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Mambulu-Chikankheni FN. Factors influencing the implementation of severe acute malnutrition guidelines within the healthcare referral systems of rural subdistricts in North West Province, South Africa. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0002277. [PMID: 37594922 PMCID: PMC10437970 DOI: 10.1371/journal.pgph.0002277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 07/18/2023] [Indexed: 08/20/2023]
Abstract
Severe acute malnutrition (SAM) is associated with 30.9% of South Africa's audited under-five children deaths regardless of available guidelines to reduce SAM at each level of a three tyre referral system. Existing research has explored and offered solutions for SAM guidelines implementation at each referral system level, but their connectedness in continuation of care is under-explored. Therefore, I examined implementation of SAM guidelines and factors influencing implementation within subdistrict referral systems. An explanatory qualitative case study design was used. The study was conducted in two subdistricts involving two district hospitals; three community health centres, four clinics, and two emergency service stations. Between February to July 2016 and 2018, data were collected using 39 in-depth interviews with clinical, emergency service and administrative personnel; 40 reviews of records of children younger than five years; appraisals of nine facilities involved in referrals and observations. Thematic content analysis was used to analyse all data except records which were aggregated to elicit whether required SAM guidelines' steps were administered per case reviewed. Record reviews revealed SAM diagnosis discrepancies demonstrated by incomplete anthropometric assessments; non-compliance to SAM management guidelines was noted through skipping some critical steps including therapeutic feeding at clinic level. Record reviews further revealed variations of referral mechanisms across subdistricts, contradictory documentation within records, and restricted continuation of care. Interviews, observations and facility appraisals revealed that factors influencing these practices included inadequate clinical skills; inconsistent supervision and monitoring; unavailability of subdistrict specific referral policies and operational structures; and suboptimal national policies on therapeutic food. SAM diagnosis, management, and referrals within subdistrict health systems need to be strengthened to curb preventable child deaths. Implementation of SAM guidelines needs to be accompanied by job aids and supervision with standardised tools; subdistrict-specific referral policies and suboptimal national policies to ensure availability and accessibility of therapeutic foods.
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Affiliation(s)
- Faith Nankasa Mambulu-Chikankheni
- Department of Curriculum and Teaching Studies (Human Ecology), Nalikule College of Education, Lilongwe, Malawi
- Centre for Health Policy, School of Public Health, University of the Witwatersrand, Johannesburg, South Africa
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2
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Tan R, Kagoro F, Levine GA, Masimba J, Samaka J, Sangu W, Genton B, D'Acremont V, Keitel K. Clinical Outcome of Febrile Tanzanian Children with Severe Malnutrition Using Anthropometry in Comparison to Clinical Signs. Am J Trop Med Hyg 2020; 102:427-435. [PMID: 31802732 DOI: 10.4269/ajtmh.19-0553] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Children with malnutrition compared with those without are at higher risk of infection, with more severe outcomes. How clinicians assess nutritional risk factors in febrile children in primary care varies. We conducted a post hoc subgroup analysis of febrile children with severe malnutrition enrolled in a randomized, controlled trial in primary care centers in Tanzania. The clinical outcome of children with severe malnutrition defined by anthropometric measures and clinical signs was compared between two electronic clinical diagnostic algorithms: ePOCT, which uses weight-for-age and mid-upper arm circumference to identify and manage severe malnutrition, and ALMANACH, which uses the clinical signs of edema of both feet and visible severe wasting. Those identified as having severe malnutrition by the algorithms in each arm were prescribed antibiotics and referred to the hospital. From December 2014 to February 2016, 106 febrile children were enrolled and randomized in the parent study, and met the criteria to be included in the present analysis. ePOCT identified 56/57 children with severe malnutrition using anthropometric measures, whereas ALMANACH identified 2/49 children with severe malnutrition using clinical signs. The proportion of clinical failure, defined as the development of severe symptoms by day 7 or persisting symptoms at day 7 (per-protocol), was 1.8% (1/56) in the ePOCT arm versus 16.7% (8/48) in the Algorithm for the MANagement of Childhood illnesses arm (risk difference -14.9%, 95% CI -26.0%, -3.8%; risk ratio 0.11, 95% CI 0.01, 0.83). Using anthropometric measures to identify and manage febrile children with severe malnutrition may have resulted in better clinical outcomes than by using clinical signs alone.
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Affiliation(s)
- Rainer Tan
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland.,Swiss Tropical and Public Health Institute (SwissTPH), University of Basel, Switzerland
| | - Frank Kagoro
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Gillian A Levine
- Swiss Tropical and Public Health Institute (SwissTPH), University of Basel, Switzerland
| | - John Masimba
- Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Josephine Samaka
- Amana Hospital, Dar es Salaam, Tanzania.,Ifakara Health Institute, Dar es Salaam, Tanzania
| | - Willy Sangu
- Dar es Salaam City Council, Dar es Salaam, Tanzania
| | - Blaise Genton
- Swiss Tropical and Public Health Institute (SwissTPH), University of Basel, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Valérie D'Acremont
- Swiss Tropical and Public Health Institute (SwissTPH), University of Basel, Switzerland.,Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | - Kristina Keitel
- Department of Pediatric Emergency Medicine, University Hospital Bern, Bern, Switzerland.,Swiss Tropical and Public Health Institute (SwissTPH), University of Basel, Switzerland
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3
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Becker PJ, Gunnell Bellini S, Wong Vega M, Corkins MR, Spear BA, Spoede E, Hoy MK, Piemonte TA, Rozga M. Validity and Reliability of Pediatric Nutrition Screening Tools for Hospital, Outpatient, and Community Settings: A 2018 Evidence Analysis Center Systematic Review. J Acad Nutr Diet 2020; 120:288-318.e2. [DOI: 10.1016/j.jand.2019.06.257] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Indexed: 12/29/2022]
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Desyibelew HD, Baraki AG, Dadi AF. Mortality rate and predictors of time to death in children with severe acute malnutrition treated in Felege-Hiwot Referral Hospital Bahir Dar, Northwest Ethiopia. BMC Res Notes 2019; 12:409. [PMID: 31307556 PMCID: PMC6631743 DOI: 10.1186/s13104-019-4467-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 07/11/2019] [Indexed: 11/30/2022] Open
Abstract
Objectives This study aimed to determine mortality rate, time to death and factors affecting the time to death among children with severe acute malnutrition admitted to therapeutic feeding unit of Felege Hiwot Referral Hospital, Bahirdar. Result A total of 401 children with severe acute malnutrition who were admitted to therapeutic feeding units from September 2012 to January 2016 were included in the study. The incidence of death rate was 8.47% (95% CI 6.11%, 11.65%). The median time to death was 3 days (Inter Quartile Range of 4 days). Children’s of age > 24 months (AHR = 0.27; 95% CI 0.1, 0.73), fully vaccinated status (AHR = 0.16; 95% CI 0.07, 0.36), HIV infection (AHR = 3.82; 95% CI 1.3, 11.15) and congestive heart failure (AHR = 6.98; 95% CI 2.42, 20.09) were significant predictors of mortality among children admitted for severe acute malnutrition.
