Integrated community case management of childhood illness in low- and middle-income countries.

BACKGROUND: The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES: To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA: Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS: At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS: We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS: iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.

Towards universal coverage for nutrition services in children under five years-A descriptive analysis of the capacity of level one hospitals to provide nutrition services in five provinces of Zambia.

BACKGROUND: Malnutrition continues to be a major public health challenge in Zambia. To effectively address this, health systems must be well strengthened to deliver an effective continuum of care. This paper examines health systems issues and services in relation to nutritional support to children under five years, in order to identify gaps and propose interventions towards universal coverage of essential nutrition services. METHODS: This analysis utilized data from a cross sectional mixed-methods study on factors associated with Severe Acute Malnutrition (SAM) in under-five children to assess health facility nutrition services on offer at select level-one hospitals in five out of ten provinces in Zambia. Stata version 13 was used for analysis. We conducted univariate analysis to assess nutrition services offered, functionality of equipment and tools, availability of human resource and human resource development, and availability of drugs used for assessment and management of nutrition-related health outcomes. RESULTS: We found large variations in the level of nutrition services on offer across districts and provinces. Eighty-eight percent of all the hospitals sampled provided group nutrition counseling and 92% of the hospitals in our sample offered individual nutrition counseling to their clients. Overall, the existence of referral and counter-referral systems between the Community Based Volunteers and hospitals were the lowest among all services assessed at 48% and 58% respectively. We also found inadequate numbers of human resource across all cadres with an exception of nutritionists as recommended by the Ministry of Health. CONCLUSIONS: This study has revealed a number of gaps in the health system and health service delivery that requires to be addressed; most notably, a lack of tools, policies and guidelines, drugs and health specialists to help care for malnourished infants and children. Our findings also reveal inadequate referral systems between the community and health facilities in the management of severe acute malnutrition. Achieving universal coverage for nutrition services in Zambia will require a lot more attention to the health systems issues found in this study.

Applying Methods for Postnatal Growth Assessment in the Clinical Setting: Evaluation in a Longitudinal Cohort of Very Preterm Infants.

AIM: To analyze different methods to assess postnatal growth in a cohort of very premature infants (VPI) in a clinical setting and identify potential early markers of growth failure. METHODS: Study of growth determinants in VPI (≤32 weeks) during hospital stay. Nutritional intakes and clinical evolution were recorded. Growth velocity (GV: g/kg/day), extrauterine growth restriction (%) (EUGR: weight < 10th centile, z-score < -1.28) and postnatal growth failure (PGF: fall in z-score > 1.34) at 36 weeks postmenstrual age (PMA) were calculated. Associations between growth and clinical or nutritional variables were explored (linear and logistic regression). RESULTS: Sample: 197 VPI. GV in IUGR patients was higher than in non-IUGRs (28 days of life and discharge). At 36 weeks PMA 66.0% of VPIs, including all but one of the IUGR patients, were EUGR. Prevalence of PGF at the same time was 67.4% (IUGR patients: 48.1%; non-IUGRs: 70.5% (p = 0.022)). Variables related to PGF at 36 weeks PMA were initial weight loss (%), need for oxygen and lower parenteral lipids in the first week. CONCLUSIONS: The analysis of z-scores was better suited to identify postnatal growth faltering. PGF could be reduced by minimising initial weight loss and assuring adequate nutrition in patients at risk.

[Effectiveness and cost of management of severe acute malnutrition with complications in Kaya, Burkina Faso]. / Performance et coût de la prise en charge de la malnutrition aiguë sévère avec complications à Kaya, Burkina Faso.

