be administered as per the manufacturer’s instructions. On average children need 50% more anti-venom than adults.

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REFERENCES 1. World report on road traffic injury prevention. World Health Organization. 2004 2. Ogden KW.Safer roads. A guide to road safety engineering. Melbourne, Ashgate Publishing Ltd, 1996. 3. Reece R.M. and Godin M.A. Injury and injury prevention. Pediatric Clinics of North America, 1985, 42-60 4. Bwibo N. Poisoning and accidents in Diseases of children in the tropics and subtropics. Eds Stanfield P, Brueton M, Chan M, Waterston T.ELBS Edward Anorld, Hodder and Stoughton, Kent, UK. 5. Baures P. The management of the road traffic victim. Post graduate doctor. June 1984. vol. 6 page 174. 6. Hendrickse R.G; Aflatoxins and Kwashiorkor in children in Africa. Post graduate doctor 1985. vol. 7, No.11, page 348. 7. Dreisbach RH. Handbook of poisoning, eleventh edition. Lange medical publications 1983, Los Altos, California. 8. Management of Poisoning: A handbook for health care workers. World Health Organization, Geneva, 1997 9. Watt CH. Poisonous snake bites treatment in the United States. JAMA 1978;140 (7):654-6 10. Oloo MA. Prevalence study on accidents in persons under twenty years of age in Marigat Division, Baringo. MMed (Paed) Dissertation, University of Nairobi. 11. Yuko AC and Kitili PN. A prevalence study of accidents and poisoning in persons under 20 years of age in a Nairobi slum, Kibera, Laini Saba. Unpublished manuscript, Department of Paediatrics, University of Nairobi. 12. Rumack BH. Poisoning in Current Paediatric diagnosis and treatment.8th edition.Ed. Kempe CH, Silver HK, O’Brien D. Lange Medical Publications, Los Altos, California.

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CHAPTER 17 CARDIOVASCULAR DISEASES IN CHILDHOOD

Christine Yuko-Jowi, Gabriel Anabwani The commonest childhood cardiovascular problems are congenital and rheumatic heart diseases. These two causes account for the majority of patients being seen with heart disease in most east and southern African countries. Congenital heart diseases are malformations of the heart and blood vessels which are present from birth. Rheumatic heart disease results from an inflammatory process of the heart following upper respiratory infection by beta haemolytic streptococcus. Less common causes of heart disease in children include viral myocarditis and pericarditis, connective tissue diseases, Kawasaki’s disease, tuberculous pericarditis and heart disease due to nutritional deficiencies. CONGENITAL HEART DISEASES Eight of every thousand children who are born alive have congenital heart malformations which account for up to 33% of all deaths during the entire neonatal period. The majority of these defects are likely caused by chance errors during the development of the cardiovascular system. However, some congenital lesions have been linked to genetic, environment factors. Majority of patients with critical congenital heart disease will present during the first year of life. About a third of children with congenital heart disease has mild heart abnormalities and never requires any treatment. Therefore it is important to identify congenital heart disease early and to refer affected children for specialist care. How Can One Identify Functionally Important Heart Diseases In Infants And Children? Suspect congenital heart disease in any newborn, infant or child who presents with any of the following symptoms: Cyanosis (blue discoloration of lips, tongue or hands) Fast breathing (tachypnoea) Laboured breathing Feeding difficulties Failure to gain weight Sweating Pallor Irritability and Lethargy Older children may complain of shortness of breath with exercise, fatigue, dizziness or palpitations. Chest pain and syncope may be associated with lesions that obstruct the flow of blood. History may reveal evidence of poor maternal health such as diabetes or chronic alcohol or drug use.

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How does one examine a child with a suspected heart problem? The traditional examination format of inspection, palpation, percussion and auscultation should be followed. Initial rapid assessment should include the following three steps; Step 1: Assess whether the infant or child is acutely ill or potentially stressed and therefore in urgent need for referral for further investigation and management Step 2: Check if the infant cyanotic or Acyanotic. Step 3: Assess if the patient is outwardly well, has minimal symptoms or is asymptomatic What should one look for during inspection? A lot of information can be gained from initial inspection before the child is disturbed. A sick infant with a heart problem often appears anxious, may have pallor, sweating, tachypnoea and dyspnoea. The infant might be hungry for air, dislikes being handled and even tolerates handling poorly. During inspection the respiratory rate should be counted. Is there skin pallor to suggest low output? Is the infant cyanotic or acyanotic? Is there evidence of finger clubbing? Is there periorbital oedema or jaundice? Is the precordium abnormally shaped? Are there any dysmorphic features? What should one look for during palpation? Pulses are assessed for rate, rhythm, volume and character. The criteria for tachycardia is a heart rate of more than 150 beats per minute in a resting infant and more than 120 beat per minute in the child. Jugular venous pressure: This examination is reliable in an older child where it is indicative of high right side pressures. The apex beat: The position and character of the apex beat should be noted since it helps to assesses ventricular hypertrophy and/or dilatation. In young infants or child the apex beat is normally at the 4th intercostals space along the midclavicular line. When the left ventricle is dilated the apex beat is displaced downward and inferiorly and is hyperactive. An apex beat which is on the right side may indicate dextrocardia or malposition of the heart. Parasternal heave: Is felt along the left sternal edge. A hypertrophied right ventricle produces a parasternal tap. When it lifts the hand is suggestive of right ventricular dilatation. Thrill: Is a palpable murmur and is indicative of a loud murmur. The precordium, suprasternal and carotid areas should be palpated for thrills. Hepatomegaly: Is the hallmark of systemic congestion in an infant. The normal liver in an infant may be palpable 2 to 3 cm below the right costal margin. When enlarged the liver is palpable more than 3 cm below the right costal margin, and may be tender.

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PERCUSSION: Percussion of the chest is an important part of a respiratory examination but is of limited value in a cardiac examination. What should one look for during auscultation? Auscultation of the normal heart has to be learned over a period of time in order to appreciate abnormal auscultatory findings. It is necessary to achieve a quiet environment during cardiac auscultation. Any abnormal findings on auscultation should be referred. Heart sounds: A loud first heart sound is associated with mitral stenosis. A fixed split second heart sound is associated with atrial septal defects. The second heart sound may be loud in severe pulmonary hypertension whereas it may be soft or inaudible in pulmonary valve stenosis. Murmurs: Are usually the main reason why paediatric patients are referred to hospital for cardiovascular assessment. Murmurs may be systolic, diastolic or continuous. Types of Congenital heart disease For simplicity these lesions are generally divided into acyanotic and cyanotic congenital heart disease. The acyanotic lesions may be due to communications between the left and right side of the heart leading to increased blood flow to the lungs and include ventricular septal defects, patent ductus arteriosus and atrial septal defects. Lesions which obstruct the flow of blood pulmonary valve stenosis aortic valve stenosis and coarctation of aorta. Common cyanotic congenital heart diseases include the “5T s” Tetralogy of Fallot, Transposition of the great vessels, Tricuspid atresia, truncus arteriosus and Total anomalous pulmonary venous return. Investigating congenital heart disease Chest X-ray- useful in demonstrating cardiac shape and size, and in assessing the pulmonary vasculature. The pulmonary vasculature is increased in left to right shunt, decreased in right to left shunts. Twelve lead electrocardiogram- this can demonstrate heart rate and rhythm, and chamber enlargement. Two dimensional echocardiogram and colour flow maps- this is currently the main tool in diagnosing congenital heart diseases- in terms of the type of malformation and the heart function Diagnostic cardiac catheterizations – this is useful in assessing the anatomy in complex congenital heart diseases and in some situations special catheters are used to treat some diseases. Common Examples of Congenital Heart Disease Ventricular Septal Defect (VSD) A VSD is a defect in which opening exists between the two ventricles. This is the most common form of congenital heart disease comprising of 30%. A VSD can exist as an isolated lesion (simple VSD) or in association with other lesions as part of a more complex cardiac malformation. Small isolated defects may be asymptomatic. Larger

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lesions present with frequent chest infections, failure to grow and tachycardia. In the absence of pulmonary hypertension the second heart sound is normal on auscultation. A long or pansystollic murmur is heard best along the lower left sternal border. A chest radiograph shows cardiomegaly with increased pulmonary vascular markings. An electrocardiogram shows left ventricular hypertrophy when the VSD is large. Two dimensional Echocardiogram is the best tool used to diagnose the type and size of VSD, and any associated complications. Cardiac catheterization may be useful in assessment of pulmonary pressures in selected patients. Small or moderate VSDs may close spontaneously. However, large VSDs can cause irreversible complications or heart failure and are treated by surgical closure. Figure 1 is a two dimensional picture of a VSD. Figure 1: A VSD as shown on two dimensional echocardiography. Pulmonary Valve Stenosis (PS) Pulmonary stenosis or narrowing is the second commonest type of congenital heart disease comprising of 20-40% of congenital heart defect cases and causes obstruction of blood flow from the right ventricle to the pulmonary arteries and lungs. It is commonly associated with maternal rubella, maternal warfarin therapy and Noonan’s syndrome. Pulmonary valve stenosis presents with a soft second heart sound and an ejection systolic murmur along the left upper sternal border. The mild cases are usually asymptomatic while severe stenosis presents with right heart failure. A chest radiograph may show right ventricular hypertrophy with normal pulmonary vascular markings. An electrocardiogram shows right ventricular hypertrophy PS is severe. Two dimensional echocardiogram with colour flow Doppler is the best tool used to confirm the diagnosis of PS and any associated complications. The treatment of choice is through therapeutic cardiac catheterization involving balloon dilatation of the valve.

LV

RV VSD

LA

AV

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Figure 4- cardiac catheterization picture showing balloon dilatation of the pulmonary valve.

Atrial Septal Defects (ASD) This is defect in which an opening exists between the left and right atriums (the upper two chambers of the heart). Because pressures are higher in the left atrium, blood returning from the lungs is shunted from the left atrium to left right atrium from where it goes back to the lungs. The defect can occur in isolation (simple ASD) or in association with other congenital heart defects. ASDs are commonly asymptomatic, the only clinical sign being a fixed split second heart sound on auscultation. A systollic murmur is best heard best along the upper left sternal border. A chest radiograph shows right ventricular cardiomegaly with increased pulmonary vascular markings. An electrocardiogram shows right ventricular hypertrophy when the ASD is large. Two dimensional Echocardiogram is the best tool used to diagnose the type and size of ASD, and any associated complications. Cardiac catheterization may be useful in assessment of pulmonary pressures in selected patients. Chest pains, palpitations, arrhythmias and heart failure present late presentation, often in adult life. When diagnosed early, surgical repair or balloon occlusion should be performed electively before school age at 4-5 years. Patent Ductus Arteriosus (PDA) The patent ductus arteriosus is a communication between the aorta and the pulmonary artery at the level of the aortic arch. It remains open in the intrauterine period and is useful way by which blood bypasses the non-functional lungs to reach the aorta. In normal full term infants it closes immediately or soon after birth. In preterm infants, it is commonly open but may but may close if it is small. If it fails to close then its persistence leads to heart disease. The clinical presentation includes bounding or full

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pulses and continuous murmurs along the left upper sternal border. A chest radiograph may show cardiomegaly with increased pulmonary vascular markings. An electrocardiogram shows left ventricular hypertrophy when the PDA is large. Two dimensional echocardiogram with colour flow Doppler is the best tool used to confirm the diagnosis of PDA and any associated complications. Cardiac catheterization may be useful in assessment of pulmonary pressures in selected patients. Treatment is by surgical ligation or occlusion using special devices as soon as the diagnosis is made. Untreated PDA can lead to congestive cardiac failure, pulmonary hypertension and is prone to infective endocarditis. Figure 3- Catheterization diagram of a patent ductus arteriosus.

Coarctation of the Aorta (CoA) CoA involves narrowing of the aorta that causes obstruction to the flow of blood through the aorta outside the heart after it has given branches to the head and neck. It is diagnosed clinically at the bedside by palpating high volume pulses in the blood vessels of the upper extremities and lower volume pulses in the legs. The upper limbs have a higher blood pressure while the lower extremities have low blood pressures. Patient may present with severe headaches, stroke due to bleeding inside the brain and heart failure. The diagnosis confirmed by echocardiography and cardiac catheterization. Treatment is by surgical repair of the narrow segment and sometimes this segment can

PDA

MPA

AO

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be dilated using balloons and stents during cardiac catheterization.

Cyanotic Congenital Heart Disease These congenital malformations are complex and associated with morbidity and mortality during the neonatal period. They present with central and peripheral cyanosis. Tetralogy of Fallot This is the commonest type of cyanotic congenital heart disease, presenting with cyanosis and a systolic murmur within the first month of life. This abnormality has four basic components: a large ventricular septal defect, pulmonary subvalvar and valve stenosis, overriding aorta and right ventricular hypertrophy. The patients can sometimes present with extreme cyanosis and hyper cyanotic or “tet” spells. Hyper cyanotic spells can be life threatening and often need urgent recognition and management. Management of the spell includes putting the child in knee chest position, giving intravenous fluids to improve on the hyper viscosity, propranolol to improve the infundibular spasms and peripheral resistance. Morphine and sodium bicarbonate may be indicated in severe states. Treatment of tetralogy of Fallot is surgical , either palliative by putting a Blalock-Tausig (BT) shunt, or total correction through open heart surgery to resect the pulmonary infundibular and close the VSD using a patch. RHEUMATIC HEART DISEASE Epidemiology The first attack of acute rheumatic fever is likely to occur between the young school ages of 5-15yrs. Crowding from inadequate housing, crowded classrooms and dormitories is probably the main risk factor in acquiring streptococcal pharyngeal infection and resulting in acute rheumatic fever. There is no difference in sex, race or ethnic susceptibility to acute rheumatic fever. Rheumatic fever does not follow group A streptococcal infections from other sites such as pyoderma. Proper treatment of acute

Aortogram showing coactation of the aorta

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pharyngitis virtually eliminates the risk of acute rheumatic fever; lack of access to good medical care remains a risk factor to developing ARF. Although the prevalence of acute rheumatic fever appears to be declining even in developing countries, the profile of the disease appears to be changing, now running a sub acute course and the severity of the cardiac process has not ameliorated. Aetiology and Pathology Rheumatic heart disease follows an untreated throat infection by group A beta-haemolytic streptococcus usually after a latency of two to three weeks. It is believed that the infection precipitates an acute rheumatic fever, an autoimmune diffuse inflammatory disease of connective tissue involving chiefly the heart, joints, brain, blood vessels and subcutaneous tissues. The major importance of acute rheumatic fever comes from its involvement of the heart. As the valves heal from the rheumatic process, there is thickening, fibrosis and shortening of the leaflets leading to regurgitation (leaking) and Stenosis (narrowing of the valves). The most affected valves in the heart are the mitral and aortic. The tricuspid and pulmonary valves are rarely involved. Clinical Presentation and Diagnosis Physical findings of acute rheumatic fever can be non-specific and misleading. Therefore, a high index of suspicion is required for diagnosis. The most commonly used criteria for diagnosis of rheumatic fever are the modified Jones criteria shown below. Two major criteria or one major plus two minor criteria plus evidence of recent streptococcal infection are required for definitive diagnosis. Major Criteria Minor criteria Carditis Previous rheumatic fever Arthritis Arthralgia Chorea Fever Erythema marginatum Acute phase reactants Subcutaneous nodules First degree atrioventricular block c) Evidence of previous streptococcal infections: Raised ASOT titers Positive throat cultures Recent scarlet fever

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Differential diagnosis Fever and arthritis must be differentiated from other conditions causing polyarthritis in children like juvenile rheumatoid arthritis, infective endocarditis, sickle cell anaemia, and immune complex disease. Carditis and heart murmurs must be excluded from functional murmurs, mitral valve prolapse, viral myocarditis and congenital heart disease. Arthritis Arthritis is the earliest and most common clinical feature which is present in approximately 80% of patients. It presents as a painful migratory arthritis involving large joints such as knees, ankles, elbows, or shoulders. The migratory polyarthritis is usually associated with fever. The arthritis of RF rarely affects the small joints of the fingers, toes, or spine; and the arthritis rarely causes permanent joint damage. Carditis Signs of carditis may include persistent tachycardia, a heart murmur which was not present previously due to valvulitis; a pericardial friction rub (due to pericarditis) and cardiac enlargement (due to myocarditis) Progressive congestive heart failure, a new is the most lethal manifestation. Mitral and aortic regurgitation are the common valvular damage during the acute process. Sydenham chorea Presents as involuntary, uncoordinated purposeless movements that occur one to six months after the initial streptococcal pharyngitis. Sydenham’s chorea is self limiting and recovers without neurological sequelae. This type of chorea is now rare seen. Erythema marginatum This presents as none-itchy patches of pink rashes with sharp border, which may eventually spread into each other that are often seen on the inner thighs. Erythema marginatum is strongly associated with the development of heart complications. Subcutaneous nodules Subcutaneous nodules present as bumps the size of peas under the skin. These nodules most commonly occur over the knees and elbows and over the spine. These nodules are non-tender and feel hard to the touch. Subcutaneous nodules are strongly associated with the development of cardiac complications. Unusual presentations, such as indolent carditis and isolated chorea, may also occur. Even rarer manifestations include epistaxis and abdominal pain due to serositis.

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Figure 1-Two dimensional echocardiogram Parasternal long axis showing thickened and clubbed mitral valve leaflets and dilated left ventricle.

Treatment and Prevention of Acute Rheumatic Fever Primary prevention involves prompt treatment and eradication of group A streptococcal pharyngitis in order to prevent the development and progression of ARF. In those already diagnosed with acute rheumatic fever or rheumatic heart disease, secondary prevention is indicated. In patients who are allergic to penicillin erythromycin should be used. The dosage and mode of administration are shown in the table below. Table: 1 Antibiotics used in secondary prophylaxis of Rheumatic Fever

Antibiotic Mode of Administration

Dose

Benzanthine penicillin

Single I/M monthly

1.2 mega units if wt>30kg

Single I/M monthly

600,000 units if wt < 30kg

Penicillin V Oral 250mg BD Sulphonamide Oral 1gm daily if

wt>30kg 500 mg daily if

wt<30kg Erthromycin Oral 250 mg twice daily

An important consideration is how long one should give secondary prevention for RF/RHD. The WHO recommendation is shown in the table below: Table: 2 WHO recommendation for secondary prophylaxis of Rheumatic Fever

Category of Patient Duration of Prophylaxis Patients without proven carditis Or those with mild or healed carditis

10 yrs after last attack

More severe valve disease Life Long After valve surgery Life long

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Other therapeutic measures Rest: Patients with carditis should have bed rest until the signs of cardiac inflammation have subsided. Antinflamatory agents: Acetyl salicylic acid (Asprin) has dramatic effect on arthritis but has no effect on carditis. High doses are used (70-100 mg/kg). Corticosteroids are used in patients with carditis. Prednisone 1-2mg kg/day divided in one or two doses for two weeks and tapered over a week. For Sydenham’s chorea Haloperidol 0.5- 1mg /kg (maximum dose 5mg) until symptoms are controlled. Prolonged treatment may be required in some patients especially those with recurrent symptoms. Heart failure may occur in severe carditis or rheumatic valvular disease. Patients with heart failure should managed with oxygen, rest, fluid restriction, furosemide (1-2 mg/kg per day) and digoxin 0.125 mg od. Patients with heart failure as well as those with carditis or cardiac complications should be referred for specialist care. Chronic Rheumatic Heart Disease Chronic rheumatic heart disease results from fibrosis or scarring of the myocardium and heart valves. Fusion of the valve apparatus result in stenosis or a combination of stenosis and insufficiency. Fusion occurs at the level of the valve commissures, cusps, chordal attachments, or any combination of these. Rheumatic heart disease is responsible for 99% of mitral valve stenosis. Recurrent episodes of RF lead to progressive damage to the valves. Associated atrial fibrillation or left atrial thrombus formation from chronic mitral valve involvement and atrial enlargement may be observed. Severely damaged valves may need valve replacement or repair.

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CHAPTER 18

COMMON SKIN DISEASES IN CHILDREN

Samuel Ayaya, Amos Odiit, Esther D. Mwaikambo INTRODUCTION The skin is the largest organ in the body. It protects us from the environmental hazards such as ultraviolet light and infections among other functions. Skin problems are common. Many of these problems never present at health care facilities as the parents may think they are minor and indeed some of the heal without treatment. Usually by the time a child is brought to a health facility there are either multiple lesions or have the lesions have not responded to home care remedies. Skin lesions may be part of a systemic disease or an allergic reaction. HIV/AIDS which presents with skin diseases in over 90% of the cases has increased the prevalence of skin conditions. The purpose of this chapter, therefore, is to enable the student understand basic dermatological terminology, recognize common skin diseases in children and adolescents and treat them. Objectives: At the end of this chapter, the student should be able to: Define and identify primary and secondary skin lesions. List the common skin diseases seen in children. Recognise common skin diseases. Understand common dermatological investigations. Treat the common skin diseases. Use topical steroids rationally. Learning Experiences: Visit the dermatology clinic in your Medical School. Watch Kodachrome slides of skin diseases. Or use a dermatological atlas preferably based on the dark skin. Clerk patients with skin diseases. Attend some practical sessions in the Department of Microbiology to perform some of the tests. Attend sessions in the Department of pathology to observe the histology of the skin diseases. Primary and Secondary Skin Lesions To identify a skin lesion one has to consider the following about the lesion: Whether there is colour change. The lesion is raised or flat.

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Contains fluid or not. Type of fluid is in the lesion. Widest diameter of the lesion ( < 1cm ). Definition of Primary Skin Lesions These are the lesions that occur when the skin disease starts, without interference by a physical activity. They include: Macule - Flat lesion that measures 1cm or less in diameter. Patch - Flat lesion that measures more than 1cm in diameter. Papule - Elevated lesion that is 1cm or less in diameter and does not contain fluid. Nodule - Elevated lesion that measures more than 1cm in diameter and depth. Plaque - Elevated lesion that measures more than 1cm in diameter, is flat topped without substantial depth. Vesicle - Elevated lesion that measures 1 cm or less and is filled with clear fluid. Bullus - Elevated lesion that measures more than 1cm and is (Blister) filled with clear fluid. Pustule - Elevated lesion that is filled with cloudy or purulent fluid Cyst - Nodule that is filled with expressible material that is either liquid or semi-solid. Petichiae – pinpoint bleeding under the skin Ecchymosis – Widespread bleeding under the skin Definition of Secondary Skin Lesions These lesions result from external interference on the primary lesions such as scratching, drying, etc. They include: Scale - Dry and usually white. Crust - Exudate on the skin that is often moist and yellowish or brow in colour. Lichenfication - Thickening of the epidermis from rubbing or scratching. Is characterized by visible palpable thickening of the skin and accentuated skin markings.

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Fissure - Thin linear tear in the epidermis that usually indicates dry skin. 5. Erosion - Tear in the epidermis that is wider than a fissure. * 6. Ulcer - Defect in the skin that involves the epidermis as well as a part or all of the dermis. 7. Atrophy - Loss of skin tissue. May involve the epidermis making the skin to appear thin and wrinkled. When the dermis is involved there is a detectable depression. N.B: Photographs of these lesions are beyond the scope of this manual but can be found in atlases on skin conditions Common Childhood Skin Diseases These include: Dermatophyte infections of the skin Bacterial skin infections Viral infections Scabies Atopic eczema I. Dermatophyte Skin Infections: Definition: Dermatophytes are filamentous fungi that possess enzymes to digest Keratin. They infect the stratum corneum, hair and nails. Nomenclature: The nomenclature used in diagnosing dermatophyte skin infections is based on the part of the body involved and the fact that the cause was earlier thought to be worms. Hence the prefix, Tinea refers to worm (Latin) and the suffix denotes the part of the body infected. Following Are The Diseases: Tinea capitis - Dematophyte infection of the scalp and the hair of the scalp. scalp. Tinea corporis - Infection of the body. Tinea cruris - Infection of the legs and thighs. Tinea pedis - Infection of the feet. Tinea manuum - Infection of the hands. T. Capitis is the most common dermatophyte infection.

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Aetiology: The fungi that cause dermatophyte infections are grouped in 3 genera namely Trichophyton, Epidermophyton and Microspora. Examples: Trichophyton tonsurans, M. ondini, M. Canis. T. Verucosum and E. Flocosum. Most common cause of T. Capitis is T. Tonsurans. Transmission: These infections are transmitted through sharing of towels, headwear, clothes, beddings, washing basins, soaps and contact with infected person or animal. Predisposing factors include: Overcrowding, low socioeconomic status, poor hygiene and low immunity as in HIV infection. Clinical Presentation: These infections present in various ways depending on the type of infection. On the scalp there may be papules, patches of hair loss, scales, and occipital lymphadenopathy. On the body there will be patches with clear centre and active advancing borders with scales. On the hands and feet there are scales, and interdigital debris. All these may be accompanied with some itch. Investigations: Potassium Hydroxide (KOH) Test is used to diagnose these fungal infections. The lesion is scrapped on the margins if it is on the scalp or the body and the test is done. One sees hyphae. 2. Cultures: Fungal cultures are rarely required. The fungi are cultured on Sabaraund Dextrose agar. Treatment: Generally, T. capitis and T. pedis are treated using oral antifungal drugs. Topical agents are less effective. The other dermatophyte infections can be treated by either oral or topical antifungal agents. Griseofulvin tablets : 15 – 25mg/kg/day for 6-8 weeks. It is given once daily. This is the standard drug for treatment of T. capitis. Ketoconazole : 3.3 – 6mg/kg/day in children, maximum 200mg, OD for 28 days used in the treatment of T. capitis, T. cruris and T. pedis. Terbinafine – 250 mg OD for children over 40 kg, 125mg OD for children 20-40 mg and 62.5mg for children < 20 kg for 2-4 weeks. Used in the treatment of T. Capitis, T. manuum and T. pedis.