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Affiliation(s)
- Hanna Demelash Desyibelew
- Department of Public Health Nutrition, College of Medicine and Health Sciences, Bahirdar University, Bahir Dar, Ethiopia
| | - Adhanom Gebreegziabher Baraki
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Abel Fekadu Dadi
- Department of Epidemiology and Biostatistics, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.,Flinders University, Health Sciences Building, Sturt Road, Bedford Park, Adelaide, SA, 5001, Australia
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5
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Stephens K, Orlick M, Beattie S, Snell A, Munsterman K, Oladitan L, Abdel-Rahman S. Examining Mid-Upper Arm Circumference Malnutrition z-Score Thresholds. Nutr Clin Pract 2019; 35:344-352. [PMID: 31175704 DOI: 10.1002/ncp.10324] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Anthropometric z-scores used commonly for diagnosis and determining degree of malnutrition, specifically body mass index (BMIz), weight-for-length (WLz), and mid-upper arm circumference (MUACz), are not wholly concordant, yet the proposed thresholds for classification are identical. This study was designed to critically examine MUACz thresholds and their ability to correctly classify nutrition status. METHODS This was a 2-year, prospective single-center study of children ≤18 years seen by registered dietitians within a large pediatric institution. The sensitivity, specificity, and predictive performance of the malnutrition classification thresholds were estimated against clinician-based classification. RESULTS Sixty-one dietitians enrolled 10,401 patients with distributions of z-scores for weight (-0.5 ± 1.9), length (-0.8 ± 1.6), BMI or WL (-0.1 ± 1.8), and MUAC (-0.4 ± 1.5), suggesting participants were smaller and shorter than the reference U.S. POPULATION Distributions of MUACz were broad and overlapped between nutrition classification groups, an observation that extended to BMIz and WLz as well. Consequently, existing thresholds do not accurately classify 100% of children. Misclassification rates increase, with increasing severity ranging from 8% in children with no malnutrition to 71% in children with severe malnutrition. Algorithm- and manually-based refinement of thresholds result in mixed improvements and can be explored by the reader with the associated supplement. CONCLUSION The sensitivity of proposed MUACz thresholds systematically decreases with increasing severity of malnutrition and will require optimization if we aim to limit the number of children at risk of misclassification. Indicators for overnutrition remain to be addressed but are explored herein.
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Affiliation(s)
- Karen Stephens
- Nutrition Services, Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Meike Orlick
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Audrey Snell
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | | | - Leah Oladitan
- Children's Mercy Hospital, Kansas City, Missouri, USA
| | - Susan Abdel-Rahman
- UMKC School of Medicine, Kansas City, Missouri, USA.,Innovation in Health Care Delivery, Children's Research Institute, Kansas City, Missouri, USA.,Section of Therapeutic Innovation, Children's Mercy Hospital, Kansas City, Missouri, USA
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Arafat Y, Islam MM, Connell N, Mothabbir G, McGrath M, Berkley JA, Ahmed T, Kerac M. Perceptions of Acute Malnutrition and Its Management in Infants Under 6 Months of Age: A Qualitative Study in Rural Bangladesh. Clin Med Insights Pediatr 2018; 12:1179556518771698. [PMID: 29760577 PMCID: PMC5946588 DOI: 10.1177/1179556518771698] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 02/19/2018] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND World Health Organization guidelines advise community-based care (CBC) for "uncomplicated" severe acute malnutrition (SAM) infants <6 months old (u6m), whereas current national protocols refer to inpatient care. Our aim was to inform and shape future management strategies by understanding caregivers' and different stakeholders' perceptions on malnutrition among infants u6m on barriers/facilitators to future CBC. METHODS The methods used in this study are as follows: in-depth interviews and focus group discussions (FGDs) in southern Bangladesh, thematic analysis of transcripts, and sample size by data saturation. RESULTS We conducted 5 FGDs with 29 caregivers, 4 with 29 health care workers, 4 key informant interviews each with community leaders and health supervisors. Five themes emerged. 1) Identification of SAM infants and care-seeking behavior: malnutrition was not noticed until severe, caregivers focused on clinical symptoms. Both allopathic and traditional healers were consulted. (2) Perceived causes of infant malnutrition: underlying illness, poor feeding practices, poverty, and local superstitions. (3) Views and preferences on treatment: hospitals and doctors were perceived as offering the best treatment, health care workers were also important, and respondents highlighted the need care of the caregiver/mother along with the infant. (4) Perceived benefits and risks of CBC: lower cost and greater accessibility were appreciated but worried about quality. (5) Community networks: wider family and social support networks were considered important aspects of care. CONCLUSIONS There is considerable potential for CBC but needs to be better and earlier identification of at-risk infants, strengthening of health systems to avoid community options being perceived as "second best," engagement with families and communities to tackle "upstream" determinants of SAM, and care for mother-infant pairs.