INTRODUCTION: The consequences of severe acute malnutrition are measured in terms of health and survival, but also of cognitive development, its productivity and the overall national economy. Its management requires enormous financial resources. The purpose of this study was to assess the effectiveness of treating severe acute malnutrition versus cost of treatment of severe acute malnutrition in children. METHODS: We conducted a retrospective study of 199 children aged 0-59 months admitted to the Centre for Nutritional Recovery and Education in Kaya, Burkina Faso, from January to December 2014. The cost of treatment, the length of stay in the Centre for Nutritional Recovery and Education, daily weight gain and the speed of recovery were analyzed based on the standards calculation methods. Mann-Whitney test and Kruskall-Wallis test were used to compare the medians (0.05 threshold). RESULTS: As expected, children aged 6-23 months were the most affected (51.8%) and acute respiratory infections were the most associated diseases (57.9%). The median length of stay in the Centre for Nutritional Recovery and Education was 9.0 (7.0-13.0) days, the mean speed of recovery was 100.0 (65.8 - 143.3) g/day and the average daily weight gain was 18.1 (11.6 - 27.7) g/kg/day. The average cost of treatment in a malnourished child is estimated to be 15 715,3 FCFA (25.2 USD). CONCLUSION: The cost of treatment is hardly affordable by the parents of malnourished children; hence the necessity for government and development partners interventions.

Assessment of Micronutrient Status in Critically Ill Children: Challenges and Opportunities.

Micronutrients refer to a group of organic vitamins and inorganic trace elements that serve many functions in metabolism. Assessment of micronutrient status in critically ill children is challenging due to many complicating factors, such as evolving metabolic demands, immature organ function, and varying methods of feeding that affect nutritional dietary intake. Determination of micronutrient status, especially in children, usually relies on a combination of biomarkers, with only a few having been established as a gold standard. Almost all micronutrients display a decrease in their serum levels in critically ill children, resulting in an increased risk of deficiency in this setting. While vitamin D deficiency is a well-known phenomenon in critical illness and can predict a higher need for intensive care, serum concentrations of many trace elements such as iron, zinc, and selenium decrease as a result of tissue redistribution in response to systemic inflammation. Despite a decrease in their levels, supplementation of micronutrients during times of severe illness has not demonstrated clear benefits in either survival advantage or reduction of adverse outcomes. For many micronutrients, the lack of large and randomized studies remains a major hindrance to critically evaluating their status and clinical significance.

Why Is Diagnosing Pediatric Malnutrition Important?

The literature indicates that pediatric malnutrition is more common than the number of times it is actually diagnosed. A new pediatric malnutrition definition is now available with criteria to make the diagnosis. If pediatric malnutrition is present, it should be diagnosed for financial, educational, and research purposes as well as the effects on patient development and mortality. These reasons extend beyond the health of an individual patient to potential impacts on society as a whole. When all of these reasons are examined and added, making the diagnosis of pediatric malnutrition becomes an obligation of the pediatric caregiver.

Challenges of malnutrition care among HIV-infected children on antiretroviral treatment in Africa.

More than 90% of the estimated 3.2 million children with HIV worldwide, at the end of 2013, were living in sub-Saharan Africa. The management of these children was still difficult in 2014 despite the progress in access to antiretroviral drugs. A great number of HIV-infected children are not diagnosed at 6 weeks and start antiretroviral treatment late, at an advanced stage of HIV disease complicated by other comorbidities such as malnutrition. Malnutrition is a major problem in the sub-Saharan Africa global population; it is an additional burden for HIV-infected children because they do not respond as well as non-infected children to the usual nutritional care. HIV infection and malnutrition interact, creating a vicious circle. It is important to understand the relationship between these 2 conditions and the effect of antiretroviral treatment on this circle to taking them into account for an optimal management of pediatric HIV. An improved monitoring of growth during follow-up and the introduction of a nutritional support among HIV-infected children, especially at antiretroviral treatment initiation, are important factors that could improve response to antiretroviral treatment and optimize the management of pediatric HIV in resource-limited countries.

Choice of design and outcomes in trials among children with moderate acute malnutrition.