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Itraconazole – 3-5mg/kg/day for 4-6 weeks used in T. capitis. Topical antifungal drugs are useful in T. corporis, T. cruris, T. manuum. They include Whitfield’s, imidazoles, and tolfenate among many. 2. Bacterial skin infections There are several skin diseases that are caused by bacterial and present with pustules and blisters A) Impetigo: Definition: Superficial skin infection caused by gram positive bacterial usually S. aureus This is very common in children. Clinical features: Starts as a single superficial lesion which is usually ignored by the parent until multiple lesions occur. Other family members may be affected. The child may have atopic eczema as well. Most common lesion is a honey coloured crust (honeycomb appearance) without ulcerations or erythema. Removal of the crust leaves an erosion Lesions are mostly distributed on the face Diagnosis is usually is usually clinical Treatment 1. Topical antibiotics e.g. bacitracin (neosporins) and bactroban (mupirocin) are used for small lesion. Systemic antibiotics are preferred where the lesions are large. Use a penicillinase resistance antibiotics e.g. Dicloxacillin or oral erythromycin Older children give 250mg qid for 7-10 days, younger child and infants give 30mg/kg/day in for divided doses for 7-10 days B). Pyoderma (Ecthyma) Definition – bacterial skin infection caused by group A, Beta haemolytic streptococcal infection. Clinical features: Discrete vesicles which become pustular and covered by a crust Removal of the crust exposes an ulcer. Lesions are surrounded with erythema and are usually found in the lower extremities. Can occur after scratch or insect bites Complications Acute glomerulonephritis may follow streptococcal but not staphylococcal infection. Treatment As in impetigo but soak the lesions with either soap and water or an antiseptic before applying the topical antibiotic. Systemic antibiotics are recommended because of the renal complication

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3. VIRAL INFECTIONS With the advent of HIV/AIDS, there has been an increase in viral infections. Viral infections present with vesicles, blisters and growths. They have no cure. Aetiology There are 3 DNA viral families that commonly cause skin diseases. These are: a) Herpes: Herpes simplex virus (HSV), Herpes zoster (shingles), and Varicella zoster (chicken pox) b) Parpovirus : Human papilloma virus c) Pox: molluscum contagiosum Pathogenesis These viruses are transmitted through direct inoculation into the skin except for varicella/zoster which is spread initially through respiratory system by inhalation. They penetrate the epidermal cells where they replicate. Their location in the skin determines the lesions produced Warts and Molluscum contagiosum replicate in the keratinised cells (upper epidermis) leading to hyperplasia and appear as growths HSV replicates in hours, devastates the cells leading to lysis and death of the host cells with formation of vesicle. Herpes simplex There are two types: HSV-1 which causes oral infection or perioral infection and HSV-2 causes genital infection. 90% of oral infections occur in children while most of the genital infections are in post pubertal individuals after sexual exposure. Finding of genital HSV in a young child suggests sexual abuse. Clinical features There is usually a prodromal itching and pain at the site of the lesion. This is followed by appearance of vesicles that are grouped. The vesicles are mostly found in the perioral region in children. Vesicles rupture, weep and crust. Healing occurs within one week. Diagnosis is usually clinical. Treatment Acyclovir is the drug of choice. It is available as a topical and oral preparation. 1. Topical – 5% acyclovir ointment is used in the treatment of initial genital herpes and localized peri-oral infection 2. Oral acyclovir is used in treating primary and recurrent infections 3. Intravenous Acyclovir is used in severe infections in immunocompromised patients Herpes Zoster (Shingles) Definition – these are intra-epidermal, vesicular eruption along the dermatomes. Cancer and AIDS patients have higher incidence of 8-25% Incidence – 10-20% of individuals develop it in their life time. It is common above the age of 50 years. Recurrence is rare

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Clinical features There is a prodromal period when the child will have pain and itching before eruption. Vesicles appear along a dermatome and have an erythematous base. They are usually these are unilateral but may be bilateral in HIV infected patients Diagnosis is usually clinical Treatment 1. Analgesics: the choice of analgesic has to be commensurate with the degree of pain 2. Acyclovir: dosage of 10mg/kg every 8 hours intravenously for 7-10 days. 3. Acyclovir 800mg 5 times a day for 7-10 days in adults. Varicella zoster Definition: acute highly contagious intra-epidermal vesicular eruption caused by varicellar zoster virus. Incidence: 90% of cases occur before 10 years of age. Clinical features The incubation period of 2-3 weeks is followed by a prodromal stage which lasts 2-3 days. Presents with: chills, fever, malaise, headache, sore throat, anorexia, and cough but these are often minimal. An intensely itchy rash appears. All types of lesions are seen at the same time. They include: macules, vesicles, papules, pustules and crusts Diagnosis: usually clinical. Treatment A) Supportive. 1)) antihistamines 2) calamine lotion 3) paracetamol( do not use aspirin due to possibility of Rye’s syndrome) B) Specific treatment Acyclovir is not indicated in immuno-competent children. IV acyclovir is used in immunosuppressed children, at 500mg/m2 Varicella zoster immunoglobulin (VZIG) is useful in immuno-deficient children Prevention - Live attenuated virus vaccine Note: In difficult to diagnose varicellar/zoster cases a Tzanck test can be done. Tzanck test reveals multinucleated giant cells. Molluscum Contagiosum Definition – Viral infection of epidermal cell caused by a pox virus Common in childhood Presents with papules 2-5mm wide dome shaped umbilicated single or grouped on the trunk, face and extremities. May be generalized in immunosuppressed children Diagnosis is usually clinical. Treatment – curettage, or cryotherapy, or Cantheridine

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Warts Definition. These are benign growth caused by infection the epidermal cells with papilloma viruses Predisposing factors include: HIV infection Renal transplant Use of steroid And use of cytotoxic drug Ano-genital occurrence in children suggests sexual abuse Clinically appear as: 1. Verruca vulgaris (common wart) which may be a papule or nodule with corrugated surface that is flesh coloured and firm with a black dot. Distributed on fingers and hands 2. Flat wart flesh coloured and 2 – 5 mm wide 3. Plantar Wart single and painful found of the plantar surface of the foot 4, Condylomata acuminata (venereal wart) Lesions is a papule or plaque that is soft, moist sessile or pedanculated usually destructive, and painful Distribution on the rectum, perineum, vagina, inguinal folds, external genitalia and urethra Treatment options include: cryotherapy electrodessication curettage laser surgical excision Venereal Warts – podophyllotoxin Common Warts – a) 17% Salicylic acid ointment b) 17% Salicylic acid in polyacrylic vehicle c) Cantheridine d) cryotherapy Flat warts a) Retin A b) 5% salicylic acid ointment Plantar warts 10% formaldehyde Salicylic acid plaster

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Condylomata acuminata 25% podophyllotoxin Cryotherapy (preferable) 4. SCABIES Definition: Infestation of the epidermis by the sarcoptes scabiei. Epidemiology: Scabies is a common disease worldwide but is more common in the developing countries. The incidence fluctuates over the years with peaks following 30 year cycles. Commonly occurs among school children and institutionalized patients. Predisposing factors include poor socio-economic status, poor hygiene and low immunity especially HIV/AIDS. Clinical features Pruritic papules (predominant lesion), vesicles and pustules are found most commonly in the finger webs, wrists, elbows, maxillae, girdle area and feet but may be generalized. The face is usually spared except in babies. May occur in other family members and the baby sitters May be contracted from pets Secondary bacterial infection can occur especially in the immune compromised. Diagnosis is often clinical but by finding a burrow usually in the finger webs. Investigations: Scalpel (No.15) is used to scrap the lesion. The highest yield is usually from the burrow. The specimen is put on a drop of oil on a microscope slide and examined. One may see the adult mite, eggs or faeces. Treatment: Mainstay of treatment is topical. Benzyl Benzoate: this is applied on the whole body from the neck down. Should not be applied on the head. Applied at night for 3 days. Patient should not bath once this applications start until they are finished then he/she may bathe on 4th day. Single application of 1% lindane lotion or 5% permethrin cream at bed-time and washed off in the morning is also recommended. This may be repeated after 1 week. Lindane should be avoided in infants. The agents are applied on the head as well. 5. ATOPIC DERMATITIS (ECZEMA) Definition: Eczema: Greek word that means “to boil over”. Atopic (Eczema) dermatitis is a chronic, pruritic condition of the skin that is associated with personal or family history of atopic diseases such as bronchial asthma and /or allergic rhinitis. Incidence: not well documented especially in Africa

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Clinical features Age of onset commonly starts after 2 months. Pruritis – most prominent symptom. In neonates it appears as cradle cap; papulo-vesicles on face and extensor surfaces in infancy; and in older children flexural lichenification is found. Thirty percent of children have associated allergic rhinitis which is also found in2/3 of their family members. Food allergy – occurs in 10% of the patients. Contact allergy – occurs in 10% of the patients. Mode of presentation: Acute - presents with papules and vesicles. Subacute- papules, vesicles and some lichenification Chronic - lichenification Diagnosis is usually made on clinical grounds Therapy: Management is usually difficult because of the chronic nature of the disease Aim of treatment is to reduce inflammation and itching. The mainstay of treatment is topical steroids and systemic antihistamines. Initiate treatment with a potent steroid and taper down to a less potent one. Use ointments for dry lesions, creams for wet lesions, and lotions where there is hair. Topical Steroid Therapy: Topical steroids are classified from the most potent to the least potent (Class I to class VII) respectively. Example class I is betamethasone and Class VII is hydrocortisone. Class I should be used for a maximum of 14 days (where applicable) and changed to a less potent one. Avoid class I steroids in: Children aged less than 5 years. Face Groin of all age groups Axillae Antihistamine Therapy: There are sedating and non-sedating antihistamines. Sedating antihistamines are more effective in controlling the itch than non-sedating. Example of sedating antihistamine is chlorpheniramine. Example of non-sedating is loratadine. Antibiotic Therapy: Antibiotics are used in cases where the lesions are weeping. If the lesions are localized then topical antibiotics such as mupirocin are used. If it is generalized then oral antibiotic effective against S. aureus such as cloxacillin is used. Atopic Advice: Children with this disease should be advised to: Bath in warm water using medicated soap. Avoid woolen fabrics instead use cotton clothes and beddings. Moisturize the skin at least twice a day. Vaseline pure petroleum jelly is commonly recommended.

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RECOMMENDED READING AND REFERENCES: Donald P. Lookingbill and James G. Marks, Principles of Dermatology; Second Edition. WB Sanders Company, Philadelphia. Sidney Hurwitz Clinical Pediatric Dermatology WB Sanders, Company, Philadelphia; Second Edition. S.O. Ayaya, K.K. Kamar, R. Kakai. Aetiology of Tinea Capitis in School Children, EAMJ (78) Oct 2001, pp 531 – 535. Okafur J.I. and Agbubaerulehe A.K. Dematophytoses among school children in Aba, Abia State, Nigeria and some physiological studies on isolated aetiological agents. J. Common Dis 1998 30; 44 – 9. Figureson J.I., Hawravek T, Abraham A, and Hay R.J.,Tinea capitis in south Western Ethiopia: A study of risk factors for infection and carriage . Int. J. Dematol. 1997 361 : 661 – 6.

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CHAPTER 19

ESSENTIAL DRUGS AND RATIONAL USE OF ANTIBIOTICS

Chris M Ndugwa, Somwe Wa Somwe, Elizabeth Maleche-Obimbo, Dalton Wamalwa, Muluwork Tefera Dinberu, Gabriel Anabwani

INTRODUCTION No discussion of health services is possible without consideration of budgeting. Where funds are limited, as is the case in most economically less developed countries, priorities must be set so that essential drugs are always available for those needing them. Thus provision of essential drugs is a fundamental element of any comprehensive primary health care programme. Getting essential drugs to people under a well organized supply system, proper prescription by the health personnel and appropriate drug use by the consumer are all essential ingredients of the Essential Drug Programme. It is therefore important for the student of medicine to understand what essential drugs are, their pharmacology, dosage and indications. Essential drugs may be defined as cost-effective drugs with proven efficacy for which adequate standards of quality have been established and which meet the health needs of the majority of the population. These are discussed in Section A of this chapter. Section B deals with rational use of antibiotics. OBJECTIVES At the end of this chapter, the student should be able to:

Explain the concept of essential drugs; Outline criteria for choosing essential drugs; List essential drugs for a defined community; Discuss guidelines for rational prescribing of antibiotics.

LEARNING ACTIVITIES To aid the student in learning about the operative essential drugs in a particular health locality visits to at least two health centers (He) considered representative of the area are recommended. At each of these health facilities the student should engage in the activities listed below: Be familiar with the essential drugs list in your country; Correlate the essential drugs available in the HC to the pattern of disease in the area;

Follow the steps of drugs procurement, storage, distribution and their use in that He.

Use these findings to assess the performance of the essential drugs programme for the area.

Provide immediate feedback on your findings to the HC staff. Prepare a written report summarizing your findings and conclusions.

SECTION A: THE CONCEPT OF ESSENTIAL DRUGS

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Within developing countries, most drugs are consumed in urban centers while the rural areas contain the majority of the population. Inequity in the distribution of health resources including drugs supply is crucial because when drugs are frequently unavailable patients tend to shun such health facilities. The Essential Drug concept was adopted by the WorId Health Assembly in 1975 in order to overcome the problems of cost, production, distribution and availability. Any selection of essential drugs must therefore depend on the following key criteria, namely:

The pattern of disease prevalence in the community; The available treatment facilities. The training and experience of the available personnel. The financial resources available. The prevailing demographic and environmental factors.

In addition, selection of specific drugs should depend on:

Adequate data on efficacy and safety from controlled clinical trials; Cost of entire treatment, not just unit cost. The anticipated conditions of storage. Formulation: fixed-ratio combinations have advantages over single

compounds. Where two or more drugs are therapeutically equivalent preference should be given to the drug:

a. which has been thoroughly investigated; b. that improves compliance while minimizing risks to health; and c. for which reliable local pharmaceutical manufacturing facilities exist.

The Essential Drug List WHO periodically publishes an essential drugs list from which countries are advised to choose those most appropriate to their local needs. The list designates drugs by their International Non-propriety Names (INN) or generic names, rather than their brand or trade names. National lists of essential drugs are stratified to reflect skills and requirements at different levels within the health infrastructure. The model list of essential drugs now contains many medications which require a high degree of expertise to ensure safe and effective use. Adequate specialist skills and complementary resources are needed before introduction of some classes of drugs. Typically a very short list is compiled for community health workers while the most comprehensive lists are reserved for large urban and regional hospitals.

Village health posts and dispensaries should receive only commonly used drugs. A health centre should first be given emergency drugs. For children, oral treatment using syrups and tablets is highly recommended. Trained community health workers can be given six basic drugs to treat common conditions prevalent in their areas. Such drugs include: paracetamol tablets; chlorhexidine solution; acetylsalicylic acid tables; oral

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rehydration salt sachets; and tetracycline eye ointment or drops. Text box: WHO recommends the following for various levels of health facilities: 6-15 drugs at a village health post 5 – 20 drugs at a dispensary 20 – 45 drugs at a health center 100 – 120 drugs at a district hospital > 250 drugs at a tertiary hospital Effecting the concept of essential drugs can have certain advantages, including economic saving. In addition ;

Storage and distribution of drugs becomes easier to manage. A careful and rational selection of drugs is made on the basis of real needs. Correct dosage is easier to remember, thus increasing safety of drug usage. There is less drug wastage. Helps to obtain reliable data on drug consumption. Favorable influence on the practices of training centers in therapeutics and

general drug management can be achieved more easily.

Before establishing essential drug programmes, there is need for selecting essential drugs using WHO criteria as a guide. The steps involved in establishing essential drug programme can be summarized as follows:

Formulation of health policies on identification of therapeutic needs; Drug identification, procurement and storage; Training of personnel; Information and education, Quality control of drugs; Supervision, monitoring and evaluation, Financial support.

At country level there are good reasons for establishing an essential drugs programme as this can avoid:

Unsatisfactory procurement procedures and erratic ordering of drugs frequently resulting in serious drug stock outs and expensive purchases.

Unsupervised importation of drugs or raw materials for their production. Acute shortage of foreign currency to import drugs or their raw materials. Under utilization of the local drug production capacity. Poor drug storage and drug distribution practices. Rapid expansion of health services without a increase in drugs supply capacity. Unsatisfactory use of drugs both by health workers and the public.

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Organization of an Essential Drug Programme

An essential drug programme is a comprehensive and complex system of drug production, procurement, packaging, distribution and use for any country. In order to execute it effectively there is need for proper organization. An organization structure consisting of four levels can be envisaged:

National Level At the national level there is an essential drugs unit or department in the Ministry of Health. While functions at this level vary from country to country, they include planning, acquisition of funds, regulatory control, drug procurement and distribution, training and liaison between ministries.

Regional and District Level At the regional or district level the Medical Officer of Health and the entire staff are involved in multiple functions which include storage and distribution, training, record keeping, prescription and dispensing and facilitation of community participation.

Health Centre/Dispensary Levels

Health centres and dispensaries are the key primary care stations implementing the programme. Therefore, managing drugs in these health .units is one of the most important functions of a primary health care worker. Management at these stations involves ordering, receiving, storing and distribution of the drugs. Health workers at this level should participate in educating the community in rational and proper drug usage.

Community Level Community participation in the storage, distribution and use of their own drugs is an essential component of the programme. Community members have to understand, cooperate and work with health providers to achieve success.

Drug Procurement is the most important activity in implementing the essential drug programme. It involves estimation of drug quantities. There are three different ways to estimate drug needs:

Population-based estimation calculates the theoretical needs of a given population based on the burden and pattern of disease in the community. Although this is probably the ideal method, it is not attainable in the short time especially where the health service do not cover the entire population or community;

Service based estimation depends on health service statistics only and considers patients who come for care. It enables us establish objectives so as to avoid stock outs. This implies that health services have been in existence for some time and past records of diseases treated and drugs prescribed are available and reliable.

Consumption-based estimation is the most commonly used method. It requires a system that provides satisfactory information on monthly drug consumption and stock level in health-care units throughout the year. However, this method can under-estimates true demands because of lack of information on diseases treated.

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Once the drugs are procured, they are packaged in kits and distributed regularly to various health units according to their requirements. Regardless of the type of distribution preferred accurate record keeping is essential. When essential drugs are received at the health unit it is important to ensure that (a) the drug kits are sealed; b) the kits are not damaged; c) each kit is opened carefully and the contents checked for signs of damage (leakage, broken glass, open tins, broken packets etc); (d) the contents of each kit are checked against the packaging slip; e) for each drug package, the expiration date, the manufacturer's batch number and identification of the manufacturer are noted and recorded; f) any damages or shortage are reported to the person in charge with explanations; and g) the drugs are then recorded into the stock recorded book and stored. Monitoring the whole programme ensures proper implementation of the drug 'policy. It is based on stock record cards. At the end of each month, stock inventory should be done. The results of the inventory are used to facilitate timely ordering of drugs and rescheduling of the drugs kits. Managerial and other problems Notwithstanding the aforegoing, observation of the situation on the ground soon reveals problems that threaten the successful implementation of the essential drugs programme. These include:

Lack of funds; Erratic procurement and supply; poor record keeping; Poor supervision; poor quality control; and misappropriation of funds and drugs.

All such, problems bust be anticipated and vigorously dealt with, if the noble aims of this programme are to be achieved. Section B1: Better medicines for children: Recent progress We are entering a new era where much more attention will be paid to children’s entitlement to well validated, safe and effective drug therapy. This important process began with WHA resolution 60.20 “Better Medicines for Children” passed by the World Health Assembly in May 2007.(1) Subsequently, on December 6, 2007, the WHO formally began implementation of a related action plan that had been recommended through the EML process. The world’s children have waited too long for improved access to well validated therapies for prevention and treatment of acute and chronic disorders. The unmitigated burden of illness related to suboptimal treatment has fallen across the entire age spectrum from infancy to adolescence and the consequences have been especially grave in African countries where so much of the overall burden of childhood illness resides. Physicians, pharmacists, and child advocates have been aware of the consequences of inaction but somehow public action has languished for almost half a

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century after general awareness of the challenge in optimal pediatric pharmacotherapy was awakened by the chloramphenicol misadventures of the 1950s. We have now reached a point at which there are an estimated 5 million deaths annually among children 5 years or younger that could be prevented by effective, affordable, accessible drug therapy. The approval and promulgation of a WHO list of essential drugs for children (EMLc) is a step forward(2); a necessary but not sufficient condition for the improvement of therapy-related outcomes in children. Now that this critical first step has been taken it is important to focus attention on the need for international regulatory harmonization and for the urgent need to develop and test appropriate new pediatric formulations. More attention must be paid to region-specific needs identified through formal needs assessments. Key actions:(3) 1. closing the know-do gap: This can be achieved in the context of many common childhood diseases through the development and dissemination of best practice guidelines. 2. addressing absolute gaps in knowledge: This can be achieved through research focused on orphan diseases and on a concerted effort to achieve improved labeling of drugs for pediatric use. 3. promoting safe medications practice in hospital and community child health care settings 4. assigning priority to the development of child-friendly formulations and fixed dose combinations 5. emphasizing drug therapy as a key tool for reduction in childhood mortality, particularly in newborn treatment settings, and in management of communicable diseases, including ARI and diarrhea 6. improving access to medications through better supply chain management Section B2. Environment for paediatric prescribing As it is not possible to know everything necessary about all the drugs available, experienced child health clinicians tend to use a few important or representative preparations. Nevertheless, whenever a drug is to be prescribed for a patient, the doctor should always consider the following key points: 1. Is the drug really necessary? Does the patient need any drug at all? Is the drug being given to relieve symptoms, to treat an underlying disease, or to make the patient feel something is being done? If so, is the drug prescribed the most suitable for that condition? What side effects may the patient suffer? Do the possible benefits outweigh the possible risks? And lastly, how may the drug interact with other drugs the patient is receiving?

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2. Is the cost of treatment acceptable? The cost of some very similar drugs can vary by a factor of up to 200. Since someone must pay, consideration of cost is only rational. Thus the cheapest effective agent should be chosen over more expensive medications. This will leave money available for other needs such as some expensive but essential drugs. 3.Is confusion caused by use of proprietary names? Often one drug is marketed under several proprietary (trade) names. This may cause confusion in prescribing. Of greater importance, however, is the fact that drugs marketed using their proprietary names are also more expensive. For these reasons, the generic (official) name should be used when prescribing. 4.Will the product have adequate shelf life in tropical climates? As stated above, most drugs are manufactured in the temperate climates of economically developed countries. The printed expiry dates for these drugs are therefore calculated for these climates. Thus when the same drugs are stored in tropical climates the shelf life may be less than half of that in their countries of manufacture. Patients and families need to be educated on this important fact. 5. Has the new drug been appropriately evaluated in children? There is an unfortunate tendency to discard old and well tested drugs in favour of new preparations. This is often done without critical appraisal of marketing claims for the new drug, its cost, or cost-effectiveness. Many references quoted by pharmaceutical companies in favour of their drugs are reports of uncontrolled or flawed trials where the company may have sponsored the trial. A good trial should involve adequate numbers and should be randomized and blind (double blind if possible). An established (gold) standard drug should be compared with the new drug and not a placebo to establish relative efficacy. Lastly, the results of the trial should have been reproduced by others and, particularly, in comparable populations. Anecdotal reports are unsatisfactory and unreliable. 6. Have families been adequately engaged in a therapeutic decision? Treatment failure can result when families do not understand how drugs should be used. Multiple drugs can cause confusion, even among educated patients and families. Worse, when drugs are not packaged and stored properly in the home, they can be ingested by children and cause poisoning. For these reasons, and in order to minimize the risk of drug interactions, the doctor or pharmacy staff should take time to provide patents and families with key information on the drug’s dose, regimen, home storage, and side effects. 7. Has the dosage been correctly calculated? Because all children, and especially neonates, differ from adults in their response to drugs, and children of the same age can vary considerably in body weight, paediatric dosages should be calculated according to body weight. Using Body Surface Area (BSA) provides more accurate dosages but it is less practical. However, when paediatric dosages are not available for a given preparation, they may be estimated by

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the formula (BSA/1.8) x adult dose, where 1.8 is the BSA of the standard 70kg human. A simple formula for calculating the BSA is height (cm) x weight (kg) 3600 Thus, a child weighing 10kg and 72cm long has a BSA of 10 x 72 = 0.45m2 3600 N.B. Both formulae require square root sign. Formula is taken from the WHO pocket book of Hospital care for Children, page 325. Section B3. Rational antibiotic use: common infectious conditions

Below is a series a tables (adapted from Guidelines to. Drug Usage) of common infectious diseases and conditions outlining their specific antimicrobial therapies, dosage and same useful notes.

Table 1. Infectious Diseases

Disease Drugs and dosage Comments Anthrax Benzylpenicillin 50,000

units/kg/dose 1M in ~ divided doses for 5 days; age> 8 years tetracycline 250 mg qid for 5 days

Tetanus Benzylpenicillin 50,000U /kg/dose daily in divided doses; plus tetanus antitoxin 10,000U 1M once

If serum is given, start with test dose and ensure epinephrine I: 1000 is drawn up and ready.

Diazepam should be used to control spasms and patients should always be immunized. Surgical debridement may be indicated.

Typhoid fever Chloramphenicol 25mg/kg/dose every 6 hours until afebrile for 2 weeks

Alternatives where there is high prevalence of resistance to chloramphenicol ceftriaxone 50-75 mg/kg daily

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Older children > 13 years ciprofloxacin

Opthalmia neonatorum Gonococcal C.trachomatis

IV ceftriaxone 50mg/kg one dose Tetracycline eye ointment applied 3-4 time daily Plus erythromycin 50mg/kg daily in 3 divided doses.

Saline irrigation

Table 2. Respiratory Conditions Upper respiratory tract infection (common cold)

Usually viral, so no treatment

Mucoid discharge often accompanies common cold and is not an indication for antibiotic use.

Acute sinusitis Amoxicillin 15mg/kg/dose 3 times a day for 7 – 10 days

Acute tonsillitis

Phenoxymethyl penicillin 30 mg/kg orally in divided doses for 5 days or amoxicillin 15 mg/kg/dose 3 times a day for 10 days Erythromycin 12.5 mg/kg/dose 4 times a day for children allergic to penicillin

The principal indication for antibiotic use is the primary prevention of acute rheumatic fever Broad spectrum antibiotics are no more effective and increase the risk of developing resistant organisms

Acute otitis media

amoxicillin 15 mg/kg/dose 3 times a day for 10 days or

Decongestants and antihistamines are not useful in acute otitis media

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cotrimoxazole 24 -30 mg/ kg/ dose every 12 hours, all for 5-10 days.

If there is chronic discharge (>2 weeks) antibiotics are usually not effective and should not be used: ear wash outs and keeping the ear dry by wicking yield the best results.

