De-escalation of the Agitated Pediatric Patient: A Standardized Patient Case for Pediatric Residents.

Introduction: Over the past 5 years, pediatric mental health emergencies requiring emergency safety evaluations and inpatient boarding of pediatric patients requiring psychiatric admission have increased. Pediatric trainees must learn to effectively and safely de-escalate a patient with agitated or aggressive behavior, as mental health patients take up a larger proportion of their patient population. This standardized patient case addresses gaps in knowledge and skills to ameliorate the care of children and adolescents with behavioral crises in the hospital. Methods: Resident learners were presented with a teenage patient admitted to the hospital and awaiting inpatient psychiatric placement for suicidal ideation who became acutely agitated with aggressive behaviors. Learners were expected to attempt to verbally de-escalate the patient and select an appropriate pharmacologic agent for decreasing agitation in the patient. A standardized debrief was conducted with the assistance of child and adolescent mental health experts. Results: Twenty-two learners participated in this activity. Residents' confidence in their management skills of the acutely agitated pediatric patient significantly increased after completion of the activity. Seventy-three percent of learners felt confident or very confident in their de-escalation skills at the end of the case, and 86% agreed that the case improved their confidence in managing acute agitation scenarios on the inpatient wards. Discussion: This case led to overall increased self-efficacy in caring for the acutely agitated pediatric patient. Future iterations may include multidisciplinary learners of various skill levels and evaluating changes in patient-centered outcomes, such as restraint use, after implementation of the case.

Infected Urachal Cyst Masquerading as Acute Appendicitis on Point-of-care Ultrasound.

CASE PRESENTATION: A seven-year-old male presented to the pediatric emergency department with one day of abdominal pain. His physical exam was significant for rebound, guarding, and tenderness in the right lower quadrant, and his labs demonstrated a leukocytosis. Both a point-of-care ultrasound and radiology-performed ultrasound were concerning for acute appendicitis with a periappendiceal abscess, but on emergent laparoscopy the patient was found to have an infected urachal cyst. DISCUSSION: Infected urachal remnants are a rare but important cause of pediatric abdominal pain. In this case, inflammation surrounding the patient's midline urachal cyst triggered a serositis that involved the appendix and pulled the cyst to the right. This created a clinical and radiologic presentation similar to appendicitis. This atypical presentation of an already rare anomaly highlights the importance of maintaining a broad differential during the work-up of pediatric abdominal pain.

Combining Home Garden, Poultry, and Nutrition Education Program Targeted to Families With Young Children Improved Anemia Among Children and Anemia and Underweight Among Nonpregnant Women in Nepal.

BACKGROUND: The impact of food-based interventions on child and maternal anthropometry and anemia has not been adequately studied. OBJECTIVE: This study tested the effect of an enhanced homestead food production (EHFP) program consisting of home garden, poultry raising, and nutrition education implemented over 2.5 years versus control (no intervention) on anthropometry and anemia among children (12-48 months) and their mothers. METHODS: An unblinded cluster-randomized controlled trial involving pre- and post-surveys with independent samples was conducted in rural areas of Baitadi District, Nepal. Data (including weight, height/length, and hemoglobin) were obtained from 2106 and 2614 mother-child pairs at baseline and follow-up, respectively. Changes in outcome variables (stunting, underweight, wasting, and anemia among children and underweight and anemia among mothers) were compared between the study groups using mixed-effects logistic regression models. RESULTS: At follow-up, anemia was significantly lower among children (odds ratio, OR [95% confidence interval, CI]: 0.76 [0.59-0.98]) and mothers (OR [95% CI]: 0.62 [0.48-0.82]) in the treatment group compared to the control. Underweight was lower among mothers in the treatment group compared to the control (OR [95% CI]: 0.61 [0.46-0.82]). There was no impact on child anthropometry. CONCLUSION: The EHFP intervention improved anemia among children aged 12 to 48 months and their mothers in Baitadi District of Nepal. The intervention also reduced underweight among these women, but had no impact on child growth, in this district.

Using formative research to design a context-specific behaviour change strategy to improve infant and young child feeding practices and nutrition in Nepal.

Global recommendations on strategies to improve infant feeding, care and nutrition are clear; however, there is limited literature that explains methods for tailoring these recommendations to the local context where programmes are implemented. This paper aims to: (1) highlight the individual, cultural and environmental factors revealed by formative research to affect infant and young child feeding and care practices in Baitadi district of Far Western Nepal; and (2) outline how both quantitative and qualitative research methods were used to design a context-specific behaviour change strategy to improve child nutrition. Quantitative data on 750 children aged 12-23 months and their families were collected via surveys administered to mothers. The participants were selected using a multistage cluster sampling technique. The survey asked about knowledge, attitude and behaviours relating to infant and young child feeding. Qualitative data on breastfeeding and complementary feeding beliefs and practices were also collected from a separate sample via focus group discussions with mothers, and key informant interviews with mothers-in-law and husbands. Key findings revealed gaps in knowledge among many informants resulting in suboptimal infant and young child feeding practices - particularly with relation to duration of exclusive breastfeeding and dietary diversity of complementary foods. The findings from this research were then incorporated into a context-specific nutrition behaviour change communication strategy.