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Affiliation(s)
- Yasir Arafat
- Department of Health and Nutrition, Save the Children (Bangladesh), Dhaka, Bangladesh
| | - M Munirul Islam
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Nicki Connell
- Department of Global Health, Save the Children USA, Washington, DC, USA
| | - Golam Mothabbir
- Department of Health and Nutrition, Save the Children (Bangladesh), Dhaka, Bangladesh
| | - Marie McGrath
- Technical Department, Emergency Nutrition Network, Oxford, UK
| | - James A Berkley
- Clinical Research Department, KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Technical Department, The Childhood Acute Illness & Nutrition Network (CHAIN), Nairobi, Kenya
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Marko Kerac
- Department of Population Health, London School of Hygiene & Tropical Medicine, London, UK
- Leonard Cheshire Disability and Inclusive Development Centre and Department of Epidemiology & Public Health, University College London, London, UK
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Chitekwe S, Biadgilign S, Tolla A, Myatt M. Mid-upper-arm circumference based case-detection, admission, and discharging of under five children in a large-scale community-based management of acute malnutrition program in Nigeria. ACTA ACUST UNITED AC 2018; 76:19. [PMID: 29657713 PMCID: PMC5890342 DOI: 10.1186/s13690-018-0266-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 02/20/2018] [Indexed: 11/10/2022]
Abstract
Background Severe acute malnutrition (SAM) threatens the lives of millions of children worldwide particularly in low and middle-income countries (LMICs). Community-based management of acute malnutrition (CMAM) is an approach to treating large numbers of cases of severe acute malnutrition (SAM) in a community setting. There is a debate about the use of mid-upper arm circumference (MUAC) for admitting and discharging SAM children. This article describes the experience of using MUAC for screening, case-finding, referral, admission, and discharge in a large-scale CMAM program delivered through existing primary health care facilities in Nigeria. Methods Over one hundred thousand (n = 102,245) individual CMAM beneficiary records were collected from two of the eleven states (i.e. Katsina and Jigawa) that provide CMAM programming in Nigeria. The data were double entered and checked using EpiData version 3.2 and analyzed using the R language for data-analysis graphics. Results The median MUAC at admission was 109 mm. Among admissions, 37.4% (38,275) had a comorbidity recorded at admission and 7.4% (7537) were recorded as having developed comorbidity during the treatment. Analysis in the better performing state program in the most recent year for which data were available found that 87.1% (n = 13,273) of admitted cases recovered and were discharged as cured, 9.2% (n = 1396) defaulted and were lost to follow-up, 2.9% (n = 443) were discharged as non-recovered, 0.7% (n = 104) were transferred to inpatient services, and 0.2% (n = 27) were known (died, to be dead or to have passed) during the treatment episode. The program met SPHERE minimum standards for treatment outcomes for therapeutic feeding programs. Factors associated with negative outcomes (default, non-recovery, transfer, and death) were distance between home and the treatment center; lower MUAC, diarrhea and cough at admission; or developing diarrhea, vomiting, fever, or cough during the treatment episode. Conclusions This study confirms that MUAC can be used for both admitting and discharging criteria in CMAM programs with MUAC < 115 mm for admission and MUAC > = 115 mm or at discharge (a higher discharge threshold could be used). Long distances between home and treatment centers, lower MUAC at admission, or having diarrhea, vomiting, fever, or cough during the treatment episode were factors associated with negative outcome. Providing CMAM services closer to the community, using mobile and / or satellite clinics, counseling of mothers by health workers to encourage early treatment seeking behavior, and screening of patients at each patient visit for early detection and treatment of comorbidities are recommended.
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Affiliation(s)
- Stanley Chitekwe
- United Nations Children's Fund (UNICEF), Nigeria country office, UN House, Plot 617/618 Central Area District Diplomatic Zone, Garki, Abuja, P M B 2851 Nigeria
| | - Sibhatu Biadgilign
- United Nations Children's Fund (UNICEF), Nigeria country office, UN House, Plot 617/618 Central Area District Diplomatic Zone, Garki, Abuja, P M B 2851 Nigeria
| | - Assaye Tolla
- United Nations Children's Fund (UNICEF), Nigeria country office, UN House, Plot 617/618 Central Area District Diplomatic Zone, Garki, Abuja, P M B 2851 Nigeria
| | - Mark Myatt
- Consultant Epidemiologist, Brixton Health, Llawryglyn, Wales UK
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8
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Laar ME, Marquis GS, Lartey A, Gray-Donald K. Reliability of length measurements collected by community nurses and health volunteers in rural growth monitoring and promotion services. BMC Health Serv Res 2018; 18:118. [PMID: 29454360 PMCID: PMC5816548 DOI: 10.1186/s12913-018-2909-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 02/05/2018] [Indexed: 11/18/2022] Open
Abstract
Background Length measurements are important in growth, monitoring and promotion (GMP) for the surveillance of a child’s weight-for-length and length-for-age. These two indices provide an indication of a child’s risk of becoming wasted or stunted, and are more informative about a child’s growth than the widely used weight-for-age index (underweight). Although the introduction of length measurements in GMP is recommended by the World Health Organization, concerns about the reliability of length measurements collected in rural outreach settings have been expressed by stakeholders. Our aim was to describe the reliability and challenges associated with community health personnel measuring length for rural outreach GMP activities. Methods Two reliability studies (A and B), using 10 children less than 24 months each, were conducted in the GMP services of a rural district in Ghana. Fifteen nurses and 15 health volunteers (HV) with no prior experience in length measurements were trained. Intra- and inter-observer technical error of measurement (TEM), average bias from expert anthropometrist, and coefficient of reliability (R) of length measurements were assessed and compared across sessions. Observations and interviews were used to understand the ability and experiences of health personnel with measuring length at outreach GMP. Results Inter-observer TEM was larger than intra-observer TEM for both nurses and HV at both sessions and was unacceptably (compared to error standards) high in both groups at both time points. Average biases from expert’s measurements were within acceptable limits, however, both groups tended to underestimate length measurements. The R for lengths collected by nurses (92.3%) was higher at session B compared to that of HV (87.5%). Length measurements taken by nurses and HV, and those taken by an experienced anthropometrist at GMP sessions were of moderate agreement (kappa = 0.53, p < 0.0001). Conclusions The reliability of length measurements improved after two refresher trainings for nurses but not for HV. In addition, length measurements taken during GMP sessions may be susceptible to errors due to overburdened health personnel and crowded GMP clinics. There is need for both pre- and in-service training of nurses and HV on length measurements and procedures to improve reliability of length measurements. Electronic supplementary material The online version of this article (10.1186/s12913-018-2909-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Matilda E Laar
- Department of Family and Consumer Sciences, University of Ghana, P O Box LG 91, Legon, Accra, Ghana.