There is a need for trials on the effects of food aid products for children with moderate acute malnutrition, to identify how best to restore body tissues and function. The choice of control intervention is a major challenge, with both ethical and scientific implications. While randomized trials are needed, special designs, such as cluster-randomized, stepped-wedged or factorial designs may offer advantages. Anthropometry is widely used as the primary outcome in such trials, but anthropometric traits do not refer directly to specific organs, tissues, or functions. Thus, it is difficult to understand what components of health might be impacted by public health programs, or the underlying mechanisms whereby improved nutritional status might benefit short- and long-term health. Measurement of body composition, specific growth markers and functional outcomes may provide greater insight into the nature and implications of growth failure and recovery. There are now several methodologies suitable for application in infants and young children, e.g., measuring body composition with deuterium dilution, physical activity with accelerometers and linear growth with knemometers. To evaluate the generalizability of the findings from nutrition trials, it is important to collect data on baseline nutritional status.

Standardised parenteral nutrition.

Parenteral nutrition (PN) has become an integral part of clinical management of very low birth weight premature neonates. Traditionally different components of PN are prescribed individually considering requirements of an individual neonate (IPN). More recently, standardised PN formulations (SPN) for preterm neonates have been assessed and may have advantages including better provision of nutrients, less prescription and administration errors, decreased risk of infection, and cost savings. The recent introduction of triple-chamber bag that provides total nutrient admixture for neonates may have additional advantage of decreased risk of contamination and ease of administration.

The effect of early stimulation on maternal depression: a cluster randomised controlled trial.

AIM: To determine the effect of early childhood stimulation with undernourished children and their mothers on maternal depression. METHODS: Mothers of 139 undernourished children (weight for age < or =-1.5 z-scores) aged 9-30 months were recruited from 18 government health centres in the parishes of Kingston, St Andrew, and St Catherine, Jamaica. They received weekly home visits by community health aides for one year. Mothers were shown play activities to do with their child using home made materials, and parenting issues were discussed. Frequency of maternal depressive symptoms was assessed by questionnaire. Child development was also measured. RESULTS: Mothers in the intervention group reported a significant reduction in the frequency of depressive symptoms (b = -0.98; 95% CI -1.53 to -0.41). The change was equivalent to 0.43 SD. The number of home visits achieved ranged from 5 to 48. Mothers receiving > or =40 visits and mothers receiving 25-39 visits benefited significantly from the intervention (b = -1.84, 95% CI -2.97 to -0.72, and b = -1.06, 95% CI -2.02 to -0.11, respectively) while mothers receiving <25 visits did not benefit. At follow up, maternal depression was significantly negatively correlated with children's developmental quotient for boys only. CONCLUSIONS: A home visiting intervention with mothers of undernourished children, with a primary aim of improving child development, had significant benefits for maternal depression. Higher levels of maternal depression were associated with poorer developmental levels for boys only.

Managing child malnutrition in a drought affected district of Rajasthan--a case study.

Rajasthan is the largest state in the country frequently affected by droughts. The year 2002 happened to be the fifth consecutive year of drought. Almost all districts of the State were hit by it. The district of Baran located in South-East of Rajasthan has 'Sahariya' tribal population concentrated in its Kishanganj and Shahabad blocks. Press reports of starvation deaths amongst tribal children in these blocks created a stir in the local district and the State Government set ups. The paper describes an objective and professional approach to deal with the situation. Rapid nutritional assessment indicated very high prevalence of severe under weight (28.3%) and wasting (4.7%) amongst under five children. Nutrition Care Centres (NCC) were set up in selected villages to provide targeted feeding and care to these children as per WHO guidelines. Local 'Sahariya' community was involved to run these NCC. Intensive public education campaign was carried out to promote improved child caring practices and referral of malnourished children with complication to hospitals. Orientation of press and electronic media on factual details regarding the situation helped create an enabling environment to implement remedial measures. The impact of 'Nutrition Care Centres' assessed after six months was found to be positive in terms of reduction in prevalence of under nutrition in children from 66.7% to 59.6%. Successful management of severe malnutrition amongst children by workers at Nutrition Care Centes and in family settings using standard protocols led to the wide scale replication of the approach by Anganwadi centres in different district of Rajasthan. The State Government also created an additional cadre of worker called 'Sahayogini' to support Anganwadi worker and promote better child caring practices at family level.