Croup

Usually viral so antibiotics are not indicated

For moderate to severe Croup oral or iv Dexamethasone 0.6 mg/kg/dose single dose Prednisone 1-2 mg/kg with other supportive including oxygen

Pneumonia Mild pneumonia (outpatient) Oral amoxicillin 15 mg/kg/dose /day 3 times a day Or cotrimoxazole 24-30 mg/kg every 12 hours Duration: 7 to 10 days Severe Pneumonia benzyl penicillin 50 000 units/kg every 6 hours Chloramphenicol 25 mg/kg/dose every 6 hrs OR If evidence of staphylococcus including pustules : cloxacillin 50-100 mg/kg/day iv or im AND

Cough medications are not beneficial in pneumonia and some may be harmful For immunocompromised children including HIV and severe malnutrition add plus gentamicin (7.5 mg/kg once daily) Do not give chloramphenicol to premature neonates. If empyema is confirmed under water seal drainage

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gentamicin 7.5 mg/kg iv once daily

Atypical pneumonia

Erythromycin 15 mg/kg/dose 3 times a day for 7 days

Pneumocystis jirovecci pneumonia (PCP)

Intravenous Cotrimoxazole 24 mg /kg/dose given every 6 hours for 21 days. Give the same dose orally if IV preparation not available

Add prednisone 2 mg/kg/day for 7 days if child is in severe respiratory distress Prophylaxis: Lifelong Daily cotrimoxazole 24 mg/kg once daily

Pertussis Erythromycin 12.5 mg /kg/dose 3 times a day for 14 days

Useful in aborting infection only if early during the catarrhal stage; no effect on course if given later. Salbutamol and steroids may be useful in severe cases

Pulmonary tuberculosis

Intensive phase (2 months) Isoniazid 5 mg/kg /day Rifampicin 10 mg/kg /day , pyrazinamide 25 mg/kg/day Once daily Continuation phase:4 months Isoniazid 5 mg/kg /day and Rifampicin 10 mg/kg /day

Table 3. Gastrointestinal disease Cholera Erythromycin 12.5 mg/kg

/dose 4 times daily for 3 days

Fluids and potassium are essential to the treatment; Antibiotic use shortens the

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Or Sulfamethoxazole 20 mg/kg and trimethoprim 4 mg/kg daily in 2 divided doses Above 8 yr: doxycycline

shedding of vibrio cholerae

Dysentery bacillary

Nalidixic acid 15mg/kg/dose 4 times a day for 5 days

Use local sensitivity pattern As second line ceftriaxone 80mg/kg once daily for 5 days

Dysentery amoebic

Metronidazole 7.5 mg/kg/dose 3 times a day for 7 days

add zinc 20 mg once daily (dose)

Table 4. Genitourinary disease Acute UTI Cotrimoxazole 24

mg/kg/dose twice a day for 7 days or amoxicillin 15 mg/kg/dose 3 times a day for 7 days OR

Nitrofurantoin 2 mg/kg/dose 3 times a day for 7 days

Encourage fluids. Consider if underlying pathology especially in children < 5years. In cases of resistance (poor response) Cephalexin 12.5 mg/kg/dose 4 times for 7-10 days

Pyelonephritis

Gentamicin 7.5 mg /kg/day for 7- 10 days Ceftriaxone 50-75 mg/kg /dose once daily for 7 days

Caution: use of aminoglycosides weighed against potential for renal compromise

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Recurrent UTI Suppressive therapy in children with trimethoprim 2 mg/kg daily and sulphamethoxazole 10 mg/kg daily in 2 divided doses Or Nitrofurantoin 2 mg/kg/dose 3 times a day

Investigate urinary tract to rule out anatomic abnormality

Table 5. Musculoskeletal Pyomyositis Surgical drainage.

cloxacillin 25 mg//kg/dose 4 times a day for 7 days Chloramphenicol 25 mg/kg/dose 4 times a day for 7 days

Acute osteomyelitis

Cloxacillin 25 mg//kg/dose 4 times a day for 4-6 weeks

In children with sickle cell disease a possible cause is Salmonella. Add chloramphenicol 25 mg/kg/dose 4 times a day Avoid prolonged treatment with chloramphenicol

Chronic osteomyelitis

Surgery is the mainstay of management

Septic arthritis Same as acute osteomyelitis

Surgical drainage

Table 6. Neurologic conditions Meningitis unknown organism

Choramphenicol 25 mg/kg/dose 4 times a day for 10 days . AND

Reserve antibiotics for 2nd line: ceftriaxone 100 mg/kg /day in 2 divided doses or cefotaxime 100 mg/kg/day in two divided

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Benzylpenicillin 75,000/kg/dose 4 times a day for 10 days For neonates with meningitis: Gentamicin 7.5 mg/kg/ once daily for 14 -21 days AND Ampicillin 50mg /kg/dose twice a day for 7 days then 50mg/kg/dose 3 times a day for 7-14 days (total duration 14 to 21 days)

doses

Streptococcus pneumoniae

Benzylpenicillin 100,000iu/kg/dose 4 times a day 2 weeks

2nd line : ceftriaxone 100 mg/kg /day for 7-10 days

Meningococcal Benzylpenicillin 100,000iu/kg/dose 4 times a day 5-7 days Prophylaxis to contacts: ciprofloxacin or cotrimoxazole

Resistance to penicillin is rare

H. influenzae type B

Chloramphenicol 25 mg/kg/dose 4 times a day for 7-10 days

2nd line ceftriaxone 100mg/kg once daily for 7-10 days Incidence reduced in those settings where routine childhood immunization is practiced

Gram negative rods (E. coli)

Chloramphenicol 25 mg/kg/dose 4 times a day or Ceftriaxone 100 mg /kg /day in 1- 2 divided doses or cefotaxime and gentamicin.

Poor CSF penetration by gentamycin but it may be useful for associated septicaemia

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Duration: minimum 14 days up to 21 days

Cryptococcal meningitis

Induction with amphotericin B 0.7-1 mg/kg/day for 2 weeks Followed by: Daily: 6 mg/kg/dose once daily at least 10-12 weeks Then Maintain fluconazole 3mg/kg/day

Prophylaxis oral fluconazole

Brain abscess Metronidazole 7.5 mg/kg /dose 3 times a day PLUS Cloxacillin 25mg/kg/dose 4 times a day PLUS Gentamicin 7.5mg/kg once daily Duration: 6 -8 weeks

Surgical aspiration or excision may be indicated

Concept of Reserve antimicrobials

Pathogens that are resistant to all normally appropriate essential drugs are increasingly emerging in various countries or regions. In such instances a reserve antimicrobial is needed. A reserve antimicrobial is an antimicrobial that is useful for a wide range of infections but, because of the need to reduce the risk of development of resistance and because of its relatively high cost, it is not recommended for unrestricted (widespread) use.

Examples:

Resistance to beta-lactam antimicrobials is generally due to the production of beta-lactamases in staphylococci, enterobacteria, Haemophilus spp., gonococci and Pseudomonas spp. In several of these organisms and in others such as pneumococci and enterococci, other non-enzymatic mechanisms are also involved. Many new beta-lactam antimicrobials have appeared and are included in the model list as reserve antimicrobials. In order to preserve the activity of these antimicrobials it is recommended that these agents are used only where rates of resistance to all normally

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appropriate essential drugs are high or for specific indications, as listed below. a. beta-lactimase inhibitor amoxicillin + clavulanic acid is active against many of the enzymes produced by enterobacteria . A specific indication for its use is in polymicrobial infections related to surgical conditions of the intestinal tract and female genital tract. Amoxicillin remains active against many common bacteria such as -haemolytic streptococci and a high proportion of Haemophilus influenzae strains in many countries. The levels of penicillin resistance in Streptococcus pneumoniae do not at this time justify replacement of the use of penicillins in the treatment of respiratory tract infections.

b. Many parenteral cephalosporins active against Gram-negative bacteria are now available and are widely used for the treatment of infection. The model essential drug list now includes ceftriaxone as a reserve antimicrobial for the treatment of meningitis due to Streptococcus pneumoniae in areas where penicillin resistance is found. Cefuroxime is not as effective as ceftriaxone or cefotaxime in pneumococcal meningitis. c. Ceftazidime is included in the essential drugs list because it is the most active cephalosporin against Pseudomonas aeruginosa. It is suggested that it should be used when the prevalence of resistance to gentamicin is high.

d. Imipenem is a broad-spectrum -lactam antimicrobial included as a reserve agent for the treatment of Acinetobacter spp. infection and Pseudomonas spp. resistant to all normally appropriate antimicrobials. Such resistant organisms are usually only found in tertiary care hospitals and in particular in intensive care units where antimicrobial usage is high.

e. Ciprofloxacin is a member of the fluoroquinolone family of antimicrobials. Although this is now listed as an essential drug, the comparative costs of alternative broad-spectrum products will be an important determinant of selection. Ciprofloxacin and certain other fluoroquinolones may still be considered of value as reserve agents. Their use may need to be restricted to the following circumstances (also note that in children below 13 years fluoroquinolones may lead to arthropathy and therefore benefits must be weighed against the potential risk):

For typhoid fever and other systemic salmonella infections where there are strains of Salmonella resistant to chloramphenicol, amoxicillin and trimethoprim + sulfamethoxazole.

For severe shigellosis where Shigella spp. strains exist that are resistant to ampicillin, chloramphenicol, trimethoprim + sulfamethoxazole, tetracyclines and nalidixic acid.

For gonorrhoea and chancroid, as alternatives to cefalosporins, when oral administration is appropriate.

For hospital-acquired infections due to Gram-negative bacilli, including Escherichia coli, Klebsiella spp. and Pseudomonas aeruginosa, that are resistant to essential drugs such as amoxicillin, chloramphenicol and gentamicin.

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Methicillin-resistant Staphylococcus aureus strains are usually resistant to all -lactam antimicrobials and also to unrelated drugs such as erythromycin, clindamycin, chloramphenicol, the tetracyclines and the aminoglycosides. The only effective reserve drug for infections due to these multiresistant organisms is vancomycin, which is expensive and must be administered intravenously.

Need for surveillance of resistance

Knowledge of prevailing susceptibility patterns is vital to the selection and use of antimicrobials and to the development of appropriate prescribing policies. Without these data the health of seriously ill patients could be jeopardized. Knowledge of susceptibility patterns should come from proper laboratory investigations. Decisions on drug use should be taken on the basis of standardized therapeutic efficacy testing.

To minimize the development of antibiotics resistance the prescription of antibiotics should satisfy the following:-

There should be clear indication for antibiotics use. All bacteriological specimens, should be taken before start of therapy;

In general for all antibiotics, prescribe for at least five days initially; Change of antibiotics should be done with guidance from the laboratory;

It is safer to add than to replace one antibiotic for another especially in an acutely ill patients where the nature of the infecting organism is not known. Always administer antibiotics in correct dosage for the right length of time:

Clinical progress of the patient should be reviewed at regular intervals; Topical use of antibiotics should be avoided except in specific defined

clinical conditions e.g. eye preparations; Preference for bactericidal antibiotics with a narrow spectrum and low toxicity.

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REFERENCES 1. WHO expert panel on Essential drugs list: The use of essential drugs. Eighth report of the WHO Expert Committee (including the revised Model List of Essential Drugs). World Health Organ Tech Rep Ser. 1998; 882:1-77 2. File T, Haley, Rational use of antibiotics to respiratory tract infections. Am J Manag Care 2002; 713-727. 3. Arroll B, antibiotics for upper respiratory tract infections: an overview of Cochrane reviews. Respiratory Medicine, 99: 255-261 4. World Health Organization. Essential medicines for children. Making medicines child size. http://www.who.int/childmedicines/en/index.html 5. WHO model list of essential medicines for children. http://www.who.int/childmedicines/publications/EMLc%20(2).pdf (accessed 29 October 2008). 6. MacLeod, Stuart; Peterson, Robert; Wang, Yi; Li, Zhiping; Gui, Yonghao; Schaller, Jane. Challenges in International Pediatric Pharmacology: A Milestone Meeting in Shanghai. Pediatric Drugs 2007;9:215-8. 7. Handbook on Paediatric AIDS in Africa by the Network for the Care of Children Affected by AIDS 2006. 8. British National Formulary, number 25; March 1993

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CHAPTER 20

CHILDREN IN ESPECIALLY DIFFICULT CIRCUMSTANCES

Nimrod O Bwibo and Mary Shilalukey Ngoma INTRODUCTION The children in especially difficult circumstances – (CEDC) – are children whose basic needs such as shelter, food, education, health care and security are not met due to prevailing adverse conditions in a community. Group or individual acts may cause harm to children and/or prevent them from realizing normal growth and development causing them to be in difficult circumstances. High rate of population growth and in some African countries and increasing urbanization in a time of economic stress is breaking down families as well as community support systems for disadvantaged children. Consequently, large and growing numbers of children end up in especially difficult circumstances. OBJECTIVES At the end of this chapter the learner shall be able to: Define children in difficult circumstances Discuss the underlying causes List the categories of CEDC Discuss psychosocial problems among CEDC Describe the main features of the various categories Describe health management of children in emergency situations Provide guidelines for prevention of the problem LEARNING ACTIVITIES Visit streets of big towns and find out if there are street children (families) Obtain and read a copy of the convention of rights of the child Find out how your country has ratified the convention (is there a children’s act that includes the rights of the child?) During the paediatric clerkship find out if there are children admitted because of child abuse Find out if there are organizations that address the rights of children in your country Find out if your government has ways of addressing the problems of CEDC Have a group discussion on possible interventions that would improve the welfare of children in these situations The child is defined as a person under 18 years of age. Though in some counties take the cut off at 16 years. Often people talk of orphans and vulnerable children. The definition of an orphan is a child under the age of 18 years who has lost a mother, father, or both parents due to death. An orphan can be further defined as a double orphan if the child has lost both parents, whereas a maternal orphan and paternal orphan is defined as the loss of a mother or father respectively.

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Vulnerability is even more difficult to define, as no single definition adequately captures what constitutes a vulnerable child. Generally, a vulnerable child is any child who has limited access to his or her basic needs. Thus, a child may be vulnerable but not an orphan. Vulnerability is further defined according to three areas, namely, material, emotional and social problems. Vulnerable children are children in situations listed below. The term refugee is applies to people who flee their country of origin and move to another while displaced refers to people who are forcibly displaced within their country TYPES OF CEDC As seen below there are many situations that adversely affect children Street children Abandoned and neglected children Orphans and destitute children Abused and neglected children Children living with disability (physical and mental) Child prostitutes Child labourers Children of imprisoned mothers Child brides Child mothers Drug addicts and traffickers Children affected by armed conflict and political violence Children in conflict with the law Children living in informal settlements Displacement due to natural disasters All these groups undergo various forms of child abuse and exploitation. Currently, the magnitude of the problem of CEDC warrants concern. Situational analysis done in our region indicate that the problem is on the increase. This alarming state of affairs and its upward trend calls for various national studies to give a clear picture. However, from the research already done it is clear that rapid social economic (and political changes in our countries) have contributed a great deal to this grave situation in Africa. CAUSES Population explosion coupled with increased urbanization have been the major culprits in bringing about CEDC. These two have adversely affected many a family giving rise to large but poor families. Children from these families more often than not fall prey to child prostitution, child labour, petty trade, drug abuse and trafficking. The girls are married off at a very young age and often to much older men. Traditional cultural values that acted as social support systems (for disadvantaged clan members) and at the same time placed a high premium on children have been eroded by modern lifestyles to the point whereby some children are regarded as liabilities. Thus, we have children virtually living on the streets of our urban centres; children being battered and killed by their next of kin are frequently reported in the media. Close

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relatives do not move in, to assist their orphaned children, thus leaving them to fend for themselves. Children who live without the guidance and protection of an adult care givers are often more vulnerable and at risk of becoming victims of violence, exploitation, trafficking, discrimination, early marriage and other abuses. Some of African traditional cultural values give rise to child abuse, which leads to children having babies when they are not physically and psychologically mature for the responsibilities of being mothers. Taboo babies arising from traditional cultural practices in some communities are unaccepted to their biological parents and are thus exposed to all sorts of abuses especially abandonment. Parents facing economic constraints may engage in illegal activities and my end up serving custodial sentences. During which time they leave their children without support. Mothers who go into prison may be allowed to go with their children who are aged below four years. At least such mothers continue to take care those children but in abnormal environment. By and large, traditional land tenure and inheritance laws in many African cultures tend not to provide for women to inherit land and property. So unmarried mothers looking for neutral areas to settle end up in urban centres. Also involved in the migration to towns are the youth – both young men and women seeking employment. More often than not, the anticipated employment is not forthcoming and like the unmarried mothers often engage in petty trades that cannot maintain their families. Their children are forced into the streets, into petty trades as child labourers or even child prostitutes. Whole families may be rendered landless due to land pressure and transactions. They become squatters and their children lack proper basic amenities. Majority of them end up as child labourers or members of other groups of CEDC. Parents suffering from HIV/AIDS are now contributing to a large and increasing numbers of CEDC. Unlike victims of other terminal illnesses, parents with HIV/AIDS often die leaving their children not only without support but also stigmatized while others may be HIV infected. An important emotional problem is space to grieve, as children are often denied the grieving process, which is an important component of the bereavement process. Children with disabilities tend to be neglected and as result suffer from malnutrition, poor health and are often victims of abuse and neglect. Children in Conflict and Emergencies: Many children within Africa have been affected by volatile political situations that have contributed to an exodus of refugee children into neighbouring countries or internally displaced families. These children end up in crowded refugee camps. In a study in Zambia, a number of complex health issues were observed at refugee settlements in remote parts of the country. Refugee children developed malnutrition and micronutrient deficiency states during flight. This may not be documented and some children die, during flight, without featuring in the statistics. About 20 % of refugee children were malnourished during the early period of arrival to camp.

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Children also need services such as immunization services, access to oral rehydration, clean water and sanitation and supplementation such as with vitamin A. These may not be easily available close to refugee settlements. Because of poor sanitation diarrhoeal diseases are prevalent During armed conflict, girls and women are raped with the increasing danger of being infected with HIV. Boys are recruited as soldiers. Separation, death of family members creates emotional and psychological trauma. APPROACH TO MANAGEMENT Provide alternative families for children already in difficult circumstances (foster care an adoption where necessary institutions) Reduce and control the influx of children into the streets Provide vocational training skills for CEDC Strengthen Government and Non-governmental Organization (NGOs) existing rehabilitation programmes. Expand government and NGOs aid to poverty stricken families through state maintenance and grants as well as professional services to poor parents attempting business so as to strengthen their role in development thereby enabling them to support their children. This would create a social safety net for vulnerable families and vulnerable children Amend and codify the existing statutes dealing with the rights of the child in every country. Carry out a National Survey to determine the magnitude of CEDC Intensify Public awareness of the plight of CEDC Encourage and support initiatives of communities and NGOs to establish alternative educational centres (informal schools) for working children and children who cannot afford conventional educational institutions. STRATEGIES Free universal primary school education has been introduced but still some vulnerable children are not in school for varied reasons Material support should also be provided to informal schools whenever they exist. Support rehabilitation programmes initiated by NGOs; improve and expand the existing governmental children’s institutions. Organization of training workshops and seminars for Children Officers and NGO officials dealing with children matters. Development of advocacy for CEDC through the print and audio- visual media to step up information in order to influence attitudes and behavioral patterns towards CEDC e.g. encourage the well – to-do to sponsor or even foster and adopt from among the CEDC: enhance awareness on handicapped children- their handling and possible training. To create awareness on AIDS affected children and the need to care for them within the community. To organize a high level policy makers seminar for law enforcement agencies e.g. police, magistrates, and lawyers to harmonize matters pertaining to children. Establish rescue / rehabilitation centres in all major urban centres with prevalent CEDC. Cary out national situational analysis to establish the magnitude of the problem of CEDC.

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Set up new and strengthen the already existing advisory committees on children and young persons in every country. Provide and promote makeshift schools and health centres for the refugee camps and to avail on standby readily available supportive personnel. The existing legal statutes on matters relating to child sexual abuse and child battering to be reviewed and strengthened in every country. The government to provide legal services and to subsidize costs incurred in investigations involved in fostering and adoption services. Strengthen and improve existing rehabilitative programmes for disabled children A specific provision in the law to be made regarding child labour with a view to dealing with their employers in formal sector e.g. Agriculture or house workers. Mandate of parents marrying off their below 18 years old daughters to be removed – thus absolutely no girl to be married before she is 18 years – to avoid child brides! A provision also to be made for child mothers to be allowed to continue with education. Relief agencies for refugee and displaced people Several international bodies respond to natural and manmade disasters. These include United Nations agencies like UNHCR, UNICEF, WFP, UNDP, and WHO; Red Cross/Red Crescent, Save the Children and many others. It is a lot easier to respond to natural disasters than conflicts as conflicts can last several years or even decades making it difficult to sustain support. There are established international regulations to safeguard the health of people in affected situations. These are set particularly benefic children and women. Responses to emergency situations include: The immediate response by relief agencies is to save lives and protect basic health by treating and/or preventing diseases. Other activities include: Provision of shelter for the affected families Provision household necessities such as clothing and blankets Setting up curative services Provision of food and setting up of feeding centres Provision of clean water Setting up sanitary facilities to prevent disease outbreaks Registration of household members or displaced individuals Setting up communication systems for tracing lost people and reuniting families Services for children in emergencies It is important to have special services for children as they are the most vulnerable. Screening for and prompt treatment of illness is essential. Provision of adequate food for all ages of children becomes crucial and especially those that have been separated from or lost their parents. Counselling to allay anxiety, depression and fear has to be provided as the trauma experience can excessive. For longer term schooling becomes important. Even in these circumstances children need to be given the opportunity to be children by providing love and a chance to play. SHORT COMMINGS OF EXISTING PROGRAMMES Non-governmental organizations make an invaluable contribution towards rehabilitation of CEDC. There are many NGOs dealing with matters relating to children. UNICEF is a major NGO in this area and is widely involved in funding of community based rehabilitation programmes for CEDC. This NGO does a lot in terms of coordinating activities for CEDC an area that have been neglected in the past. But in general the following constraints are observed:

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Lack of relevant and properly trained personnel to handle CEDC in both government and NGOs at all levels. Inadequate logistical support and lack of community – based preventive rehabilitation programmes. Lack of effective co-ordination amongst agencies working with target groups leading to duplication of projects. Overstretched facilities in terms of accommodation as well as in manpower and financial resources. Mixing of disciplines with protection cases in approved school due to lack of alternative care for such cases. Presence of undeserving cases in rehabilitative institutions meant for CEDC. This calls for professional assessment of subjects prior to admission. Lack of effective after –care following services foe graduates of rehabilitation centres. CONCLUSIONS It is crystal clear from the foregoing that CEDC is an existing problem. It has identified both internationally and nationally. This calls foe effective policy guidelines to safeguard the children’s rights with a view of arresting the existing problems and as far as possible preventing the same from recurring. The International Convention on the Rights of the Child is a blue print into solving the problem of CEDC. The aims and objective of the Conventions can only be attained for the African child in especially difficult circumstances by both the Government and NGOs. This requires immediate Action. Exercise 1 Stop to reflect on the situation of orphans and vulnerable children in your country. Form small groups to discuss the following: 1. Who is an orphan? 2. Who are vulnerable children? 3. What are the causes associated with being orphaned and vulnerable? Exercise 2 What are the health needs of children in refugee circumstances? 1. In small groups or individually itemize these health needs? 2. How can plans be made to take care of the health needs? 3. Plan to visit a refugee situation near you. What is different between your healthcare system and that of refugee children? What needs to improve in the service provision? Exercise 3 Are there other children on the margins of society in your locality? 1. Who are they? 2. How can their welfare be addressed? 3. Form small groups, visit and discuss plans for intervention and how to harness assistance.

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REFERENCES The Convention on the Rights of the child New York UNICEF 1989 UNAIDS/UNICEF/USAID, 2004; UNAIDS/WHO, 2007 http://www.Avert.org; UNAIDS/WHO, 2006. Skinner, Tsheko, Mtero-Munyati, Segwabe, Chibatamoto, Mfecane et al., 2004; Smart, 2003). Children on the Brink Report (UNAIDS/UNICEF/USAID, 2004) Altman, 1994; Pizzo & Wilfret, 1995; UNAIDS/UNICEF/USAID, 2004. Shilalukey Ngoma, Mudenda C. Ngoma J Lessons learnt in health during influx of refugees into Zambia Note: Website of the United Nations and other agencies mentioned in the chapter can give invaluable references.

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CHAPTER 21

HEALTH EDUCATION, COMMUNICATION SKILLS AND COUNSELLING

Esther D. Mwaikambo, Amos Odiit

INTRODUCTION Health education is one of the core Primary Health Care strategies. It is a process of helping change people’s behaviour in a way that will make their health and that of their families and the community better. It is concerned with helping people take greater responsibility for protection and promotion of their own health through provision of correct information and modification of the existing inappropriate attitudes and practices in respect to prevention, promotion, curative and rehabilitative care. It is also aimed at promoting healthy lifestyles of the individual and the community. In the context of child health, health education should aim at preventing common illnesses such as: diarrhoeal diseases, malnutrition, acute respiratory infections, malaria, whooping cough, measles, tuberculosis and acquired immune deficiency syndrome. Health workers therefore need to develop proper attitudes, adequate knowledge and skills that will enable them provide health education at various service delivery settings. OBJECTIVES At the end of this chapter the student will be able to: Define health education; Explain the factors which determine an individual’s behaviour; Explain the determinants of behavioural change; Describe the role of health workers in the provision of health education to communities; Describe effective communication process and effective education methods; List basic skills needed by all health workers to impart health education effectively; Identify the health education needs of different categories of patients and communities Describe the principles of counselling Describe the process of planning, organizing, implementing and evaluating a health education programmes in a community. LEARNING ACTVITIES Participate in a group of health workers discussing basic health education skills needed by all PHC workers and prepare a report. Visit a child welfare clinic and determine the incidence of missed opportunities for health education. Prepare specific health education messages aimed at preventing diarrhoeal diseases, malnutrition, and acute respiratory infections, malaria and measles. Participate in a health education session in a child welfare centre. Visit the national, regional or district health education unit and describe the different communication and education media used for the promotion of health in your country.

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DETERMINANTS OF BEHAVIOURAL CHANGE: The effects of health education efforts are strongly influenced by the individual’s cultural beliefs, attitudes and values. Clear understanding of these attributes and their consideration in preparing and giving of health education will have a positive influence on the impact of the program. For instance, in most African communities children are denied certain high protein and energy foods like eggs and fish because of cultural taboos. A health education message that does not recognize this fact will most likely be ignored by the mothers. However, knowledge of this taboo will facilitate the development of the appropriate messages that could modify this practice positively and lead to increased provision of these foods to children. DOCTOR’S LEADERSHIP ROLE IN HEALTH EDUCATION: The doctor should play a leadership role in promoting community health development. To play this role the doctor needs to develop skills in identifying the health needs and resources of the community. This will assist in the development of educational messages and strategies to respond to the community needs. He should be able to plan and organize health education programmes that respond to the priority health needs in his community. The doctor fulfils this leadership role through encouraging community involvement, intersectoral collaboration and providing health education. He thus has a responsibility for educating himself, other health workers and his patients on matters relating to health development in his or her community. COMMUNICATION SKILLS Communication is the process of transferring messages and skills from the sender to the receiver and from the receiver back to the sender. The receiver may be a person or a group. If there is no response there is no communication. Conditions which favour effective communications are: a clear and concise message; a message which is relevant to the needs and concerns of the receiver; a message related to the experience and knowledge of the receiver. Conducive environment (privacy, quietness) It is the responsibility of the doctor or any other health educator to ensure that these conditions are satisfied. The receiver is ready to learn when: he or she is interested in what is being said; she or she is alert; he or she is not occupied with some other urgent and worrying matter of a different kind; the message is relevant to the recipient’s current condition or need.