| | - Grace S Marquis
- School of Dietetics and Human Nutrition, McGill University, 21,111 Lakeshore Road, Ste. Anne de Bellevue, Montreal, Quebec, H9X 3V9, Canada
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, P O Box LG 134, Legon, Accra, Ghana
| | - Katherine Gray-Donald
- School of Dietetics and Human Nutrition, McGill University, 21,111 Lakeshore Road, Ste. Anne de Bellevue, Montreal, Quebec, H9X 3V9, Canada
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9
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Frison S, Kerac M, Checchi F, Prudhon C. Anthropometric indices and measures to assess change in the nutritional status of a population: a systematic literature review. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0104-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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10
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Myatt M, Khara T, Collins S. A Review of Methods to Detect Cases of Severely Malnourished Children in the Community for Their Admission into Community-Based Therapeutic Care Programs. Food Nutr Bull 2016; 27:S7-23. [PMID: 17076211 DOI: 10.1177/15648265060273s302] [Citation(s) in RCA: 180] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background The complexity and cost of measuring weight-for-height make it unsuitable for use by community-based volunteers. This has led community therapeutic care programs to adopt a two-stage screening and admission procedure in which mid-upper-arm circumference (MUAC) is used for referral and weight-for-height is used for admission. Such a procedure results in many individuals being referred for care on the basis of MUAC but subsequently being refused treatment because they do not meet the weight-for-height admission criterion. This “problem of rejected referrals” has proved to be a major barrier to program uptake. Objective To systematically review methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care programs. Methods Clinical and anthropometric methods for case detection of severely malnourished children in the community were reviewed with regard to their ability to reflect both mortality risk and nutritional status. Results MUAC, with the addition of the presence of bipedal edema, was found to be the indicator best suited to screening and case detection of malnutrition in the community. The case definition “MUAC < 110 mm OR the presence of bipedal edema,” with MUAC measured by a color-banded strap, is suitable for screening and case detection of malnutrition in the community for children aged between 6 and 59 months. Monitoring and discharge criteria were also reviewed. Conclusions There is no compelling evidence to support a move away from using weight in combination with clinical criteria for monitoring and discharge.
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Affiliation(s)
- Mark Myatt
- Institute of Ophthalmology, 11-43 Bath St., London EC1V 9EL, UK.
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11
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Alé FGB, Phelan KPQ, Issa H, Defourny I, Le Duc G, Harczi G, Issaley K, Sayadi S, Ousmane N, Yahaya I, Myatt M, Briend A, Allafort-Duverger T, Shepherd S, Blackwell N. Mothers screening for malnutrition by mid-upper arm circumference is non-inferior to community health workers: results from a large-scale pragmatic trial in rural Niger. ACTA ACUST UNITED AC 2016; 74:38. [PMID: 27602207 PMCID: PMC5011948 DOI: 10.1186/s13690-016-0149-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/10/2016] [Indexed: 11/24/2022]
Abstract
Background Community health workers (CHWs) are recommended to screen for acute malnutrition in the community by assessing mid-upper arm circumference (MUAC) on children between 6 and 59 months of age. MUAC is a simple screening tool that has been shown to be a better predictor of mortality in acutely malnourished children than other practicable anthropometric indicators. This study compared, under program conditions, mothers and CHWs in screening for severe acute malnutrition (SAM) by color-banded MUAC tapes. Methods This pragmatic interventional, non-randomized efficacy study took place in two health zones of Niger’s Mirriah District from May 2013 to April 2014. Mothers in Dogo (Mothers Zone) and CHWs in Takieta (CHWs Zone) were trained to screen for malnutrition by MUAC color-coded class and check for edema. Exhaustive coverage surveys were conducted quarterly, and relevant data collected routinely in the health and nutrition program. An efficacy and cost analysis of each screening strategy was performed. Results A total of 12,893 mothers and caretakers were trained in the Mothers Zone and 36 CHWs in the CHWs Zone, and point coverage was similar in both zones at the end of the study (35.14 % Mothers Zone vs 32.35 % CHWs Zone, p = 0.9484). In the Mothers Zone, there was a higher rate of MUAC agreement (75.4 % vs 40.1 %, p <0.0001) and earlier detection of cases, with median MUAC at admission for those enrolled by MUAC <115 mm estimated to be 1.6 mm higher using a smoothed bootstrap procedure. Children in the Mothers Zone were much less likely to require inpatient care, both at admission and during treatment, with the most pronounced difference at admission for those enrolled by MUAC < 115 mm (risk ratio = 0.09 [95 % CI 0.03; 0.25], p < 0.0001). Training mothers required higher up-front costs, but overall costs for the year were much lower ($8,600 USD vs $21,980 USD.) Conclusions Mothers were not inferior to CHWs in screening for malnutrition at a substantially lower cost. Children in the Mothers Zone were admitted at an earlier stage of SAM and required fewer hospitalizations. Making mothers the focal point of screening strategies should be included in malnutrition treatment programs. Trial registration The trial is registered with clinicaltrials.gov (Trial number NCT01863394).
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Affiliation(s)
- Franck G B Alé
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal
| | - Kevin P Q Phelan
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal
| | - Hassan Issa
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal
| | - Isabelle Defourny
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal ; Médecins Sans Frontières (MSF), Paris, France
| | - Guillaume Le Duc
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal
| | - Geza Harczi
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal
| | - Kader Issaley
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal
| | - Sani Sayadi
- Bien Être de la Femme et de l'Enfant (BEFEN), Niamey, Niger
| | | | | | | | - André Briend
- Tampere Centre for Child Health Research, University of Tampere and Tampere University Hospital, Tampere, Finland ; Department of Nutrition, Exercise and Sports, Faculty of Science, University of Copenhagen, Copenhagen, Denmark
| | | | - Susan Shepherd
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal
| | - Nikki Blackwell
- Alliance for International Medical Action (ALIMA), ALIMA, Fann Residence, BP155530 Dakar, Senegal ; Department of Critical Care, University of Queensland, Brisbane, Australia
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12
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Culp K, Kuye R, Donham KJ, Rautiainen R, Umbarger-Mackey M, Marquez S. Agricultural-Related Injury and Illness in The Gambia. Clin Nurs Res 2016; 16:170-88; discussion 189-94. [PMID: 17634349 DOI: 10.1177/1054773807302399] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This is an exploratory, descriptive study based on a convenience sample from a rural nursing service and in-country area farmers from The Gambia. The purpose of the study was to provide descriptive information about agricultural-related injury and illness from area farmers and to obtain data from rural nurses about the time they spent caring for and treating farmers. Employees of the nursing service could read and write English fluently and thus completed a written questionnaire; the area farmers were unable to read and write English so they were interviewed by farm extension workers in their own tribal language. The most alarming findings were the nursing respondents' report of farm workers using pesticides in their homes, the poor condition of pesticide sprayers, and the lack of personal protective equipment. Despite their claim of following pesticide instructions, farm workers reported a surprisingly high number of respiratory and neurological signs and symptoms.