Desnutrición infantil: Centro de prevención y centro de tratamiento de la Fundación CONIN / Infant malnutrition: CONIN Foundation's centers for prevention and treatment

Convencidos que de nada sirve alimentar a un niño si lo devolvemos al ambiente de miseria extrema del que proviene, se crea entonces el Primer Centro Multidisciplinario de Prevención de la Desnutrición Infantil "María Alejandrina Rosa de Arenas", único en su género. Allí, a través de distintos programas, se abordan las principales causas que dan origen a la desnutrición, entre ellos podemos mencionar: Estimulación de la Lactancia Materna, Asistencia Alimentaria Complementaria, Educación Nutricional, Educación para la salud, Ropero Familiar, Alfabetización para Adultos, Jardín Maternal e Infantil, Estimulación Temprana, Talleres de Artes y Oficios para padres, Minoridad y Familia, Documentación y Legalización de la Familia, Planificación Familiar Natural y Escuela de Capacitación Agraria. Otros Centros de similares características funcionan en el Departamento de Rivadavia, Mendoza y en la República de Paraguay (fundado en 1995 desde Mendoza). Simultáneamente se fueron dando los primeros pasos para concretar la construcción del Primer Centro de Recuperación de Lactantes Desnutridos de la República Argentina. Otro pilar fundamental en la lucha contra la desnutrición es la investigación, por ello CONIN ha creado el "Centro de Investigaciones Médico-Sociales Prof. Dr. José Luis Minoprio".

Prevención y tratamiento de la obesidad desde la niñez: la estrategia para disminuir las enfermedades crónicas no transmisibles del adulto / Prevention and treatment of obesity since childhood: a strategy to decrease the prevalence of non transmissible chronic diseases in the adult

The prevalence of obesity among children and teenagers is increasing by 1.5 percent per year, probably due to a higher consumption of highly caloric foods and to physical inactivity. Hypercholesterolemia, increased insulin levels and high blood pressure of childhood obesity, precede atherosclerosis, coronary artery disease, diabetes and hypertension in adulthood. The prevention of childhood obesity is an efficient strategy to decrease the prevalence of non transmissible chronic diseases in the adult. The recommendations of experts committees for the prevention, diagnosis and treatment of childhood obesity are reviewed. They aim at a change in dietary habits and increasing physical activity. A well balanced healthy diet and a decrease in physical inactivity time will result in a successful treatment approach for obesity

Micronutrient deficiency in urban Indonesia / Deficiencia de micronutrientes en area urbana de Indonesia

The economic situation of characterized by a large increase in the gross national product which has been on average 7 por ciento annually during the last ten years. This was accompanied by rapid urbanization. With the economic improvement, "First World" health and nutrition problems are coexisting in Indonesia. In 1992, the most common of death cause was cardiovascular disease whereas tuberculosis was the second ranking. About 40 por ciento of the preschool children are stunted. The main stable food and source is rice, although the urban population has a more diverse food pattern than the rural population. In Jakarta, many children receive too late colostrum feeding and mothers are not aware about the importance of correct breastfeeding practices after delivery. Three studies had shown that about one fidth of preschool children and one fourth of elderly take micronutriens. Nevertheless are prevalent in Jakarta. About one third of women suffer from moderate vitamin A deficiency (plasma retino <0.70 mmol/L) and 50 por ciento of pregnant women are anemic. More information is necessary on other micronutrient deficiencies. For example, a small study revealed that nearly two thirds of non-institutionalized alderly living in Jakarta experience thiamine deficiency. Appropriate interventions to reduce micronutrient deficienies should sensitiza the urban population to the fact that the government should restrict itself no use its resources to assist only the poorest individuals and groups, whereas it must be expected from the middle class to spend more to solve their own problemas