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Communication skills that are important to the health worker include: ability to concentrate attention on the client and establish an active communication process; effective speaking; explaining things to others; persuading others; Active listening; asking relevant questions. EFFECTIVE HEALTH EDUCATION METHODS An effective educator should have clear concepts of educational objectives and a clear statement of what the learner should be able to think, feel and do (behaviour, observable activity) at the end of the learning period. The objectives are obtained from the various tasks for solving the community health problems. Learning is the process that results in relatively permanent change in behavior of the individual learner. Learning is: controlled by the learner, affected by the total state of the learner, unique, individual and the result of experience or repetition. The durability of cognitive and behavioural change is proportional to the degree of active rather than passive participation of the learner. Note the Chinese proverb “What I hear, I forget; what I see, I recall; and what I do, I know”. Use of Print Visual Aids: Effective use of relevant visual aids may depict: a severely dehydrated child and a well hydrated one; a malnourished and a healthy one; a child demonstrating difficulty in breathing and one showing normal breathing; a pregnant adolescent in a school uniform and a happy adult mother. Audio Visual Messages: These may be presented in health facilities, through public radio, television and cinema. This is a powerful method of health education as it combines entertainment and education. Lecture Lecture is an easy way of providing a lot of information within a short period of time. It is however not an efficient method in causing retention of the information. To accentuate retention, a lecture must be interesting and to the point. It must be short as the attention span of people wanes after about 30 minutes. The person delivering a lecture must prepare and give real life examples or experiences. Allow time for discussion at the end. The lecture should include the following:

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An introduction explaining the importance of the topic to the students; a statement of the objectives; evaluation of what listeners already know; learning activity such as answering questions; presentation in a logical sequence; repetition of the main points; evaluation at the end and a summary. Group Discussion This is a good method because participants are actively involved. A group of 7-8 is ideal. The educator serves as the moderator of the group discussion but does not monopolise the discussion. He prepares the essential topic for discussion. An example of a topic would be, “The role of exclusive breastfeeding in young infant nutrition.” A good moderator introduces the topic; he then asks what people know before adding what he thinks. The moderator will record the views of the members of the group discussion and review them with the group at the end of the discussion. Demonstration This is a method used for teaching a skill. The skill is first described and then demonstrated. The demonstration must be correct, visible and provide an explanation of every step. Practicals Practice is the most effective method of helping acquire skills. The more the opportunities for practice are offered the more the learner can improve his/her skills. All the participants should practice and should be given feedback on how they are performing the skill. This should include practice in speaking to individuals and groups of people, demonstrating specific activities, and performing procedures. The clients should be given the opportunity to practice under supervision. Role Playing This is an effective method of teaching attitudes, and communication skills. In this method the learner acts different parts as if they are in a play, but they are only given the outline and left to think out the rest. This could be illustrated by a role play activity showing washing of hands before eating, use of the latrine, and breastfeeding as a complimentary activity for preventing diarrhea. Simulation This is a method of providing the learner with some experience and practice on an imitated thing before the actual task. For instance, the learner may use orange skin to practice injections. Here the orange simulates the skin of a person. COUNSELLING There are ways of teaching people such that they can understand and be persuaded to put what they learned into practice. The methods of health education are grouped as personal and impersonal. While personal methods involve physical presence of the

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counselor, the counselor is absent in the impersonal methods. The personal method comprises counselling of an individual patient; and includes giving health education to a small group. To be effective both the personal methods require establishment of confidence and trust between the health worker and the individual or the group. Counselling an Individual Counselling an individual is the process of helping him to think clearly about his problems, discover their causes and thus develop understanding of the causes. In the process the counsellor: first establishes a warm relationship with the client; encourages the client to talk sincerely and trustingly about his or her problems; assists the client in finding out the possible solutions; helps select the best solution and assists him on deciding the best action to take and to solve the problem himself. This form of counselling is called non-directive. The decision arrived at is that of the individual and not the counsellor. Example: Providing feedback to the mother and praising her when she has learnt something and when her baby is growing well improves learning. If the baby is not growing, she is advised accordingly and sympathetically helped to reach a decision as to what she can do to help the child acquire normal growth. Successful counselling depends on the counsellor’s ability to establish a good rapport with the person being counselled. Group Counselling: This is a method of helping a group of 10-15 people through discussing among themselves to discover or define their health problems, to discover the most effective solutions and to take action. In the discussion, the group members do offer each other support for the appropriate behavior. The discussion is usually enjoyable with exchange of experiences, enrichment of the individuals with ideas, and participation in decision-making with other people. The health worker first establishes rapport with creation of a relaxed friendly atmosphere. He then introduces the discussion with a question, a film, a newspaper cutting, a tape, a role play or a multiple choice question relevant to the issue. He also summarizes from time to time and thinks of new directions the discussion should take. During the discussion people are enabled to show their different values and attitudes, to clarify their ideas and to make plans for a new course of action with the support of the group. In this way, people can realize the motives behind their action. Some members of the group may have already solved their problems and this would be helpful to those still with a problem.

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Impersonal Health Education Methods: Impersonal health education methods include leaflets, posters, pamphlets, newspapers, magazines, books, radio, television and songs. For spreading messages, the impersonal methods have great penetrative power. These impersonal methods have the following advantages: reaching a large number of people; repetition of the message; serving as a reminder and reinforcement; assuming more authority than personal contact. The disadvantages of the impersonal methods are: lack of opportunity for questions or discussion; difficulties experienced by individuals in relating the message to their circumstances; risk of being misunderstood. NB: Combination of personal and impersonal health education methods occurs when the mass media messages reinforce individual counselling, when individual counselling clarifies the mass media messages and when small group discussions use radio messages, television programmes and newspapers as the focus or starter. IDENTIFYING THE HEALTH EDUCATION NEEDS To provide effective training of the health workers and effective health education, the doctor and other health workers should determine the learning needs of the individual patients, health workers and the community. The learning needs of individual patients are assessed by encouraging people to talk about themselves, what interests them and what they do not understand. The educators listen carefully and observe the gestures as well as facial expressions. During the interview the participants may raise some questions and express some doubts, anxieties or satisfactions. These are optimum opportunities of offering health education and should not be missed. Other opportunities for providing health education of an individual patient are immediately after recovery from an illness or at discharge from a health facility. The health education needs of a community may be discovered from health service information and by community diagnosis through: carrying out knowledge, attitude and practice surveys, focus group discussions and behavioural observations. HEALTH EDUCATION IN SCHOOLS A very important component of the community is schools. Through health education, teachers and school children can serve as agents of cultural change by changing the content of instruction in line with changing knowledge, social needs and values. Health education in school has the major goal of promoting health as a value and is a valuable means of promoting healthy behaviour for generations. In schools, health education is largely given formally in classes. Informal health education in schools may be given during the contacts of the students and the health workers. The contacts represent some teachable moments to be exploited.

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SELF EVALUATION QUESTIONS How can you evaluate the achievements of a health education programme on control of diarrhoeal diseases? Explain what counselling is and list six qualities of a good counsellor. Describe the reasons why some individuals do not immediately accept health education messages. Explain the role of informal leaders in health education. REFERENCES Guidelines for implementation of health education activities in Tanzania. Ministry of Health, Tanzania. November, 1994. Primary Health Care in Tanzania: An overview. A manual for Tanzanian Community Health Educators. Ministry of Health, Tanzania, 1994. Health Education, A manual for Tanzanian Community Health Educator, Ministry of Health, Tanzania, 1994. Determinants of Health, Introduction to A Manual for Tanzania Community Health Educators, Ministry of Health Tanzania, 1994. P Stanfield, N Bwibo Child health: A manual for medical and health workers in health centres and rural hospitals. AMREF Rural Health Series 2005

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CHAPTER 22

Integrated Management of Childhood illness*

Kopano Mukelabai

Introduction Globally the number of child deaths under five years of age has decreased by almost one quarter between 1990 and 2006. In 2006 an estimated 9.6 million children died before reaching their 5th birthday, as compared to 13 million deaths in 1990. The reduction in under-five child morality has varied widely throughout the world. Children in low to middle Figures 1

income countries are 10 times more likely to die before reaching their fifth birthday than children living in industrialized countries (1999 World Health Report). The major causes of child deaths are: pneumonia, diarrhoea, measles, malaria and malnutrition or often a combination of these conditions. HIV and AIDS has exacerbated under-five child morality, especially in countries in Africa South of the Sahara. See Fig. 1.

February 2008Child and Adolescent Health and DevelopmentCAH

Why are children dying?cause-specific mortality and contribution of undernutrition

Diarrhoea27%

Measles6%

HIV/AIDS5%

Other non-communicable

7%

Injuries5%

Pneumonia30%

Other infectious7%

Malaria13%

UnderStudy

UnderStudy

%

Deaths among children aged 28 days to five years( 6.6 million/year)

Percent of deaths from this infection that are due to the presence of undernutrition

Neonatal deaths( 4 million/year)

Preterm27%

Congenital8%

Asphyxia23% Other

7%

Diarrhoea3%

Tetanus7%

Pneumonia/ sepsis 25%

% of deaths due to maternal and neonatal undernutrition is under study

61%45%

52%

57%

*Material in this chapter on IMCI is mostly obtained from WHO and UNICEF documents.

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Since the year 2000, the global community has been focused on achieving the Millennium Development Goals (MDGs). The MDG number 4 aims at reducing under-five child mortality in the world by two thirds between 1990 and 2015. Neonatal mortality currently accounts for almost 40% of all children dying under five years of age. This number is estimated to be 4 million neonatal deaths according to the UNICEF 2008 State of the World’s Children. Between 1980 and 2000 child death in the first month of life declined by a quarter, while deaths between one month and five years of age declined by a third. Affordable and cost effective strategies are now available in most countries to prevent child deaths. These include routine childhood immunization, oral rehydration therapy, effective use of antibiotics, regular use of insecticide treated nets to prevent malaria, use of newer anti-malaria drugs, breastfeeding and prevention of mother to child transmission of HIV and AIDS. The IMCI strategy was developed by WHO and UNICEF in collaboration with many agencies and institutions, and has now been adopted by many countries and communities. The main objective of the strategy is to reduce child deaths and the frequency and severity of a child illness and disability, hence contributing to improved child growth and development. The IMCI strategy advocates for both preventive and curative care and deals with aspects of child nutrition, immunization, disease prevention and health promotion. The IMCI guidelines have been adapted at country level to address the major causes of child deaths and to provide health information to health workers, community health workers and to families.

Objectives: At the end of this chapter a student will be able to: - Define the IMCI strategy

- Familiarize him/herself with IMCI

adapted guidelines in his/her

country

- Identify the major causes of under

five child mortality in his/her

country.

- Be conversant with the national

strategy to achieve the MDGs

number 4

- Assess a sick child, including

his/her immunization and

nutritional status

- Classify the child’s illness, note

the danger signs, and decide if the

child needs urgent medical

referral.

- Give essential pre-referral

treatment (e.g., antibiotic, anti-

malarial, anti pyretic, or anti-

convulsant etc.)

- Teach the mother how to

administer treatment at home for

example an antibiotic, anti-

malarial etc.

- Advise the mother on proper

feeding practices and when to

return to the health centres if the

child becomes more sick.

- Do a follow up assessment and

give treatment for children coming

for follow-up.

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Infant and childhood mortality are sensitive indicators of inequity and poverty. It is no surprise to find that the

children who are most commonly and severely ill, are often those who are malnourished, and those who are most vulnerable. They often belong to

underprivileged populations of low income countries. However, even within middle-income and so called industrialized countries, there are often poor and neglected communities; these are often neglected geographical areas where childhood mortality remains high. Millions of children in these areas are often caught in the vicious cycle of poverty and ill health - poverty leads to ill health and ill health breeds poverty. Quality of care is another important indicator of inequalities in child health. Every day, millions of parents seek health care for their children, taking them to hospitals, health centers, pharmacies, doctors, and traditional healers. Surveys reveal that many sick children are not properly assessed and treated by these health providers, and that their parents are poorly advised. ³ At first-level health facilities in low-income countries, diagnostic supports such as radiology and laboratory services are minimal or non-existent, and drugs and equipment, combined with an irregular flow of patients, leave doctors at this level with few opportunities to practice complicated clinical procedures. Instead, they often rely on history and signs and symptoms to determine a course of management that makes the best use of available resources. Providing quality care to sick children in these conditions is a serious challenge. Yet how can this situation be reversed?

Experience and scientific evidence show that improvements in child health are not necessarily dependant on the use of sophisticated and expensive technologies, but rather on effective strategies that are based on a holistic approach, are available to the majority of those in need, and which take into count the capacity and structure of health systems, as well as traditions and beliefs in the community. Rationale for an evidence based syndromic approach to case management Many well-known prevention and treatment strategies have already proven effective for saving young lives. Childhood vaccinations have successfully reduced deaths due to measles. Oral rehydration therapy has contributed to a major reduction in diarrhoeal deaths. Effective antibiotics have saved millions of children with pneumonia. Prompt treatment of malaria has allowed more children to recover and lead healthy lives. Even modest improvements in breastfeeding practice have reduced childhood deaths. While each of these interventions has shown great success, accumulating evidence approach to managing sick children is needed to achieve better outcomes. Child health programmes need to move beyond single disease to addressing the overall health and well-being of the child. Because many children present with over lapping signs and symptoms of disease, a single diagnosis can be difficult, and may not be

Improvements in child health are

not necessarily dependent on the use of sophisticated and

expensive technologies.

A more integrated approach to

managing sick children is needed to achieve better

outcomes. Child health

programmes need to move beyond

addressing single disease to

addressing the overall health and well-being of the

child.

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feasible or appropriate. This is especially true for first-level health facilities where examinations involve few instruments, little or no laboratory tests, and no instruments, little or laboratory tests, and no X-ray. During the mid-1990s, the World Health Organization (WHO), in collaboration with UNICEF and many other agencies, institutions and individuals, responded to this challenge by developing a strategy known as the Integrated Management of Childhood Illness (IMCI). Although the major reason for developing the ICMI strategy stemmed from the needs of curative care, the strategy also addresses aspects of nutrition, immunization, and other important elements of disease prevention and health promotion. The objectives of the strategy are to reduce death and the frequency and severity of illness and

disability, and to contribute to improved growth and development. The ICMI clinical guidelines target children less than 5 years old - the age group that bears the highest burden

of deaths from common childhood diseases. (Figure 1). The guidelines take an evidence-based, syndromic approach to case management that supports the rational, effective and affordable use of drugs and diagnostic tools. Evidence-based medicine stresses the importance of evaluation of evidence from clinical research and cautions against use of intuitions, unsystematic clinical experience, and untested pathophysiologic reasoning for medical decision-making. In situations where laboratory supports and clinical

resources are limited, the syndromic approach is a more realistic and cost-effective way to manage patients. Careful and systematic assessment of common symptoms and well-selected clinical signs provides sufficient information to guide rational and effective actions. An evidence-based syndromic approach can be used to determine the: Health problem (s) the child may

have

Severity of the child’s condition;

Actions that can be taken care for

that child (e.g. refer the child

immediately, manage with

available resources, or manage at

home).

Fig. 2

In addition, ICMI promotes:

Adjustment of the curative

interventions to the capacity and

functions of the health system;

and

Active involvement of family

member and the community in the

health care process.

Parents, if correctly informed and counselled, can play an important role in improving the health by following the advice given by a health care provider, by applying appropriate feeding practices and by bringing sick children to a doctor as soon as symptoms arise. A critical example of the need for timely care is in Africa; here approximately 80% percent of childhood deaths occur at

Careful and systematic

assessment of common symptoms

and well-selected specific clinical signs

provide sufficient information to guide

rational and effective actions.

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February 2008Child and Adolescent Health and DevelopmentCAH

Main components of IMCI

Knowledge,beliefsand skills ofcaretakers

Improvehealth workerperformance

Strengthenhealth systemsupports

home, before the child has any contract with a health facility. Components of the integrated approach The ICMI strategy includes both preventive and curative interventions that aim to improve practices in health facilities, the health system and at home. At the core of the strategy is integrated case management of the most common childhood problems with a focus on the most common causes of death. The strategy includes three main components: Improvements in the case-

management skills of health staff through the provision of locally adapted guidelines on integrated management of childhood illness and activities to promote their use;

Improvements in the overall system required for effective management of childhood illness;

Improvements in family and community health care practices. See Fig. 2.

The Principle of integrated care

The ICMI guidelines are based on the

following principles:

All sick children must be examined for

“general danger signs” which indicate the need for immediate referral or admission to a hospital.

All sick children must be routinely assessed for major symptoms (for children age 2 months up to 5 years: cough or difficult breathing, diarrhoea, fever, ear problems,; for young infants age 1 week up to 2 months: bacterial infection and diarrhoea). They must also be routinely assessed for nutritional and immunization status, feeding problems, and other potential problems.

Only a limited number of carefully-selected clinical signs are used, based on evidence of their sensitivity and specificity7 to detect disease.

These signs were selected considering the conditions and realities of first-level health facilities.

A combination of individual signs leads to a child’s classification (s) rather than a diagnosis. Classification (s) indicates the severity of condition (s). They call for specific actions based on whether the child (a) Should be urgently referred to another level of care, (b) requires specific treatments (such as antibiotics or ant malaria treatment), or (c) may be safely managed at home.

The classification are colour coded:

270

“pink” suggests hospital referral or admission, “yellow” indicates initiation of treatment, “green” indicates calls for home treatment.

The ICMI guidelines address most, but not all, of the major reasons a sick child is brought to a clinic. A child returning with chronic problems or less common illness may require special care. The guidelines do not describe the management of trauma or other acute emergencies due to accidents or injuries. IMCI management procedures use a limited number of essential drugs and encourage active participation of caretakers in the treatment of children. An essential component of the IMCI guidelines is the counselling of caretaker about home management, including counselling about feeding, fluids and when to return to a health facility. Adapting the guidelines to a country’s situation The underlying principles of the IMCI guidelines are constant. However, in each country the IMCI clinical guidelines should be adapted to; Cover the most serious childhood

illness typically seen at first-level

health facilities;

Make the guidelines congruent with

national treatment guidelines and

other policies; and

Make the IMCI implementation

feasible

through the health system and by

families caring for their children at

home.

Adaption of the ICMI guidelines normally

is co-ordinated by national health

regulating body (e.g.

Ministry of Health) and incorporates

decisions carefully made by national

health experts.

For this reason, some clinical signs and

details of clinical procedures described

below may differ from those used in a

particular country. The principles used for

management of sick children, however,

are fully applicable in all situations.

The IMCI case management process The case management of a sick child brought to a first-level health facility includes a number of important elements. Outpatient health facility Assessment

Classification treatment or counselling

of the

child’s caretaker (|depending on the

classification(s) Identified);

Follow-up care

Referral health facility

Emergency triage assessment

and treatment (ETAT)’

271

Diagnosis, treatment and monitoring

of patient progress.

Appropriate home management Teaching the mother or other

caretaker to give oral drugs and treat

local infections at home;

Counselling the mother or other

caretaker about food (feeding

recommendations, feeding problems,);

fluids; when to return to the health

facility; and her own health.

Depending on child’s age, various clinical signs and symptoms have different degrees of reliability and diagnostic value

and importance. Therefore, The IMCI guidelines recommend case management procedures based on two age categories:

Children age 2 months up to 5

years

Young infants age 1 week up to 2

months

February 2008Child and Adolescent Health and DevelopmentCAH

Key family practices (1)

For physical growth and mental development

1. Breastfeed infants exclusively for six months. Mothers found to be HIV positive require counselling about possible alternatives to breastfeeding

2. Starting at the end of six months of age, feed children freshly prepared energy and nutrient rich complementary foods, while continuing to breastfeed up to two years or longer

3. Ensure that children receive adequate amounts ofmicronutrients (vitamin A and iron, in particular), either in their diet or through supplementation

4. Promote mental and social development by responding to a child’s needs for care, and through talking, playing, and providing a stimulating environment

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February 2008Child and Adolescent Health and DevelopmentCAH

Key family practices (2)

For disease prevention• Dispose of faeces safely, including children’s; and wash

hands after defecation, before preparing meals, and before feeding children

• Take children as scheduled to complete a full course of immunizations (BCG, DPT, OPV, Hib, and measles) before their first birthday

• Protect children in malaria-endemic areas, by ensuring that they sleep under insecticide-treated bednets

February 2008Child and Adolescent Health and DevelopmentCAH

Key family practices (3)

For appropriate home care1. Continue to feed and offer more fluids, including

breastmilk, to children when they are sick

2. Give sick children appropriate home treatment for infections

3. Follow the health worker’s advice about treatment, follow-up and referral

For seeking care1. Recognise when sick children need treatment outside the

home and seek care from appropriate providers

2. Ensure that every pregnant woman has adequate antenatal care

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Fgure 3. IMCI management in the health facility, first-level referral facility and at home for the sick child from age 2 months up to 5 years

274

Outpatient management of children Age 2 months up to 5 years

Assessment of sick children The assessment procedure for this age group includes a number of important steps that must be taken by the health care provider, including: (1)History taking and communicating with the caretaker about the child’s problem; (2) Checking for general danger signs; (3) Checking main symptoms; (4) Checking nutritional status; (5) Assessing the child’s feeding; (6) Checking immunization status; and (7) Assessing other problems. History taking – communicating with the caretaker

History taking

General danger signs

Main symptoms Cough or difficult breathing

Diarrhoea

Fever

Ear problems

Nutritional status Immunization status

Other problems It is critical to communicate effectively with the child’s mother or caretaker. Good communication techniques and an integrated assessment are required to ensure that common problems or signs of disease or malnutrition are not overlooked. Using

good communication helps to reassure the mother or caretaker that the child will receive good care. In addition, the success of home treatment depends on how well the mother or caretaker knows how to give the treatment and understands its importance.

The steps to good communication are:

Listen carefully to what the caretaker says. This will show her/him that you take their concerns seriously. Use words the caretaker understands Try to use local words and avoid medical terminology. Give the caretaker time to answer questions. S/he may need time to reflect and

decide if a clinical sign is present. Ask additional questions when the

caretaker is not sure about the answer. A caretaker may not be sure

if a symptom or clinical sign is present. Ask additional questions to help her/him give clear answers. A sick child brought

to an outpatient facility may have signs that clearly indicate a specific problem. For example, a child may present with chest in drawing and cyanosis, which indicate severe pneumonia. However, some children may present with serious, non-specific signs called “general danger

LETHARGY UNCONCIOUOSNESS

INABILITY TO DRINK

OR BREAST FEED

DANGER SIGNS

275

signs” that do not point to a particular diagnosis. For example, a child who is lethargic or unconscious may have meningitis, severe pneumonia, cerebral malaria or another severe disease. Great care should be taken to ensure that these general danger signs are not overlooked because they suggest that a child is severely ill and needs urgent attention.

The following danger signs should be routinely checked in all children.

The child has had convulsions during the

present illness. Convulsions may be the result of fever. In this instance, they do little harm beyond frightening the mother. On the other hand, convulsions may be associated with meningitis, cerebral malaria or other life-threatening conditions. All children who have had convulsions during the present illness should be considered seriously ill.

The child is unconscious or lethargic. An unconscious child is likely to be seriously ill. A lethargic child, who is awake but does not take any notice of his or her surroundings or does not respond normally to sounds or movement, may also be very sick. These signs may be associated with many conditions.

The child is unable to drink or breastfeed.

A child may be unable to drink either because she/he is too weak or because she/he cannot swallow. Do not rely completely on the mother’s evidence for this, but observe while she tries to breastfeed or to give the child something to drink.

The child vomits everything. The vomiting It may be a sign of serious illness, but it is also important to note because such a child will not be able to take medication or fluids for rehydration.

If a child has one or more of these signs, she/he must be considered seriously ill and will almost always need referral. In order to start treatment for severe illnesses without delay, the child should be quickly assessed for the most important causes of serious illness and death – acute respiratory infection (ARI), diarrhoea, and fever (especially associated with malaria and measles). A rapid assessment of nutritional status is also essential, as malnutrition is another main cause of death.

Checking main symptoms

After checking for general danger signs, the health care provider must check for main symptoms. The generic IMCI clinical guidelines suggest the following four: (1) cough or difficult breathing; (2) diarrhoea; (3) fever; and (4) ear problems

The first three symptoms are included because they often result in death. Ear problems are included because they are considered one of the main causes of childhood disability in low-and middle –income countries.

Child presenting with cough or difficult breathing should first be assessed for general danger signs. This child may have pneumonia or another severe respiratory infection. After checking for danger signs, it is essential to ask the child’s caretaker about this main symptom.

276

Clinical assessment

Three key clinical signs are used to assess a sick child with cough or difficult breathing:

Respiratory rate, which distinguishes children who have pneumonia from those who do not; Lower chest wall indrawing, which indicates severe pneumonia; and

Stridor, which indicates those with severe pneumonia which requires hospital admission.

No single clinical sign has a better combination of sensitivity and specificity to detect pneumonia in children under 5 than respiratory rate, specifically fast breathing. Even auscultation by an expert is less sensitive as a single sign.

Cut –off rates for fast breathing (the point at which fast breathing is considered to be fast) depend on the child’s age. Normal breathing rates are higher in children age 2 months up to 12 months than in children age 12 months up to 5 years.

Child’s age Cut-off rate fast breathing

2 months up to 12 months 50 breaths per minute or more

12 months up to 5 years 40 breaths per minute or more

Note: The specificity of respiratory rate for detecting pneumonia among the population. In areas with high levels of viral pneumonia, respiratory rate has relatively modest specificity. Nevertheless, even if the use of respiratory rate leads to some overtreatment, this will still be small compared with the current use of antibiotics for all children with an ARI, as occurs in many clinics.

Lower chest wall indrawing, defined as the inward movement of the bony structure of the chest wall with inspiration, is a useful indicator of severe pneumonia. It is more specific than “intercostal indrawing,” which concerns the soft tissue between the ribs without involvement of the bony structure of the chest wall.8 Chest indrawing should only be considered present if it is consistently present in a calm child. Agitation, a blocked nose or breastfeeding can all cause temporary chest indrawing.

Stridor is a harsh noise made when the child inhales (breathes in). Children who have stridor when calm have a substantial risk of obstruction and should be referred. Some children with mild croup have stridor only when crying or agitated. This should not be the basis for indiscriminate referral. Sometimes a wheezing noise is heard when the child exhales (breathes out). This is not stridor. A Wheezing sound is most often associated with asthma. Experience suggests that even where asthma rates are high, mortality from asthma is relatively uncommon. In some cases, especially when a child has wheezing when exhaling, the final decision on presence or absence of fast breathing can be made after a test with a rapid acting bronchodilator (if available). At this level, no distinction is made between

277

children with bronchiolitis and those with pneumonia. Classification of cough or difficult breathing

Based on a combination of the above clinical signs, children presenting with cough or difficult breathing can be classified into three categories:

Those who require referral for possible severe pneumonia or very severe disease.

This group includes children with any general danger sign, or lower chest indrawing or stridor when calm. Children with severe pneumonia or very severe disease most likely will have invasive bacterial organisms and diseases that may be life-threatening. This warrants the use of injectable antibiotics.

Any general

danger sign or

Chest

indrawing

Stridor in

calm child

SEVERE

PNEUMONIA

OR

VERY SEVERE

DISEASE

Those who require antibiotics as outpatient

because they are highly likely to have bacterial pneumonia. This group includes all children with fast respiratory rate for age. Fast breathing, as defined by WHO,

detects about 80 percent of children with pneumonia who need antibiotic treatment. Treatment based on this classification has been shown to reduce mortality.

Those who simply have a cough or cold and do not require antibiotics. Such children may require a safe remedy to a relieve cough. A child with cough and cold normally improves in one or two weeks. However, a child with chronic cough (more than 30 days) needs to be further assessed (and, if needed, referred) to exclude tuberculosis, asthma, whooping cough or another problem.

No signs of pneumonia or very severe disease

NO PNEUMONIA: COUGH OR

COLD

Diarrhoea

A child presenting with diarrhoea should first be assessed for general danger signs and the child’s caretaker should be asked if the child has cough or difficult breathing.

Diarrhoea is the nest symptom that should be routinely checked in every child brought to the clinic. A child with diarrhoea may have three potentially lethal conditions: (1) acute watery diarrhoea (including cholera); (2) dysentery (bloody diarrhoea); and (3) persistent diarrhoea (diarrhoea that lasts more than 14 days). All children with diarrhoea; (a) signs of dehydration (b)

Fast breathing

278

how long the child has had diarrhoea; and (c) blood in the stool to determine if the child has dysentery.

Clinical assessment

All children with diarrhoea should be checked to determine the duration of diarrhoea, if blood is present in the stool and if dehydration is present. A number of clinical signs are used to determine the level of dehydration.

Child’s general condition. Depending on the degree of dehydration, a child with diarrhoea may be lethargic or unconscious (this is also a general danger sign) or look restless/irritable. Only children who cannot be consoled and calmed should be considered restless or irritable.

Sunken eyes. The eyes of a dehydrated child may look sunken. In a severely malnourished child who is visibly wasted (that is, who has marasmus), the eyes may always look sunken, even if the child is not dehydrated. Even though the sign “sunken eyes” is less reliable in a visibly wasted child, it can still be used to classify the child’s dehydration.

Child’s reaction when offered to drink. A child is not able to drink if s/he is not able to take fluid in his/her mouth and swallow it. For example, a child may not be able to drink because s/he is lethargic or unconscious. A child is drinking poorly if the child is weak and cannot drink without help. S/he may be able to swallow only if fluid is put in his/her mouth. A child has the sign drinking eagerly, thirty if it is clear that the child wants to drink. Notice if you offer him/her water. When the water tank is taken away, sees if the child takes a drink only which encouragement and does not want

to drink more, s/he does not have the sign “drinking eagerly, thirsty.”

Elasticity of skin. Check elasticity using the skin pinch test. When released, the sin pinch goes back either very slowly longer than 2 seconds), or slowly (skin stays up even for a brief instant), or immediately. In a child with marasmus (severe malnutrition), the skin may go back slowly even if the child is not dehydrated. In an overweight child, or a child with oedema, the skin may go back immediately even if the child is dehydrated.