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El Habashy SA, Mohamed MH, Amin DA, Marzouk D, Farid MN. Evaluation of validity of Integrated Management of Childhood Illness guidelines in identifying edema of nutritional causes among Egyptian children. J Egypt Public Health Assoc 2015; 90:150-156. [PMID: 26854895 DOI: 10.1097/01.epx.0000475420.59037.67] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
OBJECTIVE The aim of this study was to assess the validity of the Integrated Management of Childhood Illness (IMCI) algorithm to detect edematous type of malnutrition in Egyptian infants and children ranging in age from 2 months to 5 years. MATERIALS AND METHODS This study was carried out by surveying 23 082 children aged between 2 months and 5 years visiting the pediatric outpatient clinic, Ain Shams University Hospital, over a period of 6 months. Thirty-eight patients with edema of both feet on their primary visit were enrolled in the study. Every child was assessed using the IMCI algorithm 'assess and classify' by the same physician, together with a systematic clinical evaluation with all relevant investigations. RESULTS Twenty-two patients (57.9%) were proven to have nutritional etiology. 'Weight for age' sign had a sensitivity of 95.5%, a specificity of 56%, and a diagnostic accuracy of 78.95% in the identification of nutritional edema among all cases of bipedal edema. Combinations of IMCI symptoms 'pallor, visible severe wasting, fever, diarrhea', and 'weight for age' increased the sensitivity to 100%, but with a low specificity of 38% and a diagnostic accuracy of 73.68%. CONCLUSION AND RECOMMENDATIONS Bipedal edema and low weight for age as part of the IMCI algorithm can identify edema because of nutritional etiology with 100% sensitivity, but with 37% specificity. Revisions need to be made to the IMCI guidelines published in 2010 by the Egyptian Ministry of Health in the light of the new WHO guidelines of 2014.
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Affiliation(s)
- Safinaz A El Habashy
- aPediatrics Department bCommunity Medicine Department, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Ahmad UN, Yiwombe M, Chisepo P, Cole TJ, Heikens GT, Kerac M. Interpretation of World Health Organization growth charts for assessing infant malnutrition: a randomised controlled trial. J Paediatr Child Health 2014; 50:32-9. [PMID: 24134409 DOI: 10.1111/jpc.12405] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS The study aims to assess the effects of switching from National Center for Health Statistics (NCHS) growth references to World Health Organization (WHO) growth standards on health-care workers' decisions about malnutrition in infants aged <6 months. METHODS We conducted a single blind randomised crossover trial involving 78 health-care workers (doctors, clinical officers, health service assistants) in Southern Malawi. Participants were offered hypothetical clinical scenarios with the same infant plotted on NCHS-based weight-for-age charts and again on WHO-based charts. Additional scenarios compared growth charts with a single final weight against charts with the same final weight plus a preceding growth trend. Reported (i) level of concern, (ii) referral suggestions and (iii) feeding advice were elicited with a questionnaire. RESULTS Even after adjusting for health-care worker type and experience, using WHO rather than NCHS charts increased: (i) concern: aOR 4.4 (95% CI 2.4-8.1); (ii) odds of referral: aOR 5.1 (95% CI 2.4-10.8); and (iii) odds of feeding advice which would interrupt exclusive breastfeeding (aOR 2.4, 95% CI 1.2-4.9). A preceding steady growth trend line did not affect concern, referral or feeding advice. CONCLUSIONS Health-care workers take insufficient account of linear growth trend, clinical and feeding status when interpreting a low weight-for-age plot. Because more infants <6 months fall below low centile lines on WHO growth charts, their use may increase inappropriate referrals and risks undermining already low rates of exclusive breastfeeding. To avoid their being misinterpreted in this way, WHO charts need accompanying guidelines and training materials that recognise and address this possible adverse effect.
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Affiliation(s)
- Umar N Ahmad
- UCL Institute for Global Health, University College London, London, United Kingdom
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Akugizibwe R, Kasolo J, Makubuya DB, Damani AM. Missed opportunities in the diagnosis and management of protein energy malnutrition among children under 5 years in Wakiso district, Uganda. JOURNAL OF PUBLIC HEALTH AND EPIDEMIOLOGY 2013; 5:463-470. [PMID: 25035810 PMCID: PMC4096943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Protein energy malnutrition (PEM) is one of the leading causes of death among children below 5 years in Uganda. It develops after acute childhood illnesses despite children having received treatment from health facilities. This study assessed knowledge and practices of health workers in the diagnosis and management of PEM, which was used to establish missed opportunities to prevent severe acute malnutrition (SAM) in its management. This was a cross sectional descriptive study that used questionnaires and observation of health workers at Health Center IV (HCIV) in Wakiso district, Uganda. The clinical nutrition diagnosis of the children was then obtained. There were 44 health workers that assessed 225 children. Most of the health workers 32 (72.7%) had education in PEM management and over 60% of them knew the forms of PEM, clinical signs of kwashiorkor and marasmus and the factors that predispose to PEM. Health workers did not weigh 56 (24.9%) of the children, 193 (86%) children had no height taken and only 32 (14.2%) had mid upper arm circumference measured. The weight for height of 223 (99.2%) and weight for age of 109 (93%) children was not calculated. Only 38 (16.89%) were examined for edema and 40 (17.78%) for muscle wasting. Health workers diagnosed only 21 (9%) children with malnutrition, while researchers found 94 (31.9%) with malnutrition. Children who missed opportunity to have malnutrition diagnosed at the health facility were 73 (32.9%). The knowledge of health workers on PEM is adequate, but their practice is inadequate. There is missed opportunity to diagnose and manage PEM among children who present with acute illnesses at the health centers, hence missed opportunity to prevent SAM.