Factores asociados a la desnutrición aguda en preescolares migrantes de la zona cañera de Jalisco / Factors associated with acute malnutrition in migrating preschool children from the Jalisco sugar cane area

Con el propósito de identificar la asociación de factores socioeconómicos, ambientales, alimentarios e individuales en la desnutrición aguda del preescolar migrante, se realizó un estudio observacional comparativo transversal, en 511 niños de uno a cinco años de edad en los albergues de la zona cañera de Jalisco. Mediante indicadores antropométricos, clasificados de acuerdo con Waterlow se evaluó el estado de nutrición. La prevalencia de desnutrición fue de 79.0 por 100 preescolares (68.1%adaptados y 21.5%crónico agudizados y 10.4%agudos). Se asociaron a la desnutrición aguda: ingreso familiar menor a un salario mínimo (R.M= 6.32, P= 0.00), menores con patología aguda (R.M. = 3.34, P =0.00) y tener un año de edad (R.M. =2.22, P=0.01). Existieron diferencias significativas en hijos de padres: sin escolaridad (P = 0.04) y ser cortador de caña (P = 0.05). Los hallazgos identifican factores de riesgo en la desnutrición aguda, modificables probablemente mediante estrategias de vigilancia epidemiológica nutricional

Do nutrition programs make a difference? The case of Brazil.

Four Brazilian food and nutrition programs operating during some part of 1974-86 are evaluated for their effectiveness in curing or preventing infant and child malnutrition, including low birth weight when pregnant women were beneficiaries. Two programs distributed free food to identified clients: traditional commercial foods in one case and specially formulated supplements in the other. The other two programs subsidized four or more basic foodstuffs: one experiment quantitatively restricted a subsidy to identified families, and the other was unrestricted and open to all families patronizing certain shops. The programs were more effective at curing than at preventing malnutrition, and more effective at increasing weight than height. Many beneficiaries, even when initially underweight, showed no change, and some deteriorated despite the food transfer. Results were better after than during the first year of life, when deterioration is most likely. Donation programs including medical and educational components proved more effective than pure subsidies, showing that while poverty may be the chief cause of malnutrition, the problem should be seen as poor health rather than simply low food consumption. Evaluation also shows that programs were inefficient in transferring benefits, and that clients were deterred from participating by the costs of obtaining the food and its poor quality and small volume. Longer participation improved results, but more frequent participation in a given interval did not necessarily do so.

PIP: PAHO followed nutrition programs of Brazil, which have been supported almost exclusively from internal sources, since 1983 to provide technical assistance and to learn what may be applied to other countries. The PAHO program effectiveness evaluation study compared 2 ways of running nutrition programs which presumed that malnutrition was mainly caused by poverty--a subsidy of basic foods and direct distribution--between 1974-1986. 2 programs subsidized at least 4 basic foodstuffs with 1 program restricting the amount of food to identified families while the other allowed any family coming to stores in low income areas that participated in the program to take subsidized food. 2 other programs either gave free traditional commercial foods or specially formulated supplements to identified clients. The status of most well nourished or malnourished participants did not change despite intervals as long as 48 months. Moreover the nutritional status of a considerable percentage of participants deteriorated. Nevertheless moderate or severe malnourished children who started in a program tended to recover substantially, especially children 1 year old. Further the longer a client participated in a program the more likely the nutritional status would improve, yet frequent participation did not affect status. Thus the programs were more likely to cure than prevent malnutrition. Besides participants tended to not grow much, but weight status did improve. Those programs that also provided medical care and health education were more effective than those that just provided subsidies. This finding highlights how malnutrition is not just a problem of low income and low food consumption, but also a problem of poor health. The programs did not transfer benefits efficiently. In addition, the costs of securing the food, its poor quality, and insufficient volume discouraged beneficiary participation.