After the child is assessed for dehydration, the caretaker of child with diarrhoea should be asked how long the child has had diarrhoea and if there is blood in the stool. This will allow identification of children with persistent diarrhoea and dysentery. Classification of dehydration Based on combination of the above clinical signs, children presenting with diarrhoea are classified into three categories:

Those who have severe dehydration and who require immediate IV infusion, nasogastric or oral fluid replacement according to the

Standard procedures for skin pinch test Locate the area on the child’s abdomen

halfway between the umbilicus and the side of the abdomen; then pinch the skin using the thumb and first finger.

The hand should be placed so that when the skin is pinched, the fold of skin will be in a line up and down the child’s body and not across the child’s body

It is important to firmly pick up all of the layers of skin and the tissue under them for one second then release it.

279

WHO treatment guidelines described in Plan C (see figure 4 under treatment procedures).

Patients have severe dehydration if they have a fluid deficit equalling greater than 10 percent of their body weight. A child is severely dehydrated if he/she has any combination of two of the following signs: is lethargic or unconscious, is not able to drink or is drinking poorly, has sunken skin, or a skin pinch goes back very slowly.

Two of the following signs: Restless, irritable Sunken eye Drinks eagerly, thirsty Skin pinch goes back slowly

SEVERE

DEHYDRATION

Those who have some dehydration and who require active oral treatment with ORS solution according to Who treatment guidelines described in pan B (see Figure 5 under treatment procedures).

Children who have any combination of the following two signs are included in this group: restless/irritable, sunken eyes, drinks eagerly/thirsty. Skin pinch goes back slowly.

Children with some dehydration have a fluid deficit equaling 5 to 10 percent of their body weight. This classification includes both “mild” and “moderate”

dehydration, which is a descriptive term used in most paediatric textbooks.

Two of the following signs: Restless, irritable Sunken eye Drinks eagerly, thirsty Skin pinch goes back slowly

SOME

DEHYDRATI

ON

Those children with diarrhoea who have no dehydration.

Patients with diarrhoea but no signs of dehydration usually have a fluid deficit, but equal to less than 5 percent of their body weight. Although these children lack distinct signs of dehydration, they should be given more fluids than usual to prevent dehydration from developing as specified in Who Treatment Plan A (see figure 5 under treatment procedures). Not enough signs to classify as some or severe dehydration

NO

DEHYDRATION

Note: Antibiotics should not be used routinely for treatment of diarrhoea. Most diarrhoea episodes are caused by agents for whom antimicrobials are not effective, e.g., viruses, or by bacteria that must first be cultured to determine their sensitivity to antimicrobials. A culture, however, is

280

costly and requires several days to receive the test results. Moreover, most laboratories are unable to detect many of the important bacterial causes of diarrhoea.

Note: Anti-diarrhoea drugs - including anti-motility agents (e.g., loperamide, diphenoxylate, codeine, tincture of opium), adsorbents (e.g., Kaolin, attapulgite, smectite), live bacterial cultures (e.g., lactobacillus, Streptococcus faecium), and charcoal – do not provide practical benefits for children with acute diarrhoea, and some may have dangerous side effects. The drugs should never be given to children less than 5 years old.

Classification of persistent diarrhoea

Persistent diarrhoea is an episode of

diarrhoea, with or without blood, which

begins acutely and lasts at least 14

days. It accounts for up to 15 percent of

all episodes of diarrhoea but is

associated with 30 to 50 percent of

deaths. Persistent diarrhoea is usually

associated with weight loss and often

with serious non-intestinal infections.

Many children who develop persistent

diarrhoea are malnourished, greatly

increasing the risk of death. Persistent

diarrhoea almost never occurs in infants

who are exclusively breast-fed.

All children with diarrhoea for 14 days or more should be classified based on the presence or absence of any dehydration.

Children with severe persistent diarrhoea who also have any degree of dehydration require special treatment and should not be managed at the outpatient health facility.

Referral to a hospital is required. As a rule, treatment of dehydration should be initiated first, unless there is another severe classification.

Dehydration Present

SEVERE

PERSISITENT DIARRHOEA

Children with severe persistent diarrhoea and no signs of dehydration can be safely managed in the out-patient clinic, at least initially.

Proper feeding is the most important aspect of treatment for most children with persistent diarrhoea. The goals of nutritional therapy are to: (a) temporarily reduce the amount of animal milk (or Lactose) In the diet; (b) provide a sufficient intake of energy, protein, vitamins and minerals to facilitate the repair process in the damaged gut mucus and improve nutritional status; (c) avoiding giving foods or drinks that may aggravate the diarrhoea; and (d) ensure adequate food intake during convalescence to correct any malnutrition.

Persistent diarrhoea

accounts for up to 15 percent of all

episodes of diarrhoea but is

associated with 30 to 50 percent of

deaths

281

Routine treatment of persistent diarrhoea with antimicrobials is not effective. Some children, however, have non-intestinal (or intestinal) infections that require specific antimicrobial therapy. The persistent diarrhoea of such children will not improve until these infections are diagnosed and treated correctly.

No dehydration

PERSISTENT DIARRHOEA

Classification of dysentery

The mother or care taker of a child with

diarrhoea should be asked if there is

blood in the stool.

A child is classified as having

dysentery if the mother or

caretaker reports blood in the child’s

stool.

B

lood

in the

stool

DYSE

NTRY

It is necessary to examine the stool or perform laboratory tests diagnose dysentery. Stool culture, to detect pathogenic bacteria, is rarely possible. Moreover, at least two days are required to obtain the results of a culture.

Although :dysentery” is often described as a syndrome of bloody diarrhoea with fever, abdominal cramps, rectal pain and mucoid stools, these features do not always accompany bloody diarrhoea, nor do they necessarily define its etiology or determine appropriate treatment. Bloody diarrhoea in young children is usually a sign of invasive enteric infection that carries a substantial risk of serious morbidity and death. About 10 percent of all diarrhoea episodes in children under 5 years old are dysenteric, but these cause up to 15 percent of all diarrhoeal deaths. ¹¹ Dysentery is especially severe in infants and in children who are under nourished, who develop clinically-evident dehydration during their illness, or who are not breast –fed. It also has a more harmful effect on nutritional status than acute watery diarrhoea. Dysentery occurs with increased frequency and severity in children who have measles or have had measles in the preceding month, and diarrhoeal episodes which begin with dysentery are more likely to become persistent than those that start without blood in the stool. All children with dysentery (bloody diarrhoea) should be treated promptly with an antibiotic effective against Shigella because : (a) bloody diarrhoea in children under 5 is caused much more frequently by shigella than by any other pathogen; (b) shigellosis is more likely than other causes of diarrhoea to result in complications and death if effective antimicrobial therapy is not begun promptly; and (c ) early treatment of shigellosis with an effective antibiotic

About 10 percent of all diarrhoea

episodes in children under 5 years old are dysenteric, but these

cause up to 15 percent of all

diarrhoea deaths.

282

substantially reduces the risk of severe morbidity or death.

Fever All sick children should be checked for fever. Fever is a very common condition and is often the main reason for bringing children to the health centers. It may be caused by minor infections, but may also be the most obvious sign of a life-threatening illness, particularly malaria (especially lethal malaria P.Falciparum), or other severe infections, including meningitis, typhoid fever, or measles. When diagnostic capacity is limited, it is important first to identify those children who need urgent referral with appropriate pre-referral treatment (anti-malaria or antibacterial). Clinical assessment Body temperature should be checked in all sick children brought to an outpatient clinic. Children are considered to have fever if their body temperature is above 37.5ºC axillary (38ºC rectal). In the absence of a thermometer, children are considered to have fever if they feel hot. Fever also may be recognized based on a history of fever. A child presenting with fever should be

assessed for:

Stiff neck. A stiff neck may be a sign of meningitis, cerebral malaria or another very severe febrile disease. If the child is conscious and alert, check stuffiness by tickling the feet, asking the child to bend his/her neck to look down or by very gently bending the child’s head forward. It should move freely.

Risk of malaria and other endemic

infections.

In situations where routine microscopy is not available or the results may be delayed, the risk of malaria transmission must be defined. The World Health Organization (WHO) has proposed definitions of malaria risk settings for countries and areas with risk of malaria caused by P.falciparum. A high malaria risk setting is defined as a situation in which more than 5 percent of cases of febrile disease in children age 2 to 59 months are malarial disease. A low malarial risk setting is a situation where fewer than 5 percent of cases of febrile disease in children age 2 to 59 months are malarial disease, but in which the risk is not negligible. If malaria transmission does not normally occur in area, and imported malaria is uncommon, the setting is considered to have no malaria risk. Malaria risk can vary by season. The national malaria control programme normally defines areas of malaria risk in a country. If other endemic infections with public health importance for children under 5 are present in the area (e.g., dengue hemorrhagic fever or relapsing fever), their risk should also be considered. In such situations, the national health authorities normally adapt the IMCI clinical guidelines locally. Runny nose. When malaria risk is low, a child with fever and a runny nose does not need an anti malarial. This child’s fever is probably due to a common cold. Duration of fever. Most fevers due to viral illnesses go away within a few days. A fever that has been present every day for more than five days can mean that the child has a more severe disease

283

such as typhoid fever. If the fever has been present for more than five days, it is important to check whether the fever has been present every day. Measles. Considering the high risk of complications including death due to measles, children with fever should be assessed for signs of current or previous measles (within the last three months). Measles deaths occur from pneumonia and laryningotracheitis (67 percent), diarrhoea (25 percent), measles alone, and a few from encephalitis. Other complications ( usually nonfatal) include conjunctivitis, otitis media, and mouth ulcers. Significant disability can result from measles including blindness, severe malnutrition, chronic lung disease (bronchiectasis and recurrent infection), and neurologic dysfunction.12

Detection of acute (current) measles is based on fever with a generalized rash, plus at least one of the following signs: red eyes, runny nose, or cough. The mother should be asked about the occurrence of measles within the last three months (recent measles). Despite great success in improving immunization coverage in many countries, substantial numbers of measles cases and deaths continue to occur. Although the vaccine should be given at 9 months of age, immunization often does not take place (because of false contraindications, lake of vaccine, or failure of the cold chain system), or is delayed. In addition, many measles cases occur early in a child’s life (between 6 and 8 months of age), especially in urban and refugee populations.

If the child has measles currently or within the last three months, s/he should be assessed for possible complications. Measles damages the epithelial surfaces and immune system, and lowers vitamin A levels. This results in increased susceptibility to infections caused by pneumococcus, gram-negative bacteria, and adenovirus. Recrudescence of herpes virus, Candida, and malaria can also occur during measles infection. It is important to check every child with recent or current measles for possible complications such as pneumonia, stridor in a calm child, diarrhoea, malnutrition and ear infection are assessed in relevant sections of the IMCI clinical guidelines. Before classifying fever, check for obvious causes of fever (e.g. ear pain, burn, abscess, etc.). Classification of fever All children with fever and any general danger sign or stiff neck are classified as having very severe febrile disease and should be urgently referred to a hospital after pre-referral treatment with antibiotics (the same choice as for severe pneumonia or very severe disease).

Note: In areas where malaria P.falciparum is present, such children should also receive a pre-referral dose of an antimalarial (intramuscular quinine).

Any danger sign or Stiff neck

VERY SEVERE

FEBRILE DISEASE

284

Further classifications will depend on the level of malaria risk in the area.

In a high malaria risk area or season, children with fever and no general danger sign or stiff neck should be classified as having Malaria Presumptive treatment for malaria should be given to all children who present with fever in the clinic, or who have a history of fever during this illness. Although a substantial number of children will be treated for malaria when in fact they have another febrile illness, presumptive treatment for malaria is justified in this category given the high rate of malaria risk and the possibility that another illness might cause the malaria infection to progress. This recommendation is intended to maximize sensitivity, ensuring that as many true cases as possible receive proper ant malarial treatment.13

Fever (by history or feels hot or temperature

37.5OC

or above)

MALARIA

In a low malaria risk area or season, children with fever (or history of fever) and no general danger sign or stiff neck are classified as having Malaria and given an ant malarial only if they have no runny nose (a sign of ARI), no measles, and no other obvious cause of fever (pneumonia, sore throat, etc.).

Evidence of another infection lowers the probability that the child’s illness is due to malaria. Therefore, children in a low malaria risk area or season, who have

evidence of another infection, should not be given an antimalarial.

No runny nose and No measles and No other causes of fever

MALARIA

In a low malaria risk area or season, children with runny nose, measles or clinical signs of other possible causes of fever are classified as having fever – malaria unlikely. These children need follow-up. If their fever lasts more than five days, they should be referred for further assessment to determine causes of prolonged pyrexia. If possible, in low malaria risk settings, a simple malaria laboratory test is highly advisable.

Runny nose

PRESENT OR Measles

PRESENT or Other causes

of fever PRESENT

FEVER – MALARIA UNLIKELY

In a no malaria risk area or season, An attempt should be made to distinguish cases of possible bacterial infection, which require antibiotic treatment, from cases of non-

285

complicated viral I infection. Presence of a runny nose in such situations has no or very little diagnostic value.

When there are obvious causes of fever present such as pneumonia, ear infection, or sore throat, children could be classified as having possible bacterial infection and treated accordingly.

Obvious causes

of fever

POSSIBLE BACTERIAL INFECTION

In a no malaria risk area or season, if no clinical signs of obvious infection are found, the working classification becomes uncomplicated fever. Such children should be followed up in two days and assessed further. As in other situations, all children with fever lasting more than five days should be referred for further assessment.

NO obvious

causes of fever

UNCOMPLICATED

FEVER

Note: Children with high fever, defined as an axillary temperature greater than 39.5oC or a rectal greater than 39oC, should be given a single dose of paracetamol to combat hyperthermia. Classification of measles All children with fever should be checked for signs of current or recent measles

(within the last three months) and measles complications.

Severe complicated measles is

present when a child with measles displays any general danger sign, or has severe stomatitis with deep and extensive mouth ulcers or severe eye complications, such as clouding of the cornea. These children should be urgently referred to a hospital.

Any danger sign; or

Clouding of cornea or

Deep or extensive mouth ulcers

SEVERE COMPLICATED MEASLES

Children with severe measles complications, such as pus draining from the eye (a sign of conjunctivitis) or non –deep and non –extensive mouth ulcers, are classified as measles with eye or mouth complications. These children can be safely treated at the outpatient facility. This treatment includes oral vitamin A, tetracycline ointment for children with pus draining from the eye, and gentian violet for children with mouth ulcers.

Children classified with pneumonia,

diarrhoea or ear infection AND measles

with eye or mouth complications should

be treated for the other classification (s)

AND given a vitamin A treatment

regimen. Because measles depresses

the immune system, these children may

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also be referred to hospital for

treatment.

Pus

draining from the eye or

Mouth ulcers

MEASLES WITH EYE OR MOUTH COMPLICATIONS

If no signs of measles complications have been found after a complete examination, a child is classified as having Measles. These children can be effectively and safely managed at home with vitamin A treatment.

Measles now or

within

the last three

months

MEASLES

Ear problems are the next condition that should be checked in all children brought to the outpatient health facility. A child presenting with an ear problem should first be assessed for general danger signs, cough or difficult breathing, diarrhea and fever. A child with an ear problem may have an ear infection. Although ear infections rarely cause death, they are the main cause of deafness in low-income areas, which in turn leads to learning problems.

Clinical assessment When otoscopy is not available, look for the following simple clinical signs:

Tender swelling behind the ear. The most serious complication of an ear infection is a deep infection in the mastoid bone. It usually manifests with tender swelling behind one of the child’s ears. In infants, this tender swelling also may be above the ear. When both tenderness and swelling are present, the sign is considered positive and should not be mistaken for swollen lymph nodes.

Ear pain. In the early stages of acute otitis media, a child may have ear pain, which usually causes the child to become irritable and rub the ear frequently.

Ear discharge or pus. This is another important sign of an ear infection. When a mother reports an ear discharge, the health care provider should check for pus drainage from the ears and find out how long the discharge has been present.

Classification of ear problems

Based on the simple clinical signs above, the child’s condition can be classified in the following ways:

Children presenting with tenderness and swelling of the mastoid bone are classified as having mastoiditis and should be referred to the hospital for treatment. Before referral, these children first should receive a dose of antibiotic and a single dose of paracetamol for pain.

Tender

welling behind the ear

MASTOIDITIS

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Children with ear pain or ear discharge (or pus) for fewer than 14 days are classified as having acute ear infection \and should be treated for five days with the same first-line antibiotic as for pneumonia.

Ear discharge for fewer than 14 days or Ear pain

ACUTE EAR INFECTION

If there is ear discharge (or pus) for more than 14 days, the child’s classification is chronic ear infection. Dry the ear by wicking. Generally, antibiotics are not recommended because they are expensive and their efficacy is not proven. Ear discharge for more than 14 days

CHRONIC EAR

INFECTION

If no signs of ear infection are found, children are classified as having no ear infection and do not require any specific treatment.

No ear pain and No ear discharge seen draining from the ear

NO EAR INFECTION

Checking nutritional status-malnutrition and anaemia

After assessing for general danger signs and the four main symptoms, all children should be assessed for malnutrition and anaemia. There are two main reasons for routine assessment of nutritional status in sick children: (1) to identify children with severe malnutrition who are at increased risk of mortality and need urgent referral to provide active treatment; and (2) to identify children with sub-optimal growth resulting from ongoing deficits in dietary intake plus repeated episodes of infection (stunting), and who may benefit from nutritional counselling and resolution of feeding problems. All children also should be assessed for anaemia.

Clinical assessment

Because reliable height boards are difficult to find in most outpatient health facilities, nutritional status should be assessed by looking and feeling for following clinical signs:

Visible severe wasting. This is as severe wasting of the shoulders, arms, buttocks, and legs, with ribs easily seen, and indicates presence of marasmus.

Oedema of both feet. The presence of the eodema (accumulation of fluid) in both feet may signal kwashiorkor. Children with oedema of both feet may have other disease like nephrotic syndrome; however, there is need to differentiate these other conditions in the outpatient settings because referral is necessary in any case.

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Weight for age. When height boards are not available in outpatient settings, a weight for age indicator (a standard WHO or national growth chart) helps to identify children with low (Z score less than-2) or very low (Z score less than-3) weight for age who are at increased risk of infection and poor growth and development.

Palmar pallor. Although this clinical sign is less specific than many other clinical

signs included in IMCI guidelines, it can allow doctors to identify sick children with severe anaemia often caused by malaria infection. Where feasible, the specificity of anaemia diagnosis may be greatly increased by using a simple laboratory test (e.g., the HB test).

Classification of nutritional status and anaemia

Using a combination of the simple clinical signs above, a health care provider can classify children in one of the following categories:

Children with severe malnutrition or severe anaemia (exhibiting visible severe wasting, or sever palmer pallor or oedema of both feet) are at high risk of death from various severe disease and need urgent

referral to a hospital where their treatment (special feeding, anti-biotic or blood transfusions, etc) can be care monitored.

Visible severe

wasting or

Severe palmar

pallor or

Oedema of

both feet

SEVERE

MALNUTRITION OR

SEVERE ANAEMIA

Children with anaemia or low (or very low)

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weight for age also have a higher risk of severe disease and should be assessed for feeding problems. This assessment should identify common, important problems with feeding that feasibly can be corrected if the caretaker is provided with effective counselling and acceptable feeding recommendations based on the child’s age.

When children are classified as having anaemia they should be treated with oral iron. During treatment, the child should be seen every two weeks (follow- up), at which time an additional 14 days of iron treatment is given. If there is no response in pallor after two months, the child should be referred to the hospital for further assessment. Iron is not given to children with severe malnutrition who will be referred. In areas Where there is evidence that hookworm, whipworm, and ascaris are the main causes and contributors to anemia and malnutrition, regular deworming with mebendazole every four to six months is recommend. Mebendazole is expensive and safe in young children.

Children who are not low (or very low) weight for age and who show no other signs of malnutrition are classified as having no anaemia and not very low weight. Because children less than 2 years old have a higher risk of feeding problems than older children do. Their feeding should be assessed. If problem are identified, the mother needs to be counselled about feeding her child according to the recommended national IMCI clinical guidelines (see following section).

NOT (very) low

weight for age and

other signs of

malnutrition

NO ANEMIA AND NOT

(VERY) LOW

WEIGHT

Assessing the child’s feeding

All children less than 2 years old and all children classified as anaemia or low (or very low) weight need to be assessed for feeding. Feeding assessment includes questioning the mother or caretaker about: (1) breastfeeding; (2) types of complimentary foods or fluids, frequency of feeding and whether feeding is active; (3) feeding patterns during the current illness. The mother or caretaker should be given appropriate advice to help overcome any feeding problems found. (for more details, refer to the section on counselling the mother or caretaker).

The immunization status of every child brought to a health facility should be checked. Illness is not a contraindication to immunization. In practice sick children may even be in more need of protection provided by immunization than well children. A vaccine’s ability to protect is not diminished in sick children.

All children under age 2 should have a feeding assessment,

even if they have normal Z-score

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As a rule there are only four situations when immunization is relatively contra-indicated: - Children being referred urgently to hospital should not be immunized. There is no

medical contraindication, but if a very sick child dies on the way, the vaccine may be incorrectly blamed;

- Live vaccines (BCG, measles, polio, yellow fever) should not be given to children with immunodeficiency diseases, or to children who are immunosuppressed due to malignant disease, or therapy with immunosuppressive agents or irradiation. Children suspected to be HIV positive who are currently asymptomatic should receive all recommended vaccinations for children.

- DPT2 / DPT3 should not be given to children who had convulsions or shock within three days of a previous dose of DPT. Instead DT can be given.

- DPT should not be given to children with recurrent convulsions or active neurologic disease. DT can be administered instead.

- Referral of children age 2 months up to 5 years All infants and children with a severe classification (pink) are referred to a hospital as soon as assessment is completed and necessary pre-referral treatment is administered. Successful referral of severely sick children to hospital depends on effective counseling of the caretaker. If she does not accept referral, available options (to treat the child by repeated clinic or home visits) should be considered. If the caretaker accepts referral, she should be given a short clear referral note, and should get information on what to do during referral transport, especially if the hospital is far away. The referral note must indicate the name and age of the child, date and time of referral, description of child’s illness, reason for referral, and treatment given so far. Urgent pre- referral treatment for children age 2 months up to 5 years (see Figure 4) Appropriate antibiotic Quinine (for severe malaria ) Vitamin A Prevention of hypoglycemia with breast milk or sugar water Oral antimalarial Paracetamol for high fever (38.5⁰C or above) or pain Tetracycline eye ointment (if clouding of the cornea or pus draining from eye) ORS solution so that the mother can give frequent sips on the way to the hospital

Note The first four treatments above are urgent because they can prevent serious consequences such as progression of bacterial meningitis or cerebral malaria, corneal rupture due to lack of vitamin A, or brain damage from low blood sugar. The other listed treatments are also important to prevent worsening of the illness. Non-urgent treatments, e.g. wicking a draining ear or providing oral iron treatment, should be deferred to avoid delaying referral or confusing the caretaker. If a child does

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not need urgent referral, check to see if the child needs non-urgent referral for further assessment; for example, for a cough that has lasted more than 30 days, or for fever that has lasted five days or more. These referrals are not as urgent, and other necessary treatments may be done before transporting for referral. Treatment in outpatient clinics The treatment associated with each non referral classification (yellow and green) is clearly spelled out in the IMCI guidelines. Treatment uses minimum of affordable essential drugs (see Figure 5) Oral Drugs Always start with a first line drug. These are usually less expensive, more readily available in a given country, and easier to administer. Given a second line drug (which are usually more expensive and more difficult to obtain) only if a first line drug is not available, or if the child’s illness does not respond to the first line drug. The health care provider also needs to teach the mother or caretaker how to give oral drugs at home. Oral antibiotics: The IMCI chart shows how many days and how many times each

day to give the antibiotic. Most antibiotics should be given for five days. The number of times to give the antibiotic each day varies (two, three or four times per day) determine the correct does of antibiotic based on the child’s weight. If the child’s weight is not available, use the child’s age. Always check if the same antibiotic can be used for treatment of different classifications a child may have. For example, the same antibiotic could be used to treat both pneumonia and acute ear infection.

Oral antimalarials: Oral antimalarials vary by country. Consult recommended treatment schedules for malaria for your country.

Figure 4. Urgent pre-referral treatments for the sick child from age 2 months to 5 years.

CLASSIFICATION

Treatment

For all children before referral :

Prevent low blood sugar by giving breast milk or sugar water.

DANGER SIGN – CONVULSIONS

If the child convulsing give diazepam (10mg/2ml solution) in

dose 0.1 ml/kg or paraldehyde in dose 0.3-0.4ml/kg rectally; if

convulsions continue after 10 minutes, give a second dose of

diazepam rectally.

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SEVERE PNEUMONIA OR VERY SEVERE DISEASE

Give first dose of an appropriate antibiotic. Two recommended

choices are cotrimoxazole and amoxicillin. If the child cannot

take an oral antibiotic (children in shock or those who are

vomiting incessantly or are unconscious), give the first dose of

intramuscular chloramphenicol (40mg/kg). options for an

intramuscular antibiotic for pre-referral used include

benzylpenicillin and ceftriaxone.

VERY SEVERE FEBRILE DISEASE

Give one dose of paracetamol for high fever (38.5° C or

above).

Give first dose of intramuscular quinine for severe malaria

unless no malaria risk.

Give first dose of an appropriate antibiotic.

SEVERE COMPLICATED MEASLES

Give first dose of appropriate antibiotic

Give vitamin A.

If there is clouding of the cornea or pus draining from the eye,

apply tetracycline eye ointment.

SEVERE DEHYDRATION WHO TREATMENT PLAN C If there is no other severe classification, IV fluids should be

given in the outpatient clinic according to WHO Treatment Plan

C. Give 100ml/kg IV fluids. Ringer’s lactate solution is the

preferred commercially available solution. Normal saline does

not correct acidosis or replace potassium losses, but can be

used. Plain glucose or dextrose solutions are not acceptable

for the treatment of severe dehydration.

If IV infusion is not possible, urgent referral to the hospital for

IV treatment is recommended. When referral takes more than

30 minutes, fluids should be given by nasogastric tube. If

none of these are possible and the child can drink, ORS must

be given by month.

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Figure 5. Treatment in the outpatient health facility of the sick child from age 2 months up to 5 years CLASSIFICATION PNEUMONIA TREATMENT

Give appropriate antibiotic for five days. The choice of antibiotic is bases on the fact that most childhood pneumonia of bacterial origin is due to Streptococcus pneumonia or Haemophilus influenza. The treatment of non-severe pneumonia can utilize a five-day course of either oral cotrimoxazole or amoxicillin. These two oral antibiotics are usually effective

Note: in areas where cholera cannot be excluded for patients

less than 2 years old with severe dehydration, antibiotics are

recommended. Two recommended choices are cotrimoxazole

and tetracycline.

SEVERE PERSISTENT DIARRHOEA

If there is no other severe classification, treat dehydration

before referral using WHO Treatment plan B for some

dehydration and Plan C for severe dehydration. Then refer to

hospital.

MASTOIDITIS Give first dose of an appropriate antibiotic. Two recommended

choices are cotrimoxazole and amoxicillin. If the child cannot

take an oral antibiotic (children in shock or those who are

vomiting incessantly or who are unconscious), give the first

dose of intramuscular chloramphenicol (40mg/kg). Options for

an intramuscular antibiotic for pre-referral use include

benzylpenicillin and ceftriaxone.