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Sunguya BF, Poudel KC, Mlunde LB, Urassa DP, Yasuoka J, Jimba M. Nutrition training improves health workers' nutrition knowledge and competence to manage child undernutrition: a systematic review. Front Public Health 2013; 1:37. [PMID: 24350206 PMCID: PMC3859930 DOI: 10.3389/fpubh.2013.00037] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2013] [Accepted: 09/09/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Medical and nursing education lack adequate practical nutrition training to fit the clinical reality that health workers face in their practices. Such a deficit creates health workers with poor nutrition knowledge and child undernutrition management practices. In-service nutrition training can help to fill this gap. However, no systematic review has examined its collective effectiveness. We thus conducted this study to examine the effectiveness of in-service nutrition training on health workers' nutrition knowledge, counseling skills, and child undernutrition management practices. METHODS We conducted a literature search on nutrition interventions from PubMed/MEDLINE, CINAHL, EMBASE, ISI Web of Knowledge, and World Health Organization regional databases. The outcome variables were nutrition knowledge, nutrition-counseling skills, and undernutrition management practices of health workers. Due to heterogeneity, we conducted only descriptive analyses. RESULTS Out of 3910 retrieved articles, 25 were selected as eligible for the final analysis. A total of 18 studies evaluated health workers' nutrition knowledge and showed improvement after training. A total of 12 studies with nutrition counseling as the outcome variable also showed improvement among the trained health workers. Sixteen studies evaluated health workers' child undernutrition management practices. In all such studies, child undernutrition management practices and competence of health workers improved after the nutrition training intervention. CONCLUSION In-service nutrition training improves quality of health workers by rendering them more knowledge and competence to manage nutrition-related conditions, especially child undernutrition. In-service nutrition training interventions can help to fill the gap created by the lack of adequate nutrition training in the existing medical and nursing education system. In this way, steps can be taken toward improving the overall nutritional status of the child population.
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Affiliation(s)
- Bruno F Sunguya
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Krishna C Poudel
- Department of Public Health, School of Public Health and Health Sciences, University of Massachusetts Amherst , Amherst, MA , USA
| | - Linda B Mlunde
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - David P Urassa
- School of Public Health and Social Sciences, Muhimbili University of Health and Allied Sciences , Dar es Salaam , Tanzania
| | - Junko Yasuoka
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
| | - Masamine Jimba
- Department of Community and Global Health, Graduate School of Medicine, The University of Tokyo , Tokyo , Japan
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Abstract
Malnutrition is one of the leading causes of morbidity and mortality of children in the world. In The Gambia, malnutrition is one of the major public health problems. Among the factors determining its high prevalence, cultural norms play a crucial role. Food taboos influence the amount, frequency, and quality of nutrients that mothers and children consume. In this qualitative study carried out in the Upper River Region, The Gambia, seventeen mothers whose ethnic affiliation is Fulla were interviewed. The objective was to describe their food taboos and how they influence their nutritional health. The findings of this study demonstrate that some of the taboos practiced by the Fulla may be regarded as contributing factors to protein-energy malnutrition in children and pregnant and lactating women. The findings will inform the design of future health education strategies targeting malnutrition in this specific cultural context.
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Duggan MB. Anthropometry as a tool for measuring malnutrition: impact of the new WHO growth standards and reference. ACTA ACUST UNITED AC 2013; 30:1-17. [DOI: 10.1179/146532810x12637745451834] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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Cobb G, Bland RM. Nutritional supplementation: the additional costs of managing children infected with HIV in resource-constrained settings. Trop Med Int Health 2013; 18:45-52. [PMID: 23107420 PMCID: PMC3717178 DOI: 10.1111/tmi.12006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To explore the financial implications of applying the WHO guidelines for the nutritional management of HIV-infected children in a rural South African HIV programme. METHODS WHO guidelines describe Nutritional Care Plans (NCPs) for three categories of HIV-infected children: NCP-A: growing adequately; NCP-B: weight-for-age z-score (WAZ) ≤-2 but no evidence of severe acute malnutrition (SAM), confirmed weight loss/growth curve flattening, or condition with increased nutritional needs (e.g. tuberculosis); NCP-C: SAM. In resource-constrained settings, children requiring NCP-B or NCP-C usually need supplementation to achieve the additional energy recommendation. We estimated the proportion of children initiating antiretroviral treatment (ART) in the Hlabisa HIV Programme who would have been eligible for supplementation in 2010. The cost of supplying 26-weeks supplementation as a proportion of the cost of supplying ART to the same group was calculated. RESULTS A total of 251 children aged 6 months to 14 years initiated ART. Eighty-eight required 6-month NCP-B, including 41 with a WAZ ≤-2 (no evidence of SAM) and 47 with a WAZ >-2 with co-existent morbidities including tuberculosis. Additionally, 25 children had SAM and required 10-weeks NCP-C followed by 16-weeks NCP-B. Thus, 113 of 251 (45%) children were eligible for nutritional supplementation at an estimated overall cost of $11 136, using 2010 exchange rates. These costs are an estimated additional 11.6% to that of supplying 26-week ART to the 251 children initiated. CONCLUSIONS It is essential to address nutritional needs of HIV-infected children to optimise their health outcomes. Nutritional supplementation should be integral to, and budgeted for, in HIV programmes.
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Affiliation(s)
- G Cobb
- Africa Centre for Health and Populations Studies, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
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20
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Mogeni P, Twahir H, Bandika V, Mwalekwa L, Thitiri J, Ngari M, Toromo C, Maitland K, Berkley JA. Diagnostic performance of visible severe wasting for identifying severe acute malnutrition in children admitted to hospital in Kenya. Bull World Health Organ 2011; 89:900-6. [PMID: 22271947 PMCID: PMC3260901 DOI: 10.2471/blt.11.091280] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2011] [Revised: 09/04/2011] [Accepted: 09/06/2011] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To determine the diagnostic value of visible severe wasting in identifying severe acute malnutrition at two public hospitals in Kenya. METHODS This was a cross-sectional study of children aged 6 to 59.9 months admitted to one rural and one urban hospital. On admission, mid-upper arm circumference (MUAC), weight and height were measured and the presence of visible severe wasting was assessed. The diagnostic performance of visible severe wasting was evaluated against anthropometric criteria. FINDINGS Of 11,166 children admitted, 563 (5%) had kwashiorkor and 1406 (12.5%) were severely wasted (MUAC < 11.5 cm). The combined sensitivity and specificity of visible severe wasting at the two hospitals, as assessed against a MUAC < 11.5 cm, were 54% (95% confidence interval, CI: 51-56) and 96% (95% CI: 96-97), respectively; at one hospital, its sensitivity and specificity against a weight-for-height z-score below -3 were 44.7% (95% CI: 42-48) and 96.5% (95% CI: 96-97), respectively. Severely wasted children who were correctly identified by visible severe wasting were consistently older, more severely wasted, more often having kwashiorkor, more often positive to the human immunodeficiency virus, ill for a longer period and at greater risk of death. Visible severe wasting had lower sensitivity for determining the risk of death than the anthropometric measures. There was no evidence to support measuring both MUAC and weight-for-height z-score. CONCLUSION Visible severe wasting failed to detect approximately half of the children admitted to hospital with severe acute malnutrition diagnosed anthropometrically. Routine screening by MUAC is quick, simple and inexpensive and should be part of the standard assessment of all paediatric hospital admissions in the study setting.