Using program impact pathways to understand and improve program delivery, utilization, and potential for impact of Helen Keller International's homestead food production program in Cambodia.

BACKGROUND: Evidence of the impact of homestead food production programs on nutrition outcomes such as anemia and growth is scant. In the absence of information on program impact pathways, it is difficult to understand why these programs, which have been successful in increasing intake of micronutrient-rich foods, have had such limited documented impact on nutrition outcomes. OBJECTIVE: To conduct a process evaluation of Helen Keller International's (HKI's) homestead food production program in Cambodia to assess whether the program was operating as planned (in terms of design, delivery, and utilization) and to identify ways in which the program might need to be strengthened in order to increase its potential for impact. METHODS: A program theory framework, which laid out the primary components along the hypothesized program impact pathways, was developed in collaboration with HKI and used to design the research. Semistructured interviews and focus group discussions with program beneficiaries (n = 36 and 12, respectively), nonbeneficiaries (n = 12), and program implementers (n = 17 and 2, respectively) and observations of key program delivery points, including health and nutrition training sessions (n = 6), village model farms (n = 6), and household gardens of beneficiaries (n = 36) and nonbeneficiaries (n = 12), were conducted to assess the delivery and utilization of the primary program components along the impact pathways. RESULTS: The majority of program components were being delivered and utilized as planned. However, challenges with some of the key components posited to improve outcomes such as anemia and growth were noted. Among these were a gap in the expected pathway from poultry production to increased intake of eggs and poultry meat, and some weaknesses in the delivery of the health and nutrition training sessions and related improvements in knowledge among the village health volunteers and beneficiaries. CONCLUSIONS: Although the program has been successful in delivering the majority of the program components as planned and has documented achievements in improving household production and intake of micronutrient-rich foods, it is likely that strengthening delivery and increasing utilization of some program components would increase its potential for nutritional impacts. This research has highlighted the importance of designing a program theory framework and assessing the components that lie along the primary program impact pathways to optimize program service delivery and utilization and, in turn, potential for impact.

Determinants of delayed initiation of breastfeeding in rural Ethiopia: programmatic implications.

BACKGROUND: A number of studies have examined the possible adverse impact of services offered by health workers and community members on postpartum infant feeding practices. The present analysis utilized extant data collected previously through the baseline surveys of two related child health and nutrition projects implemented in rural Ethiopia and explored key risk factors associated with delayed initiation of breastfeeding for more than 1 hour after birth. OBJECTIVE: To investigate the most important determinants of delayed initiation of breastfeeding. METHODS: Multivariate logistic regression was performed to analyze data from baseline cross-sectional surveys carried out in 2003 and 2004 in selected districts across three regions in Ethiopia. RESULTS: Attendance at delivery by a health worker was found to be an important risk factor for the delayed initiation of breastfeeding, whereas attendance by traditional birth attendants or family and/or friends represented a protective factor for early initiation of breastfeeding. Additional analysis suggests that targeting of behavior change interventions on optimal infant feeding to these health workers could reverse the risk relationship and lead to improvements in the rate of early initiation of breastfeeding. CONCLUSIONS: Provision of inadequate breastfeeding information in the health system and attendance at delivery by health workers are associated with a delay in the initiation of breastfeeding. Births attended by trained traditional birth attendants and family members are associated with better practices. Targeting health workers, community members, families, and women to promote optimal infant feeding practices is likely to hold much potential to increase the adoption of early initiation of breastfeeding.

Implementing an integrated nutrition package at large scale in Madagascar: the Essential Nutrition Actions framework.