Give first dose of paracetamol for pain.

SEVERE MALNUTRITION OR SEVERE ANAEMIA

Give first dose of vitamin A

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treatment for these two bacteria, both are relatively inexpensive, widely available, and are on the essential drug list of most countries. {The advantages of cotrimoxazole are that it is used twice a day, is affordable and compliance is good. It has been shown that with a twice-daily dosing, compliance levels can reach 75 percent or higher. Amoxicillin almost twice as expensive as cotrimoxazole and standard dosages are usually given three times a day. The compliance with three-times –a-day dosing is about 60 percent or less.] Soothe the throat and relieve the cough with a safe remedy

NO PNEUMONIA –COUGH OR COLD Soothe the throat and relieve the cough with a safe remedy.

SOME DEHYDRATION WHO Treatment Plan B

Give initial treatment with ORS over a period of four hours. The approximate amount of ORS required (in ml) can be calculated by multiplying the child’s weight (in Kg) times 75; during these four hours, the mother slowly gives the recommended amount of ORS by spoonfuls or sips. Note: If the child is beast-fed, breast-feeding should continue.

After four hours, the child is reassessed and reclassified for dehydration, and feeding should begin; resuming feeding early is important to provide required amounts of potassium and glucose. When there are no signs of dehydration, the child is put on Plan A. If there is still some dehydration, Plan B should be repeated. If the child now has severe dehydration, the child should be put on Plan C.

NO DEHYDRATION WHO Treatment Plan A

Plan A focuses on the three rules of home treatment: give extra fluids, continue feeding, and advise the caretaker when to return to the doctor (if the child develops blood in the stool, drinks poorly, becomes sicker, or is not better in three days).

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Fluids should be given as soon as diarrhoea starts, the child should take as much as s/he wants. Correct home therapy can prevent dehydration in many cases. ORS may be used at home to prevent dehydration. However, other fluids that are commonly available in the home may be less costly, more convenient and almost as effective. Most fluids that a child normally takes can also be used for home therapy especially when given with food.

Recommended home fluid should be:

Safe when given in large volumes. Very sweet tea, soft drinks, and sweetened fruit drinks should be avoided. These are often hyperosmolar owing to their high sugar content (less than 300 mOsm/L). They can cause osmotic diarrhoea, worsening dehydration and hypenatraemia. Also to be avoided are fluids with purgative action and stimulants (e.g., coffee, some medicinal teas or infusion).

Easy to prepare. The recipe should be familiar and its preparation should not require much effort or time. The required ingredients and measuring utensils should be readily available and inexpensive.

o Acceptable. The fluid should be one that the

mother is willing to give freely to a child with diarrhoea and that the child will readily accept. Effective. Fluids that are safe are also effective. Most effective are fluids that contain carbohydrates and protein and some salt. However, nearly the same result is obtained when fluids are given freely along with weaning food that contains salt.

PERSISTENT DIARRHOEA Encourage the mother to continue breastfeeding.

If yoghurt is available, give it in place of any animal milk usually taken by the child; yoghurt contains less lactose and is better tolerated. If animal milk must be given, limit to 50ml/kg per day; greater amounts may aggravate the diarrhoea. If milk is given, mix it with the child’s cereal and do not dilute the milk. At least half of the child’s energy intake should come from foods other than milk or milk

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products. Food that are hyperosmolar (these are usually foods or drinks made very sweet by the addition of sucrose, such as soft drinks or commercial fruit drinks) should be avoided. They can worsen diarrhea. Food needs to be given in frequent, small meals, at least six times a day. All children with persistent diarrhea receive supplementary multivitamins and minerals (copper, iron, magnesium, zinc) each day for two weeks.

DYSENTERY The four key elements of dysentery treatment are:

Antibiotics Fluids Feeding Follow-up

Selection of an antibiotic is based on sensitivity patterns of strains of Shigella isolated in the area (nalidixic acid is the drug of choice in many areas). Recommended duration of treatment is five days. If after two days (during follow-up) there is no improvement, the antibiotic should be stopped and a different one used.

MALARIA Give an oral ant malarial drug. The selection of first-line and second-line treatment for P. falciparum malaria in endemic countries is an important decision made by health regulating authorities (e.g.; Ministry of Health) based on information and technical advise provided by malaria control programmes.

Give one dose of paracetamol for high fever (38.5º C or above).

FEVER- MALARIA UNLIKELY Give one dose of paracetamol for high fever (38.5º

C or above). POSSIBLEBACTERIAL INFECTION Treat other obvious causes of fever. UNCOMPLICATED FEVER

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MEASLES WITH OR Give first dose of Vitamin A. If clouding of cornea or pus draining from the eye, apply tetracycline eye ointment

MOUTH COMPLICATIONS If mouth ulcers, treat with gentian violet. MEASLES CURRENTLY (OR Give first dose of Vitamin A. WITHIN THE LAST 3 MONTHS) ACUTE EAR INFECTION Give appropriate antibiotic for five days.

Give one dose of paracetamol for pain. Dry the ear by wicking.

CHRONIC EAR INFECTION Dry the ear by wicking. ANAEMIA OR LOW WEIGHT Assess the child’s feeding and counsel the mother

according on feeding. If pallor is present: give iron; give oral anti malarial if high malaria risk. In areas where hookworm or whipworm is a problem, give mebendazole if the child is 2 years or older and has not had a dose in the previous six months.

NO ANAEMIA NOT LOW WEIGHT If the child is less than 2 years old, assess the

child’s feeding and counsel the mother accordingly on feeding.

Paracetamol. If a child has a high fever, give one dose of paracetamol in the clinic. If the child has ear pain, give the mother enough paracetamol for one day, that is, four doses. Tell her to give one dose every six hours or until the ear pain is gone.

Iron. A child with anaemia needs iron. Give syrup to the child under 12 months of age. If the child is 12 months or older, give iron tablets. Give the mother enough iron for 14 days. Tell her to give her child one dose daily for those 14 days. Ask her to return for more iron in 14 days. Also tell her that the iron may make the child’s stools black.

Note: If a child with some pallor is receiving the antimalarial treatment using sulfadoxine- pyrimethamine (Fansidar), do not give iron/folate tablets until a follow-up visit in two weeks. The iron/folate may interfere with the action of the sulfadoxine-pyrimethamine that contains antifolate drugs. If an iron syrup does not contain folate, a child can be given an iron syrup with sulfadoxine pyrimethamine. Consult recommended treatment charts for malaria in your country

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Antihelminth drug. If hookworm or whipworm is a problem in the area, an anaemic child who is 2 years of age or older may need mebendazole. These infections contribute to anaemia because of iron loss through intestinal bleeding. Give 500 mg of mebendazole as a single dose in the clinic.

Vitamin A. Vitamin A is given to a child with measles or severe malnutrition. Vitamin A helps resist the measles virus infection in the eye as well as in the layer of cells that line the lung, gut, mouth and throat. It may also help the immune system to prevent other infections. Vitamin A is available in capsule and syrup form. Use the child’s age to determine the dose, and give two doses. Give the first dose to the child in the clinic. Give the second dose to the mother to give her child the next day at home. Every dose of Vitamin A should be recorded because of danger of an overdose.

Safe remedy for cough and cold. There is no evidence that commercial cough and cold remedies are any more effective than simple home remedies in relieving a cough

or soothing a sore throat. Suppression of a cough is not desirable because cough is a physiological reflex to eliminate lower respiratory tract secretion. Breast milk alone is a good soothing remedy.

Treatment of local infections If the child, age 2 months up to 5 years, has a local infection, the mother or care taker should be taught how to treat the infection at home.

Instructions may be given about how to: Treat eye infection with tetracycline eye ointment; Dry the ear by wicking to treat ear infection; Treat mouth ulcers with gentian violet; Soothe the throat and relieve the cough with a safe remedy.

Counselling a mother or caretaker A child who is seen at the clinic needs to continue treatment, feeding and fluids at home. The child’s mother or caretaker also needs to recognize when the child is not improving, or is becoming sicker. The success of home treatment depends on how well the mother or caretaker knows how to give treatment, understands its importance and knows when to return to a health care provider.

Eye treatment for children being referred If the child will be referred, and the child needs treatment with tetracycline eye ointment, clean the eye gently. Pull down the lower lid. Squirt the first dose of tetracycline eye ointment onto the lower eyelid. The dose is about the size of a grain of rice.

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The steps to good communication were listed earlier. Some advice is simple; other advice requires teaching the mother or caretaker how to do a task. When you teach a mother how to treat a child, use three basic teaching steps: give information; show an example; let her practice. When teaching the mother or caretaker: (1) use words that s/he understands; (2) use teaching aids that are familiar; (3) give feedback when s/he practices, praise what was done well and make corrections; (4) allow more practice, if needed; and (5) encourage the mother or caretaker to ask questions and the answer all questions. Finally, it is important to check the mother’s or caretaker’s understanding. The content of the actual advice will depend on the child’s condition and classifications.

Below are essential elements that should be considered when counseling a mother or caretaker: Advise to continue feeding and increase fluids during illness; Teach how to give oral drugs or to treat local infection; Counsel to solve feeding problems (if any); Advise when to return.

Advise to continue feeding and increase fluids: The IMCI guidelines give feeding recommendations for different age groups. These feeding recommendations are appropriate both when the child is sick and when the child is healthy. During illness, children’s appetites and thirst may be diminished. However, mothers and caretakers should be counselled to increase fluids and to offer the types of food recommended for the child’s age, as often as recommended, even though a child may take small amounts at each feeding. After illness, good feeding helps make up for weight loss and helps prevent malnutrition. When the child is well, good feeding helps prevent future illness. Teach how to give oral drugs or to treat local infection at home: Simple steps should be followed when teaching a mother or caretaker how to give oral drugs or treat local infections. These steps include: (1) determine the appropriate drugs and dosage for the child’s age or weight; (2) tell why it should be given; (3) demonstrate how to (5) watch the mother or caretaker practice measuring a dose; (6) ask the mother or caretaker to give the dose to the child; (7) explain carefully how, and how often, to do the treatment at homes; (8) be used to finish the course of treatment, even if the child gets better; (9) check the mother’s or care-takers understanding. Counsel to solve feeding problems (if any) Based on the type of problems identified, it is important to give correct advice about the nutrition of the young child both during and after illness. Sound advice that promotes breastfeeding, improved weaning practices with locally appropriate energy – and nutrient – rich foods, and giving nutritious snacks to children 2 years or older, can counter the adverse effect infections have on nutritional status. Specific and appropriate complementary foods should be recommended and the frequency of feeding by age should be explained clearly. Encourage exclusive breastfeeding for the first four months, and if possible, up to six months; discourage use of bottles for children of any age; and provide guidance on how to solve important problems with breastfeeding. The latter includes assessing the adequacy of attachment and suckling.

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Specific feeding recommendations should be provided for children with persistent diarrhoea. Feeding counselling relevant to identified feeding problems is described in the IMCI national feeding recommendations. Advise when to return: Every mother or caretaker who is taking a sick child home needs to be advised about when to return to a health facility. The health care provider should (a) teach signs that mean to return immediately for further care; (b) advise when to return for a follow-ups visit; and (c) schedule the next well-child or immunization visit.

The table below lists the specific times to advise a mother or caretaker to return to a health facility.

Advise to return immediately if the child has any of these signs. Any sick child Not able to drink or breastfeed

Becomes sicker

Develops a fever

If child has no pneumonia: Fast breathing Cough or cold, also return if: Difficult breathing If child has diarrhea, also Blood in stool Return if: Drinking poorly If the child has: Return for follow-ups Not later than: Pneumonia 2 days Dysentery Malaria, if fever persists Fever malaria unlikely or uncomplicated Fever, if fever persists Measles with eye or mouth complications Persistent diarrhea 5 days Acute ear infection Chronic ear infection Feeding problem Any other illness, if not improving Pallor 14 days Low (very low) weight for age 30 days

A. IMMEDIATELY

B. FOR FOLLOW-UPS VISIT

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Advise when to return for the next immunization according to immunization schedule. FOLLOW-UP CARE Some sick children will need to return for follow-up care. At a follow-up visit, see if the child is improving on the drug or other treatment that was prescribed. Some children may not respond to a particular antibiotic or antimalarial, and may need to try a second-line drug. Children with persistent diarrhoea also need follow-up to be sure that the diarrhoea has stopped. Children with fever or eye infection need to be seen if they are not improving. Follow-up is especially important for children with a feeding problem to ensure they are being fed adequately and are gaining weight. When a child comes for follow-up of an illness, ask the mother or caretaker if the child has developed any new problems. If she answers yes, the child requires a full assessment: check for general danger signs and assess all the main symptoms and the child’s nutritional status. If the child does not have a new problem, us the IMCI follow-ups instructions for each specific problems: Assess the child according to the instructions; Use the information about the child’s signs to select the appropriate treatment; Give the treatment.

Note: If a child who comes for follow-up has several problems and is getting worse, or returns repeatedly with chronic problems that do not respond to treatment, the child should be referred to a hospital. The IMCI charts contain detailed instructions on how to conduct follow-ups visits for different diseases. Follow-up visits are recommended for sick children classified as having: Dysentery Malaria, if fever persists Fever – Malaria Unlikely, if fever persists Measles with eye or mouth complications Persistent diarrhoea Acute ear infection Feeding problem Pallor Very low weight for age Any other illness, if not improving

NEXT WELL CHILD VISIT C. NEXT WELL-CHILD VISIT

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Outpatient management of young infants age 1 week up to 2 months.

Assessment of sick young infants While there are similarities in the management of sick young infants (age 1 week up to 2 months) and children (age 2 months up to 5 years), some clinical signs observed in infants differ from those in older children. The remainder of this chapter covers instances where the management of young infants differs from that of the small child. For example, it is essential to pay attention to the following clinical signs as an infant’s illness can progress rapidly to death. Assessment includes the following steps: Checking for possible bacterial infection; Assessing if the young infant has diarrhoea;

Checking for feeding problems or low weight; Checking the young infant’s immunization status; Assessing other problems. It is important to remember that the guidelines above are not used for a sick new –born who is less than 1 week old. In the first week of life, new born infants are often sick from conditions that related to labour and delivery, or have conditions that require special management. New–born may be suffering from asphyxia, sepsis from premature ruptured membranes or other intrauterine infection, or birth trauma. Or they may have trouble breathing due to immature lungs. Jaundice also requires special management in the first week of life. Checking for main Symptoms Bacterial infection While the signs of pneumonia and other serious bacterial infections cannot be easily distinguished in this age group, it s recommended that all sick young infants be assessed first for signs of possible bacterial infection. Clinical Assessment Many clinical signs point to possible bacterial infection in sick young infants. The most informative and easy to check signs are; Convulsions (as part of the current illness). Assess the same as for older children.

Note Important

information on use of oral drugs, continued

feeding, mother or caretaker counseling,

and assessment of immunization and

nutrition status can be found in sections of

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Fast Breathing. Young infants usually breathe faster than older children do. The breathing rate of a healthy young infant is commonly more than 50 breaths per minute. Therefore, 60 breaths per minute is the cut off rate to identify fast breathing in this age group. If the count is 60 breaths or more, the count should be repeated, because the breathing rate of a young infant is often irregular. The young infant will occasionally stop breathing for a few seconds, followed by a period of faster breathing. If the second count is also 60 breaths or more the young infant has fast breathing. Severe Chest Indrawing . Mild chest indrawing is normal in a young infant because of softness of the chest wall. Severe chest indrawing is very deep and easy to see. It is a sign of pneumonia or other serious bacterial infection in a young infant. Nasal Flaring . (When an infant breaths in) and grunting (when an infant breathes out) are an indication of troubled breathing and possible pneumonia. A bulging Fontanel (when an infant is not crying), Skin pustules, umbilical redness or pus draining from the ear are other signs that indicate possible bacterial infection. OUTPATIENT MANAGEMENT OF YOUNG INFANTS 1 WEEK UP TO 2 MONTHS Lethargy or unconsciousness, or less than normal movement also indicates a serious condition. Temperature (fever or hypothermia) may equally indicate bacterial infection. Fever (axillary temperature more than 37.5⁰C or rectal temperature more than 38⁰C) is uncommon in the first two months of life. Fever in a young infant may indicate a serious bacterial infection, and may be the only sign of a serious bacterial infection. Young infants can also respond to infection by dropping their body temperature to below 35⁰C (36⁰C rectal). Classification of Possible infection There are two possible classifications for bacterial infection: A sick young infant with possible serious bacterial infection is one who has any of

the following signs: fast breathing, sever chest indrawing, grunting, nasal flaring, bulging fontanel, convulsions, fever, hypothermia, many or sever skin pustules, umbilical redness extending to the skin, pus draining from the ear, lethargy, unconsciousness, or less than normal movement. This infant should be referred urgently to the hospital after being given intramuscular benzyl penicillin (or ampicillin) plus gentamicin, treatment to prevent hypoglycemia, and advice to the mother on keeping the young infant warm

Convulsions or Fast breathing or Sever chest indrawing

or Nasal flaring or Grunting or Bulging fontanelle or Pus draining ear or

POSSIBLE

BACTERIAL INFECTION

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Umbilical redness extending to skin or

Fever or hypothermia Many or sever skin

pustules or Lethargy or

unconsciousness or Less than normal

movement

A sick young infant with local bacterial infection is one who has only a few skin pustules or an umbilicus that is red or draining pus, but without redness extending to skin. This infant may be treated at home with oral antibiotics but should be seen in follow up in two days.

Red umbilicus

or draining pus or

Skin pustules

LOCAL

BACTERIAL INFECTION

Diarrhoea All sick young infants should be checked for diarrhoea. Clinical assessment and classification of diarrhoea Assessment, classification and management of diarrhoea in sick young infants are similar to those in older children. However, assessing thirst by offering a drink is not reliable, so “drinking poorly” is not used as a sign for the classification of dehydration. In addition, all young infants with persistent diarrhoea or blood in the stool should be referred to the hospital, rather than managed as outpatients. Feeding problems or low weight All sick young infants seen in outpatient health facilities should be assessed for weight and adequate feeding, as well as for breast feeding technique. Clinical assessment Determine weight for age. Assess the same as for older children. Assessment of feeding. Assessment of feeding in young infants is similar to that in older children. It includes three main types of questions about: (1) breastfeeding frequency and night feeds (2) types of complimentary foods or fluids, frequency of feeding and whether feeding is active or not; and (3) feeding patterns during this illness.

Breastfeeding: Signs of good attachment Chin touching breast Mouth wide open Lower lip turned outward; and More areola visible above than below the mouth

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If an infant has difficulty feeding, or is breastfed less than 8 times in 24 hours, or taking other foods or drinks, or has low weight for age, then breastfeeding should be assessed. Assessment of breastfeeding in young infants includes checking if the infant is able to attach, if the infant is sucking effectively (slow, deep sucks, with some pausing), and if there are ulcers or white patches in the mouth (thrush).

Classification of feeding problems or low weight Based on an assessment of feeding and weight, a sick young infant may be classified into three categories;

Not able to feed possible serious bacterial

infection. The young infant who is not able to feed, or not attaching to the breast or sucking effectively, has a life threatening problem. This could be a bacterial infection or another severe illness. The infant should be referred to a hospital after receiving the same pre-referral treatment as infants with possible serious bacterial infection.

Not able to feed

or

No attachment at

all or

Not sucking at all

NOT ABLE TO FEED POSSIBLE BACTERIAL INFECTION

Infants with feeding problems or low weight are those infants who present with feeding problems like not attaching well to the breast, not sucking effectively, getting breast milk fewer than eight times in 24 hours, receiving other foods or drinks than breast milk , or those who have low weight for age or thrush (ulcers/white patches in mouth).

Not well attached to

breast or

Not suckling

effectively or

Fed fewer than 8

times in 24hours or

Receiving other foods

or drinks or

Low weight for age

Thrush

FEEDING PROBLEMS

OR LOW WEIGHT

Appropriate counselling of the mother should be based on the identified feeding problem; (a) if the infant is not well attached or not sucking effectively, teaching correct positioning and attachment; (b) if the infant is breastfeeding fewer than eight times in 24hours, advise the mother to increase frequency of feeding; (c) if the infant receives other food or drinks, counsel the mother about breastfeeding more, reducing other foods or drinks, and using a cup; (d) if the mother is not breastfeeding at all, refer for breastfeeding counselling and possible

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relactation, and advise how to correctly prepare a breast milk substitute. In infants with thrush, teach the caretaker how to treat thrush at home using gentian violet. Ensure follow up for any feeding problem or thrush in two days and follow up low weight for age in 14 days.

Infants with no feeding problems

are those who are breastfed exclusively at least eight times in

24hours and whose weight is not classified as low weight for age according to standard measures.

Not low weight age

and no other signs of inadequate feeding

NO

FEEDING PROBLEMS

Checking Immunization status A for older children, immunization status should be checked in all sick young infants. Equally, illness is not a contraindication to immunization. Note: Do not give OPV 0 to an infant who is more than 14 days old. If an infant has not received OPV 0 by the times/he is 15 days old, OPV should be given at age 6 weeks old as OPV 1. Assessing other problems As for older children, all sick young infants need to be assessed for other potential problems mentioned by the mother or observed during the examination. If a potentially serious problem is found or there is no means in the clinic to help the infants, s/he should be referred to hospital.

Treatment procedures for sick infants Referral of young infants’ age 1 week up to 2 months. The first step is to give urgent pre-referral treatments (s). Possible pre-referral treatments include:

First dose of intramuscular or oral antibiotics

Keeping the infant warm on the way to the hospital

Prevention of hypoglycemia with breast milk or sugar water

Frequent sips of ORS solution on the way to the hospital

If an infant does not need urgent referral, check to see if the child needs no-urgent referral for further assessment. These referrals are not as urgent. Any other necessary treatment may be done before referral.

Treatment in outpatient clinics

The treatment instructions for a young infant are given in IMCI guidelines. The antibiotics and dosages are different than those for older children. Exceptions are the fluid plans for treating diarrhoea and the instructions for preventing low blood sugar. WHO Plans A, B, and C and the guidelines on how to prevent low blood sugar are used for young infants as well as older infants and young children.

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Oral drugs The first dose of oral drugs for a young infant should always be given in the clinic. In addition, the mother or caretaker should be taught how to give an oral antibiotic at home. That is teaching how to measure a single dose, showing how to crush a tablet and mix it with breast milk, and teaching the treatment schedule. Note: Avoid giving cotrimoxazole to a young infant less than 1 month of age who is premature or jaundiced. Give this infant amoxicillin or benzylpenicillin instead.

Figure 6. Urgent pre-referral treatments for sick young infants age 1 week up to 2 months CLASSIFICATION TREATMENT For all infants before referral: Prevent low blood sugar by giving breast milk or sugar water.

Advise mother how to keep the infant warm on the way to the hospital

CONVULSIONS If the child is convulsing, give diazepam (10 mg/2 ml solution) in

dose 0.1 ml/kg or paraldehyde in dose 0.3 – 0.4 ml/kg rectally; if convulsions continue after 10 minutes, give a second dose of diazepam rectally. Use Phenobarbital (200 mg/ml solution) in dose of 20 mg/kg to control convulsions in infants under 2 weeks of age.

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POSSIBLE SERIOUS BACTERIAL Give first dose of intramuscular antibiotics the recommended choice are Gentamycin (2.5mg/kg) plus Benzylpenicillin(50,000 units per kg) or ceftriaxone OR cefotaxime

INFECTIONS AND/OR NOT ABLE TO FEED-POSSIBLE SERIOUS BACTERIAL INFECTIONS ______________________________________________________________________ SEVERE DEHYDRATION See recommendations for older children

Figure 4 . DYSENTRY AND/OR Se recommendations for older children Figure 4 SEVERE PERSISTENT DIARRHOEA --------------------------------------------------------------------------------------------------------------------- CLASSIFICATION TREATMENT Local bacterial infection Give an appropriate oral antibiotic. The recommended choices

are cotrimoxazole and amoxicillin

SOME DEHYDRATION See recommendations for older children, figure 5 NO DEHYDRATION See recommendations for older children, figure 5

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FEEDING PROBLEM OR LOW WEIGHT Give appropriate feeding advice. If thrush, teach the mother to treat thrush at home. Treatment of local infections There are three types of local infections in a sick young infant that a caretaker can treat at home: an umbilicus that is red or draining pus, skin pustules, or thrush. These local infections are treated with gentian violet. Counselling a mother or caretaker As with older children, the success of home treatment depends on how well the mother or caretaker knows how to give the treatment, understands its importance, and knows when to return to a health care provider. Counselling the mother or caretaker of a sick young infant includes the following essential elements: Teach how to give oral drugs or to treat local infection. Teach correct positioning and attachment for breastfeeding:

a) Show the mother how to hold her infant b) With the infant’s head and body straight c) Facing her breast, with infant’s nose opposite her nipple d) With infant’s body close to her body e) Supporting infant’s whole body, not just neck and shoulders.

Show her how to help the infant to attach. She should: a) Touch her infant’s lips with her nipple b) Wait until her infant’s mouth is opening wide c) Move her infant quickly onto her breast , aiming the infant’s lower lip well

below the nipple. Look for signs of good attachment and effective suckling. If the

attachment and effective suckling is not good, try again. Advise about food and fluids : advise to breastfeed frequently, as often as

possible and for as long as the infant wants, day and night during sickness and health.

Advise when to return:

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Advise to return immediately if the infant has any of these signs: Breastfeeding or drinking poorly

Becomes sicker

Develops a fever

Fast breathing

Difficult breathing

Blood in stool

If the infants have: Return for follow-up . not later than: Local bacterial infection Any feeding problem 2 days Thrush Low weight for age 14 days Advise when to return for the next immunization according to immunization schedule. Follow-up care If the child does not have a new problem, use The IMCI follow-up instructions for each specific problem: Assess the child according to the instructions; Use the information about the child’s signs to select the appropriate

treatments; Give the treatment.

IMCI charts contain detailed instructions on how to conduct follow-up visits for different disease. Follow-up visits are recommended for young infants who are classified as: Local bacterial infection Feeding problems or low weight (including thrush).