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Affiliation(s)
- Polycarp Mogeni
- KEMRI/Wellcome Trust Research Programme, Centre for Geographic Medical Research Coast, Kilifi, Kenya
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22
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Sikorski C, Kerac M, Fikremariam M, Seal A. Preliminary evaluation of the Moyo chart—a novel, low-cost, weight-for-height slide chart for the improved assessment of nutritional status in children. Trans R Soc Trop Med Hyg 2010; 104:743-5. [DOI: 10.1016/j.trstmh.2010.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2010] [Revised: 07/29/2010] [Accepted: 07/29/2010] [Indexed: 10/19/2022] Open
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Lima AMD, Gamallo SMM, Oliveira FLC. Desnutrição energético-proteica grave durante a hospitalização: aspectos fisiopatológicos e terapêuticos. REVISTA PAULISTA DE PEDIATRIA 2010. [DOI: 10.1590/s0103-05822010000300015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
OBJETIVOS: Apresentar a conduta para o tratamento da desnutrição energético-proteica grave e os principais aspectos fisiopatológicos da doença. FONTES DE DADOS: Tomando como base o Manual da Organização Mundial da Saúde (OMS, 1999), realizou-se uma busca por trabalhos publicados em inglês, espanhol e português sobre o tratamento hospitalar de crianças com desnutrição grave, nas bases de dados Lilacs, Medline e SciELO, publicados nos últimos dez anos, utilizando-se as palavras-chave: desnutrição, criança, hospitalização, terapia nutricional, diretrizes, OMS. SÍNTESE DE DADOS: Foram abordadas as principais características fisiopatológicas da desnutrição grave e a conduta recomendada para o tratamento. Identificaram-se as principais complicações clínico-metabólicas, como a hipotermia, a hipoglicemia, a desidratação e as infecções recorrentes, além da má absorção e a fase de estabilização ou de recuperação do desnutrido grave. A compreensão de todos esses conceitos relacionados à fisiopatologia da desnutrição energético-proteica, associada ao adequado planejamento e execução da terapia nutricional, pode reduzir o risco de morbimortalidade em crianças com idade inferior a cinco anos. CONCLUSÕES: As diretrizes da OMS devem ser implantadas levando-se em consideração a realidade de cada região e a capacitação do profissional da saúde quanto ao conhecimento da complexidade e fisiopatologia da desnutrição energético-proteica grave, para adequado diagnóstico e tratamento. O sucesso do tratamento está associado ao cuidado e à atenção ao paciente.
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Kerac M, Seal A, Blencowe H, Bunn J. Improved assessment of child nutritional status using target weights and a novel, low-cost, weight-for height slide chart. Trop Doct 2009; 39:23-6. [DOI: 10.1258/td.2008.080096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Correctly identifying malnourished or at-risk children is the critical first step towards appropriate nutritional interventions. To improve weight-for-height assessment and classification of nutritional status, we present a novel, low-cost, weight-for-height slide chart. We also describe a target weight system for monitoring children's progress towards nutritional recovery.
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Affiliation(s)
- Marko Kerac
- Departments of Paediatrics, College of Medicine, Private Bag 360, Blantyre 3, Malawi
- UCL Centre for International Health and Development, Institute of Child Health, London
- Valid International, UK
| | - Andrew Seal
- UCL Centre for International Health and Development, Institute of Child Health, London
| | - Hannah Blencowe
- Departments of Paediatrics, College of Medicine, Private Bag 360, Blantyre 3, Malawi
| | - James Bunn
- Community Health, College of Medicine, Private Bag 360, Blantyre 3, Malawi
- UCL Centre for International Health and Development, Institute of Child Health, London
- Liverpool School of Tropical Medicine, Liverpool
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Myatt M, Bennett DE. A novel sequential sampling technique for the surveillance of transmitted HIV drug resistance by cross-sectional survey for use in low resource settings. Antivir Ther 2008. [DOI: 10.1177/135965350801302s10] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This article describes the development of a novel sequential sampling method for the surveillance of transmitted HIV drug resistance by cross-sectional survey. Two commonly used sequential sampling methods are described and their applicability to the problem of classifying the prevalence of transmitted HIV drug resistance investigated. Both methods are rejected due to insufficient savings in sample size and operational complexity. A novel method is proposed and this is tested using computer-based simulation. This method provides useful sample size savings and operational simplicity and could provide the basis for a rapid and reliable survey method for classifying the prevalence of transmitted HIV drug resistance in circumstances where monitoring HIV drug resistance is an important issue, but resources do not allow full-scale surveillance to be established. The method is currently being used in several such settings.
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Affiliation(s)
- Mark Myatt
- Division of Epidemiology, Institute of Ophthalmology, University College London, London EC1V 9EL, UK
| | - Diane E Bennett
- HIV Drug Resistance Strategy, HTM/HIV/ATC, World Health Organization, Geneva 1211, Switzerland
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Gwer S, Newton CRJC, Berkley JA. Over-diagnosis and co-morbidity of severe malaria in African children: a guide for clinicians. Am J Trop Med Hyg 2007; 77:6-13. [PMID: 18165469 PMCID: PMC2669774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023] Open
Abstract
Severe malaria is clinically similar to other severe febrile illnesses. However, in endemic areas, parasitological confirmation of parasitemia is often unavailable or unreliable. False-positive malaria microscopy is common. The most important consequence of treating only for malaria when no parasitemia exists is failure to address other life-threatening conditions. Invasive bacterial infections are detected in up to one third of children with clinical features of severe malaria but a slide with results negative for malaria. Even among genuinely parasitized children, severe illness is not always due to malaria in endemic areas. We believe that routine use of parenteral antibiotics among children with a slide that indicates malaria and life-threatening disease is warranted because invasive bacterial infections are likely to be under-ascertained and are associated with increased mortality. Published data on co-morbidity with HIV infection and malnutrition are reviewed. A structured approach to assessment and care is essential, and is largely independent of underlying etiology.