BACKGROUND: Madagascar has some of the highest rates of child stunting, maternal malnutrition, and infant mortality in sub-Saharan Africa. OBJECTIVE: To improve infant and young child feeding practices, increase uptake of micronutrient supplements, and improve women's dietary practices through implementation of a nutrition project based on the Essential Nutrition Actions (ENA) framework. METHODS: Interventions included training, interpersonal communication, community mobilization, and mass media. Changes in practices were assessed through a comparison of data for children under 2 years of age from representative cross-sectional household surveys collected at baseline in 2000 (n = 1,200) and at the end of program implementation in 2005 (n = 1,760). The surveys were conducted in six districts with a population of 1.4 million. RESULTS: The rate of initiation of breastfeeding within 1 hour of birth increased from 32% to 68%, the rate of exclusive breastfeeding of infants under 6 months of age increased from 42% to 70%, the rate of continuation of breastfeeding at 20 to 23 months increased from 43% to 73%, the rate of feeding children the minimum recommended number of meals per day at 6 to 23 months increased from 87% to 93%, the rate of iron-folic acid supplementation during pregnancy increased from 32% to 76%, and the rate of postpartum vitamin A supplementation increased from 17% to 54% (p < .001 for all changes). Modest improvement was achieved in maternal dietary practices during lactation and feeding of the sick child after illness. The results were inconclusive regarding food diversity for complementary feeding. No improvements were reported in increasing food intake during child illness or pregnancy. CONCLUSIONS: The ENA framework allows broad-scale improvement of nutritional practices to be achieved through the maximization of contacts using multiple program opportunities within existing health systems and community structures and through mass media.

Assessing impact and impact pathways of a homestead food production program on household and child nutrition in Cambodia.

BACKGROUND: Homestead food production programs have the potential to improve maternal and child health and nutrition through multiple pathways. OBJECTIVE: To evaluate the impact of a homestead food production program in Cambodia on household production and consumption of micronutrient-rich foods and on maternal and child health and nutrition (intake of micronutrient-rich foods, anthropometry, hemoglobin, and anemia prevalence); and to assess pathways of impact on maternal and child health and nutrition. METHODS: Two cross-sectional surveys (baseline and endline) were used to assess differences between intervention (n = 300) and control (n = 200) households using t-tests and chi-square tests. Using endline data and multivariate analyses, we examined the pathways of impact of the program on maternal and child health and nutrition. RESULTS: Intervention and control households were similar at baseline in sociodemographic characteristics, but more intervention households owned animals, earned income from homestead food production, and produced and consumed micronutrient-rich foods. At endline, some of these differences had widened; more intervention households produced and consumed more vegetables, had higher dietary diversity, and had a lower prevalence of fever among children under 5 years of age. In the intervention group, more children consumed more eggs and more mothers consumed micronutrient-rich food more frequently than in the control group. There were no other differences between the groups in maternal and child health and nutrition. Greater household production of fruits and vegetables was associated with greater household dietary diversity, which was associated with dietary diversity among mothers and children. Dietary diversity was not associated with other maternal and child health and nutrition outcomes. CONCLUSIONS: Cambodia's homestead food production program increased household production and consumption of micronutrient-rich foods and maternal and child intake (or frequency of intake) of some of these foods. Weaknesses in the evaluation design (e.g., lack of comparability between groups at baseline, failure to control for self-selection of households into the intervention, and collection of baseline and endline data during different seasons) prevent drawing firm conclusions about the program impacts. Analysis of impact pathways also shows that household-level benefits from the program did not translate into significant improvements in maternal and child health and nutrition. A careful redesign and rigorous assessment of the program using a program theory framework would help unleash its true potential to improve maternal and child health and nutrition outcomes.

Improving breastfeeding practices on a broad scale at the community level: success stories from Africa and Latin America.

Large-scale community-level behavior change programs designed to improve breastfeeding practices were implemented in Bolivia, Ghana, and Madagascar. These programs reached sizable populations: Bolivia, 1 million; Ghana, 3.5 million; and Madagascar, 6 million. Over 3 to 4 years, timely initiation of breastfeeding (within 1 hour of birth) increased from 56% to 74% (P < .001) in Bolivia, 32% to 40% (P < .05) in Ghana, and 34% to 78% (P < .001) in Madagascar. Marked increases in exclusive breastfeeding of infants 0 to 6 months of age were also documented: from 54% to 65% (P < .001) in Bolivia, 68% to 79% (P < .001) in Ghana, and 46% to 68% (P < .001) in Madagascar. In Ghana and Madagascar, significant results were seen within 1 year of community interventions. The authors conclude that large-scale programs designed to improve breastfeeding practices are feasible and should be a central component of any child survival strategy.

Promotion and advocacy for improved complementary feeding: can we apply the lessons learned from breastfeeding?

Although many successes have been achieved in promoting breastfeeding, this has not been the case for complementary feeding. Some successes in promoting complementary feeding at the community level have been documented, but few of these efforts have expanded to a larger scale and become sustained. To discover the reasons for this difference, the key factors for the successful promotion of breastfeeding on a large scale were examined and compared with the efforts made in complementary feeding. These factors include definition and rationale, policy support, funding, advocacy, private-sector involvement, availability and use of monitoring data, integration of research into action, and the existence of a well-articulated series of steps for successful implementation. The lessons learned from the promotion of breastfeeding should be applied to complementary feeding, and the new Global Strategy for Infant and Young Child Feeding provides an excellent first step in this process.