A. IMMEDIATELY

B. FOR FOLLOW-UPS VISIT

C. NEXT WELL-CHID VISIT

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CHAPTER 23

Approaches to Improve Quality of Services for Hospitalized Sick

Children

Stephen N. Kinoti INTRODUCTION More than 11 million children worldwide die each year, mainly in developing countries due to common and treatable illnesses. Interventions to reduce child mortality have paid little attention to the district hospitals and other facilities providing inpatient care, where the sickest 20% of children are cared for but quality of care is often poor. Led by WHO’s Department of Child and Adolescent Development (CAH), the initiative has many facets, including a study that assessed 21 hospitals providing paediatric care in seven less-developed countries.i The study (hereafter “Nolan study”) found that 12–34% of sick children under five who visit health facilities need hospital care. The hospitals exist, albeit for many children, perhaps half, these hospitals are too far from home. Nevertheless, if extant paediatric hospitals and paediatric departments of secondary and tertiary service hospitals were performing optimally, they could save many children—or spare them immeasurable suffering. The Nolan study found that 14 of the 21 hospitals lacked an adequate system for triage (both assessment and quick treatment) and that most emergency treatment areas were poorly organized and lacked necessary supplies. In addition, poor case management (assessment, treatment, and monitoring) occurred in 76% of hospitalized children. Last, staff had inadequate knowledge for managing childhood illnesses. The study interpreted these findings as indicating that “strengthening care for sick children referred to hospital should focus on achievable objectives with the greatest potential benefit for health outcome. Possible targets for improvement include initial triage, emergency care, assessment, inpatient treatment, and monitoring. Priority targets for individual hospitals may be determined by assessing each hospital.” “One of many tragic events: In 2004, three other paediatricians, seven medical officers, 10 nurses and I entered a developing country paediatric ward just as a gasping 5-year-old was being admitted. We had come to prepare for practical training in Emergency Triage, Assessment and Treatment (ETAT), which was not yet established in this hospital. We could not save the child: There was no oxygen; no emergency tray nor emergency drugs; the medicine cabinet was locked and the key was not immediately available; no airways, no ambu-bag nor endotracheal tubes, essentially no resuscitation equipment or medicines were available. The child was bleeding from cracked lips. He died right there in front of all of us, and there was nothing we could do. We needed more than skilled staff. We needed equipment, drugs and other supplies. When you have an experience like that, it really drives home the fact that skilled human resources are not all that is needed. To have a hospital that is not basically equipped and has no emergency response system in place is not just a tragedy for the patients

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involved, it’s a waste of the investment made in creating and staffing the hospital,” personal communication, Stephen Kinotiii LEARNING OBJECTIVES At the end of this chapter the student will be able to: Define quality of care; Explain the factors which determine and influence quality of care Understand some of the approaches that can be applied to improve quality of services for seriously ill children Describe the role of team work in improving quality of services Describe the scientific basis of modern improvement methods Identify ways in which he or she could contribute to the quality improvement process Understand the principle of change and measurement of change as key elements of modern improvement theory and practice LEARNING ACTIVITIES Participate in the adaptation to a national or institutional situation, standards of care for seriously ill children from internationally accepted standards. Being part of ensuring the standards of care are available at the care facilities, are well understood, and available in simplified forms that they can service as job aids when needed to save lives Participate in setting up response systems, patient flow processes and procedures that increase system efficiencies and eliminate redundancies Participate as a membership of multidisciplinary quality improvement teams Actively participate in planning, doing, testing and acting (PDSA) on changes that are found to work and help institutionalize them into routine procedures of work. Regularly participate in sharing best practices with other teams in other facilities so that ultimately, the institution, the health system and the country is transformed into a community of best practice. What is quality health service? Quality care is what happens at all the points of service along the continuum of care, and high quality care is a function of the system's ability to produce care that will address the client's needs in an effective, responsive and respectful manner, personal communication, Dr. David Nicholasiii, former director of United States Funded Quality Assurance Project, 2008.

Quality comprises three elements:

Structure refers to stable, material characteristics (infrastructure, tools, technology) and the resources of the organizations that provide care and the financing of care (levels of funding, staffing, payment schemes, and incentives). Process is the interaction between caregivers and patients during which structural inputs from the health care system are transformed into health outcomes. Outcomes can be measured in terms of health status, deaths, or disability-adjusted life years—a measure that encompasses the morbidity and mortality of patients or groups of patients. Outcomes also include patient satisfaction or patient responsiveness to the health care system (WHO 2000iv).

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Deficiencies in quality of care represent neither the failure of professional compassion nor necessarily a lack of resources (Institute of Medicine 2001v). Rather, they result from gaps in knowledge, inappropriate applications of available technology (Murray and Frenk 2000vi), or the inability of organizations to change (Berwick 1989vii). Local health care systems may have failed to align practitioner incentives and objectives, to measure clinical practice, or to link quality improvement to better health outcomes.

In recent years the concept of quality has been expanded to include specific aims for improvement. For example, the Institute of Medicine's (2001viii) landmark report, Crossing the Quality Chasm, explains how process changes can improve care, processes that ensure: Patient safety. Are the risks of injury minimal for patients in the health system? Effectiveness. Is the care provided scientifically sound and neither underused nor overused? Patient centeredness. Is patient care being provided in a way that is respectful and responsive to a patient's preferences, needs, and values? Are patient values guiding clinical decisions? Timeliness. Are delays and waiting times minimized? Efficiency. Is waste of equipment, supplies, ideas, and energy minimized? Equity. Is care consistent across gender, ethnic, geographic, and socioeconomic lines? The Institute of Medicine in 2001further emphasized the essence of performance improvement as a function changes in processes. Performance is a characteristic of a process / system. In order to improve, the system must be changed in ways that yield better results. Various inputs in a system yield improvement only to the extent that they can effect change in that system. Changes should not only address the individual parts of a system - inputs, processes, and outcomes, but also the links between them. A wide range of research activities to test quality assurance methods and approaches, including studies on training and supervision strategies for the Integrated Management of Childhood Illness (IMCI), measurement of client satisfaction, and performance assessment techniques have been undertaken mostly in the 1990s providing increasing evidence that quality can be improved rapidly. However, to improve clinical practice and thus quality of care, quality must be defined and measured, and appropriate steps taken (Silimperi et al 2002ix). This chapter highlights approaches to improving clinical practice and quality of care for seriously ill children that take place over months instead of years demonstrating that better quality can improve health much more rapidly than can other drivers of health, such as economic growth, educational advancement, or new technology.

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Figure 1: TheThe Framework for Clinical Framework for Clinical Quality ImprovementQuality Improvement

Content of CareContent of Care

EvidenceEvidence--basedbased••StandardsStandards••ProtocolsProtocols••GuidelinesGuidelines

TraditionalTraditionalQuality ImprovementQuality Improvement

Adapted from: Paul Adapted from: Paul BataldenBatalden, Patricia , Patricia StoltzStoltzA Framework for Continual Improvement in HealthcareA Framework for Continual Improvement in HealthcareJoint Commission Journal on Quality ImprovementJoint Commission Journal on Quality ImprovementOctober 1997October 1997

Process of CareProcess of CareQuality Improvement Quality Improvement MethodologyMethodology

Continuous Continuous Quality ImprovementQuality Improvement

=

=

Application of proven standard guidelines WHO commissioned a study of small hospitals in 1997 that would become known as the seven-country study (Bangladesh, DR, Ethiopia, Indonesia, Philippines, Tanzania, and Uganda) (WHO CHD 1998x). The results were published in The Lancet January 2001 (Nolan et al. 2001xi). Results suggested that interventions in referral facilities that are likely to improve care are clinical training and improvements in organization, such as patient flow, triage and improving the ability of the health system to provide a regular supply of drugs and other treatment materials is also needed” WHO CHD 1998. Going on alongside these efforts was the development of guidelines for Referral Care published in 2000, “ Management of the Child with a Serious Infection or Severe Malnutrition: Guidelines for Care at the First-Referral Level in Developing Countries, also known as the referral care manual or RCMxii. The CHD of WHO noted that the guideline would also provide the technical foundation for improving quality of care in referral facilities (WHO CHD 1998). This took care of the content of care in the framework for quality improvement an essential component but not sufficient to intervention for higher level of care. This content has been disseminated widely and used in the 11 days IMCI training, the reduced 6day course and even put into interactive computer based training formats. It has become clear that the process of care needs to be improved as well. Improving processes of care A fundamental concept of improvement as described by Paul Bataldenxiii is that, “Every system is perfectly designed to get exactly the results it gets”. This leads to the conclusion that for improvement to occur there must be a change and for one to know that the change is an improvement, the change must be measured. A major problem in many developing counties is the lack or limited culture of measurement to monitor changes in processes and outcomes of care. It also implies that to bring about change, service providers must be aware of where they are, what the system is doing currently, make an hypothesis that a certain changes made in the system will lead to an improvement, implement the change, measure the outcome and determine whether there was an improvement or not. This is what is referred to as the Plan. Do, Study, Act,

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the PDSA cycle of testing changes and if they prove effective, acting to institutionalize them into routine practice. The following is a model for improvement:

IDENTIFY: What are we trying toaccomplish?

ANALYZE: How will we knowThat a change is an improvement?

DEVELOP: What changes can we make That will result in improvement?

Model for Improvement

Act Plan

Study Do

Steps 1-3

Step 4 Testing changes

An example of the use of the model for improvement and the PDSA cycles to reduce waiting time for laboratory results: Gives current practice and changes that were tested to lead to an improvement. Current Practice–Clinician collects samples at OPD, places it in a container in OPD; laboratory technician collects the samples once daily from OPD, works on them and sends back results back following day, a 24 hours wait!! 1st PDSA Cycle Plan OPD staff take samples to lab, lab works on it and sends back by internal delivery system OPD Staff take samples to lab, lab works on it and sends back by internal delivery system results back Results are received back in 6-8 hours Study. Some little improvement but not good enough Plan more improvement in the 2nd cycle 2nd PDSA cycle Plan for OPD staff take samples to lab and asks the lab tech to bring back the results Staff take samples to lab and asks the lab tech to bring back the results The Lab tech returns results in 4 hours Study---Better but not best Plan more improvement in the 3rd cycle 3rd PDSA cycle Plan to set up small lab in OPD on a trial basis, to equip and staff lab and measure time taken to receive results Small lab in OPD on a trial basis, to equip and staff lab and measure time taken to receive results

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Waiting time reduced to 1 hour; start of Patients treatment much faster and results based Observations over a few days covering weekends still good This is a good improvement Decision made by Hospital Director to make OPD lab permanent Spread of an innovation: This innovation was shared during the next learning session involving service providers from six other hospitals. They thought it was a good idea and adopted it. Through this process, the innovation was scaled up to many other hospitals. Examples of such changes may lead to redesign of systems such as introducing triage systems where they do not exist to better sort out patients that require more urgent care than those who do not, flow charting to reduce waiting times, using report and request systems to reduce stock outs of essential drugs and commodities and task shifting to trained lower level cadres of service providers to increase access to care especially in the era of HIV/AIDS which is overwhelming health systems, linking PMTCT to child Health clinics and care and treatment centers to reduce loss to follow up of infants born to HIV positive mothers. Another of redesign is presented by Molyneux and Malengaxiv 1998, in which they state, “The introduction of forms called critical care pathways into the pediatric unit of a hospital in Malawi has strengthened team work, helped to increase the efficiency with which resources are employed. They serve the dual function of indicating good management and providing an opportunity to note actions and potential progress.” Certification and accreditation During this era of HIV/AIDS, health facilities both private and public sector have to be certified or accredited before they can provide ART and PMTCT services. Some of the criteria that have been used have included: Availability of guidelines of care that are adapted to the local settings in the health system of the country for each level of care Trained staff in AIDS care The ART/PMTCT program required that regional referral hospitals capacity to train and service lower health facilities was strengthened, clinical teams in each facility comprising of 1 medical, 1 clinical officer, 2-3 Nurses, 2-3 Counselors, pharmacist/ dispenser , lab person and strengthened referral network across a continuum and improved coordination. Available or easily accessible VCT services Available space for patient counseling and assessment that ensures reasonable confidentiality including those for children Functioning laboratory services that can conduct basic and minimum investigations as outlined in the national ARV treatment guidelines including facilities for testing or screening infants before they are 18 months old ARV drugs procurement and safe storage systems including Paediatric formulations Health management information system (HMIS) where proper records are kept for tracking patients on ART/PMTCT and on treatment of opportunistic Infections Follow- and referral system including arrangements for consultations with other ART/PMTCT centers

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If the facility which could a hospital or health center is found short of the required level arrangements are made to support, strengthen the facility to improvement its capacity in each area of deficiency using quality improvement approaches such as training , coaching, testing improvement changes, measuring improvements and reassessments. Pay for performance In the USA, Pay-for-Performance programs have been shown to improve both medical care and quality of life by giving health care providers a financial incentive to seek measurable improvements in the health of their patients. The findings, released at a National Press Club briefing, are the combined result of seven experimental projects designed to test a variety of pay-for-performance models known as the Rewarding Results program, the three-year effort is both the largest and most diverse of its kind. The projects "provide some of the first tangible evidence that (Private for Profit” (PFP) incentives can raise the quality of patient care," says Suzanne Delbanco, CEO of the Leapfrog Groupxv.The examples of recent P4P research and tools supported by the Agency for Healthcare Research and Quality (AHRQ) provide further evidence for possible value of Pay for performance which must be tailored to deferent settings to different country settings. According to Louis Rusa, (National PBF Coordinator-Ministry of Health Rwanda), and Gyuri Fritschexvi, (Health Care Financing Specialist-Management Sciences the Rwanda performance-based financing in health has demonstrated improved performance by the health care system that can serve as guide to similar schemes. Essential elements in the success in Rwanda were the roll out and strong consistent leadership at the highest level in the ministry of health. The key premise in output-based aid is that it “seeks to address weaknesses by delegating service delivery to a third party under contracts that link payment to the outputs or results delivered. It thus has the potential to improve incentives and accountability, while also expanding opportunities for mobilizing private financing. The focus shifts not only from inputs to outputs, but also toward the Holy Grail of development outcomes” as presented in: “Contracting for public services; Output-based aid and its applications”, WB/IMF 2001, Page 91. Measuring process of service delivery

Technical advances have mitigated longstanding difficulties in measuring process. Five approaches and their strengths and weaknesses merit consideration: chart abstraction, direct observation and recording of visits, administrative data, standardized patients, and clinical vignettes. I will review these as possible options for measuring processes improvements.

Chart Abstraction

Chart abstraction, or review of the medical record, has long been used to measure technical quality. Such familiar quality evaluations as clinical audits, physician report cards, and profiles are based on chart abstraction. The core strength of the medical record is that it is ubiquitous and can generally be obtained after each encounter. Chart reviews, however, suffer from problems of legibility when notes are handwritten. Often they are generated for reasons other than recording the actual events of the clinical visit

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(legal protection or obtaining payments, for example) and thus lack crucial clinical details. One prospective study showed that charts identified only 70 percent of items performed during the clinical encounter (Luck and others 2000xvii). In a related analysis, 6.4 percent of the items recorded in the chart were false and had never really occurred. Nonetheless Yawn and Wollanxviii recommended interrater reliability of completing the medical records and conclude that it can provide important information to investigators and to the consumer for assessing the reliability of the data and therefore the validity of the study results and conclusions.

Where resources and infrastructure are sufficient, the electronic medical record (EMR) is becoming a priority for health systems worldwide. EMR technology promotes uniformity, legibility, and communication, which can lead to guideline use and reduce prescription errors. It also holds the promise of managing populations rather than individuals by aggregating patients into groups. However, the EMR has not always lived up to its potential. In many countries, some impressive successes have occurred—as have spectacular failures, costing billions of dollars (McConnell 2004xix). The great heterogeneity in record-keeping practices, problems with medical records (both paper and electronic), and costs of trained medical abstractors have led to a search for other reliable ways to measure quality.

Direct Observation and Recording of Visits

Direct observation and recording of visits is a commonly used approach in developing countries. Ethically, the provider and the patient must be informed of the observation or recording, which introduces participation bias because provider behavior may change as a result of being evaluated. In addition, trained observers are costly, and variation between observers is difficult to remedy. Himle, Chang and Woods et alxx, suggest that clinical behavior analysts do not abandon direct observation in favor of other measurement techniques, rather, call to behavior analysts to develop, investigate, and incorporate new direct and indirect measurement techniques that will enhance scientific investigation of the environment–behavior relations involved in clinical problems.

Administrative Data

Administrative data, collected for purposes of managing the delivery of care, are available in all but the poorest settings. A data collection system, once established, is ubiquitous and can provide information on charges and many cost inputs. Administrative data, however, lack sufficient clinical detail to be useful in evaluating process. In a 2003 study, an incorrect diagnosis was recorded in the data 30 percent of the time (although the diagnosis was made correctly). Overall, these data reflected the actual clinical diagnosis only 57 percent of the time (Peabody, Luck, Jain, and others 2004xxi). As information systems advance, accuracy problems may be mitigated, although the lack of adequate clinical detail will continue to limit the use of administrative data.

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Standardized Patients

Standardized patients can be a gold standard for process measurement (Luck and Peabody 2002xxii). Trained to simulate illness, standardized patients present themselves unannounced into a clinical setting to providers who have previously given their consent to participate in the study. At the conclusion of the visit, the standardized patient reports on the technical and interpersonal elements of process. Standardized patients are reliable over a range of conditions and provide valid measurements that accurately capture variation in clinical practice among providers over time. However, they are expensive and useful only for adult conditions and only those conditions that can be simulated. Thus, they are not practical for routinely evaluating quality.

Clinical Vignettes (typical description of a condition)

Clinical vignettes were developed explicitly for measuring quality within a group of providers and evaluating quality at the population level. Vignettes are responsive to variation in quality, and providers readily accept them if they are given anonymously (Peabody, Luck, Glassman, and others 2004xxiii). More than 20 vignettes have been used in 13 countries around the world. They can be administered on paper, by computer, or over the Internet. Providers are typically presented with several cases. When process is being measured for many providers, each provider is presented with the same case or set of cases, thus eliminating the need for case-mix adjustment. The provider completing the vignette is asked to take a history, do an examination, order the necessary tests, make a diagnosis, and specify a treatment plan. The questions are open ended and include interactive responses that simulate the visit and evaluate the physician's knowledge. In two separate, prospective validation studies among randomly selected providers, vignettes consistently demonstrated greater predictive validity of process than did the abstracted medical record. Vignettes have been validated against the gold standard of standardized patient visits, and they reflect actual clinical practice, not just physicians' knowledge. Vignettes have several other advantages. Because exactly the same case can be given to many providers, vignettes are useful for comparison studies. They are also useful for pre- and post evaluations of policy interventions designed to improve quality. Finally, they are inexpensive to administer and straightforward to score, making them particularly useful in developing countries.

Improvement Collaborative Approach Growing evidence suggests that the Improvement Collaborative approach has been shown to increase compliance with standards of care for seriously ill childrenxxiv and to lead to better outcomes in a number of countries including Malawi, Nicaragua, Niger and Eritrea in Africa, and Nicaragua in Latin America. Partners in the implementation of these collaboratives included UNICEF, WHO, Care International, Pan American Organization and Ministries of Health in the participating countries. An Improvement Collaborativexxv (developed by the Institute for Health Improvement in Boston, Massachusetts, USA) is an organized effort of shared learning by a network of teams to:

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• Adapt to their local situations a known, best practice model of care for a priority health problem • Achieve significant results in a short period, i.e., 12-24 months, reducing the gap between best and current practice • Scale up the adapted model throughout the organization using an intentional spread strategy Thus, improvement collaboratives seek to adapt and spread existing knowledge (e.g., best practices, evidence-based guidelines) to multiple settings. An improvement collaborative is made up of 20-40 teams from different organizations or geographic regions that are all focused on making rapid incremental improvements in a single technical area and committed to working and learning together intensively for 12 to 18 months. The collaborative engages the teams in working out the operational details in implementing known best practices in their respective settings. A collaborative can achieve dramatic improvements in the quality and outcomes of care in a short period of time by monthly tracking of the pace of improvements and active sharing of strategies for improvement of services between participating teams. A collaborative is often followed by a second phase, often known as an expansion collaborative, that provides a framework for spreading the improvements from the initial or demonstration site to the rest of the parent health system. Basic Principles of Improvement Collaboratives A collaborative is organized around a specific topic. The program or organizational leaders who sponsor the collaborative begin with a health care issue that is important to them, such as Pediatric Hospital care, tuberculosis case management or prevention of mother-to-child transmission of HIV. Such a topic encompasses both evidence-based clinical care and the organization of services to meet the needs of patients, including issues of wasted resources, community links, and health policies.

1. 2. Expert knowledge about the topic is assembled and made available to

participants in a readily usable form. Since new ideas for changes to existing systems are usually required to make improvements, the first step in the collaborative process is to research and organize the relevant knowledge of the topic and make it easily available to collaborative participants. This is often done through an expert meeting, which brings together content experts and those with experience in implementing best practices to define the set of key changes that need to be made in a facility to achieve desired levels of service quality for the chosen topic. These ideas are organized in a set of improvement objectives sometimes referred to as a “change package” which provides collaborative participants concrete ideas that they can then test and adapt in their local settings.

Emphasis on rapid testing of changes: One difference with traditional process improvement efforts is that in a collaborative, teams are encouraged to continuously test changes, often on a very small scale and in a short period of time, and then apply that learning on increasingly larger scale: start small, quickly, and learn from each test (“What change can you introduce by next Tuesday with two patients?”). What works on a small scale is then applied on a larger scale and adapted as needed to expand

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application and continually improve results. Monthly tracking of the collaborative’s key measurement indicators keeps teams focused on results. An improvement collaborative creates a “community of practice” focused on achieving results in a short period of time. Collaboratives are designed to provide a critical mass, usually 10 to 30 teams, that is large enough to create a wide range of ideas for how to improve the selected service, but small enough to constitute a peer group. The teams exchange experiences frequently, through meetings, e-mail, telephone or internet-based communications, and brief written reports. Coaching visits from the organizational unit sponsoring the collaborative also facilitate the sharing of experiences across teams. The collaborative seeks to make each team familiar with the work of the other teams, with what efforts were successful, and which were not. This interested peer group provides an intangible but important incentive to keep records, report regularly, and contribute actively to the overall goals of the group. Collaboratives seek to create a culture among participants where everyone learns and everyone teaches, with friendly competition and urgency to action. Health systems in developing countries are often viewed as static. Known deficiencies in quality of care, such as missed opportunities for immunization, persist with no response. Ineffective processes, such as the referral of the sickest patients, are widely recognized as deficient, but typically providers do not feel a sense of urgency or a mandate to improve them. In a collaborative, participants are motivated to participate by the attraction of being part of a focused, national or international effort; by the desire to apply the latest scientific or medical knowledge; and by the sense of competing with other teams to show the greatest improvement. The facilities that join a collaborative usually do so voluntarily, out of interest in improving an element of care. If there is an administrative mandate to participate, the senior managers are responsible for making the work of the collaborative attractive for the teams. Collaboratives use several mechanisms for learning and changing current practices, chiefly mutual learning by peers. In some cases, clinical training is needed to develop capacity to apply new standards of care (e.g., emergency, triage assessment and treatment) but most improvements involve changes in the way health care is organized. The improvements shown in the PHI collaborative in Niger did not result from simply conducting a training course. Rather, each of the participating teams studied how ETAT was implemented, identified specific obstacles to complying with national standards for emergency care, and tested different ideas to improve performance. The premise is that external improvement or content experts can facilitate the collaborative, but it is regular health workers who identify how solve local problems. Key clinical and nursing staff from the facilities were identified and trained in clinical care using standard WHO guidelines adapted to the country situation, and in the use of standardized tools to monitor case management and outcomes of care. Mentoring was provided by collaborating partners’ on a regular at basis using standardized tools to monitor systems improvements and outcomes of care and compliance with standards While each PHI Collaborative addressed emergency triage assessment and treatment and adaptation of WHO referral care guidelines, additional activities addressed specific problems:

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• Nicaragua included an emphasis on essential newborn care, neonatal resuscitation, and prevention of mother-to-child transmission of HIV. • Niger addressed nutritional recuperation of severely malnourished children in 15 sites. • Tanzania emphasized improving pediatric AIDS care. At the start of each collaborative, teams self-assessed their care and then began introducing site-specific improvements. Teams met 4-6 times over three years to acquire new knowledge and skills and share experiences in implementing changes. They also received periodic coaching visits by local experts. High-performing teams provided peer coaching to slower ones. Teamwork and coaching help institutionalize the process, create local ownership, and facilitate faster spread of improvements. Illustrative Results Key areas of pediatric service with specific improvements introduced by teams participating in improvement collaboratives National clinical standards and guidelines National clinical standards and guidelines Adapted international clinical standard guidelines (WHO Referral Care Manual) to national situation Trained staff in the use of the Referral Care Manual Displayed chart booklets and laminated charts to remind staff of the Manual’s guidelines while they worked The Manual is available in all service areas Emergency triage, assessment, and treatment Designated triage personnel to undertake triage immediately on arrival of ill child Instituted triage assessment 24 hours, 7 days a week Designated emergency care areas and fully stocked emergency trays with drugs and equipment Assigned escorts to very sick patients Introduction and use of job aids HIV screening algorithm in all child care service areas, including outpatient department, maternal and child health clinics, wards Charts from Referral Care Manual in all care areas Counseling cards for prevention of mother-to-child transmission of HIV in Antenatal Care and HIV Counseling and Testing Centers Infant and child nutrition guidelines in the recuperation and malnutrition wards/units Reducing waiting time Documenting arrival and discharge times for patients (to monitor duration of stay) Escorting those who are very sick to care areas Calling and informing wards of incoming patients Bringing lab services to outpatient departments Using rapid diagnostic tests Improving patient flow at each provider-patient contact Monitoring compliance with standards of care and treatment

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Introducing critical care pathways or care monitoring charts for all admitted patients Reviewing case notes every month for major common conditions Death audits on all deaths monthly Monitoring trends in mortality and case fatality monthly Improving referral systems Mapping of referral networks throughout the continuum of care Developed referral forms and guidelines Work with community-based organizations to improve linkages between facilities and community services Each service area represented on the Quality Improvement team Baby and child friendly services Toys and other stimulation equipment available Collaborative sites certified and recertified as baby and child friendly Rooming-in services for newborns and their mothers Increasing availability of commodities and essential drugs Regular use of reporting and requesting (R&R) system to avoid stock-outs Maintaining an up-to-date inventory of commodities, drugs, and equipment Daily use of check lists at handover Inclusion of pharmacy and procurement staff on the hospital Quality Improvement team Illustrative results The illustrative results of aggregated data from Tanzania, Niger and Nicaragua are presented below in the form of time series charts two showing improvements in compliance with standards of care and one showing improvements in outcomes of care over the life of the collaboratives in months for demonstration sites and for new spread sites. Figure1 shows the percentage of children who were triaged upon entry to the hospital in Niger and Tanzania. Figure 1: Percentage of Children Who Were Triaged upon Entry to the Hospital in Niger and Tanzania (2003-2007)

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Figure 2 shows that in both Niger and Nicaragua the trend is an improvement of children presenting with emergency conditions who were treated according to norms. Figure 2: Correct Treatment/Case Management of Children Seen in the Emergency Room in Niger and Nicaragua (2003-2007)

Figure 3: Correct Case Management of Pneumonia in Nicaragua, Niger, and Tanzania (2003-2007)

In all three countries, the trends are that there was improved care for severe pneumonia in Nicaragua, increased proportion of children treated correctly for Pneumonia in Tanzania and proportion of children treated for pneumonia according the standard

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norms in demonstration and spread sites. Figure 4 shows reduction in case fatality among malaria, Pneumonia and HIV/AIDS cases in Tanzania

Disease specific Case Fatality Rates in 5 demostration sites in children with HIV,Maralia and Pneumonia

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

Months

Cas

e Fa

talit

y Rat

e (%

)

Malaria.Demo 12 12 10 8% 6% 7% 6% 6% 7% 10 12 9% 9% 12 13 6% 7% 4% 4% 6% 5% 5% 9% 6% 8% 8% 6% 6% 4% 4% 4% 5% 5% 8% 7% 5% 3%

Pneumonia. Demo 20 23 14 16 17 17 10 12 16 9% 11 12 17 13 16 11 9% 12 14 14 15 15 17 15 14 12 9% 8% 7% 9% 8% 10 11 15 18 10 12

HIV. Demo 28 42 10 14 20 41 30 30 30 19 24 29 19 16 17 21 13 18 17 21 4% 11 19 23 22 19 21 8% 14 10 12 21 8% 16 6% 18 26

F 05

M A M J J A S O N D J 06

F M A M J J A S O N D J 07

F M A M J J A S O N D J 08

F

Conclusions A number of quality improvement options have been tried in many countries both in the developed and developing countries with various degrees of success. Over time however, it has become clear that these different options have a role to play in bringing about improvement in systems of care and outcomes of care. The improvement collaboratives have been used extensively in developed countries and are taking root in developing countries and have contributed to improving the quality of pediatric services in first referral hospitals. Significant improvements in patient flow and triage have been set up, special areas for very sick children have created such as emergency rooms and spaces equipped with emergency trays and drugs, oxygen concentrators and means of resuscitation provided. Compliance with standards of care has improved by a range of 30%-50%; case fatality came down by about 15-30% among the most difficult situations and by about 50% in the more affluent countries all in a short period of time and with little financial investment. Staff morale has significantly improved in all the PHI countries. Other system improvements include the application of standard care and treatment guidelines, building capacity of providers in continuous quality improvement, and monitoring changes in care quality over time. Improvements achieved in demonstration sites have been spread to new sites, where improved outcomes have been achieved more rapidly than in the original sites. The collaborative approach by combining a number of other improvement methods is not the only way but an effective way to introduce standards of care, apply them, and rapidly increase compliance with these standards leading to improved outcomes of care.