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Affiliation(s)
- Samson Gwer
- Centre for Geographic Medicine Research (coast), Kenya Medical Research Institute, Kilifi, Kenya
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Abstract
Severe acute malnutrition (SAM) affects approximately 13 million children under the age of 5 and is associated with 1-2 million preventable child deaths each year. In most developing countries, case fatality rates (CFRs) in hospitals treating SAM remain at 20-30% and few of those requiring care actually access treatment. Recently, community-based therapeutic care (CTC) programmes treating most cases of SAM solely as outpatients have dramatically reduced CFRs and increased the numbers receiving care. CTC uses ready-to-use therapeutic foods and aims to increase access to services, promoting early presentation and compliance, thereby increasing coverage and recovery rates. Initial data indicate that this combination of centre-based and community-based care is cost effective and should be integrated into mainstream child survival programmes.
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Affiliation(s)
- Steve Collins
- Centre for International Health and Development and Valid International Ltd, Unit 14 Standingford House, 26 Cave Street, Oxford OX4 1BA, UK.
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Allen S, Lagunju I. The management of severe malnutrition: taking a broader view. Arch Dis Child 2007; 92:191-2. [PMID: 17337675 PMCID: PMC2083436 DOI: 10.1136/adc.2006.109470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Perspective on the paper by Karaolis et al(see page 198)
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Affiliation(s)
- Stephen Allen
- The School of Medicine, Swansea University, Swansea, UK.
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Abstract
Severe acute malnutrition (SAM) is defined as a weight-for-height measurement of 70% or less below the median, or three SD or more below the mean National Centre for Health Statistics reference values, the presence of bilateral pitting oedema of nutritional origin, or a mid-upper-arm circumference of less than 110 mm in children age 1-5 years. 13 million children under age 5 years have SAM, and the disorder is associated with 1 million to 2 million preventable child deaths each year. Despite this global importance, child-survival programmes have ignored SAM, and WHO does not recognise the term "acute malnutrition". Inpatient treatment is resource intensive and requires many skilled and motivated staff. Where SAM is common, the number of cases exceeds available inpatient capacity, which limits the effect of treatment; case-fatality rates are 20-30% and coverage is commonly under 10%. Programmes of community-based therapeutic care substantially reduce case-fatality rates and increase coverage rates. These programmes use new, ready-to-use, therapeutic foods and are designed to increase access to services, reduce opportunity costs, encourage early presentation and compliance, and thereby increase coverage and recovery rates. In community-based therapeutic care, all patients with SAM without complications are treated as outpatients. This approach promises to be a successful and cost-effective treatment strategy.
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Brewster DR. Critical appraisal of the management of severe malnutrition: 1. Epidemiology and treatment guidelines. J Paediatr Child Health 2006; 42:568-74. [PMID: 16972961 DOI: 10.1111/j.1440-1754.2006.00931.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Hospital case-fatality rates for severe malnutrition in the developing world remain high, particularly in Africa where they have not changed much over recent decades. In an effort to improve case management, WHO has developed treatment guidelines. The aim of this review is to critically appraise the evidence for the guidelines and review important recent advances in the management of severe malnutrition. We conclude that not only is the evidence base deficient, but also the external generalisability of even good-quality studies is seriously compromised by the great variability in clinical practice between regions and types of health facilities in the developing world, which is much greater than between developed countries. The diagnosis of severe wasting is complicated by the dramatic change in reference standards (from CDC/WHO 1978 to CDC 2000 in EpiNut) and also by difficulties in accurate measurement of length. Although following treatment guidelines has resulted in improved outcomes, there is evidence against the statement that case-fatality rates (particularly in African hospitals) can be reduced below 5% and that higher rates are proof of poor practice, because there is wide variation in severity of illness factors. The practice of prolonged hospital treatment of severe malnutrition until wasting and/or oedema has resolved is being replaced by shorter hospital stays combined with outpatient or community follow-up because of advances in dietary management outside of hospital.
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Gartner A, Maire B, Kameli Y, Traissac P, Delpeuch F. Process evaluation of the Senegal-Community Nutrition Project: an adequacy assessment of a large scale urban project. Trop Med Int Health 2006; 11:955-66. [PMID: 16772019 DOI: 10.1111/j.1365-3156.2006.01644.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Although essential for understanding the reasons for success or failure of large scale nutritional interventions, process evaluation results are rarely reported. Our objective was to assess whether the process output objectives of the Community Nutrition Project (CNP) in Senegal, West Africa, were adequately met. METHODS An adequacy assessment study based on monitoring data for individuals collected during the CNP was used to assess 'fidelity', 'extent' and 'reach' of participants recruitment and of the services provided. The CNP provided underweight or nutritionally at risk 6- to 35-month-old children in poor districts with monthly growth monitoring and promotion and a weekly food supplementation for 6 month periods, provided that mothers attended weekly nutrition education sessions. An exhaustive sample of the participating children (n = 4084) in Diourbel was used for evaluation over the first 2 years. RESULTS At recruitment, only 66% of children were underweight (vs. 90% expected) varying with the CNP center and cohort, and the child's sex and age. Attendance at growth monitoring reached expected levels (93%vs. 90%) whereas numbers of food supplements distributed and education sessions attended were lower than expected (45%vs. 90% and 62%vs. 80%, respectively). At the end of follow-up, 61% of underweight children recovered vs. 80% expected. CONCLUSIONS Because of CNP design for underweight diagnosis and bias in the targeting process, respect for selection criteria was low and consequently under coverage and leakage occurred. Besides a globally satisfactory process, wide discrepancies were observed between CNP centres concerning the utilization and effectiveness of services. This formative evaluation helped diagnose weaknesses; ongoing feedback enabled the CNP to improve targeting and supply of supplements. It also informed a larger impact evaluation. Some generalizable lessons for similar programmes have been highlighted.
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Affiliation(s)
- Agnès Gartner
- Nutrition Unit, UR 106 (WHO Collaborating Centre for Nutrition), IRD (Institut de Recherche pour le Développement), Montpellier, France.
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