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CHAPTER 24 NATIONAL HEALTH SECTOR REFORMS AND HEALTH CARE FINANCING Esther D. Mwaikambo, Stephen Kinoti, Amos Odiit, Samuel Ayaya 1.0 INTRODUCTION Equal access to health care is accepted as a right and this was endorsed by member states of WHO in the Alma Ata Declaration (WHO/UNICEF 1978) with commitment to the target of health for all by the year 2000. Since then, many achievements have been made in terms of health infrastructure, health service delivery, and human resource development in the health sector. Due to inadequate allocation of financial resources by many governments to the social sector, particularly to the health sector, alternative methods of financing health Services had to be developed. Other broad areas included within health reforms are: human resource development, quality assurance, decentralization, integration of services, health information management and research. At this time when most countries in Sub-Saharan Africa (SSA) are instituting health reforms, all health workers particularly medical doctors need to be knowledgeable in all aspects of health reforms formulation and implementation. 1.1 Need for Health Sector Reforms Following the World development report 1993 and the subsequent World Bank report: “Better Health in Africa 1994,” many countries in Sub Saharan- Africa are undertaking health sector reforms. The major identified problems include:

inadequate resources for the health sector; inadequate managerial capacity at all levels especially at the district level

including lack of supervision and lack of motivation; the growing gap in knowledge between the community and public health

providers; poor implementation of programs leading to poor quality of care including

dependence on donor funding for basic health programs; inadequate human resources and poor human resources management; lack of clear policies in relation to integration of services; need for decentralization; lack of an appropriate research priority policy.

It has become necessary therefore for countries to develop a comprehensive health reform framework. 2.0 OBJECTIVES At the end of this chapter the student will be able to:

Describe government financing of health sector in your country Describe the alternative health financing systems in his/her country;

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Describe human resources necessary to provide quality child health care services at the health center level;

Estimate the cost of providing such a service; Describe the integrated management of common childhood and maternal

illnesses including family planning; Plan the evaluation and monitoring of services provided to children at a health

facility; Describe health information needs at various levels of the health care system; Identify research needs at various levels of health care with respect to child

health. Describe the available clinical protocols and guidelines at the health facility for

specific health service management. 3.0 LEARNING ACTIVITIES

Visit a health center and describe staffing level and adequacy in respect to the services being provided to children.

Write a report on the adequacy of equipment, supplies and drugs at the facility. Visit and acquaint yourself with Health Sector Reform Unit, and write report on

how current health reforms address the health needs of children in your country. Visit a health center and work out the cost of providing various services, such as

drugs, laboratory supplies, personnel, transport, and building maintenance. 4.0 Efficient Use of the Allocated Resources Efficient use of the allocated resources means that there should be improved and better services without additional resource allocation. Such resources should be directed to services that have a multiplier effect and are accessible to the majority of the population. For example: immunization of children, treatment of common childhood illnesses such as diarrhea and acute respiratory infections (ARI), treatment of malaria, tuberculosis, maternal and child health and family planning services. 5.0 Financing in the Health Sector Reform The financing of health care services has profound influence on the quality, quantity and equity of health services. For many years and until health sector reforms have been instituted in most countries, governments have been the main financier of health services with support from donor countries. Apart from the public sector financing the current reforms, should develop various alternative financing options. UNICEF advocates that all governments should allocate at least 20% of their national budgets to the social sector, especially to Health and Education (the 20/20 principle). This can be easily done by reducing on military spending. 5.1 Alternative Financing 5.1.1 Health Insurance Schemes In addition to other sources of financing, many countries in the region are currently developing national health insurance schemes which will initially cover the formal sector of employment and provide a wide range of health services at low cost to the users.

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Some countries in East Africa have started health insurance schemes for their employees and this seem to be working well. Many private health insurances schemes have also being established and a few people have joined them. However the majority of the Africans especially the grass-root people from the rural and urban areas are still without health insurance. Health care financing for these people is still a major challenge. 5.1.2 Cost Sharing Cost sharing in the form of user-charges is another source of financing that has been introduced in the health reform as a supplementary financial option in improving the deteriorating condition of health services. Cost sharing has been introduced in most East African countries in the past several years. Initially there was a lot of resistance to the programme but now slowly people are accepting the reality. Everybody is expected to contribute a small amount of money for the services. Exempted are children below 5 years and people with chronic illnesses. 5.1.3 Private medical services There are three modalities of private medical services:

Private medical services within public medical facilities Private not for profit services such as those provided by some faith based

organization Private for profit medical services such as those provided by individual

practitioners and other organizations. In many countries in the region, private medical services within the public medical facilities are used to help generate supplementary funds for the public health facility. 5.1.4 Community financing In the current health sector reform, community financing is suggested as an alternative method of raising revenue at the community level. Community financing is part of community participation and one of the principles of the Alma Ata declaration. It is used to generate or increase awareness of health leading to greater demand and utilization of health services. Community financing schemes such as the Bamako Initiative schemes are already being implemented successfully in several countries with full community participation. The communities themselves have established criteria on who should be exempted from paying fees, such as the very young and elderly. Revenues from such payments can then be used to promote health services in the area. Community financing can be in form of: giving cash, labor, or other provisions from which no single individual benefits, but the whole society. Tanzania introduced community health financing several years back. The programme has been well accepted in the three districts of Tabora regions. The programme is now being scaled up in the country. 6.0 Human Resource Development This aspect of health reform includes: personnel development and their adequate deployment with respect to number, qualification and skills and also with respect to service needs at various levels of the health service. In order to interpret and implement

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health and health related policies there should be capacity building at all levels in planning, management and delivery of health services under a reformed environment. A capacity building approach which is task-oriented, competitive and team-based should be adopted in all levels of health care delivery. 7.0 Quality Assurance There has been little effort to ensure that the health care provided is of good quality. With general increase in public expectations for quality health care in all spheres (particularly where the public is required to contribute towards the cost of the service) there is a need to focus on quality assurance in health reform. It is the responsibility of the Ministry of Health to ensure quality through proper supervisory, monitoring and evaluation tools. Logistic support should be provided at various levels to enable them to fulfill their supervisory roles and ensure that the quality of health services is maintained. This could be achieved by the development of management support guidelines, manuals and systems for various health care delivery levels. 8.0 Decentralization Though many countries have embarked on decentralization, effective decentralization including delegation of authority to hire and fire, and to manage financial resources is still lacking. A number of factors that have rendered the decentralized health system less effective are:

The central level still retained most of the authority, some of which would be necessary to facilitate implementation at the district level. Vertical programs are planned at the central level with very little participation of the implementers.

The concept of decentralization is not well understood and there was a tendency of by-passing the relevant authorities in the handling of health management issues and also in decision-making involving finances.

Lack of clear decentralization Policy that would empower district authorities to attain full administrative and managerial powers.

Inadequate support to the district health management teams to enable them to fulfill their supervisory roles and ensure that the quality of health services is maintained by providing guidelines and manuals.

Lack of comprehensive health sector plans that would be used by central ministries to implement health activities at all levels and coordinate donor input.

Inadequate health staffing and equipment for delivery of a minimum level of acceptable health care.

9.0 Integration of services Health reforms should aim at integrating various aspects of health delivery services such as clinical services, preventive services with training in financial management and supervision. The health services delivery system at all levels should be integrated and a multi-sectoral approach should be adopted in the implementation of a community-based health care system. There should also be a serious consideration for program integration where feasible at all levels. Such integration should be reflected in the decentralization policy.

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10.0 Health Information System This aspect of reform must include development and coordination of health information systems that are useful for:

Advocacy and policy development, documenting the burden and nature of illnesses, Monitoring quality and performance of health services. Estimating the cost of health service, Monitoring trends and changes on the overall health sector and Regular synthesis of health information useful in planning.

A comprehensive health management information system (HMIS) should be implemented in the districts to support the planning and budgeting exercise. 11.0 Research Most of the research on health including operational and bio-medical have not depended on the demand of the national health system. Research in the reforms should include essential national health research at all levels and the objectives should be:

To identify operational health research priorities necessary to implement successful health service delivery,

To suggest the type of research needed to strengthen the management of the

health systems; and

To select relevant and reasonable priority research projects and

To identify researchers, institutions and donors who can implement them. Operational research should especially address the aspects that deal with strategies, approaches, access and utilization of services. They should also address technologies, financial systems, quality assurance, case studies of functioning systems or strategies and disease control.

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REFERENCES:

1. UNICEF. Strategic use of resources for child survival and development in times of economic adjustment, 1988: Dar es Salaam.

2. World Bank. Financing health services in developing countries: an

agenda for reform, 1987 World Bank.

3. Ministry of Health, Tanzania. Proposals for Health Sector Reform, December 1994, Dar es Salaam.

4. Better Health in Africa 1994, World Bank Report.

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CHAPTER 25 BASIC STATISTICS FOR HEALTH CARE Dalton Wamalwa and Jeremiah Banda INTRODUCTION Statistics is the science of collecting, organizing and interpreting numerical facts which we refer to as data. Data are not just numbers, they are numbers within a context. The statistical approach in health care pertains to defining and interpreting health phenomena using numbers. This chapter presents some of the basic statistical techniques which can be used to analyze and present statistics pertinent to primary health care. The purpose of the chapter stimulate students and other health workers to study more statistical theory and methods in order to be equipped to collect reliable data and accurately analyze such data. OBJECTIVES At the end of the chapter students should be able to: Explain the role of statistics in Health Care Discuss common and possible data sources on Health Care Understand basic statistical parameters relevant to health related data including: Rates and proportions Measures of central tendency Measures of dispersion Tabular and graphic presentation of data Sources of health care data 1. Censuses For many countries a population census is conducted in every 10 years. Most developing countries currently conduct their censuses on a complete enumeration basis. This means that theoretically every household and person, in a country, is enumerated. This results in having data for the whole country, at relatively small administrative levels/domains. Through censuses, information on deaths and births is usually collected. In addition, the census is a source of information on denominators used in calculating rates to assess public health. 2. Vital registers Registration of all deaths and births is required by law in most countries. A death certificate is required for claiming insurance benefits of other administrative rights of the deceased’s property. For countries which have complete or near complete vital registration systems, vital statistics, including births and deaths can be generated on a continuous basis. Unfortunately for most African countries the systems for registration

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of births and deaths are not comprehensive. In general registration is better in the urban settings compared to the rural areas. Demographic Health Survey At intervals of 5 years, countries carry out demographic health surveys. In these surveys, a sample survey is carried out on a nationally representative number of people (men and women aged 15 to 54 years) selected from about 400 sample points (clusters) across the country. A sample comprises of a proportion of individuals or units from the target population. Here a population is defined as a collection of individuals or units from which a sample is selected. The results obtained from the sample can be generalized to the population from which it is selected. Thus a probability sample enables the researcher to make inferences from the sample results to the population. The national demographic and health survey obtains detailed information on fertility levels, marriage, and sexual activity, breastfeeding practices, nutritional status of women and children, childhood and maternal mortality, maternal and child health, vaccination coverage, awareness and use of family planning methods, behaviour related to HIV/AIDS. Some countries also include information on malaria and use of mosquito nets, domestic violence and HIV testing of adults. Some key outcomes of the demographic and health survey include: Infant mortality rate: this is the probability of a child dying before they reach their first birthday, expressed as number of deaths per 1000 live births. Under-five mortality rate is the probability of a child dying before they reach their fifth birthday. Maternal mortality rate: this is the number of women who die during pregnancy or within 42 days of termination of the pregnancy irrespective of the duration or site of pregnancy from any cause related to or aggravated by pregnancy or its management but not from accidents or incidental causes. It is expressed as deaths per 100,000 live births. 4. Surveillance data and medical records Public surveillance systems: Surveillance is a process that is carried out on an ongoing basis to monitor changes in disease frequency or to changes in the pattern of risk factors. A good surveillance system will detect and possibly lead to prevention of a disease outbreak. The information obtained from public health surveillance is analyzed and disseminated to the health care implementers. For example the measles surveillance will report all cases to the department of immunizations to institute mass vaccination and catch up vaccination activities. In implementing a typical surveillance system doctors, medical laboratories and other health care providers may be required, by law, to record and report all cases of health conditions that may be specified as being notifiable. Surveillance is mainly put in place for conditions that are infectious in origin. Hospital, clinic records and other primary health care records: health statistics can also be generated as byproducts of hospital, clinic and other administration systems. In

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general information from the hospital records may not be representative of what happens in the community. For instance during an outbreak of measles the children who get admitted and die in the hospital may only represent the sickest subset. Useful tools in public health statistics 1. Count: The absolute number of an event (e.g. infant’s deaths) occurring in a specified area in a specified time period. For example, there were, 24,560 infant deaths recorded in South Africa in 1996. Absolute numbers are important for planning. In a specific country the number of malaria infections may be used to plan the quantity of antimalarials required for a given duration. 2. Ratio: a ratio is an expression of a relationship of any two quantities such as infant deaths in a particular year to the number of live births in the same year. 3. Proportion: A proportion is a ratio in which the numerator is included in the denominator. For example the number of children born HIV positive in a hospital, in a particular year, over the total number of children born, in the same, that year. Consider the proportion of patients infected with HIV in two countries (hypothetical). Country A has a total population of 2,000,000 people of whom 200,000 are HIV infected. The proportion of people with HIV is: 200,000/2,000,000 = 10% Country B has a population of 100,000,000 and has 1 million HIV infected people. The proportion of HIV infected people in country B is: 1,000,000/100,000,000 = 1%. Thus even though the absolute number of cases is higher in country B (1 million vs. 200,000), the proportion is higher in country A (10% vs. 1%). 4. Rate: A rate, measures a frequency of public health events among, say, children in a specified time period. For example the infant mortality rate for Egypt, in 1999, was 29.4. This rate is the annual number of deaths of infants under one year of age per, 1,000 live births in the same year. 5. Incidence rate: Is the count of new (incident) cases divided by the amount of at-risk experience from which the cases arose. The denominator is measured in units of person-time. Note: person-time is defined as the amount of follow-up time each individual contributes e.g. 50 people followed for 1 year contribute the same number of person years as 100people followed for 6 months (i.e. 50 years)

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6. Prevalence rates: Count of prevalent cases of a disease is the number of persons in the population who are in the diseased state at a specified time. The proportion is obtained by dividing the count of prevalent cases by the population size at the time. Descriptive Statistics Descriptive statistics are frequently used and can be used in different aspects of primary health care. For instance, they are used when we want to describe how the data at hand looks like and its common features. Descriptive statistics summarize data. The summarized data, in most cases, facilitate easy and quick interpretation of the detailed set of data. In health care, descriptive statistics can be and are used to manage, monitor and evaluate health services and the persons working in such services Descriptive statistics are, in general, categorized into two types: The first being measures of central tendency, namely, the mean, median and mode. The second category is measures of dispersion/variability, among them the range; inter quartile range; variance and standard deviation. 1. Types of Data variables There are 2 types of variable namely categorical variable and continuous variables. Categorical variables include those which naturally occur in distinct groups e.g. sex whereby one can only be either a male or female. Continuous data on the other hand does not fit into natural groups and changes occur in gradual increments. Examples of continuous variable are height and age. 2. Measures of Central Tendency A measure of central tendency is a statistic which summarizes a given set of one variable data. For example we may state that the average age of sick children in the children’s ward at a particular hospital is 3 years and 5 months. This is a summary figure derived from the total value of ages of children divided by the number of children. It should, however, be pointed out that there a number ways of defining the measures of central tendency. In this section we shall consider the following measures of central tendency: Mean Median Mode Mean The arithmetic mean, which is the most commonly used measure of central tendency, is simply the total of a set of values of a variable divided by the number of observations. Thus, it is calculated by summing all the values in a set of data and then dividing the total by the number of items involved. The data may come from the whole population of interest, or a sample for example, recorded height in centimeters of a sample of children (see table 1).

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The formula for the population mean is

Nxxxx N

321 (1)

Where 1x up to Nx are the observations for the whole population N in our example

above of sick children in a particular hospital ward. The Greek letter mu represents the mean of the population. The algebraic expression in (1) can also be presented as

= N

xN

ii

1

(2)

N

iix

1 is the summation of all ix values in the population from 1x to? Nx The formula for a sample mean is presented as follows:

x nxxxx n

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(3) Where: x is a sample arithmetic mean? n is the sample size

ix is the thi observation of the random variable? X

n

iix

1 is the summation of all ix values in the sample from 1x to? nx Data on the growth, in height in centimeters, for a hypothetical sample of 20 children aged 1 to 20 years. The data depicts the extent of growth over the period. We shall use this data to calculate the measures of central tendency and dispersion/variation. Table. 1 Growth though childhood

Serial number of child

Height in centimeters ix

2

ix

1 65 4,225 2 75 5,625

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3 85 7,225 4 95 9,025 5 100 10,000 6 105 11,025 7 115 13,225 8 120 14,400 9 125 15,625 10 125 15,625 11 127 16,129 12 135 18,135 13 145 21,025 14 155 24,025 15 170 28,900 16 170 28,900 17 170 28,900 18 170 28,900 19 170 28,900 20 170 28,900

Average height in centimeters of the sample observations is

x = nxi

= 2017010095857565

= 20476,2

= 123.35 123 Median: The median, which is another common measure of central tendency, is the middle value, thus the physical centre, in an ordered sequence of data of a distribution or data set. If the order set of number is odd, half of the observations will be smaller and half will be larger than the middle value. The observations should be ranked from lowest to highest value before determining the median. The median is less affected by outliers in a set of data than the mean. Instead of using all the values to calculate the measure of central tendency, it uses only the value in the middle of the distribution. It is, therefore, often preferred as a measure of central tendency for skewed distributions. To calculate the median, therefore, first the raw data should be put in an ordered array, say in ascending order. In general the positioning point formula is:

21n

(4)

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where n is the number of observations? (a) If the number of observations is odd, the median is represented by the numerical

value corresponding to the positioning point, which is the 21n

ordered observation. (b) If the number of observations is even, then the positioning point lies between the two middle values. In this case the median is the arithmetic average of the numerical values corresponding to the two middle observations. We shall illustrate the above two situations in the examples that follow. Example From table 1, the median is calculated as follows: We must recognize that the observations are ordered in ascending order and they are even therefore we go by the formulation in (b) above. The two middle values are 125 and 127, taking an average of these two values means.

Median = 2127125

= 126 If the number of children we only 19 the median height should have been 25 by applying formula (4) above in locating the median position. Mode: The mode is the value in a set of data (distribution) which occurs most frequently. It is easily obtained from an ordered array. The mode, unlike the mean is not affected by presence of outliers a set of data. It should however, be noted that the mode is used mostly for descriptive purposes because it is, in practice, more variable from sample to sample compared to other measures of central tendency. From table 1 it is clear the most frequent value is 170, thus six observations in the distribution. Summary on measures of central tendency The mean is the most commonly used measure of central tendency. All values in a selected distribution are used in its calculation, in this way it is the most sensitive. As it arithmetically based it can be used in other calculation as illustrated below under the measurement of variation. As earlier stated, however, it is easily distorted by extreme values. In addition, the mean can only be used on data of interval or ratio level of measurement. The median does not take into account the values of cases, therefore is not affected by extreme values. It can be derived from ordinal, thus ranked data.

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The mode is most useful categorical data, although it can be used on all levels of measurement. Measures of Dispersion A single summary measure such as the mean is, under normal circumstances, sufficient to describe or define a distribution, because it does not reflect the second important characteristic of a distribution, namely, its variation or dispersion. In order, therefore, to enhance our understanding of the pattern of the data there is also a need to measure its dispersion. Why do we need to measure and understand dispersion of a distribution? It gives additional information that enables one to assess the reliability of the measure of central tendency. For example, if data are widely dispersed, the measure of central tendency is less representative of the data as a whole than it would be if the data were more closely clustered around the mean, for instance. The measure of dispersion is the one of the first steps to take in an attempt, to resolve peculiar problems associated with widely dispersed data. It is common in empirical statistical research to compare dispersions of various samples. This helps researcher to recognize and perhaps avoid distributions with the greatest dispersion. It is important to note that in the health care field it is important to know the variability in children’s health. 1. Range: To calculate the range you subtract the smallest value, in a data set, from the largest value. As example once again refer to table 1. The smallest and largest value in the distribution is 65 and 170, respectively. In this case the range will be: 170 – 65 = 105 The range is the simplest measure of dispersion. 2 Inter-quartile range: In order to deal with outliers in a distribution the use of an inter-quartile range ( IQR ) is advisable. A quartile is derived by partitioning a data set into quarters. The data are placed in an ascending order and then divided into four quarters. The numbers at the upper boundaries of these quarters are called quartiles. Thus the quartiles are the highest values in each of the four parts. The IQR measures, approximately, how far from the median one has to go on either side before one includes 50 per cent of the data set. The IQR is, therefore, the range for the middle fifty per cent of the data. The IQR is calculated by locating the upper value of the 1st quartile, and subtracting it from the upper value of the 3rd quartile. Thus

340

IQR = 13 QQ (5) = 170 – 100 = 70 It will be observed that the dispersion is somewhat reduced compared to the value of the range. This is because its calculation, to the extent possible does not include outliers such as 65. One obvious shortcoming of the range and the IQR is that while they give an indication about the spread of values of observations, they do not take into consideration the concept of the level of deviation from the central tendency ( such as the mean). 3. Variance: The variance is an average of squared deviations from the mean. As can be seen from the formulas below, The sum of squared deviations/distances between the mean and each item divided by the total number of elements in the population. In the case of population variance, by squaring each deviation, we make every number positive.

Population and sample variances: The Square of the Greek letter sigma )( 2 usually represents the population variance, while the sample variance is commonly represented by

2s . The formulas for variances are as follows:

Population: 2 =

2

Nxi

= 2

2

N

xi

(6)

Sample: 2s =

2

1

nxxi

=

22

11

nxn

nxi

(7) Where:

ix is a value of an element? is the population mean x is the sample mean? N is the total number of observations in the population? n is the sample size N-1 is the number of observations in the sample minus 1

2 is the population variance 2s is the sample variance

In the calculations we use the data in table 1 which we assume to be sample data. In our calculation we use the simplified formulation, thus:

341

2s =

22

11

nxn

nxi

Substituting the values

2s =

1922.215,1520

19404,358

=

19404,358

1940.304,304

= 18,864.37- 16,016.02 = 2,848. 35 = 2,848 4. Standard deviations (SD) The standard deviation of the population and sample variances is the square root of their variances.

i) Population

Nxi

2

= 2

2

Nxi

(8)

ii) Sample s =

2

1

nxxi

= 11

22

nxn

nxi

(9)

SD 35.848,2s = 53.37 53 The standard deviation is the most commonly used measure of dispersion in describing data. It is the measure of the variation in the data that assesses how much each value deviates from the mean. Use of Mean and Median (distribution of data) Most naturally occurring distributions are normal. In such distributions, the mean is very close (or equal) to the median. However some distributions are skewed (either right skewed in which case the mean is far greater than the median, or left skewed in which case the mean is significantly less than the mean. The median is relatively unaffected by extremes figures (in statistics the mean is considered to be robust).

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The best representation of normal data uses the mean and standard deviations while skewed data is best represented using the median and inter quartile range. Tabular and graphic representation of data When data are collected, there is need to present them in an orderly manner for them to be understood, especially, when you have a large array of data. Data can grouped into classes or frequency distributions; presented in a tabular form or charts and as discussed above calculated and presented as summary statistics. Tables and graphs summarize and present data in a way that is easy to understand and assimilate. Displaying data is usually an important part of analyzing the data. According to Scott and Mazhindu, (2005) “it allows you to establish how data are distributed, to see unusual cases and generally get a feel for the data.” Tables present information in a text form while graphs help display patterns although some details are lost. We briefly discuss and present a table; line graph; bar chart; multiple bar chart and pie charts derived from the small data set given in table 2. It should be pointed out that many more graphs and charts are used by statisticians and other data users to display data. 1. Tables: The purpose of tables is to summarize and thereby facilitate the comparison of data. Listed below are the general features of which a good table should have: A title which is a brief explanation of the contents of the table including the units of measurement; A column title or caption showing the classification with respect to columns A row title or stub to showing classification with respect to rows. A source note at the bottom of the table indicating the source of data. Table 2. Age, sex distribution of battered babies at Kenyatta Hospital,

Age

Sex

Male Female 10-11months 11 7 12-24 months 1 2

2-5yrs 2 4 6-10 yrs 2 1 Total 16 14

Source: Nduati and Muita, Nairobi, 1989

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Questions: What proportion of the all children are males? What is proportion of female sin the age group 6-10 years? From this table do you think male infants are more likely to be battered? 2. Line graph: To draw a line graph we must have values which are pertinent to the y - axis (vertical axis) and x - axis (horizontal axis). The position of any point on the graph is located by the y and x coordinates. With respect to figure 1 examining the female line graph the number of battered children in the age range 10-11 months is 7, as we move along the x -axis the number reduces to 2 battered children in the age range 12-24 months. Then we move upward on the scale until the number 4 for those battered aged 2-5 years and then declines to 1 for those aged 6-10 years. A straight line is then drawn through the located points.

Figure 1. Number of battered children at Kenyatta Hospital by age and sex (1989)

0

2

4

6

8

10

12

10-11mons 12-24 mons 2-5yrs 6-10 yrs

Age

Num

ber

MaleFemale

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Bar Chart: In a simple bar chart the bars are of equal thickness but the length is varied in proportion to the values represented. This chart is given in figure 2. below. 4. Multiple Bar Charts In figure 3 we see a graph where two sets of data have been graphed using the same values (age ranges) in the horizontal axis. This graph, for example, facilitates easy graphic comparison of number of battered boy and girls by age group.

0

2

4

6

8

10

12

10-11mons 12-24 mons 2-5yrs 6-10 yrs

Num

ber

age

Figure 2. Battered male children at Kenyatta Hospital by age

Series1

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5. Pie chart: A pie chart displays a count of observations in a nominal group as a proportion (per cent age) of the total number of counts. The total data is represented as a circle which is divided into segments whose sizes represent the frequency of each group. For example figures 4 and 5 shows the proportions of battered boys and girls, respectively, under different age groups. Pie charts are ideal for simple data. If you include many subgroups or categories it may be difficult to read.

Figure 3. Battered children at kenyatta Hospital by sex and age (1989)

0

2

4

6

8

10

12

10-11mons 12-24 mons 2-5yrs 6-10 yrs

Age of children

Num

ber

Sex Male Sex Female

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Spend some time analyzing the graphs and charts and come up with an objective story!

Figure 4: Male battered children at kenyatta Hospital by age

10-11mons68%

12-24 mons6%

2-5yrs13%

6-10 yrs13%

10-11mons12-24 mons2-5yrs6-10 yrs

Figure 5.Female battered children at Kenyatta Hospital by age (1989)

10-11mons50%

12-24 mons14%

2-5yrs29%

6-10 yrs7%

10-11mons12-24 mons2-5yrs6-10 yrs

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